PRE-ACCREDITATION ENTRY LEVEL

STANDARDS FOR HCO & SHCO

NABH EDUCATION SERIES (ENTRY LEVEL)

VERSION 2.1 BASIC TRAINING

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS

© CAHO 2018-21. All rights reserved

CARE OF PATIENTS (COP)

Dr . Parivalavan Rajavelu MS, DNB, FRCS.,

Consultant Surgeon,
Sundaram Medical Foundation, Chennai.
Founder, SkillsForMED Patientcare Skills Training Centre

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 2
 Summary of Standards
Care of patients (COP)

COP2 COP3
COP1 COP4
Emergency Transfusion
Norms and ICU and HDU
services policies
practices (2) care (2)
(5) (5)

COP7
COP5 COP6 COP8
Anaesthesia
Obstetrics care Paediatric care Surgical patient
administration
(3) (5) care (7)
(9)

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 3
 Intent of COP

The NABH Care of Patients (COP) chapter aims at:

▪ Encouraging health care professionals

to identify and adopt clinical practice guidelines.

▪ Encouraging patient safety as the overall principle for providing care to patients.

▪ Addressing specific services- ICU, transfusion, ER, anaesthesia, OG and paediatrics.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 4
COP1: Care of patients is guided by accepted norms
and practice.

▪ COP1a: The care and treatment orders are

signed and dated by the concerned doctor.

▪ COP1b: Clinical practice guidelines are

adopted to guide patient care wherever
possible.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 5
 How to implement COP1?

Treatment Orientation

▪ List common ailments. ▪ Doctors should

▪ Develop Clinical understand the need for
Practice Guidelines. filling Sign, Date Name
▪ Adopt Clinical Care and Time (SNDT).
Pathways and follow it. ▪ Doctors should be
▪ Discuss variations. oriented to fill relevant
details.
▪ In-house residents should
ensure consultant fills
relevant details.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 6
Clinical Practice Guidelines Vs Clinical Care Pathways

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 7
Clinical Practice Guidelines Clinical Care Pathways

Clinical Practice Guidelines Clinical Care Pathways

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 8
 How to implement COP1?

Audit Documentation

▪ Check patient’s ▪ Document

medical records. pathway in the
▪ Provide feedback apex manual.
to doctors.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 9
Where can I find the guidelines for this?

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 10
 COP2: Emergency services including ambulance
are guided by documented procedures.

▪ COP 2a: Documented procedures address care of patients arriving in the

emergency including handling of medico-legal cases.
▪ COP 2b: Staff should be well versed in the care of emergency patients in
consonance with the scope of the services of hospital.
▪ COP 2c: Admission or discharge to home or transfer to another organisation is also
documented.
▪ COP 2d: Ambulance is appropriately equipped.
▪ COP 2e: Ambulance(s) is manned by trained personnel.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 11
 How to implement COP2?

Emergency department Emergency department staff

▪ Should be easily accessible ▪ Register patient.

and at hospital’s entrance. ▪ Provide first aid.
▪ Should have adequate ▪ Be aware of services available.
number of beds. ▪ Be able to manage all patients.
▪ Manpower and other ▪ Identify MLC.
resources should be ▪ Follow processes and
available 24/7. procedures for MLC.
▪ Be able to provide CPR.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 12
 How to implement COP2?

Ambulance services Ambulance staff

▪ Area should be
demarcated for ▪ Licensed driver.
ambulance parking. ▪ Trained medical staff.
▪ Well equipped. ▪ Be able to provide
▪ Resuscitation equipment CPR.
must be available.
▪ Emergency medicines
must be available.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 13
 Ambulance

▪ COP 2b: Staff should be well versed in the

care of emergency patients in consonance
with the scope of the services of hospital. • Basic Life Support
• Advanced Cardiac Life
Support (ACLS)
▪ COP 2e: Ambulance(s) is manned by trained
personnel.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 14
▪ COP 2d: Ambulance is appropriately equipped.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 15
 What should be documented?

▪ Nominal register: Patient details.

▪ Apex manual: Polices for emergency
management.
▪ Patient case sheet: Transfer
form/discharge notes and vital
parameters.

Note: Provide the patient with a transfer form/discharge note as appropriate.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 16
 Where can I find the guidelines for this?

