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Junior Internship Report Internship At K. B.BHABHA Hospital , Bandra.

(30th January 2012- 24th March 2012)

Prepared ByDr. Rinky Mansukhani, MHA (Hospital Administration) Roll number 2011HO036 TISS, Mumbai

K B Bhabha hospital

K B Bhabha hospital

First Internship Report At


K.B.BHABHA HOSPITAL, BANDRA(January 29 March 24 )
th th)

Submitted to : Dr. Gowri School of health system studies Tata Institute of Social sciences Mumbai

Efforts by: Dr Rinky Mansukhani 2011HO036 Master of Hospital Administration Tata Institute Of social sciences

K B Bhabha hospital

INDEX Serial No. Name Of the department Page No.

1.

Introduction of the Hospital

2.

Outline of an ideal hospital

3.

Overview nursing services

11

4.

Overview maintenance

14

5.

Overview-Laboratory

17

6.

Overview-Security

20

7.

Overview-Mortuary

23

8.

Overview-Library

25

9.

Overview-ICTC

27

K B Bhabha hospital

10.

Overview-Social workers department

29

11.

Overview-Time keeper

31

12.

Overview-Radiology

33

13.

Overview-ECG

35

14.

Overview-Sonography

36

15.

Overview-Pharmacy

38

16.

Overview-OPD

40

17.

Overview-Post partum care OPD

42

18.

Overview-Post natal care unit

43

19.

Overview-Paediatric ward

45

20.

Supportive services 1-medical records department

48

K B Bhabha hospital

21.

Supportive services -2 occupational therapy /physical therapy

55

22.

Supportive services 3- blood bank

61

23.

Supportive services 4-kitchen and dietics department

69

24.

Clinical department 1-casulty

79

25.

Clinical department 2 ICU

89

26.

Clinical department 3-Labor and delivery ward

97

27.

Clinical department 4-Operation theatre

106

28.

Case study Dilaasa

118

29.

General analysis of the hospital

133

K B Bhabha hospital

History of hospital
K.B. Bhabha Mumbai general hospital, Bandra (W) was originally established in 1914. It was known to be Reddimanj Kawasji Dispensary which was established by Bandra Municipal Corporation for providing facilities to locality of Bandra Public. In the year 1950 Shri Bhabha and hus family donated the present plot to establish hospital building. This was given name as Khursheedji Beheramji Bhabha Municipal General Hospital, Bandra(W). in the year 1952 Bandra Municipal Corporation merged with Brihanmumbai Mahanagarpalika. This structure was allotted 44 beds. In the year 1957, 21 more beds were added for Labour ward and bed strength rose to 65 beds. In the year 1962, 30 more beds for Paediatric ward were added to the original bed strength and bed strength was 85 beds. Again in year 1967, 70 beds were added and bed strength became 165 beds. In the year 1978, Out Patient department was shifted to ground floor of DMC Zone III building and same year 39 general beds were added and bed strength became 204. 30 April 1987 was milestone for K.B. Bhabha hospital, opening of multi-storeyed 10 floor building and bed strength increased to 436. 29 April 2007 newly renovated well equipped OPD building was opened for rendering services to locality of Hward people. Health services Total bed strength 436 beds Operation theatre 10 K.B. Bhabha municipal general hospital is a big peripheral hospital of western suburbs situated in middle of Bandra Taluka. This hospital runs following speciality departments Medicine Surgery Orthopaedic Paediatric ENT Ophthalmic Skin/STD Obstetrics and Gynaecology Psychiatric Dental Casualty Well-equipped operation theatres Intensive Care Unit (ICU) Paediatric Intensive care unit (PICU) Premature babies Unit (PU) Electrocardiography (ECG) Ultrasound (USG)

K B Bhabha hospital

24 hours service of Pathology, Blood Bank and x ray department K.B. Bhabha hospital also provides its own Ambulance, Hearse services and Mortuary.

Contact details
Telephone numbers - 022 - 26422541, 26422542, 26422775, 26429828 , 022 26405226 Address - R K Patkar Marg, Near Globus Showroom, Bandra West, Mumbai - 400050

Physical structure/layout of the hospital The hospital consists of four buildings namely the old main building, the staff quarters building, the new OPD building and the extension, mortuary and AC plant building, structure to store medical gases, pump house and minor OT building and old OPD building. The new OPD building is the centre for certain OPDs like all the super speciality and radiology services. The old OPD building has OPDs of general medicine, surgery, paediatrics, sonography, Dilaasa, etc. the pump house and minor OT structure houses the pump and the minor OT. The mortuary building has the AC plant and the mortuary. The quarters building has the matrons office, medical records office, certain OPDs like OT/PT, ECG and the security office. The main building is a multi-storeyed building with around 10 floors. The layout of each floor is described below: Ground floor the in patients x ray department, casualty, major OT, meter room and AMO offices

K B Bhabha hospital

First floor blood bank, male surgical ward, social workers station, immunization cell and staff room Second floor Chief medical Superintendent (Dr Seema Malik) office and labour & delivery suite Third floor Post Natal care ward (PNC), female orthopaedic ward, Dilaasa, AMO duty room, pantry Fourth floor female surgical and gynaecological ward, surgical store, Medico Electronics Cell, nurses station, pantry, toilet and paying room Fifth floor male paying ward, male surgical and medical ward, Intensive Care Unit, female paying ward, Female medical ward, female surgical ward Sixth floor paediatric ward consisting of the general paediatric ward, premature unit, intensive paediatric care unit and a nursing station. Just outside the paediatric wards consultation room is located which is used by doctors belonging to two unit. Seventh floor office of Chief Medical Superintendent and all the administrative offices along with offices for the cashier and the clerk, kitchen Eighth floor male medical ward, male orthopaedic ward, clinic room, toilets with two baths, pantry, store room, male orthopaedic store room, laboratory Ninth floor pharmacy, RMOs rooms and RMOs mess Tenth floor library and RMOs rooms

K B Bhabha hospital

Organisational structure
Doctors

Chief Medical Superintendent Dr SeemaMalik Medical Superintendent Dr. Shashikant Wadekar Senior Medical Officer Dr. Singh and Dr. Kale Assistant medical officer

Honorary Doctors

Registrars

House officers

K B Bhabha hospital

Nursing department

Matron 1 Sister In charges 20 Staff nurses

Auxillary nurses

Office

Office Superintendent

Head Clerk

Clerk

Peon

K B Bhabha hospital

Outline of an ideal hospital


A hospital consisting of over 425 beds is categorised as a large hospital. A teaching hospital of this size should have the following clinical and supportive services.

Medical and ancillary services


OPD services Emergency Clinical laboratories Radiological services Diagnostic radiology Radiation therapy Nuclear medicine Surgical department Labour and delivery suite Physical medicine and rehabilitation physical therapy, occupational therapy, recreational therapy, speech and hearing therapy Pulmonary medicine Cath lab Paediatrics department Orthopaedics department

Nursing services
General nursing unit Paediatric nursing unit Obstetrical Psychiatric Isolation rooms Intensive care unit (ICU) / Coronary care units (CCUs) New born nurseries

Supportive services
Admitting department Medical records department Central Sterile supply Department (CSSD) Pharmacy Materials management Food services department Laundry and linen services Housekeeping Volunteer department

K B Bhabha hospital

Planning and designing services


Engineering department Maintenance department Biomedical(clinical) engineering Electrical system Air conditioning system Water supply and sanitary system Centralised medical gases system Communication system Environmental control Solid waste management Transportation

Overview of K.B. Bhabha hospital


As compared to an ideal hospital the departments listed below are present in K.B. Bhabha hospital. A brief overview has been given alongside. in addition to this a detailed description has been given of eight departments along with one department which has been dealt with as a case study. These nine departments have not been mentioned in the overview. The departments covered in brief are as follows Supportive services Maintenance department Air conditioning department ICTC centre Laboratory Time keeper Library Security system Mortuary Radiology department Social workers department Pharmacy Clinical services Post natal care unit Paediatric ward Intensive Paediatric care unit Premature unit Nursing department Gynaecology OPD General services OPD Post-partum care centre OPD

K B Bhabha hospital

The departments covered in detail are Supportive services Blood bank Occupational therapy/physical therapy Kitchen Medical records department Clinical services Operation theatre Labour ward Casualty Intensive care unit

Case study Dilaasa

K B Bhabha hospital

SUPPORTIVE SERVICES DEPARTMENT I MEDICAL RECORDS DEPARTMENT


Ideal medical records department Location - In order to provide prompt medical ecord service for the care of all patients at all hours and to foster a close working relationship and good communication among the related departments, the medical records department should be located close to the admitting area, outpatient department, emergency room and the business office. It should also be close to or on the corridor leading to the doctors lounge so that the medical staff can conveniently stop by and complete their records and study area. Design - The front office of medical records the registration together with the enquiry- is often the patients first point of contact with the hospital. In addition to courteous and helpful staff, the physical design should be one that projects a wrm and welcome feeling. The department should also be designed with the best possible means of transportation of medical records through all stages of their use and processing. Organisation the medical records department should be headed by a medical record administrator or officer who reports to the director for medical or administrative services. He should be a graduate with a degree or diploma in medical record administration. The remaining staff in the department consists of medical records technicians and medical record clerks. Space requirements The medical records department require space and facilities for the following: Reception cum registration area Office for the medical records officer and assistant medical records officer Space for sectional supervisors Work area for record processing, assembling, numbering, indexing, utilization review, discharge analysis, correspondence, work processing, quality analysis etc. Record storage for active and inactive files. Active files are the files where the data of discharge or last visit is within three to five years of the current date. These files should be readily accessible. Inactive record storage should also be located near the active files area as far as possible. Inactive records may be stored in a computer-assisted system. Space for copier that is used to a considerable degree. A room for medical staff to complete records, study cases and review and abstract records with tables chairs dictating equipment etc.

K B Bhabha hospital

An area with bookcases or shelves for the central recording equipment, tables, computers, etc. for medical secretaries to transcribe dictation. Should be close to the doctors records completion room to clear any doubts in dictation Space for master patient index depending on the kind of system used, for immediate identification of current and past patients. Computer assisted system is now widely used. Storage area for medical records charts. Supplies storage space for unused medical record file folders, forms, etc. Staff facilities If the medical record department is on two floors with the record storage area on a lower floor an electrically operated dumbwaiter may be necessary. This must be planned at the design stage.

Medical records department at Bhabha Staff Hierarchy of staff

Medical Records Officer (MRO)

Medical Records Technician(MRT)

Senior Registration Assistant (RA)

12 full time Registration Assistants (RA's)

8 part time Registration Assistants (RA's)

The MRO and MRT are Shri Dinanath Gharat and Shrimati Asha Kamath. The senior Registration Assistant is Mrs. Kaluskar who is currently stationed in the Out Patient Department. The total strength of staff in the department is 23. There are no ward clerks or secretaries. There is one medical officer in charge of the administrative aspect of every ward.

K B Bhabha hospital

Physical structure/Layout The medical records department is located on the first floor of the quarters building. It consists of two rooms where the MRO and MRT sit. Two rooms are present on the seventh floor of the main building for storage of files along with one room on the first floor. Duties of the various personnel in the department The Senior Registration Assistant issues certificates and supervises the duties of the Registration Assistants. The part time and full time registration assistants perform duties of registration of patients attending the medical OPD as well as cash collection from various departments like casualty, laboratory etc. The part time Registration Assistants are apprentices undergoing training and will become full time soon. Various duties performed by the department include the following Medical registration Cash collection from the ICU, paying patients, X ray department, Ultrasound, ECG and OT charges Casualty registration Notification of cases of Acute Flaccid Paralysis and malaria Obtaining and recording permission for transfer of dead bodies by road/air/train Reporting of cases of gastroenteritis to the Food and Drug Department Maintaining post mortem records Issuing injury certificate and death certificate Responding to Right To Information requests by verifying and examining them

Duty timings The senior personnel i.e. the MRO, MRT and senior RA do a general duty that lasts from 8 am to 3 pm. The full time and part time RAs are rotated in shift duties between morning duty between 7 am to 3 pm, afternoon duty from 2 pm to 10 pm and the night shift from 10 pm to 7 am. Working of the Medical Records Office Registration system during normal OPD timings the patient goes to counter number 5 gets an OPD paper at the sum of rupees 19 which is valid for 14 days. The OPD timings are from 6 am to 11 am. The registration assistant at the counter judges which OPD to send the patient to, be it medical, surgical, orthopaedic etc. the registration paper records the details of the patient like name, age and sex and each paper has a registration number. Once the OPD counter shuts a patient can go the casualty and depending on the assessment of the casualty medical officer, he/she is issued a K B Bhabha hospital

casualty paper. The casualty functions 24 hours a day. A receipt is given to the patient and no duplicate cope is maintained by the registration counter. In cases of emergency indoor admission the patient is required to first visit the casualty medical officers and then visit registration counter number 31. No identity proof is required and no money is required to be paid at the time of admission unless it is an admission to the ICU in which case a deposit of rupees 400 needs to be made. After registration the patient is sent to the office on the seventh floor from where he/she is directed to whichever ward is deemed appropriate. In cases of routine admission the patient has to take the OPD paper on which admission is advised and visit the registration counter after which he/she is sent to the office an directed to the wards. The patient is fully investigated on admission and treatment decisions are taken. In cases of OPD patients requiring X rays or ultrasounds they are required to take the prescription the registration assistant, pay the required amount and bring the receipt to the radiology department. All the cash is submitted to the office at the end of every day. The records from the radiology department are sent to the MRO after a period of 3 4 months although monthly statistics are recorded at the end of every month. Spoilt X rays are sent to the MRO and stored for a period of five years after which they are tendered for scrap. Cash collection - Cash is collected from the Intensive Care Units(ICUs)/Coronary Care Units(CCUs), paying patients, X ray departments, sonography departments, ECG and OT charges for both major and minor surgeries. The entire cash is handed over to the accounts departments on a daily basis. VIP patients of the total patient load around 2% are VIP patients. These patients are admitted to the paying ward at the sum of Rupees 200 per day. Investigations that are carried out are charged at different rates. The inpatient departmental paper and discharge papers are received by the medical records department. The major chink of these papers are received during the morning time between 8 am to 12 pm from the medical, surgical and supra speciality OPDs. The division of male and female patients in all wards is done by the sister in charge of the wards and sent to the medical records department. The IPD papers are sorted and divided on the basis of Medico legal Cases (MLC) and non MLC cases. The MLC cases are recorded daily for court, police and LIC purposes. The cases of notifiable diseases like malaria, leptospirosis, dengue, tuberculosis etc, are sent to the Chief Medical Superintendent of the hospital (CMS) that is Dr. Seema Malik. All cases of Acute Flaccid Paralysis (AFP) and malaria are notified to the Medical Officer of Health which is a part of the health system policy. The Ministry of Health (MOH) will subsequently send personnel to visit the households of every such patient in order to investigate the case further. For example in cases of malaria the MOH will hunt for breeding grounds for flies in the neighbourhood and give advice on application of pesticides. In cases of AFP they might take stool samples and send for culture and sensitivity testing.