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 17
 COP 3: Documented procedures define rational
use of blood and blood products.

▪ COP 3a: Documented policies and procedures are used to guide the rational
use of blood and blood products.
▪ COP 3b: Documented procedures govern transfusion of blood and blood
products.
▪ COP 3c: The transfusion services are governed by the applicable laws and
regulations.
▪ COP 3d: Informed consent is obtained for donation and transfusion of blood
and blood products.
▪ COP 3e: Procedure addresses documenting and reporting of transfusion
reactions.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 18
 Blood Bank

▪ Should have appropriate license.

▪ Should have inventory and ordering
schedules.
▪ Should arrange for safe transportation of
blood.

Note: If the blood bank is not available, the hospital should sign a MOU with
another blood bank. Blood storage centre should be licensed and follow NACO
guidelines.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 19
 Informed Consent

▪ Multiple transfusions during

same admission: Obtain single
consent.
▪ Transfusion dependent
patients: Obtain consent once
in six months.

Note: Patient and their family should be informed about the risks, benefits,
transfusion reactions and educated about blood donation.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 20
 Management of Suspected Transfusion Reaction
For major
reactions,
Inform send
Blood Blood bank
doctor, Report remaining
bank presents
Stop blood recognise transfusion blood,
performs report to
transfusion. and reactions to blood
root cause transfusion
manage blood bank. sample and
analysis. committee.
reactions. urine
sample to
blood bank.

Note: The transfusion committee/haemovigilance is a mandatory committee for in-house blood bank
and blood storage centre.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 21
 How to implement COP3?

Pre-transfusion Transfusion Post-transfusion

▪ Doctor orders transfusion. ▪ Connect blood ▪ Monitor

▪ Obtain informed consent. bag to the patient closely
▪ Send request to patient. for two hours.
laboratory. ▪ Monitor ▪ Discard blood
▪ Send request for cross patient every bags after
matching to blood bank. half an hour. autoclaving.
▪ Crosscheck blood bag with
doctor’s order.
▪ Check vital parameters.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 22
 What should be documented in the apex manual?

▪ Indications for blood and blood

components.
▪ Policies for blood donation, consents,
managing blood and blood components,
storage, transfusion reactions and
discarding blood bag.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 23
Where can I find the
guidelines for this?

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 24
 COP 4: Documented procedures guide the care of
patients as per the scope of services provided by hospital
in intensive care and high dependency unit.

▪ COP4a: Care of patients is in

consonance with the documented
procedures.
▪ COP4b: Adequate staff and
equipment are available.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 25
 How to implement COP4?
Staff Equipment

▪ Be familiar with admission and discharge ▪ Availability of adequate and

criteria. well calibrated and proper
▪ Adopt infection control practices. functioning equipment.
▪ Be able to provide basic and advanced CPR. ▪ UPS backup.
▪ Be aware of protocol for evacuating ▪ Well-stocked crash cart.
patients. ▪ Central medical gas lines
▪ Perform mock drills. should have alarms.
▪ Maintain equipment and monitor its ▪ Have operational checklist.
downtime. ▪ Availability of fire detection
▪ Be able to provide appropriate end of life and fighting equipment.
care.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 26
 Staff in the ICU

▪ Duty doctor: Must be available 24/7.

▪ Admitting consultant: Should be available
on call.
▪ Ventilated patients: One nurse/patient.
▪ Non-ventilated patient: One nurse/three
patients.

Note: Other area nurses should not be posted in ICUs. And, number of doctors
who should be available in ICU depend on the size of the ICU and its complexity.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 27
 What should be documented in the apex manual?

▪ Policies for management of ICU and

HDU patients.
▪ Admission and discharge criteria in
ICUs.
▪ Counselling given to patient’s relatives.
▪ SOP for non-availability of beds and
equipment.

Note: The procedures for management of patients should be as per the current
evidence-based practices and national / international guidelines.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 28
Where can I find the guidelines for this?

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 29
 COP 5: Documented procedures guide the care of
obstetrical patients as per the scope of services
provided by hospital.