K B Bhabha hospital

In cases of gastroenteritis the Sanitary Inspector is notified who will subsequently investigate if the food is homemade or purchased. If the food was purchased, the respective shop will be sealed to prevent further outbreaks of such cases. If the food was homemade, inquiries will be made to check if the incident was caused intentionally (homicidal intent) or unintentionally. Autopsy (post mortem) of dead bodies of patients who have expired within the last 24 hours of admission to the hospital is conducted. Records of these post mortem investigations are maintained by the medical records department. ML case papers and records are made of these cases after 15 days. Birth records census - The records of all births in the hospital are maintained by the MR department and a birth records register is maintained. A municipal number is given to each birth and the register is signed by the ward in charge who had initially given this information. Filing system In January of every year bundles of IPD(admission) papers are made, each bundle consisting of 100 papers each. Around 25 000 to 28 000 in patient record are received each year. Out of this total around 3000 are Medico legal cases of which 250 300 are of prime importance. The details from these bundles are entered into a register and the MLC case papers are marked with a red pen. The details of these MLC cases are maintained in a different register. These papers are separated from the IPD papers and different bundles of 100 cases each are made. Similarly different bundles are made for casualty records. These bundles are then checked to see if no other series have been entered in these bundles. The bundles are colour coded according to the year in which they have been made. For example papers issued in the year 2010 are coded orange, those in 2011 are coded in green and those of the current year 2010 are coded in blue. Weekly, fortnightly, monthly and yearly reports are made from the above said registers. Weekly reports are issued on Friday regarding the attendance of doctors from KEM who come in to conduct the five new supra specialty OPDs that have been newly started. Requests for records records can only be requested by the patient, relatives or the police in case of an MLC. Patients require to put in an application and the records re handed over almost immediately the MRO retains the original and gives an attested photocopy at the sum of Rupees 2 per page. Storage of records IPD papers are stored for an average of 7 8 years. MLC case papers are stored permanently as one doesnt know when they may be required. The papers from the mortuary i.e. death cases are stored for a period of 10 -15 years. The rule regarding the storage of IPD papers is of 5 years and that of mortuary papers is of 7 years.

K B Bhabha hospital

Equipment possessed by the department 1 computer 1 printer Stationery Registers and case papers 10 Cupboards for storage

Problems faced by the department Incomplete records of those patients who were unconscious at the time of admission and subsequently passed away before any information or history could be gathered. Problems encountered whilst attempting computerization of records. The staff of the MR department feels that it is more convenient and faster to enter the data manually. No identity proof is requested for the registration counter. This may lead to a lot of fraudulent cases to be admitted.

Recommendations Coding and indexing records according to a system which classifies cases on the basis of their importance Introducing a computerised system and conduction computer literach programs for the staff for a period of four to six months Introducing a policy of requesting for identity proof in the form of a ration card, pan card, voters id card etc. at the time of admission

K B Bhabha hospital

Nursing services
Staff
Hierarchy of the department

matron black belt Assistant matron Yellow belt


Sister In charges of various departments
21 sanctioned posts of which 20 are currently occupied

Staff Nurses

The total strength of the present staff is 171. The number of sanctioned posts is 174 leaving 3 posts vacant. Out of the 171 present staff, 14 are fully trained, 7 are nursing midwives who are trained for a period of one and a half years and 20 work on a contractual basis for a period of 3 months. The nurse to patient ratio cant be determined as at any given point in time if the contract nurses retire a lot of posts ate vacated. The nurse to patient ratio hence varies from time to time. There are no M Sc nurses in the hospital as the hospital is not a teaching one for nurses.

K B Bhabha hospital

Allocation of nurses to wards


10 nurses are allocated to the ICU. In addition to the 10 staff nurses there is one Sister in Charge and one assistant in the mornings. 2 nurses each are allocated to the ICU in the afternoon and the night shifts. 5 nurses are allocated to each In Patient Ward. 5 nurses are allocated to the operation theatre out of which 2 or 3 work in the mornings, 1 in the evening and 1 in the night. After initiation of their nursing duties every nurse is rotated for 2 years amongst all the departments.

Duty assignments - Nurses work in three shifts mainly morning evening and night.
The morning shift lasts from 8 am to 3 pm for OT nurses and from 7 am to 2 pm for ward nurses. The evening shift lasts from 2 pm to 9 pm and the night shift from 9 pm to 7 pm respectively. Every nurse succeeding the nurse of the previous shift is required to take a handover from the nurse who was on duty before her. Nurse doctor communication - The Intercom is made use of by nurses to communicate between departments. A call book is maintained by each ward which list the referrals made to a particular unit or doctor and also contains contact details like mobile numbers of all available doctors.

Nursing In Service Education MSCIT programs that train nurses in the basic skills to handle computers are made compulsory as part of their undergraduate training. The nursing degrees are awarded only conditionally on completion of this program. Certain programs are conducted to train nurses as to how to deal with patients suffering from HIV/ AIDS. Programs to train nurses about the importance of proper nutrition leading to good health are conducted. Also certain programs are conducted by the Dilaasa counsellors against sexual harassment and the importance of screening patients who may be suffering from domestic violence. Nurses are given specialised training of three months each in areas like paediatric nursing, OT skills etc. these programs are opted for by the nurses voluntarily and depending on her area of interest she can subsequently join that particular department after completing her training. Records/Registers/Musters maintained Attendance muster is maintained in the Matrons office. It requires every nurse to sign against their name for any respective day. It also keeps a record of all the nurses who have taken casual leave (CL), holidays (Hol), etc.

K B Bhabha hospital

State book this book is a record of all the sanctioned posts and all the nurses allotted for the morning, evening and night shifts in different wards. It also records all those nurses who are on leave or have taken maternity/abortion leave. Day and night Report book this book is maintained in each ward. This is a record of the census that is conducted every night at 12 am. It records how many admissions, transfers, deaths or surgeries that have occurred. It also contains a record of all serious patients. The days events are recorded by the nurse who comes in the evening and the nights records are maintained by the nurse during the night shift. A report book is made yearly.

Storage/Dispatch of Records - All musters are maintained for 4 months after which they are submitted to the administrative office. The report book is sent to the dispatch office. Residential facilities - 1 Matron quarters are present so that during emergencies the Matron may reside there. In addition one more staff quarters are also present. Problems faced Promotions are caste based (SC/ST/OBC). The nurses for the general category feel that it is unfair that a junior nurse belonging to these categories get promoted earlier. Nurses face domestic problems when faced with night shifts. Maternity leave of 6 months is considered unsatisfactory. The break up is 3 months that can be taken before delivery and 3 months after. Even after this period gets over these nurses are given 3 months straight shift in order to allow them to nurse their babies.

K B Bhabha hospital

Maintenance/Engineering Department
Staff Hierarchy of staff

Medical superintendent

Sub Engineer

Maintenance Plumber Carpenter Gardener Civil worker Labour Painter

electrical Electrician Pump man Wire man Labour

air conditioning AC operator Helpers

Total strength of staff present in the department is about 50. Duty timings The department functions 24 hours a day. The sub engineer Mr. Santosh Sainande, works in a general shift from 8 am t o 5:30 pm. All maintenance work during the general shift and if any request is sent during the night it is handled the next day. All air conditioning staff works in 3 shifts. The staff in the electrical department works in three shifts. The morning shift begins at 7 am and ends at 3 pm. The afternoon shift starts at 3 pm and ends at 9 pm and the night shift from 9 7 pm respectively. Location/physical structure - The engineering department is situated on the ground floor of the matrons office and MRO building. The department consists of the following rooms: Office of the sub engineer Workshop which also serves as the welding section AC department is situated just above the mortuary In the mortuary building.

K B Bhabha hospital

One room to store cylinders of medical gases.

Repair requisitioning procedure Any ward that desires to make a complaint does so on a store return book. The sub engineer inspects the particular equipment and passes judgement on whether the repair can be done in the hospital or whether the hospital personnel possess the necessary skills to conduct the repair. If the above conditions are satisfied the repair work is carried out in the hospital premises. If not, the sub engineer has the leeway to spend up to INR 5000. Per day on getting the equipment repaired privately. If the cost is greater than INR 5000 but lesser than INR 50 000, the engineer requires to contact and consult with the Mechanical and Electrical (M & E) office in Andheri. Personnel from there are then sent to the hospital to inspect the equipment and decide whether to repair or replace it. All hospitals situated along the Western line that is in the western suburbs report to the M and E office situated in Andheri. Similarly all cases of mechanical and carpentry work which may cost above INR 5000 have to be reported to the Executive Engineering and Mechanical office situated at Grant Road which is also known as the Workshop. All civil work cases which may cost above INR 5000 but below INR 50 000 are reported to the ward office of that particular area. The office is headed by a civil engineer with the designation of Assistant Engineer of the Maintenance Department. The office then sends personnel to inspect and decide further course of action. Once the faulty equipment is repaired a note is made recording details of the problem ant the solutions and the signature of the sister in charge is taken once she receives the repaired equipment. If new equipment is to be ordered the old equipment is returned to the General Stores on the 7th floor. Planned maintenance of hospital equipment The tender for maintenance contracts are invited for all their respective equipment by the three main offices. The tenders are awarded to the winning companies and the hospital is informed of which company has entered into a contract for which kind of equipment. Annual maintenance contract (AMC) is used for the maintenance of lifts. Comprehensive maintenance contracts (CMCs) may be used for generators, pumps, fire fighting equipment etc. if a company desires to bid for an AMC contract it requires to deposit one and a half lakh rupees with the BMC and acquire a registration number. Records/Registers/files maintained File of all Purchase Orders (POs) File with details of fire fighting equipment File with details of telephone system Complaint register

K B Bhabha hospital

Register maintained for audit related papers File containing electrical bills Files containing circulars and official letters File containing all sanctions File of all maintenance contracts of different equipment

Problems faced by the department Shortage of man power reasons for this vary from general expansion of the hospital to vacating posts due to deaths, retirements etc. This leads to the creation of vacancies that are not being filled due to the BMC policy of recruitment. Machinery possessed by the department is limited and not very advanced. This requires them to contract out some of the repair work to private contractors. Eg the hospital lacks a welding machine and the presence of such a machine would help the hospital to conduct minor welding work on the premises. Extensive workload due to the functioning of a new OPD. Cost wastage on contractors which are hired to do repair work that coukd be done by the hospital itself if it possessed the appropriate equipment. Conflict amongst workers belonging to different unions occur frequently and disrupt the daily functioning of the department.

K B Bhabha hospital

Laboratory
Staff Hierarchy

Junior Scientific 1 Officer (JSO) Technicians Assistants 14 5

The JSO is Mr Jaglekar. Total strength of staff is 20 Duty timings The laboratory is open 24 hours a day. The JSO works in a general shift from 8 am to 5 pm. The technicians work in shift duties of three shifts. The morning lasts from 8 am to 4 pm and the next shift lasts from 4 pm in the afternoon till 8 am in the morning. The OPD lab takes samples between 8 am to 12 pm in the afternoon. The post prandial blood samples are received after lunch up to 12 pm. The bulk of samples from in patients are received in the morning. Physical structure/Layout The laboratory is situated on the eighth floor of the main building. There is one biochemistry, one haematology and one histopathology section. There is one sample collection room which is situated in the OPD. Tests conducted in the laboratory are divided into various sections as follows Biochemistry Blood sugar Urea Creatinine Electrolytes like sodium potassium etc.

K B Bhabha hospital

Total protein, albumin, globulin, Albumin/globulin ratio Total bilirubin, direct bilirubin Liver enzymes like SGOT, SGPT Total cholesterol, lipids, triglycerides Uric acid Alkaline phosphatase Calcium, phosphorus PT time Ascetic/plural/CSF fluid analysis for protein

Haematology Complete blood count for haemoglobin, Red blood cells, White Blood cells, platelets Blood grouping and Rh antigen matching Routine urine and stool

Serology Glucose 6 Phosphate deficiency Hepatitis C virus Human immunodeficiency virus Australia antigen (HBSag) C Reactice protein VDRL Vidal test for typhoid ASO titre Dengue Malaria

No microbiological tests or immunoassays are conducted. Tuberculosis testing isnt done here. Test requisition and processing Samples from the wards are sent with a request form. The test results are recorded manually and dispatched to the wards on the same day and the OPD on the next day. The test results are signed by the JSO in the morning and in case of emergency tests they are signed by the technician. The request form with the report is maintained by the laboratory staff and a copy is sent to the wards. Average number of tests performed in the laboratory is listed as follows Biochemistry 600 700 Haematology 150 Histopathology 5 6 Fine Needle Aspiration Cytology and pap smear 3- 4 Staining and microscopy 3 4

K B Bhabha hospital

All tests are done free of cost. Only paying patients are charged for different tests. Records/registers maintained Register is maintained both test wise and patient wise. Daily patient and test records are maintained Computerisation of records is not done Equipment Autoanalyser Semi autoanalyser Blood gas analyser Electrolytes analyser Calorimeter Weighing balance Microscope 8 10 Centrifuges multiple Blood cell counter Auto processor for histopathology Microtome Oven Multiple incubators Water bath Blood gas machines 2 1 counter for CBC Machines required for histopathology tests Consumables like reagents are purchased by the store. Bigger equipment like machines is purchased by the hospital.

K B Bhabha hospital

SUPPORTIVE SERVICES DEPARTMENT II OCCUPATIONAL THERAPY/PHYSICAL THERAPY


Ideal occupational therapy/physical therapy department Space and facilities are required for the following Reception and control station so located that visual control of waiting area and activities is possible Office and clerical area with space for clerical work and storage of files. In smaller hospitals, office and clerical area may be combined with reception control station. Offices for physiotherapist ahd chief phycial therapist with facilities for consultation Examination and special procedure room Waiting area out of traffic for patients Patientstoilets with basins and accessible to wheelchairs Storage space for wheelchairs and stretchers out of traffic Janitors closet with service sink, and facilities for housekeeping Staff lounge, lockers and toilets Conference room for demonstration, teaching etc. Ramp with handrails at the main entrance and of sufficient width for wheelchairs Individual treatment cubicles with screens for privacy Hand washing facilities close to the threatment area Hydrotherapy area Work stations and counters at different laces Space for paraffin wax bath. As this can be messy this area should be recessed Gymnasium(exercise area) with all facilities Storage for clean linen and towels Storage for equipment and supplies Area for temporary storage of soiled linen, towels and supplies etc. Changing/dressing rooms for outpatients

Many hospitals establish what they call a Back School in which physical therapists hold classes and impart instructions to patients suffering from back pain or injury as to how to avoid these problems.

K B Bhabha hospital

Physical therapy / Occupational therapy


Therapy is indicated as a result of surgery, trauma, stroke and other functional impairment. A well-developed department may now offer specialty programmes like cardiac programmes, chest therapy in cooperation with respiratory therapy and sports medicine. Staff Hierarchy

Medical Superintendent
1

Physiotherapists - 1 Occupational therapists - 2


Ayah - 1
Maitrani - 1
Total strength of staff in the department is 5. There is a sanctioned post of a Registration Assistant however it is currently vacant. The therapists are Mrs Sholadru, Mrs Chandushree and Mrs Kalyan. Duty timings All staff in the department work in a straight shift. The physiotherapists work from 9 am in the morning to 4 pm. The ayah works in a general shift from 8 am to 4 pm and the maitrani from 7 pm to 3 pm. On Saturdays the physiotherapists and the occupational therapists work from 9 am to 12 pm. The OPD timings are officially till 12:30 after which the therapists visit the wards if any references are macde. Average number of visits - The number of patients visiting the department averages between 60 to 80 visits per day. The figures would stand higher at 100 in the past. Location/physical layout The department is situated on the ground floor of the new OPD building. It is OPD number 21. The department consists of one therapy room which contains one exercise cycle and one wide table which has all the instruments required for hand exercises. K B Bhabha hospital

This leads to an office which has chairs for the therapists and two beds for patients who would require short wave diathermy or traction(cervical or lumbar). The big therapy room at the entrance leads to one small therapy room which has two beds and some storage space. Functions of the PT/OT department 1. The department offers physiotherapeutic services to all patients on an OPD basis. Examples of ailments treated are dystrophy, fractures, frozen shoulders, hemiplegia etc. 2. All in patients that require these services to are also catered to either in the OPD if they are mobile or as ward visits in case they are bed ridden eg ICU patients, post-operative orthopaedic case as well as post-operative surgical cases. 3. Services are provided for all paediatric patients as well except for patients suffering from severe cerebral palsy. Attention Deficit Hyperactivity disorder patients are also catered to. 4. Cardiac rehabilitation services are provided to those with cardiac conditions on an OPD basis once they are discharged from the ICU. 5. Due to the presence of one psychiatric occupational therapist fitness tests used to be conducted for staff in the past 6. One of the occupational therapists also provides services to the counselling centre against domestic violence (Dilaasa) Procedure/policy followed the patient is referred to the OT/PT by doctors from various OPDs. The patient is sent to counter number 5 and at the sum of INR 10 the patient receives a case paper which is valid for 15 days. Once they come to the OT/PT department the details of the patient are recorded in a register along with details of what kind of therapy is given to the patient. Occasionally due to lack of registration assistant patients with old case papers are also taken in and treated without having to issue a new paper. IPD patients if an IPD patient requires physiotherapy a reference from the ward is sent on a paper via the mausi or ward boy. The physiotherapist then visits the ward after OPD timings are over. Private patients sometimes patients are referred from private doctors. In such cases the patient is still required to go the concerned OPd for his/her ailment, get a reference and then come to the OT/PT. OT/PT register once the patient comes to the department his/her details are recorded as in this format in a linear fashion: name, age, sex, registration number, diagnosis, modality of treatment given electrical or physical. Code is entered which gives information at a glance for example E1BA3 which means that electrical therapy has been given to the patient ant this is his/her third sitting. The register is K B Bhabha hospital

maintained in a continuous format and is stored in the department for a period of five years. Earlier an OT/PT card was issued to the patient which maintained a brief history of the patient and the treatment given. Due to shortage of supplies of such cards by the municipal press these details are nowadays recorded on a small piece of paper which the patient is requested to bring every time he/she visits the department next. Equipment present in the department Floor mat Short wave diathermy machine Diagnostic and therapeutic muscle stimulator Electrotherapy machine Machine to provide cervical and lumbar traction Paraffin wax bath Interferential current therapy Transcutaneous electrical nerve stimualtor Infrared lamp Ultraviolet light lamp Machine to provide laser therapy Nebuliser Recumbent exercise cycle that measures heart rate, calories consumed, distance covered, speed etc. this achine has both in built as well as customisable programs Pulleys for vertical and horizontal standing Therapy ball ( Diameter 60 cm) Stepper Quadriceps bell Rowing machine Exercise table with hand instruments where patients can perform various pronation, supination and grip exercises Hand cycle Exercise station Various types of weight cuffs ranging from half kg to three kg Equipment for hand grip exercises Hot packs/cold packs for pain relief

There are no machines for hydrotherapy and no hydro collator Problems faced by the department Shortage of staff leading to deterioration of quality of service provided. This is the main reason that prevents the staff from conducting a full-fledged cardiac rehabilitation and preventive cardiology program. Shortage of appropriate equipment- the department ha to rely on donated equipments that are a little old and outdated.

K B Bhabha hospital

In house training programmes/Continuing Medical Education programs are not conducted in the department due to shortage of staff and funds Vacant post of a Registration Assistant puts pressure on the therapists to carry out the clerical work in addition to their normal duties. Vacant post of a speech therapist doesnt allow the conduction of any programs for the deaf and mute.

Recommendations Expansion of space and setting up of more beds Recruitment of more staff. Requests have been sent to the medical superintendent towards the same however not much can be done due to the BMC policy of non-recruitment. Acquisition of specialised equipment like a hydro collator. Setting up a full-fledged preventive cardiology and cardiac rehabilitation program. Recruitment of a speech and a child therapist to extend the services offered by the department.

K B Bhabha hospital

SUPPORTIVE SERVICES DEPARTMENT III BLOOD BANK


Ideal blood bank Every hospital should have a committee of which the pathologist is a member to establish written procedures for the proper use of blood and blood derivatives including identification and compatibility testing, criteria for use, and review of all transfusion reactions occurring in the hospital. Storage facilities under adequate control and supervision are necessary. An alarm system should be instituted to notify personnel of the loss of electric power and faulty temperature.

With a view to modernizing the blood banking system in the country, the Government of India recently introduced amendments to the Drugs and Cosmetics Rules, 1972. The salient conditions of the conditions are: Seven rooms within a pace of 100 sq. metres (1076 square feet) Two laboratories one for blood group serology and another for screening the blood for Hbs Ag, HIV antibodies and syphilis. The two laboratories and the blood collection room should be air-conditioned. Two refrigerators maintaining temperature between 4 6 degree centigrade with the recording thermometer and alarm advice one for the blood collection room and another for the laboratory. Personnel: a medical officer trained in blood banking for six months, a registered nurse and two trained technicians(MLTs) For AIDS test the hospital can have its own testing facilities or can avail the facilities of Central Government laboratories.

K B Bhabha hospital

Blood bank
Staff Hierarchy

Blood Transfusion Officer - 1 Blood Bank Medical Officer - 1 Senior Techinican - 1 Technicians - 5 Registration Assistant - 1 Nurse - 1 Attendants - 1 Servants - 1

The Senior Technician in this department is Mr Dhaojekar. The total strength of staff of the Blood Bank is 12. Timing of the department and the staff The blood bank runs 24 hours a day 7 days a week. The timings for routine work are from 8 am to 4 pm. After 4 pm only emergency requests are handled. The senior staff are on duty from 8 am to 4 pm. The technicians are posted in the morning from 8 m to 4 pm and one technician works from 4 pm in the afternoon to 8 am the next morning. K B Bhabha hospital

The second shift lasts for sixteen hours as only emergencies are handled during this time. Layout/physical structure The blood bank occupies a space of 1150 square feet. The rooms provided are as follows: Sterilisation room 1 Registration area 1 small Medical examination room 1 Bleeding room 1 Laboratory for processing samples 1 Cold storage room 1 Store room to store all these materials required to conduct blood donation camps outside 1 Refreshment room 1

Equipment Sealer tube 1 Biomixer 1 Donor bed 1 Recovery bed 1 Sphygmomanometer 1 Centrifuge used to wash the blood to expose antigens for cross matching 1 Mixer - 1 Microscope 1 Big tube centrifuge 1 Incubator to store blood at 37 degrees centigrade for Rh factor matching as well as for warm antibodies 1 Refrigerator used to store patients blood. Blood is stored for maximum of 1 week in order to safeguard against any reports of transfusion reactions that may take place in the wards -1 Cold storages these are walk in coolers which are two in number one is used to store grouped and tested blood and the other one is used to store untested blood. Each cold storage unit has a thermograph (a temperature graph) which maintains a graphical record for 24 hours. Every unit is equipped with an alarm system which sounds if the temperature rises beyond 7 degree centigrade. This is because blood that has been stored for over half an hour at a temperature over 6 centigrade cannot be transfused. The temperature in the cold storage is maintained at 4 degrees centigrade. The ideal temperature of such cold storages should be between 2 and 6 degrees centigrade. Donor bags are stored in these storages for about 35 days whilst those mixed with SAGAM solution are stored for 41 days. Refrigerators these are two in number and are used to store reagents and antiseras. The temperature is maintained between 4 5 degrees centigrade. These are also equipped with alarm systems that sound if the temperature rises

K B Bhabha hospital

beyond 6 degrees centigrade as reagents are rendered ineffective if stored above a certain temperature. Autoclave 1, all HIV/HBSAg infected vlood is autoclaved for 20 minutes under 15 pounds of pressure at 120 degrees centigrade. After this the clood os sent to the incinerator at Sewri. Oven 1, al test tubes are dried here after washing with 1 degree hypochlorite solution and water. All wasted blood that is not infected is disposed off in this way. Reagents/Antiseras Antiseras of all blood groups(A,B,AB,O) are indented on a weekly basis.

Procedure for requesting blood A request for any particular patient is sent from the ward via a ward boy or ayah bai with a sample of the patients blood. The patients blood is cross matched with the donors blood and the blood bags are taken from the blood bank by a ward boy from the concerned ward. At the blood bank in Bhabha hospital Bandra, very few volunteers are seen due to the higher socio economic class of the residents in the locality. No professional donors are entertained. The maximum amount of blood is collected in the camps conducted across the city from Dahisar to Churchgate. Stock is maintained for emergency situations otherwise blood is ordered from the central institutions like KEM/Nair/Sion. Registers/Records/Written Records maintained Blood issue register this register maintains details of when and for whom blood is issued. Register for Medico Legal Cases Cross matching report details of cross matching of patients blood with donors blood are recorded in this register. Master register Donors register all records of donors are maintained in this register. No test reports are maintained in the blood bank. The test reports are not disclosed to the donor either for fear of adverse psychological reactions.

Storage of records - All records are stored in the blood bank for 5 years. All MLC records and the register for the same are maintained permanently. Quality control Quality control by titration to know the strength of the antisera is done daily. It is also done for the entire batch when new stock of antisera arrive. In order to prevent transfusion reactions due to transfusion of wrong blood, lots of checks and counter checks are carried out prior to transfusion. Grouping is done, after which serum and cell grouping is conducted. Cross matching is done before grouping. Grouping is also done before transfusion as a last check. K B Bhabha hospital

Problems faced Arguments with donors or with the local public during blood donation camps. Sometimes a wrong sample is sent from the wards which lead to the wrong donor blood bag being sent for transfusion. Sometimes doctors may request for blood however, once the blood bags arrive the indication for transfusion may have passed or the doctor may forget about the available blood. In such cases the blood lies outside at ambient temperature for long periods of time and this renders it ineffective for transfusion.

Recommendations The blood bank should acquire equipment to perform apheresis. This would be done by equipment that separates blood into its various components. There also require to acquire centrifuges, negative degree refrigerators, platelet agitators etc.

K B Bhabha hospital

Security system
Staff Hierarchy

Assistant Security Officer - 1

Head Guards - 3

Writer Assistant - 1

Security Guards - 44
The assistant Security Officer is Mr Ravindra Patil. There are four sanctioned post for head guards however currently only three are working out of which one guard is a reliever. The security guards work in three shifts and their duty timings are 7 am to 3 pm in the morning, 3 pm to 11 pm in the evenings and 11 pm to 7 am in the mornings. The Assistant Security Officer works in a general shift from 8 am to 4 pm occasionally works as the liaison officer at the head office of the ward. The writer assistant works from 8 am to 6 pm. In addition to the guards deployed by the BMC, security guards from a private agency called Crystal are also employed. There are nine private female security guards and 3 male. General Security measures employed 1) Closed Circuit Televisions (CCTVs) are situated at vantage points at 16 different locations and happenings at all these points are recorded automatically. The footage is deleted automatically after one day these cameras are provided by Samarth Security Surveillance. The 16 different locations are listed as follows K B Bhabha hospital

Chief medical superintendent office Paediatric ward Post natal care ward Labour and delivery suite Intensive care unit Female medical ward Medical superintendent office Paediatric wards Casualty Main gate New gate Mortuary Labour ward

2) Positioning of security guards at different places throughout the hospital. The placement of security guards along with the number posted in each shift as per shift timings is listed in the table given below. Positions Main gate Gate number 3 Morgue Casualty Life gate RMO quarters Paediatric ward PNC ward/delivery ward ICCU Gynaecology OT New OPD Patrolling security 1st shift 1 2 1 1 2 1 1 1 2nd shift 1 2 1 1 1 1 1 1 3rd shift 1 2 1 1 1 1 1 1 1 1 1

1 1 1 1 1 in a general shift from 8 am to 5 pm 1 1

3) Metal detectors are located at the main gate . 4) Police constables are stationed at the hospital throughout the day. 5) Thefts of new born babies are now prevented by installing grills around the cribs as well as not entrusting the baby to any relative except for the mother. In case the baby needs to be moved from one ward to the other only ayah bais are entrusted with the task. Also security guards are stationed outside the PNC ward and are instructed to not allow unauthorized persons in. 6) Disaster preparedness mock drills are conducted by the Medical Superintendent. In addition to this every month security guards are sent to the training centre of the BMC for parades and refresher courses. There are no in hospital parades that are conducted.

K B Bhabha hospital

Problems faced by the department Thefts of personal belongings of the staff as well as that of the patients as there are no lockers in the hospital. Trade union strikes

Future plans There are plans to increase the number of patrolling and casualty security guards. Plans have been made to station security guards clad in civil dress at various points in the hospital. Plans are made to demarcate the parking spots for RMOs and honoraries so as to avoid conflict.

K B Bhabha hospital

Mortuary
Staff Hierarchy

Moruray In Charge - 1

Clerks - 4

Driver - 1

Attendants - 2

Sweeper - 1

Clerk - 1

The total number of staff employed by the department is 12. During every shift four staff is working. Duty timings - There are three shifts throughout the day and they last from 7 am to pm, 2 pm to 9 pm and 9 pm to 7 am the next day. The mortuary in charge works in a general shift from 8 am to 4 pm. The mortuary functions 24 hours and one ambulance is allotted for its work of bringing the dead bodies to the hospital. Physical structure/layout of the department The morgue has the following rooms 1 office 1 morgue with 24 boxes which has only one door for entry and exit 1 AC plant room which is given to the driver to rest during the night 1 room for machinery which is situated on the floor above the mortuary

K B Bhabha hospital

1 room for conducting post mortem of bodies which is currently non functional

The bodies are placed in these boxes in as is how is condition. The morgue is maintained at 3 degrees centigrade temperature. Storage of bodies Bodies are only taken in only on inspection of the death certificate issued by either the doctor in K B Bhabha hospital or a private doctor. Bodies wont be taken in without a death certificate. Sometimes in cases of bodies that have gone in for post mortem the mortuary might wait for a maximum of 24 hours. In case of natural deaths the body is kept in the ward for about two hours after which it is sent to the morgue along with the death certificate and the IPD papers. Once the body is handed over to the relative the signature of the relative is taken and the body is dispatched. When bodies are brought in for post mortem by the Bandra Police Chowki the body is checked and opened up after which it is sent to Cooper hospital for conducting autopsy. If unknown bodies are brought in to the hospital, the police is informed and put in the Post Mortem centre. The body is stored for anywhere between 7 to 30 days. Private bodies are stored for 3 to 5 days as requested by the relatives. Average number of bodies per day At least 8 boxes are occupied on a daily basis out of which 5 to 6 are those belonging to private patients. Records/registers maintained One register is maintained with all the entries and handovers. This register is maintained on a continual basis and records are kept for 3 years and submitted to the Medical Records Office after that period. As soon as hand over occurs the relatives signature is taken on the papers and dispatched to the MRO on the same day or the next day.