▪ COP 5a: The organisation defines the

scope of obstetric services.
▪ COP 5b: Obstetric patient’s care includes
regular antenatal checkups, maternal
nutrition and post natal care.
▪ COP 5c: The organisation has the facility
to take care of neonates.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 30
 How to implement COP5?
Antenatal care Postnatal care
▪ Register antenatal mothers.
▪ Conduct ANC check ups. ▪ Provide newborns with ID
▪ Immunise antenatal mothers. bands.
▪ Check vital parameters, Hb, urine and ▪ Initiate breastfeeding
abdomen. within one hour of
▪ Monitor mother and foetus. delivery.
▪ Administer medications. ▪ Immunise new born.
▪ Prepare expectant mother for delivery. ▪ Provide family planning
advice.
▪ Obtain informed consent for mode of
delivery and taking ultrasound. ▪ Encourage kangaroo
mother care.
▪ Provide nutritional education.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 31
 Obstetrics Department

▪ Bilingual display of obstetrics services at prominent locations.

▪ Specify services available 24/7.
▪ Display name and qualification of doctors available.
▪ Display “ Sex determination is not done” at entrance of ultrasound room.
▪ Display if hospital is equipped to manage high-risk pregnancies.
▪ Define high risk obstetrics cases and have facility to take care of such cases.
▪ Display MTP license.
▪ Maintain records as per MTP act.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 32
 Obstetrics Department

▪ Availability of immunisation services.

▪ Availably of sick new born care unit.
▪ Management of low birth weight
babies.
▪ Availability of referral services to higher
centres.
▪ CC TV facilities and entry restriction
protocol.
▪ Availability of child abduction
prevention measures.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 33
 New born Care Corner

▪ Equipment for placing new born.

▪ Suction device and oxygen.
▪ Warm towels.
▪ Clock.
▪ Calibrated phototherapy units and
weighing scale.
▪ Equipment for resuscitation of
asphyxiated new born.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 34
 Where can I find the guidelines for this?

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 35
 COP 6: Documented procedures guide the care of
paediatric patients as per the scope of services.

▪ COP 6a: The organisation defines the scope of paediatric services.

▪ COP 6b: Provisions are made for special care of children by competent staff.
▪ COP 6c: Patient assessment includes detailed nutritional, growth and
immunisation assessment.
▪ COP 6d: Procedures address identification and security measures to prevent
child abduction and abuse.
▪ COP 6e: The children’s family members are educated about nutrition,
immunisation and safe parenting.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 36
 How to implement COP6?
Staff Facilities

▪ Have adequate age-specific competency. ▪ Child friendly

▪ Trained to handle paediatric environment.
emergencies. ▪ Breast feeding room and
▪ Adequate nurse/patient ratio. play room.
▪ Able to conduct patient assessment. ▪ Safe storage of
▪ Able to identify Code Pink and act medications.
accordingly. ▪ Availability of charts and
▪ Trained to prevent child abduction and scales.
abuse. ▪ CCTV cameras to prevent
▪ Security personnel should be available unauthorised entry.
24/7.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 37
 Paediatric Department

▪ Bilingual display of paediatric services

at prominent locations.
▪ Specify services available 24/7.
▪ Display name and qualification of
doctors available.

Note: ID band with the mother’s name and

UHID should be affixed on the newborn.
And, the baby’s footprint should be taken
and recorded.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 38
 Safe Parenting

▪ Educate parents about child abduction.

▪ Ask parents to never leave child
unattended.
▪ Authorise only close family members to
handle baby.
▪ Teach parents about age specific
nutritional and immunisation requirements
and safe parenting techniques.
▪ Follow visitor’s policy.
▪ Ask visitors to carry visitor’s pass.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 39
 Code Pink

Rapid response Staff competency

▪ Define the process. ▪ Ability to handle the
Security/surveillance ▪ Test it at pre-defined situation.
Install CCTV camera. intervals (Table-top ▪ Awareness to
exercise or mock escalate child abuse,
drill). if any.

Note: Written guidance should direct organisation regarding prevention of

abduction and abuse.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 40
 Where can I find the guidelines for this?

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 41
 COP 7: Documented procedures guide the
administration of anaesthesia.