Cleaning /disinfecting procedures Daily sweeping and mopping is done of the mortuary. Every week the morgue is washed and the boxes are opened and cleaned with a certain disinfecting liquid. An air freshener is used to get rid of the odour.

K B Bhabha hospital

Library
Staff Hierarchy

1
1

Librarian
Assistant

Duty timings - The library is open from 9 am to 5 pm. The librarian works from 9:30 to 4:30 pm and the assistant works from 9 am to 5pm. Duties of the librarian - When a requirement is put in from the honoraries and permanent staff the librarian is supposed to request for the sanction of the Medical Superintendent to purchase the books. The library is allocated a budget of 8 lakhs per year for the purchase of books and journals. Duties of the assistant the assistant Mr Waghela works full time and performs the duties of photocopying, stamping and dusting. He is given the task of opening and shutting the library. Cataloguing and indexing Procedure of Issuing books books are issued for 15 days, journal for 4 days, DVDs for 4 days. They can be renewed three times. After this period gets over a late return fine is charged at the rate of INR 1 per day till 1 month, INR 2 per day for the next 2 months and after that offender is charged 5 rupees per day for the remaining days. Outside books and journals can be brought into the library too. Physical structure/Layout/books and equipment possessed The library consists of one big room which has books for DNB students from medicine, surgery, orthopaedics, gynaecology and paediatrics. The library also contains international and national online and printed journal as well as other medical books. The library contains 2 computers. Xerox facilities for reference books are available as a paid facility. Journals printed in the hospital but print outs can only be taken outside the premises. Separate reading rooms are present in each ward and the conference room is available as well. The library can be used by both medical and paramedical staff. 4 newspapers are also received by the library daily out of which 3 are Marathi newspapers and 1 in English (Hindustan Times).

K B Bhabha hospital

Records/Registers maintained Accession Register for both books and journals. Issue register each candidate is given a page The registers are stored permanently from 1989.

Problems faced Staff shortage Shortage of funds

Recommendations Space expansion Computerisation Increasing the number of computers Opening a reading room which would be attached to the library.

K B Bhabha hospital

ICTC centre Integrated Counselling and testing Centre


This centre was established in 2002 and is a project of the central government. The centre was the brainchild of UNICEF and WHO. The funding is derived from the National AIDS Control Organisation. The head office is situated at Vadala Road. The ICTC is currently in phase 3 of its existence. Phase 4 is starting in a little while. Functions Pre-test counselling and imparting of information about the Human Immunodeficiency Virus and modes of transmission is done. Consent for the test is taken and a slip is made and they are sent to the laboratory for testing. The patients are called in the afternoon to take the report. The report is valid for 6 months not any longer. The report doesnt mention the clients name it just has a code that is printed on the top of the sheet. As per NACO guidelines the report cant be given to the family members. Two signatures of the client are taken before he test and one is taken after the test report is handed over. The patients blood is tested on three principles. Test negative - The counsellor gives the report to the client if the test is negative. If the client is negative and still at high risk he/she is counselled about the existence of a window period of 3 6 months and advised to repeat the test after 6 months. The validity of the report is for 6 months. Test indeterminate if the test results are indeterminate the sample is sent to KEM hospital for confirmation. The client is then called after 15 days to report the results. Test positive if the patient is positive the test results are told to the patient by the counsellor. In case the patient is married and positive the spouse and the children are also tested.

The average number of visits per day is about 25 to 30 patients. Patients with accidental pinprick in cases where medical or Para medical personnel get pricked accidentally by a needle used for a patient. Post Exposure Prophylaxis is given within 72 hours. The wound is first washed with tap water and first aid is given. The patient whose needle pricked the staff is tested for HIV. One dose of AntiRetroviral Therapy is given to the patient and the client is tested after 28 days again. After 3 months the client is tested again. The client is advised about precautions that can be taken to prevent such incidents in the future. No re capping of needles, burning sharps, using a puncture proof container containing a 1 % hypochlorite solution are told to the patient as ways to avoid such incidents in the future. Ante Natal Case patients that are positive if an ANC patient is tested and is found to be positive the patient is counselled and followed up till delivery. This information is then sent to the labour ward to exercise caution during delivery. If a patient comes in labour and doesnt possess the necessary reports, an emergency spot test is carried K B Bhabha hospital

out. If the patient is found to be positive one tablet of Nevirapine is given. If the patient delivers within 2 hours then there is no indication to give another dose. However if the labour progresses beyond two hours of the first does another dose is given once two hours elapse. After delivery the child is given Nevirapine at the rate of 2 mg/kilogram. When the child is beyond 6 weeks of age but before 6 months a DNA PCR test is conducted and the sample is sent to KEM. If the reports are positive then the child is given early treatment. In patients all labour patients, paediatric patients and Tuberculosis patients are tested after obtaining consent. The consent form along with the sample is sent to the centre and once the test results are obtained the patient is either called to the centre or the results are delivered to the ward. Sometimes the emergency test kits that are kept in the labour ward may yield indeterminate results and the tests have to be redone in the centre. Problems faced by the department Occasionally workload is excessive when too many patients come in at the same time for testing or for testing and reporting. Shortage of space- the available space is only enough for two counsellors Shortage of staff especially lab technicians causing excessive pressure on the existing technicians Sweepers are not allocated to the department and they have to share the common sweepers of the OPD. The staff feels discriminated against by other BMC staff as they are employed by the state government.

Records/registers maintained Pre-test registers Address book Consent form Lab register Stock register in which entries are made as to how many kits are used per day Dispatch book Temperature log the temperature of the refrigerators used to store reagents.

The registers are maintained on an annual basis and they are stored for a minimum of 5 years.

K B Bhabha hospital

SUPPORTIVE SERVICES DEPARTMENT IV KITCHEN AND DIETICS DEPARTMENT


Ideal kitchen Location a food service department located below the ground level is certain to have a deleterious effect on the quality of food and efficiency of the department. a ground floor location is preferable and is also convenient to deliver supplies. Current corporation/municipal by-laws in most places prohibit locating kitchens in basement floors. The department should be close to the materials management department. the storage area should be close to the unloading dock. Easy access to vertical transportation system serving patient care units is important to facilitate delivery of patient meals and return of used trays and utensils. Design in the general layout the most important factor to be borne in mind is the logical work flow-receiving supplies, storing and refrigerating them, preparing and serving food, returning trays and washing dishes. There should be adequate space and facilities to perform the work in each of the functional areas. Facilities and space requirements The following facilities and space are required. Food service managers office. It should offer an unobstructed view of all the parts of the department and be ventilated and preferably soundproofed. Secretarial, clerical office with space for file cabinets and other equipment, seating for visitors, vendors, etc. Office space for chief dietician and staff dieticians. Some hospitals locate the office of therapeutic dieticians on the patient floors so that they can be available quickly to the medical staff and patients. Receiving area Storage and refrigeration area with walk in refrigerators, coolers and dry storage. Pre-production preparation area. Cooking or food production areas, separate for vegetarian and non-vegetarian foods. Special diet kitchen. Tray assembly or make up area Dishwashing area.

K B Bhabha hospital

Pot washing area. Trolley, cart washing area and clean cart storage area. Deep sinks and hand washing facilities in various places. Garbage disposal facilities Storage with racks and cabinets for clean trays, dishes, cutlery, etc. Storage with racks for clean pots, pans, vessels etc. Employee facilities like lockers, staff toilet, etc. Janitors closet. Dining hall with self-service counter, cashiers booth, clean tray storage area, seating for adequate number of people, used tray depositing area, hand washing facilities, drinking water fountain, etc. Special(private) dining rooms for officers, medical staff, special guests, meetings, etc. Coffee shop/snack bar, preferably off site.

Organization traditionally a dietician has been the chief of the food service department also called the dietary or nutrition department. in smaller hospitals, the dietician may serve a dual role as both dietic supervisor and department manager. The manager usually reports to one of the associate administrators. The department has two main functional divisions: one relating to the administration of the department and food production and the other relating to therapeutic food service and instructions to patients and their counselling. Administrative duties ranging from purchases to planning of menus occupy most of the managers time. The therapeutic duties include diet therapy, planning patient menus and special diets, supplying a special diet list to patients and counselling. Educational activities include teaching students and training dietician trainees. The bulk of workers in the department are unskilled.

K B Bhabha hospital

Kitchen
Staff Hierarchy

Dietician 1 Cooks 2 Cook Mates 3 Ayah Bai 2

The dietician is Mrs Snehal Kodre. There are 8 sanctioned posts in the department and 2 posts are vacant. The total number of staff in the department is 7. There are 2 cooks and 3 cook mates. Post of 1 cook and one cook mate is vacant. There are two ayah bais stationed in the kitchen out of which one is given the task of only preparing tea for the staff of the hospital. Only one sanctioned post for a dietician exists. In all the periphery hospitals the total number of sanctioned posts for dieticians number to about 5. Duty timings The dietician works in a general shift from 8 30 to 3 30. The staff work in two shifts one lasting from 6 am to 2 pm and the afternoon shift lasting from 12 pm to 8 pm. Duties are changed on the 1st and the 15th of every month. Functions of the department The kitchen provides meals to about 200 250 in patients a day. Two meals ie lunch and dinner are given to the patient in addition to milk and bread in the morning and tea which is provided twice a day. No meals are given to relatives or to OPD patients. No meals are provided to the staff of the hospital. Tea is given twice a day to nurses, AMOs and honoraries i.e. only to permanent staff and not to resident medical officers.

K B Bhabha hospital

Tea for theatre staff tea powder ad sugar is indented by the sister in charge of the OT on a weekly basis. A ward boy from the OT takes warmed milk from the kitchen daily and they prepare their tea in the OT itself as they have a connection the centralised pipeline providing gas. Educational activities of the dietician educational activities are now conducted by the dietician on the premises. In October 2011 the first batch consisting of two third year students pursuing their undergraduate degree in Food Nutrition and Dietetics were sent to Bhabha for a period of 45 days. Now students pursuing Home Science from SNDT college as well as students from Nirmala Niketan are sent on a regular basis. The students are asked to observe the dieticians functions throughout the day. She also sends them to the wards to conduct follow ups. They however are not allowed to plan a diet chart.

Routine diet There are no special menus for paediatric, geriatric or pregnant patients. The menu us fixed for all patients and the meal served consists of one serving of pulses, one serving of vegetables, one serving of rice and one cereal. The food is purely vegetarian. No meat is served on the premises. The diet is fixed for all municipal hospitals by the Diet Sub Committee. Om Mondays, Wednesdays and Saturdays three different kinds of pulses are given instead of vegetables. The types of vegetables are changed every week. If a certain vegetable has been made once in a aweek it cant be repeated till next week. Every week the dal is changed. On Mondays Kadhi is made which is made from the milk saved on Sundays. Sometimes in case of severe malnourishment or under nutrition the dietician may advise relatives to bring home made food. In case if the patient is an affording one the relatives may be prescribed protein supplements. In case outside food is brought in the hospital menu is used as a base. Special diets Diabetic patients are given more leafy vegetables, less rice and more chapattis or bread. By internal sanction the dietician has introduced a rice moong dal mixture which is given to infants as weaning food. The dietician also formulated a feed that can be given via Ryle tubes which is a thin mixture of dal and rice kanji or 500 ml of milk. She has also introduced a jejunostomy feed which consist of half kg curd which is made in the kitchen. Dispatch of meals the food trolleys are dispatched for lunch by 11 30 and dinner by 6 30 pm. The trolleys are sent to the pantry of the respective wards. The ayah bai in charge of distributing tea to all the staff delivers it in a small aluminium kettle.

K B Bhabha hospital

Records/Registers maintained A monthly register is maintained about how many patients belonging to which ward have been served. This register mentions details of name, registration number, referring doctor, diet advised and th calorie/protein content of the diet. Menu book this book maintains details of what kind of food is served on which day. Types of dal and pulses served every week are also recorded.

Protocols followed to maintain hygiene and prevent infestation Pest control is done once a year and medicines are left by the personnel to prevent infestation by rodents. Since the kitchen is situated on the seventh floor rats and mice are unable to enter the kitchen. Cockroaches are rarely seen. OPD services provided by the dietician Patients from medical, surgical, paediatric OPDs are referred to the dietician between 10 am to 11 am in the dietetics OPD. Diet charts are prepared for every disease by the dietician in advance. Printed diet sheets in Marathi, English and Hindi are given to the patients and they are counselled about the type of diet that they need to consume. Information on Jejunostomy and RT feeds is also printed on separate sheets and the same is distributed to the relatives of patients requiring the above. Acquisition of food material Annual contracts are awarded to the same contractor for a period of 15 years. Three contractors by the name of Tetsales, Evernew and Cheruvattam supply food stuff to the hospital. Milk is supplied by the Worli dairy. Rice, dal, tea powder and sugar are delivered to the hospital once every month. Vegetables and bread are delivered once in two days. Milk is given by the dairy to the hospital on a daily basis. The transport to and fro the hospital is organised by the contractors themselves. On an average rice is consumed at the rate of 10 15 kilograms a day, 8 10 kilograms of dal per day, 2 kilograms of tea powder per day, 6 7 kilograms of sugar per day, 80 litres of milk per day, 25 20 kilograms of vegetables in the morning and 10 15 kilograms of in the evening, 80 100 kilograms of legumes like chana, vatana, moong and masoor per month. Payment is made to the contractors using the SAP system. Storage facilities and Waste disposal The kitchen doesnt have any cold storage facilities for raw vegetables. The waste generated by the kitchen is dumped into a single dustbin and is taken daily by the compound sweeper. Spices, green chillies and curry leaves are kept in plastic containers in a small fridge.

K B Bhabha hospital

Quality control The food served for lunch is tasted by the dietician before it is dispatched. Whenever raw vegetable and other food stuff is received by the hospital, it is always inspected and weighed by the diet clerk. Pest control of the kitchen is one regularly. Sanitary inspectors from the BMC visit the hospital once every year. Safety measures employed in the kitchen One fire extinguisher is kept in the kitchen in case a fire breaks out. A request for one more has already been put in to the maintenance department. the kitchen is now supplied gas through a centralised gas pipeline. All LPG cylinders have been evacuated from the kitchen. Exhaust fans are stationed at strategic positions in the kitchen. The gas cabin is located in a separate structure near the mortuary. This prevents any untoward incident from occurring. Problems faced by the department Shortage of staff and servants The presence of only one dietician is not conducive to carry out any educational or general awareness activities for hospital staff.

Recommendations Recruitment of more cooks and cook mates should be done in order to ease the pressure on the existing staff. A junior or assistant dietician should be recruited. Seminars on nutrition and health should be scheduled on a regular basis to train the hospital staff.