▪ COP 7a: There is a documented policy and procedure for the administration of
anesthesia.
▪ COP 7b: All patients for anaesthesia have a pre-anaesthesia assessment by a
qualified / trained anaesthetist.
▪ COP 7c: The pre-anaesthesia assessment results in the formulation of an
anesthesia plan which is documented.
▪ COP 7d: An immediate preoperative re-evaluation is documented.
▪ COP 7e: Informed consent for administration of anesthesia is obtained by the
anaesthesiologist.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 42
 COP 7: Documented procedures guide the
administration of anaesthesia.
▪ COP 7f: Anaesthesia monitoring includes
regular recording of heart rate, cardiac
rhythm, respiratory rate, blood pressure,
oxygen saturation, airway security and
patency and end tidal carbon dioxide.
▪ COP 7g: Each patient’s post-anaesthesia status
is monitored and documented.
▪ COP 7h: Defined criteria are used to transfer
the patient from the recovery area.
(Alderete/PADSS)
▪ COP 7i: Adverse anesthesia events are
recorded and monitored.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 43
 How to implement COP7?
Pre-anaesthesia assessment Anaesthesia plan

▪ Done prior to the day of surgery. ▪ Identify ASA grading.

▪ Take patient’s history. ▪ Finalise the type of
▪ Perform examination and investigations. anaesthesia.
▪ Take expert opinion. ▪ Discuss the plan with the
▪ Perform special investigations, if patient.
required. ▪ Get informed consent.
▪ Instruct patients about pre-op and post-
op medication.
▪ Give fasting instructions.
▪ Document in pre-anaesthesia
assessment form.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 44
 How to implement COP7?
Immediate Pre-op. re-evaluation Anaesthesia monitoring

▪ Done just before administering ▪ Involves continuous monitoring

anaesthesia. of airway and vital parameters.
▪ Check vital parameters, fasting ▪ Done in all stages of anesthesia.
status and integrity of IV line. ▪ Ensure appropriate equipment
▪ Check for any new medications. is available for basic and
▪ Review recent development in advanced monitoring of
medical condition, patient.
investigations results and ▪ Check integrity of anaesthesia
medication history. machine circuit.
▪ Reassess mouth opening. ▪ Post anesthesia care is
monitored.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 45
 Roles and Responsibilities

▪ Pre-anaesthesia assessment: Qualified

anaesthetist /surgeon/physician(trained
anaesthetist gist).
▪ Immediate pre-operative re-evaluation:
Anaesthetist/team member.
▪ Post-anaesthesia monitoring: Qualified
staff/anaesthetist/intensivist.

Note: Standard guidelines should be formulated and implemented for

administering anaesthesia.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 46
 Anaesthesia Administration

▪ Type of surgery.
What determines
▪ Duration.
procedure for
▪ Patient’s co-morbid conditions.
anaesthesia?
▪ Risk involved.

▪ Pre-anaesthesia medication.
▪ Induction, maintenance and reversal of
What should be
anaesthesia.
mentioned in the
▪ Medications used.
procedure?
▪ Post anaesthesia care.
▪ Post-operative analgesia. Moderate sedation

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 47
 Informed Consent

▪ Should be bilingual.
▪ Should include type of anaesthesia, name of the anaesthetist, risk involved,
benefits and alternatives available.
▪ Anaesthesia consent should be taken by the anaesthetist.
▪ High risk consent should be obtained from a patient having ASA risk grade
greater than three.

Note: The consent form should be explained to the patient before obtaining
signature. And, a witness should endorse the consent form.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 48
 Transferring the Patient

Nurse
▪ Monitors patient using transfer criteria.
(PADSS scoring, modified Alderete scoring)
▪ Documents transfer score.
▪ Informs anesthetist.
Anaesthetist
▪ Monitors care.
▪ When the patient is ready, re-evaluates
patient.
▪ Writes order for shifting patient to ward.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 49
 What should be documented in the apex manual ?

▪ Procedure for anaestheisa administration.

▪ Anaesthesia consent.
▪ Anaesthesia monitoring.
▪ Vital parameters of the patient.
▪ Level of consciousness.
▪ Post-anaesthesia care criteria.
▪ Specific criteria.
▪ List of adverse anaesthesia events.
▪ Transfer criteria.
▪ RCA and CAPA.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 50
 Where can I find the guidelines for this?

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 51
 COP 8: Documented procedures guide the care
of patients undergoing surgical procedures.

▪ COP 8a: Surgical patients have a pre-operative assessment and a provisional

diagnosis documented prior to surgery.
▪ COP 8b: An informed consent is obtained by a surgeon prior to the procedure.
▪ COP 8c: Documented procedure address the prevention of adverse events like
wrong site, wrong patient and wrong surgery.
▪ COP 8d: Qualified persons are permitted to perform the procedures that they
are entitled to perform.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 52
 COP 8: Documented procedures guide the care
of patients undergoing surgical procedures.

▪ COP8e: The operating surgeon documents the operative notes and post-
operative plan of care.
▪ COP8f: The operation theatre is adequately equipped and monitored for
infection control practices.
▪ COP8g: Patients, personnel and material flow conform to infection control
practices.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 53
 Informed Consent
▪ Provisional diagnosis, date of surgery, surgery details, advantages and disadvantages of
surgery and other options.
▪ Details of implant type chosen with other options, advantages and disadvantages of
chosen implant.
▪ Patient’s name, signature/thumb impression and date and time.
▪ Next of kin’s signature and their ID proof.
▪ Name and signature of translator.
▪ Name and signature of the witness with address.
▪ Special mention of any high risk involved in surgery.
▪ Surgeon’s signature with time, date and medical council registration number.

Note: The consent form should be bilingual.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 54
 Post-operative Care Plan
The post-operative care plan should include:
▪ IV fluids.
▪ Medications.
▪ Wound care.
▪ Complications.
▪ Nursing care.
▪ Fitness criteria for discharge.
▪ Details of surgeon and surgery team members.
▪ Detailed account of surgery.
▪ Implant details with batch number and expiry date.
▪ Post-operative diagnosis.
▪ Patient's status.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 55
 How to implement COP8?

Preoperative Adverse events prevention

▪ Hospital is well equipped ▪ Two identifiers.

to perform pre-op ▪ Site, side and organ
assessments. marking.
▪ Trained and qualified ▪ Pre-op check list at
doctors to assess elective transfer.
and emergencies. ▪ Protocols for sign, time out
▪ Informed consent is and sign out.
taken. ▪ Perform CAPA.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 56
 How to implement COP8?

Operating surgeon Infection control

▪ Valid qualification, ▪ Unidirectional flow of people and materials

registration and is recommended.
experience. ▪ Transport contaminated items in closed
▪ Leads surgical safety container.
practices. ▪ Have hand washing facilities.
▪ Writes procedure notes. ▪ Have designated areas for waste
▪ Write post-operative care management, linen and laundry
plan. management and for performing unsterile
activities.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 57
 Best Practices For Preventing Infections in OT
▪ Semi-sterile zone and sterile zone should be entered only after changing into OT
clothing.
▪ OT clothing should not be worn outside the OT.
▪ Transfer trolleys should be used while transferring patient from ward to OT.
▪ Food should not be taken/eaten inside the OT premises.
▪ Labour ward should not be part of the OT complex.
▪ All surface of OT should be easily cleanable.
▪ Cleaning practices.
▪ The flooring should be anti-static.
▪ Walls and ceiling should be non-porous, smooth and seamless without corners
(coving).

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 58
 Points To Remember
Organisation
▪ Should have well-equipped OT.
▪ Should provide diagnostic services.
▪ Have a recall procedure in case of infection.
OT staff
▪ Should be trained on universal precautions and zoning activities.
▪ Should be provided with adequate prophylaxis.
▪ Should ensure sterile and unsterile personnel and patients do not touch each
other.
▪ Should keep sterile and unsterile instruments separately.
▪ Should dispose linen and unsterile items separately.
▪ Should adhere to OT zoning guidelines.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 59
What should be documented in the apex manual?

▪ Pre-operative assessment.
▪ Provisional and differential diagnosis.
▪ Investigations with reporting.
▪ Surgical safety list.
▪ Post-operative care plan.
▪ Adverse events.
▪ Procedures for monitoring asepsis of OT, sterilisaton of instruments
and disposables, cleaning, fogging/terminal cleaning of OT, linen
management, waste management, usage and disposal of
consumables and ETO usage.

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 60
 Where can I find the guidelines for this?

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 61
 Any Questions

BASIC PROGRAM TO TRAIN CPQIH

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 62
Thank You! 63