K B Bhabha hospital

Social workers department


Staff

Office Superintendent

Social Workers -3

Patients

The total strength of staff in the department is 3. The social worker in charge of the Paediatric ward, Gynaecology ward, Post natal care unit and the Ante Natal care unit is Mrs Marita Cardoz. Mr Kharat is the social worker in charge of the blood bank and Mrs Chitra is the third who is stationed at Dilaasa. Physical structure and layout 3 cabins have been given to the social workers department. Mrs Maritos office is on the first floor. Mr Kharat sits in the blood bank and Mrs Chitra is given a Dilaasa room in the old OPD building. Duty timings the social workers work in a general shift from 9 am to 4 pm and they work half days on Saturdays from 9 am to 12 pm. Functions of the department a reference is made to the social worker by the treating physician. At that time the social worker request the relatives for a detailed history of the patient, his/her family, socio economic and medical history. The situation is assessed and remarks are made in the OPD or IPD paper. Non-Governmental Organisations that are affiliated are listed below Childline Various adoption agencies Vision rescue this NGO picks up injured people from the roadside and brings them to the hospital for treatment Certain trusts like the Lioness club donate equipment to the hospital on a regular basis

K B Bhabha hospital

Problems faced by the department Fraudulent relatives who pretend to be poor The hospital is pretty big and this makes it difficult to co ordinate between different departments and personnel. Attitude towards poor patients changes from department to department. Shortage of staff Attitude of donors

K B Bhabha hospital

Radiology Department
Staff

Honorary - Dr B R Shah 1 Housemen 3 Registrars 3 senior technician - vacant post 1 Technicians 6 posts of which only 4 are occupied Assistants 5 posts of which only 4 are occupied Attendants 4 (only 2 posts are filled) Sister In Charge 1 Staff nurse 1

K B Bhabha hospital

The total strength of staff in the department is 19. There are 2 vacant posts for attendants, 1 for an assistant, 2 posts of technicians and 1 of a senior technician. Duty timings - 13 staff work during the morning from 7 am to 3 pm, 3 staff ie 1 technician, 1 assistant and 1 attendant work from 3 pm to 9 pm and 3 staff work during the night from 9 pm to 7 am. Physical structure/Lay out of the department the x ray department consists of two separate sections one is room number 17 in the OPD and the other is room number 23 on the ground floor of the main building. There is one dark room which has two safe lights, one tube light and one cassette hanger. Adjoining that is a CR room and an X ray room which is about 250 square feet in size. There is one attached bathroom. The walls are made thick that is they are at least 9 inches wide. There is one lead partition and one lead laden main door to prevent leakage of radiation. Functions of the department - x ray facilities are provided to indoor patients, casualty and OPD patients. An x ray issue form is filled by the doctor and is brought by the patient to radiology OPD. The patient is required to pay the required fee to the registration assistant and is asked to bring the receipt back to the department. The official processing time is 1 and half hour however the normal machine takes around 1 hour but the CR machines 10 15 minutes. The patient X ray films are directly sent to the OPD or the IPD depending on where the request was sent from. The staff of the radiology department then makes a note of the serial number in their register. Records/registers maintained and storage - The register is maintained annually and sent to the MRO at the end of that year along with the x ray films. They are stored for a minimum of 5 years although Medico legal case films are stored forever. Average number of patients received per day is about 200 -2 30 out of which 150 visits occur during the morning tine, 35 during the afternoon and 35 during the night. Equipment possessed by the department Portable equipment 5 in number, at least 6 7 requests are received daily for bedside X rays. X Ray machines 3 CR Machine 1, this machine processes films in a computerised fashion and sends them online to the medical and orthopaedic department Wiproft control machine Normal cassettes of varying sizes of 12 by 15, 10 by 12, 8 by 12 and 8 by 6. CR cassettes of varying sizes of 8 by 10, 10 by 12, 14 by 17 and 12 by 12. Computers 2

K B Bhabha hospital

Timekeeper/Housekeeping department
Staff Hierarchy

Head Timekeeper 1 Timekeeper = Mr Sakhan 1 Assistants 2 havildar 1 assistant 1 Labour 1

The total strength of staff in the department is 274. The total number of sanctioned posts is 321 and the total vacant posts is 47. Functions of the department servants are sent to the OPDs and wards in 3 shifts. The servants are under the staff nurse in every ward. Every year the servants allocated to each department change. Each servant stays in every department for an average of 1 2 years. Physical structure and Lay out the time keepers office is located on the ground floor of the staff quarters building and consists of one administrative room and one small area where the register is placed. Duties of the staff - The duties and responsibilities of the ward boy or ayah bai are to shift patients, change their clothes, give them a bath, feed them etc. Sweepers are given the responsibility of sweeping, mopping, cleaning the bathrooms and disposing off urine. Sweeping and mopping of every department is done at least twice a day and it is the duty of the departmental sister in charge to ensure that work is done properly. The cleaning equipment is given to the servants by the sister in charge.

K B Bhabha hospital

The Timekeeper is given the task of dealing with complaints if any that have been made against the servants by the staff or patients. He is also in charge of granting leave to servants or assessing cases of chronic or uncalled for absenteeism. Duty timings in the wards the servants are posted in three shifts the first one being from 7 am to 23 pm, the next one being from 2 pm to 9 pm and the last from 8 pm to 7 am. The servants in the OPD work in a general shift from 7 am to 3 pm, 8 am to 4 pm or 9 am to 5 pm. The staff allocated to the kitchen work from 6 am to 2 pm. The duty schedule remains foxed for a period of 1 year. There is a certain Leave Reserve Quota from which servants are appointed in case somebody is on leave. Records/Registers maintained The attendance muster is kept at the timekeepers office. Where very servant is supposed to sign at the beginning of his/her shift. Presentee Roll Call book Duty list book

All these registers are stored for a minimum period of 20 25 years in the timekeepers office. Problems faced by the department Shortage of senior staff it becomes difficult to coordinate and take decisions about the administration of the department. Servants take leave without obtaining permission or providing prior notice. Conflicts often break out between various servants which may disrupt the working of the department Strict action is not taken against those who do not perform effectively Partiality may be shown to certain staff members.

K B Bhabha hospital

Electrocardiography (ECG) Department


Staff

1 1

Technician - Mrs Pradhan Assistant

The total strength of the department is 2. The staff works in a general shift from 8 am to 4 pm. There are no vacant posts in the department. Functions of the department the department does around 30 ECGs a month for both OPD and IPD patients. The department also performs ECGs by the bed side for ICU and casualty patients. When OPD patients come into the ECG department the patients details and the OPD registration number is entered into a register. Once the ECG is done for the patient the graph is given over to the patient immediately. No duplicate copies of the ECG are maintained with the department. In case an ECG is requested for during the night the ICU staff will conduct the ECG if emergent otherwise the request is handled the next morning. Records/Registers maintained there is only one register which is maintained by the department which contains the OPD registration number, IPD registration number, patient details etc. this register is maintained on a continual basis and is stored for a minimum of 5 10 years. Problems Shortage of staff the department requires at least two technicians to work throughout the day in different shifts. Shortage of space the space in the department is too limited for two people to pass together.

K B Bhabha hospital

CLINICAL DEPARTMENT I- CASUALTY


Ideal emergency department Location - The emergency department should be located on the ground floor with easy access for patients and ambulances. There should be a separate entrance to the department which is away from the main hospital and the outpatient entrances. It should be well marked with proper lighting and signs and should be easily visible and accessible from the street. The department should be close to the admitting department, medical records and cashiers booth. Wherever possible registration of new patients and creation of their medical records, receiving of cash and admitting functions should be done in the department. Design the entrance to the department should be sheltered to protect ambulance patients from the weather while unloading. There should be a paved access to permit discharge of patients comfortably from ambulances and cars. Adequate reserved parking space for ambulances and cars of patients and medical staff should be provided. If there is a raised platform for ambulance discharge, ramps should be provided for wheelchair and pedestrian access. The following are the essentials of well-organized services for the care f fractures and other traumas in the emergency and accident department as listed by the American College of Surgeons through its committee on Trauma: An efficient, prompt, well-equipped ambulance service with competent personnel in charge. A well-equipped emergency operating room with supplies always ready for use. A small recover room. Efficient personnel including at least a competent physician, nurse, and attendant on round-the-clock duty or on call. Supervision of treatment of fracturs and other injuries by qualified and competent surgeons in their own respective fields. Adequate diagnostic and therapeutic facilities under competent medical staff. A well-documented medical record for every patient that includes immediate record of all injuries, physical findings, treatment, etc.

Among other things, policies and procedures should cover the following subjects: Medico legal cases such as road accidents, assaults, attempted suicide, poisoning, industrial accidents, deaths resulting from criminal acts, etc. Police procedures and reporting Notifiable deaths Patients brought dead or in a dying condition

K B Bhabha hospital

Disposal of bodies, autopsy, morgue procedures Accident and emergency room register Medical record and release form procedures.

Facilities required Trauma room(s) for emergency trauma procedure or where the severely injured surgical cases are handled. Facilities required here are resuscitation and life support equipment and drugs, medical gas outlet (oxygen, vacuum and compressed air) of central gas is provided, examination/procedure table, examination lights, X ray film illuminators, cabinets and supply shelves. If the room is used for orthopaedic and cast work, it is necessary to have closed storage space for splints and other orthopaedic supplies , a plaster sink, traction hooks etc. Examination/treatment rooms with examination tables, examination lights, work counters, cabinets, wash basins, X ray film illuminators, medication storage facilities and medical gas outlets. Scrub stations conveniently located to each trauma and orthopaedic room. Additional adjustable space for triage, treatment, observation etc. in the event of disaster handling. Staff work area and charting space with counters, cabinets, medication storage facilities, dictating facilities, etc. Storage space for equipment such as portable X ray and crash carts (cardio pulmonary resuscitation emergency carts) which should be easily accessible Separate soiled and clean utility rooms Public toilets Janitors closet Rooms for duty/on call doctors separate for men and women, with sleeping accommodation, shower and toilet facilities Locked cabinets etc. for staffs personal effects

K B Bhabha hospital

Casualty
Staff Hierarchy

Casualty Medical Officers - 5 Sister In charge (red belt) - 1 Staff nurses - 8 Barber - 1 Ward Boy - 1 Sweeper - 1 Dresser - 1
The total strength of staff in the department is 18. The Casualty Medical Officers OCMOs) work in shifts of three. The first shift is from 8 am in the morning to 2 pm in the night. The second shift t is from 2 pm in the afternoon to 8 pm in the evening and the night shift lasts from 8 pm to 8 am the next morning i.e. its 12 hours long. The duties are arranged in such a way that every doctor is assigned a morning shift, an evening shirt and a night shift one after the other. After this the doctor is given a holiday. The sister in charge of the ICU works in a general shift from 9 am to 4 pm. The staff nurses work in three shifts from 7 am to 2 pm, 2 pm to 9 pm and the 9 pm to 7 am.

K B Bhabha hospital

Physical structure/Layout of the department There are 5 beds in casualty. At the entrance there is a big observation room with one table for the CMOs and one table for the staff. It leads on to a narrow door which opens into a small room that contains medicine cabinets and tray trolleys as well as cupboards used to store material. This room has one bed for patients as well. On the left side there are two doors one of which open into a dressing room which contains a table, with one lamp and a washbasin along with all the material that may be required for dressing wounds or abrasions. This room also contains a steriliser which is used to disinfect all the instruments of the casualty. The second door opens into a plaster room which is also used as a store room. The connecting room leads to a CMOs duty room which is used by the CMOs to rest during the night time. It contains bed, one table and lockers belonging to the staff. The CMO table has two phones, one that is sued for normal interdepartmental use and one that is a disaster phone. The ICU is allocated one ambulance for its purposes. The average number of patients seen throughout the day is 300. Maximum numbers of patients come in during the night. In times of disaster the number may shoot up to 200 overnight. Procedures/Policies followed The casualty handles police custody cases as well. The police brings the client in, a MLC stamp is put on the case paper, the patient is examined and asked for any complaints and then the doctor gives a fitness certificate. Roadside accident victims are also brought in and these then become Medico legal cases. All victims of accidents, assault, burns and natural disasters are beought here as well. Procedure of body brought dead when the body is brought in by the police or by any spectators exact details of where the body was found, the location, timing and belongings of the body are noted. The belongings are wrapped in plastic by the police and taken to the police station concerned. The post mortem form is filled and subsequently the body is taken to Cooper hospital for post mortem after a punchnama has been done by the police. Procedure of handling mentally agitated/psychiatric patients such patients are given sedatives to calm them and they get registered as an MLC case. After this the patient is assessed and sent to a higher centre. Transfer within the hospital if a patient comes in to casualty with a surgical complaint the CMO assesses the patient and refers him/her to the surgeon on call. The surgery houseman decides further course of action. Patients are not kept in the casualty overnight for observation. The patient stays in the casualty for a maximum of 2 hours. The patient is then either discharged, admitted to the hospital or transferred to another hospital. If it is paediatric case the patient is K B Bhabha hospital

referred to the sixth floor. If a cardiac case comes in, basic resuscitation is given and then patient is then sent to the ICU or to the medical ward. In case the patient is undergoing a heart attack the CMO calls the ICU registrar to administer basic resuscitation. In cases of non-accidental injuries to children like violence, poison consumption etc. the child is given immediate treatment in casualty and then admitted in the appropriate ward. During their visit they are referred to Dilaasa for further counselling. In case a patient requires radiological investigations like x ray, ECG and ultrasound in the morning, the CMO fills up the requisition form and then sends the patient to the concerned OPD directly. If the patient is not mobile he/she is sent on a stretcher. If the patient requires these investigations in the evening or night after the OPD has shut the patient is then referred to the ICU for an emergency ECG or to the in door X ray department for an X ray respectively. Laboratory investigations are not done in the casualty. The patient is admitted only after which he/she is worked up. Safety of patient/staff belongings the casualty medical officers have around 10 lockers allocated to them which are present in the casualty. Staff nurses have lockers that are situated in the main building. There are no lockers where the patients can keep their belongings. Infection control policies After use all instruments are sent to the gynaecology OT for autoclaving. The trays are checked twice a week and after..days they are sent for autoclaving irrespective of whether they have been used or not. Forms/formats available Case paper the case paper issued by the department can of three types, normal, police custody or Medico Legal case. Post mortem form is ordered from the AMO and the signature of the AMO is taken and the form is sent to the mortuary. Alcohol consumption form Amputation form ECG requisition form X Ray requisition form

Stamps used in the casualty MLC stamp Custody stamp for clients brought in for medical fitness by the police Police custody stamp

K B Bhabha hospital

Follow up advice to come to the hospital in case of certain incidents CLW sututing and advice X ray requisition stamp Patient brought by the police for certificate Discharge against medical advice stamp as allowed by the relative Advice for malaria

Records/Registers Maintained Call book this maintains details of which doctor of which speciality has been requested to attend to a certain patient. In case a referral is made, a written request is sent to the concerned doctor along with a phone call to convey the same. Medico Legal case book this register records detail of all the MLC cases that have come into the casualty along with their, name, address and the ward that they have been transferred to. Death book this book maintains records of all books that have been brought into the casualty or if a patient has died after being brought into the casualty. Such bodies or patients are generally brought by the police. All details of the patient are recorded in the book and if information cannot be elicited in the case of an unknown unclaimed body it is clearly mentioned in the register. Register with details of the injectables used daily every shift is supposed to fill in a different page regarding which injectables have been used during the shift IV fluids book for all shifts Book to record details of all the anti-rabies injections given during the day Ambulance call book this register maintains details of where the ambulance was sent and at what time. One doctor along with one staff is sent with the ambulance for every visit. Over book details of what quantity of stock is maintained in the department are maintained in this book along with important instructions for the the staff in the next shift. Bio medical waste book this maintains details of the needles, sharps and other biomedical waste that is generated during every shift. This waste is collected by the the servant once during the morning every day Noting stock book AMO visit book

K B Bhabha hospital

Complaint book any complaints about missing staff or absent staff and faulty instruments are recorded in this book. The AMO and matrons signature is taken on each page. Post mortem book this maintains records of how many bodies have been sent for post mortem to Cooper hospital and the details of the patients. The signature of the AMO, matron and attendant are taken at the bottom of the page. Handing taking book the staff in every shift maintains a record of which instruments have been used during the shift. Instrument tray book this register maintains records of how many trays are present, which instruments are present in which tray, time of last autoclaving, time of last checking etc.

Equipment possessed by the Casualty Trolley with nebulizer 1 (only asthalene is kept in stock, if devolin is needed its ordered from outside ) UV lamp for flies 1 Ambu bag Laryngoscope Suction machine 2 Wheel chair 3 Trolley 4 ENT lamp 1 Plastic cutter 1 Steriliser 1 ECG machine 1 Head Mirror 1 X ray viewing box 1 Shadow lamp 1 Otoscope 1 Ophthalmoscope 1 O2 cylinder 3 Nebulizer 2 Syringe cutter 1 + 1 Emergency tray 1

Problems faced by the department Shortage of staff- this causes excessive workload for the existing staff Doctors to carry out sonography are unavailable The staff face difficulty in shifting patients from one ward to another.

K B Bhabha hospital

The night shift is very heavy patient wise and too long(12 hours) for one medical officer to conduct. OPD patients come to casualty directly in order to avoid the long queues outside the OPD.

Recommendations There should be two CMOs on duty during the night shift. A security guard should be positioned outside the casualty throughout the day to endure safety of the staff. Clear signages should be put up directing patients to the casualty. There should be one person allocated outside to direct the patient appropriately to the OPD if required.

K B Bhabha hospital

Sonography department
Staff Hierarchy

Head of department - 1 Lecturer (clinical associate/honorary) - 1 Residents - 4 (2 housemen + 2 registrars - 2 posts vacant) 2 sisters

1 mausi

Total strength of staff in the department is 11. The sonography department does ultrasound of OPD, IPD and casualty patients. Physical structure/Layout the sonography OPD is situated in OPD number 95 in the old OPD building on the ground floor. It consists of two rooms with one machine and one bed located in each room. Duty timings the official OPD timings are fro, Function of the department - Casualty patients are assessed by the CMO and then sent for an ultrasound. The various types of ultrasound carried out are USG abdomen pelvis, USG obstetrics, colour Doppler for both arteries and veins. Obstetric ultrasounds are taken three to four times during the pregnancy. Average number of patients seen during one day would be around 100. This consists of patients who have taken a prior appointment as well as those from casualty. Out of this 60 70 % of the patients are those who have come for an obstetric ultrasound and

K B Bhabha hospital

the rest are those who require an abdo pelvis scan. 2 -3 Doppler are carried out throughout the day. On Mondays and Thursdays the obstetric OPD is conducted between 2 pm to 6 pm in the evening. Nearly 30 to 40 ultrasounds are conducted by the doctor on call on those two days. Procedure two forms are required to be filled and consent is taken from the doctor as well as the patient. This form states that the doctor cant determine sex. Before establishing a sonography centre it requires Pre Natal Detection license. Registration is required to be obtained from the Medical Council of India. Equipment possessed by the department 3 ultrasound machines which are 2 D these can be used to conduct sonography and color dopplers. Registers/Records maintained 1 appointment book for Doppler 1 book which is an obs book 1 book which records details of abdo pelvis scans. These two books mention all details like registration number, name, age, sex, payment etc. 1 register that records abnormal scans mainly congenital anomalies, fetal deaths, Intra Uterine Fetal deaths, abortions etc All records and registers are submitted to the Medical Records Office after a period of 3 5 years.

Problems faced by the department Shortage of resident medical officers this puts excessive pressure on the existing staff. Patients are not cooperative and sometimes dont comprehend the language being used.

K B Bhabha hospital

CASE STUDY - Dilaasa


Staff The department consists of four therapists and one staff in charge of administration. The Centre In Charge is Mrs Chitra Joshi. The other two therapists are a sister in charge of the OT and one occupational therapist. The fourth therapist is Mrs Mridula who is a counsellor with another BMC hospital and comes in to Dilaasa three times a week. The OT sister in charge comes in once a week and the Occupational Therapist visits the centre twice a week on Mondays and Fridays. Physical structure/Layout Dilaasa is located on the Ground floor of the old OPD building in a room with the OPD number being 101. Introduction to the initiative Dilaasa, crisis centre for Women is the first hospital based crisis centre in India designed to respond to the needs of women facing violence within their homes and families. The centre is a joint initiative of the Public Health Department of the Brihanmumbai Municipal Corporation (BMC) and the Centre for enquiry into Health and Allied Themes (CEHAT), a Mumbai based multi-disciplinary non-governmental institution promoting and supporting socially relevant health and related research, action, services and advocacy. Dilaasa is a Hindi word which mean reassurance. Dilaasa represents the first attempt in India to sensitise the public health system to domestic violence through the establishment of a public hospital based crisis centre. The goals of this partnership were to Institutionalise domestic violence and more broadly violence against women as a legitimate and critical public health concern within the government hospital system Build the capacity of hospital staff and systems to adequately, sensitively and appropriately respond to health needs of the victims and survivors of domestic violence. Dilaasa is located in K B Bhabha hospital which is one of the 16 peripheral general hospitals of the BMC.

Dilaasas journey in a nutshell (2001 2008) Needs assessment 2001 The commencement of the work of Dilaasa was a long drawn orocess. Due to the fact that it was the first such attempt in India to set up a hospital based crisis centre for women facing domestic violence, the team felt that it was crucial to understand the hospital system first. A needs assessment study was undertaken. This included components such as observation at the casualty, in depth interviews of the hospital staff and study of the medico legal records. These studies reveaked a very crucial K B Bhabha hospital

aspect that we would have to deal with on a regular basis i.e, Health Care Practitioners saw domestic violence as a legal problem. They did not feel that it was their role to screen women and provide her with supportive services. The findings of the needs assessment prompted a need to develop a training module for the HCPs Developing a training model (2001 2005) Training of trainers 2001 - 2003 This was peer to peer training for adult learning. It was thought that it eould be more acceptable. Initially a mixed group was chosen. Once key trainers were trained they were given the responsibility of taking initiative and training their own cadre of staff doctor for doctors, nurses for nurse and so on. The training covered issues such as understanding of the concept of domestic violence in patriarchy, role of health systems screening methods, communication skills and eventually how to become trainers. The tools used for training included role plays, case studies, and discussion debates etc. Only 12 members of the staff emerged as key trainers. This was a challenge in itself. However they were very committed. They developed a module with the help of CEHAT and trained 833 other staff at the hospital. In order to increase the visibility of Dilaasa they put up posters around the hospital. Expansion of the Dilaasa initiative in other hospitals By 2004, Dilaasa had received a lot of attention from to other public hospitals too. By the then Municipal Commissioner wanted to replicate such centres across all the Mumbai hospitals. However, this was not a feasible idea. We felt there was a need for capacity building of staff of other hospitals who once trained could not only screen women for domestic violence but also provide referrals to centres close by. With this view Dilaasa proposed to conduct another Training of Trainers: course across 5 hospitals. This included staff from of 12 from each of the four hospitals Rajawadi hospital, Ghatkopar; MT Agarwal hospital , Mulund(W); K.B. Bhabha hospital, Kurla and Cooper hospital, Vile Parle(W). By 2005, core groups of trained hospital staff across 5 hospitals had emerged; they had also started conducting orientation trainings/poster exhibitions/pamphlet distribution and film screenings in their respective hsopitals. It was around the same time that a group of committed HCPs came forward to set up the second Dilaasa crisis centre in Kurla Bhabha hospital. This centre is completely run by the hospital with its current personnel and infrastructure. Establishing a training cell (2006 2009) Dilaasa was expanding and more and more HCPS were getting interested in the issue of domestic violence. However the current public health system lacked a formal mechanism to sustain the interest of the HCPS and formalise their roles. This led to the development of the Training Cell(TC). It was formed to share resources and experiences of HCPs with the aim of mainstreaming the training cell in the current health system. The cell began with a modest number of 25 HCPs and has now more than doubles (56).

K B Bhabha hospital

This year, Rajawadi hospital and Oshiwara maternity home have gone one step gurther. They are keen to respond to women reporting sexual violence as well and use a uniform protocol for examination and evidence collection in cases of sexual assault. It was wit their enthusiasm and keenness that they implemented the SAFE kit (Sexual Assault and Forensic Evidence collection kit). Currently these hospitals are also ensuring that their staff gets trained in not just the use of the kit but also develop a perspective on the issue of sexual violence itself. Hospital Kurla Bhabha No. of trainings 3 trainings with health care providers 1 training with the police officials 2 training on domestic violence with HCPs 1 training on sexual violence at Oshiwara Maternity Home with HCPs 1 training on Domestic Violence with HCPs 2 on sexual violence with HCPs 2 trainings on Domestic Violencewith HCPs 1 training on Sexual Violence with HCPs 3 trainings of student nurses in 3 teaching hospitals Attendance of participants 60 HCPs 30 police officials 40 HCPs 10 HCPs

Cooper

Rajawadi

18 HCPs 70 HCPs 44 HCPs 70 HCPs 100 student nurses

M T Agarwal KEM Sion Badlapur

The process I counselling In order to provide the necessary help to women approaching the centre the counsellors at the crisis centre have been trained in women centric perspective and skills. Feminist counselling gices the counsellor a perspective through which womens experiences can be understood in view of their general oppression in society. Domestic violence is understood as a result of patriarchal structure and a tool to maintain status quo within a relationship. Consent is sought for counselling and if women are not willing, their decision is respected. Once at Dilaasa, women are given emotional, psychological, legal and social support as needed and desired by them. It was of utmost priority to make the women survivors feel that they themselves were not responsible for the violence that they had faced and to address their fears, anxieties and needs. We also do a safety assessment of the women along with a safety plan and necessary support in terms of referrals. While assessing the need for a safety plan the woman is asked a few questions pertaining to the history of violence. These include whether there has been an escalation of abuse if in earlier episodes of violence instruments had not been used K B Bhabha hospital

but in recent ones they have been has there been a threat to life of children, any attempt to commit suicide etc. in the event that the counsellor feels that the woman is in danger she devises a safety plan. This plan can include helping the woman to enhance her ability to cope (like seeking immediately the help of a reliable neighbour) or even a shelter. Methodology of training/inducing new counsellors A new counsellor at Dilaasa undergoes training which is an intensive three month long process. They observe actual sessions of counselling. Issues are highlighted on a case to case basis. Over time they undertake counselling sessions in the presence of senior counsellors. This is followed by a discussion on the session. Shortfalls on the part of the counsellor are identified and rectified. Thus it is a continuous learning and relearning process where each case is unique and poses challenges for counselling. Training and orientation of staff for referrals On order that the staff at the hospital refer women facing domestic violence to the centre, it was necessary that as part of Dilaasa and the rest of their co-workers underwent a complete change in perspective and responsibilities. In order to achieve this orientation and training of staff was essential. The training given to hospital staff enables them to screen cases of domestic violence refer them to the crisis centre. This can happen from the various wards or at outpatient departments of the hospital Linkages with shelters Depending on their analysis of the situation of a womans need this hospital provides temporary shelter as admission for upto 48 hours to women. If needed there is also provision of temporary shelters at two shelter homes in Mumbai. Besides this we have a strong network with organisations and community based organisations (CBO) in Mumbai for mutual support and referral. Legal counselling Majlis has been providing legal counselling as well as litigation support to women at Dilaasa. A lawyer is available once a week at both the centres. They provide legal guidance as well as litigate cases. In the year 2007 2008 alone, legal counselling was sought by and provided for almost 50 women. Legal counselling for maintenance was given to 26 women, for divorce 16. Streedhan and property matters 8, issues related to visitation rights and custody of child 9. Litigation was pursued in case of five women for divorce as well as maintenance and restraining orders. One women was able to get a restraining order due to the new act on domestic violence, i.e. The Protection of Women from Domestic Violence Act(PWDA), 2005. As a logical extension of legal counselling they need to liaison with the police. We therefore had included them for awareness, sensitisation and training programmes.

K B Bhabha hospital

Research activities An initiative called Pehel was set up in 2005 with the aim of creating a resource centre on Violence Against Women within CEHAT. Pehel is engaged in Research, Advocacy and Training in gender based violence to create a comprehensive health care response. The focus of this initiative goes beyond Domestic Violence to include other forms of violence against women such as sexual assault and violence against women in conflict situations. Some of the research areas have been around understanding Medico Legal Procedures across various hospitals in Mumbai analysis of counselling, Case records of Dilaasa, experiences of female health care professionals vis a vis violence and assessment of the nursing curriculum to include incorporate the discourse on VAW in the nursing education modules on VAW. Pehel conducts regular Capacity Building Workshops with professionals in various parts of the country to respond to Violence against Women. Counselling services at K.B. Bhabha hospital After years of hard work, the number of women that Dilaasa has managed to reach out to and help has increased manifold. 472 women approached Dilaasa department for counselling services since April 2007 to March 2009. Out of which 52 were referred from the casualty, 34 from the Out Patient Department (OPD) while a large number of women i.e. 81 women were screened from the wards especially from the Female Medical Ward(FMW) with the history of poison consumption. 87 women were referred from community. It was seen that posters and pamphlets continue to have a large impact on women where by 67 women came by seeing the IEC material. 38 clients were referred from other organisations. 947 women followed up for counselling sessions and 155 came in for legal counselling. Amongst these legal counselling was provided for maintenance(39), divorce(38) and property matters(11). 14 women were provided legal counselling under the PWDVA. In the year 2007 08 alone more than 500 follow up counselling sessions were conducted. Moreover it was realised through counselling that if women facing violence could meet each other on a regular basis, then they would be better to cope with their situations and trauma if they were in a support group sharing experiences. Thus began the monthly support group meetings. Topics such as women and mental health, education, menopause, how women view the support that they receive from Dilaasa, portrayal of women in media and various issues impacting womens lives and health were taken. During the meetings storytelling, role plays and games are used to communicate issues. The counsellors continue to hold weekly meetings with women coming for counselling. Counselling services at K.B. Bhabha hospital, Kurla The Dilaasa department located at K.B. Bhabha hospital, Kurla, provides counselling services twice a week. Eighty new women approached the crisis centre at Kurla Bhabha hospital in the year 2007 28. A large number of these have been referred from the hospital itself whereas 87 women followed up with the counselling centre. Twenty nine women were referred from the casualty, whereas nine women were referred from the OPD. Seventeen women came in contact with Dilaasa as they were admitted in the wards. Out of these, a majority of them were admitted for an attempt K B Bhabha hospital

to suicide, 14 women were referred by staff of the hospital itself, while 6 women came from the community. Only 5 women came after reading the posters and pamphlets. This shows that such a large number of women were actually referred by the hospital staff itself which indicates a good assimilation of the department in the hospital. By the end of 2008, more than 1800 women have accessed the services offered by Dilaasa. Challenges to counselling As mentioned earlier, women referred to the centre, can deny counselling or choose not to come for follow up sessions or seek any other help as perceived necessary by the counsellors. This is frustrating often emotionally taxing for the counsellors themselves. Interacting with traumatised women leaves an impact on us too. As a result of this we also often risk burnouts. Therefore, we as counsellors too need to keep having appropriate outlets and refresher courses. Counsellors are constantly provided for a venting their fears and concerns. Moreover we felt that more advanced counselling skills are required for serious cases such as women having consumed poison. Therefore capacity building of the team of counsellors is a constant on going activity. Moreover, in order to get a better perspective towards certain approaches to counselling in our Indian context, it was necessary to understand our own social determinants therefore they underwent perspective training on issues such as intersectionality of class, caste and its effect on women facing violence. Over and above all the specialised counselling training, a senior consultant comes to Dilaasa every quarter. The consultant observes with the womans permission actual counselling sessions. Following this the counsellor handling that session is given relevant feedback. Our team of counsellors also present issues that we need to discuss and issues that we were unable to resolve satisfactorily. The forum provides for ways to better resolve and handle such issues. Training nurses as counsellors also proved to be a counsellor. In 2005, nurses were officially deputed to the Dilaasa crisis intervention department as counsellors. However, after receiving intensive training in crisis counselling, some of the deputed astaff withdrew, while some came intermittently. Each time a staff member withdraws, another has to be trained. Considerable amount of our resources and energy is wasted. We were also concerned with maintaining of confidentiality if the histories women share during counselling. Therefore a trainee leaving mid-way or immediately after the training causes a certain amount of uneasiness. The source of the problem could be selection of staff, relief from other hospitals, departmental pressure or staff shortage. This was an important key to enable replication of the centre at other hospitals. Eventually by 2006, a significant development has been that if the deputed staff, the CDO has started counselling women independently and there are two nurses who are currently providing support to women under the guidance of a senior counsellor. Thus the counselling services are currently being handled by the BMC staff.

K B Bhabha hospital

Outreach activities of Dilaasa The women seeking services at Dilaasa had expressed need for support at the community level. In order to be able to meet such a need we identified one community based organisation (CBO), Navjeet Community Centre. It is based in a slum in Bandra. In 2005 2006 a series of trainings were conducted in order to create a deeper understanding on the issue of domestic violence in the community setting. In the second phase of training the community volunteers were trained in basic counselling skills. Case studies related to their daily lives were developed and we encouraged the participants to get into the role of a counsellor. Most of the principles, values and techniques related to counselling were woven around the case studies itself. A feminist counselling methodology was specially developed for grassroots workers. This had proved to be a challenge. Issues covered during the training included principles and techniques of feminist counselling, values of a counsellor, techniques/skills in counselling and the like. The coordinator og the community centre has started a counselling centre. Working at the community level continues to be an important part of their activities. Since the past 8 years Dilaasa has been able to establish its name in the field of counselling. Various organisations are aware of our work. They approach the centre for training and inputs for their own staff and organisation. For example, Jagurti Kendra, a community based organisation approached them to design a counselling module for their workers who are already engaged in providing support to women facing domestic violence at the community level. A two day module was designed where in emphasis was given on principles and values of feminist counselling, ways of assessing safety of the woman as well as deciding a safety plan and suicide prevention counselling. Future plans Since Dilaasa was started in a hospital which obviously had an established system, any desirable change was an uphill task. Full cooperation of all the stakeholders right from the planning stages was needed. For this, involvement and participation of our hospital staff was indispensable. Accordingly, for example for orientation and training of staff, the content was evolved through involvement and contribution of our coworkers across various cadres. Today since adequate time was spent in involving us we have sense of ownership towards Dilaasa. This encourages us to take initiative to take it forward in the best possible manner. And for the same reason ou work is better understood, accepted and integrated within the hospital. Today the centre was being completely managed by the hospitals with technical inputs for training and counselling from CEHAT. Moreover they see nurses as having huge potential and a lot to contribute. They are underutilised. Their formal training as nurses provides them with skills that can be used to the optimum, provided they are allowed to do so. This is not the case at present because our healthcare model is doctor centric. In Dilaasa however nurses and other staff contribute in a big way. Nurses, in fact have been officially deputed to provide counselling services and they are doing very well.

K B Bhabha hospital

There has been very little research and documentation in India on violence and related issues particularly on issues such as health sector response. The Dilaasa department had successfully created and continue to be the resource for such work in India. The research that has been undertaken will contribute in a big way in improving our responses to women facing domestic violence and our systems can be further improved and evoked. The experience of this crisis centre further reiterates the earlier findings and leaves no doubt that such a hospital based department increases access to services for survivors of domestic violence. Thus hospitals with appropriate support through capacity building and with constant improvisation through research can have crisis centres as an integral part of their services without any additional burden on resources both human resources and financial. And with a cultivated sense of ownership the intervention is also sustainable.

SAMPLE STANDARD OPERATING PROCEDURES

This is a proposed SOP developed at mid-sized public hospitals in Mumbai 1. Any survivor 12 years of age or above may give consent for sexual assault examination (as per section 89 of the IPC). If the survivor is younger than 12 years the parent/guardians consent must be taken 2. It is not mandatory to admit the patient in case of sexual assault if her medical condition does not warrant admission. Every efficient effort should be made to ensure that all evidence collection and examination is completed within a few hours and the patient is allowed to leave immediately without admission. In case some investigations (such as radiographs) are pending the patient must be informed of their importance and explained that it would be preferable if she stayed admitted in the hospital so that these investigations may be completed. if she still refuses admission after being informed then she must be asked to come the next day for the relevant investigations and this must be taken in writing from the woman. The responsibility thereafter rests on the woman herself. In case the woman doesnt come the next day the examining doctor must make note of the investigations that were not completed and then dispatch the sealed SAFE kit to the MRO. 3. The responsibility of preserving and sealing the collected evidence lies with the examining doctor. Assistance can be sought from the nurse who is the witness in the course of examination/ or any other nurse on duty for air drying evidence and sealing the evidence. Each piece of evidence must be sealed and signed individually by the examining doctor. 4. Each sealed evidence requires the hospital stamp which should be taken from the MR department. 5. Once evidence is sealed it should be handed over to the MRO.

K B Bhabha hospital

6. In case the evidence needs to be preserved in a refrigerator it must be kept in the labour ward. 7. The evidence will be handed over to the police by the MRO. 8. Once the evidence is handed over by the examining doctor to the MRO, it is the responsibility of the MRO to ensure that it is collected by the police. This might require following up with thr police station. In case follow up is required the CMO may be called upon to contact the relevant police station through the police constable on duty. 9. It is the responsibility of the MRO to make sure that the evidence is preserved until collected by the police. 10. In case the evidence remains uncollected by the police, the MR department has to preserve the evidence ofr 15 years or till the time that it is collected by the police.

CEHATs work CEHAT, research centre of Anusandhan Trust, through its Research, Action, Service provision and Advocacy (RASA) has been addressing issues of right to health care to all as well as preventing violence and caring for survivors. CEHAT was established to conduct academically rigorous and socially relevant health research and undertake health action for the well-being of the disadvantaged masses, for strengthening peoples health movements and for realising the right to health and health care. Work at CEHAT had developed along four inter related themes (i) health services and financing (ii)health legislation, ethics and patients rights (iii) women and health and (iv) investigation and treatment of psychosocial trauma. CEHATs work is directed at demanding access to health and health care as a right and investigating and combating violence. Anusandhan trust and CEHAT have pioneered work on violence as a health issue since 1991. They have participated in the investigation of violence and assisted human rights lawyers in getting justice for the survivors. They have aksi conducted studies written extensively on the subject continued education and training for university students, doctors, teaching facilities, NGO staff and government officials. CEHATs work on violence has addressed issues of violence against women (domestic violence, sex determination and sex selection and sexual assault); violence against children (investigation of torture, police custody deaths and atrocities by police) and caste and communal violence. The issue of domestic violence was taken up as the starting point of the organisations work to legitimise human rights issues within the public health system through conducting research and service provision for victims of violence. It was thought that once the public health system became sensitive to this issue, the adoption and incorporation of other human rights issues into the system would be relatively easy. At the time Dilaasa was being conceptualised CEHAT had prepared a systematic review of various studies on violence against women in India and had begun the K B Bhabha hospital

process of establishing a women centred and community based action and research project in a slum in Mumbai Arogyachya Margavar(1998 2003). Here (1) community women were trained to respond to primary and reproductive health care needs and domestic violence and (2) research was undertaken on the nature and magnitude of domestic violence in the community. The goals of the research study were: to study the levels and determinants of domestic violence, to identify the perpetrators and precipitating factors of incidents of domestic violence, to examine help seeking behaviour and coping mechanisms utilized by victims and to understand the social and economic roots of violence against women. Around this time CEHAT had begun to focus on concerns around violence against women by linking up with the public health services provided by the Brihanmumbai Municipal Corporation and discussions had been initiated with high ranking officials of the BMC and a hospital to establish a crisis centre. CEHATs engagement with this community based domestic violence project strengthened its ability to convince the officials of the BMC to start a hospital based crisis centre. The implementation of Dilaasa is not only an addition to CEHATs prior work on domestic violence but represents the mainstreaming of this issue into a larger public structure.

K B Bhabha hospital

K B Bhabha hospital

K B Bhabha hospital

K B Bhabha hospital

K B Bhabha hospital

Pharmacy
Staff Hierarchy

Head Pharmacist 1 Pharmacists 4 Labourers 3

The total strength of staff is 8 in the department. the pharmacists work in a general shift from 8 am to 4 pm. The labourers work from 8 am to 5 pm. The dispensary that is situated in the OPD is also run by the pharmacy. There is no sales counter that is provided by the pharmacy. There is a fixed tender schedule which is governed by a central authority. Indents are given on a weekly basis by the wards. The sisters in charge put in an indent every week. Daily issues are maintained manually by the pharmacy. In the pharmacy Enough stock is ordered to last for 4 to 5 months. A month and a half before stock is expected to get over the pharmacy orders news stock. Orders are placed in a computerised fashion. The drugs ordered are fixed by the WHO for a period of two years only the quantity required is decided by the hospital. Nearly 15 schedules are in place by the WHO. K.B Bhabha hospital doesnt possess the necessary license for narcotics hence such medicines are neither ordered for nor dispensed. Equipment possessed by the department the pharmacy is centrally air conditioned. It possesses two refrigerators to store medicines as well as one computer. Records maintained by the department Ledger issue book File containing copies of all the purchase orders File of all requisition slips that have been sent from the ward. The original remains with the concerned ward sister in charge.

K B Bhabha hospital

All issue books are stored permanently in the department. All other records are stored here for a period of 5 years. Monthly and yearly checks a monthly check of all drugs is done and those that have been found to cross their expiry date are thrown away. Every 2 months an unannounced audit is done by the hospitals vigilance committee. FDA inspectors also come in once every year, collect samples for testing and then send the reports to the hospital in a little while. Also if a side effect is recorded in ward after the consumption of a certain medication, a sample of the medication is sent by the pharmacy to the FDA for testing. Problems faced The grant given to the pharmacy is inadequate. Once the old schedule elapses there is a certain time period before which the new schedule is put up by the WHO. All 12 15 schedules are published at different points in time and therefore expire at different points in time. Shortage of space is faced as there is inadequate place to store in fluids.

K B Bhabha hospital

CLINICAL DEPARTMENT III LABOUR AND DELIVERY WARD


Ideal labour suite Two specific areas make up the obstetrical department (a) patient accommodation which may consist of private and semi-private rooms and general wards and (b) clinical facilities which consist of a preparation room. Pre-delivery or labour rooms, birth and delivery rooms and nursery. In addition to the above the obstetrical department requires the services of a host of adjunct and ancillary departments such as laboratory, X ray and ultrasound. Location within the clinical facilities the labour and delivery suite should be as remote as practicable but easily accessible from the entrance to the department so as to avoid unnecessary traffic and to provide privacy to the patients. The facility should be close to the nursery, obstetrical nursing unit, and to the vertical transport so that patients can access it easily. The department should be close to the operating rooms if it doesnt have one of its own Preparation room patients who are admitted in labour have to be prepared for delivery. Although this can be done in the patients private room or in the ward it is preferable to do this in a special room. The patient receives a cleansing bath, is shaved and is given an enema before being sent to the labour room. The preparation room should be located within the labour delivery suite but away from the labour and delivery rooms. This room should have an examining table, bath, washbasin, kit for giving enema and preparation tray. A locker to keep the patients clothes is desirable. Labour rooms in which the patient remains during the first stage of labour must be designed in such a way that then can serve as emergency delivery rooms. To that end them must be of adequate size preferably 5.48 by 5.48 metre (18 Feet by 18 feet). Single rooms are recommended. They provide greater privacy for the patient and permit the father to visit during labour. they should be equipped with electronic foetal monitors. It should be sound proofed. Doors should be four feet wide to permit passage of the bed or stretcher with attendants. The bed must be furnished with oxygen, suction and compressed air outlet, nurse call systems, and lighting controls. Delivery room the delivery room should be as follows scrub up area with view windows to observe the delivery room, where possible, general lighting and operating lights, oxygen, suction and air, a clock with a seconds timer, built in protection against explosion hazards, equipment and supplies. A delivery room should accommodate only one patient at a time. The delivery room should also contain a designated area to receive the new born baby immediately after birth. This area should have a baby receiving tray, warmer, suction, oxygen and other resuscitating facilities like an Ambu bag. Recovery rooms although recovery can be in the delivery room, the labour room or in the obstetrical nursing unit a room exclusively for this purpose is recommended so that the patients can be under close observation. Each recovery room can have two or K B Bhabha hospital

more beds. It should have a nursing station with charting facilities and visual control of all beds. Provision must be made for dispensing medicine, washing hands, clinical sink with bedpan flushing device and storage for supplies.

Facilities and space requirements Preparation room Delivery rooms Labour rooms Recovery rooms Operating rooms (optional)

Service areas Control/nursing station. Should be so located as to permit observation of all traffic in and out of the obstetrical suite. Supervisors office Fathers waiting room Sterilizing facilities with high speed autoclaves convwnient to the caesarean section and delivery rooms Recessed scrub area with sink equipped with gooseneck spouts foot operated controls, thermostatically controlled temperature valves, space for nail brushes, sterile caps and masks An easily visible clock with a seconds timer Controlled storage for drugs Enclosed soiled workroom/storage room with sink, counter etc. Clean workroom/ supply room Anaesthesia storage facilities Equipment storage Staff clothing change area Lounge and toilet facilities for obstetrical staff Janitors closet Alcove for stretchers A recessed place for film illuminator, a desk and chair fpr chart work Duty rooms with sleeping accommodation, toilet and bath for resident suty, doctors and on-call doctors, separate for men and women. Bunk beds may be provided to accommodate more doctors.

K B Bhabha hospital

Labour ward
Staff Hierarchy

Sister in Charge - 1

Staff Nurses - 8

Servants - 6
and two servants. The total strength of the staff in the department is 15. Duty timings the sister in charge works in a general shift in the morning from 9 am to 4pm. There are two staff nurses allocated to each shift that is morning Physical structure and layout of the department The labour ward is situated on the 1st floor of the main building. There is one small area at the entrance which contains a table and a chair for the security guard. Outside the labour ward there are chair for the relative so f the patient. Once inside the labour ward there is a long corridor approximately 12 feet by 4 feet. At the left hand most corner there is room for staff which leads into a small store room. Right adjacent to the staff room is a room that is used for autoclaving and sterilisation. Walking along the corridor on the left there is a small washroom the corridor leads to an observation room with five beds. These beds are occupied by patients who have just delivered.. this room leads on to the main labour room which has five beds. Within the labour room a small door leads to a new born nursery. The nursing station is situated in the labour room along with cupboards to store equipment. Functions of the labour ward The labour ward accepts both registered and unregistered patients who come in during labour or immediately after delivery. Sometimes an unregistered patient is brought in with complications during delivery like breech baby, convulsions etc and this is then K B Bhabha hospital

registered as a Medico Legal Case. In an unregistered patient comes in a spot HIV test is done by the houseman of the unit under which she is to be admitted. After a normal delivery the patient is moved to the recovery room just outside the labour room and is kept for observation for 2 hours. In the meantime the relatives are asked to bring tea and biscuits for the patient as the hospital does not provide refreshments to the patient immediately after delivery. The patient is then transferred to the PNC ward conditional on passing of urine. If the patient has suffered from complications like convulsion or Pregnancy Induced Hypertension she is observed for a longer time in the recovery area. Registered patients who may have delivered at home are also taken in by the labour ward. They are examined and then shifted to the PNC ward. The babies are administered the initial vaccinations and Vitamin K. Spontaneous abortion or cases of complete abortion are also taken in the labour ward. They are observed for two hours and then sent to the gynaecology ward. Relationship with the paediatrics ward - The paediatrician on call examines the child. One mega dose of vitamin K is given to every new born baby. The patient is examined and then transferred to the Post Natal Care unit where she is admitted for a minimum of two days. Counselling advice as to proper techniques of baby care and breastfeeding are provided to the patient in the PNC ward. If the baby is premature or suffering from any congenital deformities he/she is shifted to the Intensive Paediatric Care Unit. If patients come in after the gynaecology OPD timings get over they are seen by the houseman or registrar on call in the labour ward. Relationship with outsiders outsiders are not permitted to enter the labour ward. No men or relatives are allowed inside whilst the patient is in labour. After the delivery the patient is moved to the recovery unit where the relatives are called to give the patient tea and biscuits. Equipment possessed by the labour ward 5 labour beds 6 recovery beds 1 wheel chair 1 Doppler machine 1 computer 1 bed for new-born babies with lamps to provide heat 1 hand dryer 1 oxygen mask 1 Ultraviolet lamp for flies Various trays containing sterilised equipment 1 drum for iv fluids 1 autoclave 1 notice board 1 oxygen cylinder

K B Bhabha hospital

Basic resuscitation equipment

Cleaning procedure The labour ward is mopped rtwice a day and washing of all the tables and the ward is done in the night. After every delivery the tables are washed and the sheets are changed. Fumigation of the ward is not done generally except in cases of high risk/HIV/HBSAg infected patients. Linen Soiled linen if blood stained is first washed in the department itself after which it is sent to the laundry department on Mondays and Thursdays before 10:30. Clean linen is received on Fridays.

Records/registers maintained by the department Confinement book this book records the details of all the patients who have been inside the labour ward. Medico Legal cases are marked in red in the same book and a separate medico legal register is not maintained. The book has a certain format. It maintains the following details in a linear sequential order :confinement number, date and time of admission, indoor registration number, OPD number, name of honorary, name and address of patient, age, caste, parity, presentation and position, duration of labour, mode of delivery and complications, birth records stating time and date of delivery, name of which doctor conducted the delivery, names of who witnessed the delivery, condition of placenta and membranes, condition of perineum, condition of mother, details of the baby which include sex, weight, condition and ny general remarks that may be made by the paediatrician on call. Admission book Issue book Census book Staff nurse duty book Servant duty book Handing taking book which records how many instruments have been used, the total number of drums present in the ward etc. Gown book Internal transfer book Transfer to other hospitals book Zero prescription book this book maintains details of patients who have received prescriptions from outside Over book Injection account book Bio medical waste book (black only) Baby shifted to premature Unit book Drum book Linen book

K B Bhabha hospital

Prescription book Medical Officer round book Complaint book Sisters report book Deaths book Call book this book records details f any referral made and has the contact details of the doctors from all specialities

Performance analysis Jan Admission 272 confinement 238 Booked 235 Normal 164 Abnormal 57 Multi 181 Primi 89 Vacuum Forceps 1 Breech 1 LSCS 57 Still born 1 BNB 1 IUFD Taxi Rickshaw Home 1 Lift Passage Bathroom Verandah Road Casualty feb 208 174 176 116 53 139 69 1 53 0 1 1 1 march 277 234 217 132 86 173 104 1 1 84 2 8 6 2 2 April 255 234 252 146 60 177 96 2 1 2 73 2 1 May 273 255 228 193 62 157 88 June 262 254 222 148 47 177 77 1 1 47 1 1 Total 1547 1389 1360 899 365 1004 533 3 5 4 376 7 12 7 0 6 7 1

62 1 0

1 2

2 2 1

July

august

Admission Confinement Booked Normal Abnormal Multi Primi

276 236 222 187 75 185 90

250 240 239 189 75 177 81

September October November December Total of full year 274 288 315 266 3224 251 271 391 244 2992 274 267 288 243 2893 183 200 197 175 2030 31 62 85 45 790 188 104 207 185 2130 86 101 207 81 1182

K B Bhabha hospital

Vacuum Forceps Breech LSCS Still born BNB IUFD Taxi Rickshaw Home Lift Passage Bathroom Verandah Road Casualty

1 7 47 5 2

11 4 1 2 1 2

5 3 73 3 1

1 3 58 1 1 3 3 6 79

3 10 45

1 1

1 1

4 17 30 689 19 17 13 2 8 14 2 1

Twin Triplets Ectopic Curettage Abortion Ambulance Railway Gate Male Female Emergency Exploratory lap D&E Hysterectomy Laparaoscopy Preterm Cleft palate Premature

Jan 2

February march 4 21 22 8

April

May 2

June

Total 8 21 181 38 1 696 618 161 11

28 6

36 9

32 8

31

32 7 1

128 118 29 2

104 72 72

11 116 30 1

125 103 21 8

110 110 27

118 99 32

July Twin Triplets Ectopic Curettage Abortion

august September October November December Total 1 1 3 4 17

30 2

40

17

13 4

12 8

17 3

284 55

K B Bhabha hospital

Ambulance Railway Gate Male Female Emergency Exploratory lap D&E Hysterectomy Laparaoscopy Preterm Cleft palate Premature

1 120 117 53 1 129 112 19 2 142 112 21 2 143 129 21 148 146 14 133 155 23 1511 1389 312 16 3 3

1 3

2 2

Relationship with blood bank cross match of every patients blood is done beforehand. If required a request is sent to the blood bank for blood. Otherwise blood stays in reserve for at least 1 month. Relationship with radiology departments in case an unregistered patient comes in the laboratory is open 24 hours and immediate cross matching can be done. There is one on call sinologist throughout the day. Although there are no portable ultrasound machines the patient is sent on a stretcher to the department. Problems faced by the department Excessive workload on the existing gynaec housemen causing frustration and exhaustion. Recommendations Two on call doctors should be stationed in the labour ward during every shift. Ante natal Lamaze classes should be conducted in the hospital and such exercises should be taught to pregnant women in order to facilitate easy and short delivery.

K B Bhabha hospital

Out Patient Department


The services provided in the old OPD building are Gynaecology, oaediatrics, Ante Natal care and family planning. Timings of the OPD The Gynaecology OPD services are provided on Tuesdays and Saturdays. The asthma OPD is conducted once a week. The Paediatric services are offered on .. the ANC OPD is on Tuesdays from 2 pm to 6pm. The OPD paper is issued for a sum of 10 rupees. Staff the sister in charge works in general shift from 8 am to 4 pm. 6 staff nurses have been assigned to the OPD and some of them from 8 am to 4 pm and others from 7 am to 3 pm. Sanctioned posts of servant assigned to the OPD number 6 however only 5 of them are occupied currently. The servants works from 8 am to 3 pm. There around 5 to 6 doctors that currently work in the gynaecology OPD and around 3 to 4 work in the paediatric side. Registers/Records maintained 5 6 Indent books for medicines, surgical disposable items, stationery, general stores and ERV Ledger book this records details of which medicines have been issued.

These registers are stored for a period of 10 years in the OPD. Equipment possessed by the OPD 3 Ultrasound companies 1 Doppler machine 1 colposcope Other instruments like torch etic Different types of vaccinations

Problems faced by the department Shortage of servants is faced by the OPD so cleanliness is affected. Waiting time for patients is very long and this causes dissatisfaction amongst them.

K B Bhabha hospital

The OPD services provided in the New OPD building are medicine, surgery, psychiatry, Dental services, Orthopaedics, Tuberculosis, Dermatology and Leprosy. Twice a week super speciality services like Cardiology, Neurology, Urology and and Endocrinology are conducted by 4 KEM doctors who come in to Bhabha hospital. These OPDs are conducted in the medicine and surgical OPD room and each one lasts for one hour from 10 am onwards. DOTS(directly observed treatment) opd in this OPD tuberculosis patients are given two containers for sputum collection. Medicines are administered under clinical supervision. A separate register is maintained which records details of such patients. 2 to 3 technicians work in the sample collection centre situated in the OPD, 1 technician in a Tuberculosis OPD and 1 in the malaria OPD. Only blood collection is done in these OPDs and the samples are sent to the central laboratory. Reports are ready by 4 pm the same day but they are sent to the OPD the next day in the morning. Equipment possessed Dressing material Sphygmomanometer Instruments Microscope and otoscope for the ENT OPD. Ophtalmoscope for the Opthalmology OPD. Woods lamp Suction machine Dental chair X Ray machine Skin cautery machine One machine to wash wounds for leprosy patients

The OPD papers are issued from the registration counter at counter number 5 for a sum of rupees 10 between 7 am to 11 am. The OPD lasts from 7 am to 1 pm. Staff one staff nurse is allocated to each and she works from a period of 7 am to 2 pm. 1 ward boy and 1 sweeper are allocated to each OPD. Around 11 servants are allocated to the OPD in general. Records/Registers maintained Indent book for surgical items Indent book for medicines Book recording details of which patient receiving which injections A dead stock indent is maintained for orthopaedic and psychiatry items

Problems faced Shortage of servants

K B Bhabha hospital

Shortage of space Robberies of small items from different OPDs. Clash between the patients and doctors of the Dental OPD and the general medical OPD regarding the X Ray machine. Due to this conflict the dental pateints are sent outside to get their X Rays done.

Post-Partum care OPD


The OPD works from 9 am to 4 pm from Monday to Saturday. It is situated on the ground floor of the old OPD building. Staff the centre employs 1 paediatrician, 1 gynaecologist, 2 sisters and shares the OPD servants. On an average 15 to 20 patients are seen every day. The centre consists of two rooms, one where the doctors sit and the other room is used for examination fo the patient. Condoms (Nirodh) are also distributed along with oral contraceptives to patients who are seeking contraceptive methods. Case papers are issued by the main registration counter. However, if there is an emergency papers are issued from the centre itself. All supplies are received from the F south ward annually. Indents are put in once every month. Functions patients requiring copper T insertion, gynaecologicial surgery or postpartum patients attend this OPD. Equipment possessed 3 trays of instruments that are used to insert copper T. 1 sonography machine 1 steriliser 1 table to examine patients

Records/Registers maintained One register is maintained to record details of patient who undergo insertion of copper T Register to maintain details of patients who have undergone tubal ligtion Register maintaining details of patients who have undergone gynaecology surgeries Book to maintain details of vasectomies

Every year a new register is opened. Old books are stored for an average of 5 years and then submitted to the MRO. Problems faced by the department This centre has to share the servants allocated to the OPD hence cleanliness is affected.

K B Bhabha hospital

Post Natal Care Unit


Staff

Sister in Charge - 1

Staff nurses - 10

Servants - 13

The total strength of staff in the department is 24. The sister in charge works in a general shift whilst 2 nurses are assigned to each shift. On alternate days 3 and 4 servants come during the mornings respectively. During the evening 4 servants are on duty and during the night 3 are allocated to the department. the duty schedule is prepared in such a way that every nurse does 4 morning duties, 2 nights and then gets an off or she has to do two evenings and then she gets the next day off. Physical structure/Layout the ward a 60 bedded unit with one nursing station located right in the centre. There is one pantry situated in the ward. At any point occupancy averages around 30 40 %. Visiting hours relatives are allowed to visit patients only from 4:30 pm to 6:30 pm. Discharge of patients is done only during 12 pm to 2 pm. Doctors tale rounds suring the morning time. Housemen generally take their rounds in the evenings. Meal times are a follows Milk and bread is served at 9 am Tea is served at 7 am Lunch is served at 12 pm Dinner is served at 7 pm. Equipment possessed 2 phototherapy machines 1 portable suction machine 4 central suction machines

K B Bhabha hospital

3 oxygen cylinders 1 wheelchair 1 stretcher 30 lockers 1 refrigerator 39 beds with cradles 18 Fowlers beds for post operative patients 10 12 iv stands 1 screen X Ray illumination view box 1 steriliser 1 nebuliser 1 examination bed 1 oxygen trolley 1 stethoscope 1 Gas light Paediatric size laryngoscopes Ambo bags

Records/registers maintained Nurses over book which records details of any X Rays, medicines, procedures or transfers that have been performed in the previous shift or that need to be carried out in the next shift Injection books Diet book Medicines book Bio Medical Waste book Complaint book Special bboks are maintained for twin babies born to any mother, eclamptic patients or those who have undergone a C section. Call book for referrals Servants names book Staff nurses book

Problems faced by the department Certain patients are encountered who are either illiterate or unwilling to give a proper and detailed history. Patients are admitted with constantly fluctuating blood pressure and are this difficult to manage. Sometimes patients opt to get discharged against medical advice. Sometimes the workload is excessive for the existing staff Shortage of servants

K B Bhabha hospital

Paediatric ward
The paediatric ward includes the premature unit as well as the Intensive Paediatric care Unit(IPCU). Premature unit Functions - This is a 10 bedded unit where new born babies are kept till 1 day after delivery. All premature babies, babies who havent cried immediately after birth, septic babies as well as septicaemic babies are treated here. Counselling advice regarding proper methods of breastfeeding is also provided to mothers. Babies of mothers who have undergone a C section are fed every 2 hours by the nurses using vati spoon. Timing the mothers of the babies admitted here stay with their children all day and nurse them except for meal timings when they move back to the PNC ward. Apart from mothers no other relatives are allowed inside. Weekly indents are made by the IPCU and the PU by the Sister In charge. Staff 1 doctor is on duty for every shift. 1 sister in charge works in a general shift during the morning. There are 5 staff nurses allocated to the unit. 2 sisters are on duty in the mornings, 1 during the evening, 1 in the night and 1 is given off. There are 6 servants allocated to this unit and they are divided into couples of two for very shift. Every shift 1 ayah bai and 1 sweeper are on duty. The average length of stay of infants is 15 days. After this period the infants are moved to the IPCU. Physical structure/Layout this unit has one septic room, 1 store room, 1 feeding room and 2 normal rooms with cribs. Equipment possessed 1 warmer Infusion pumps Lamps to provide phototherapy

Problems faced by the department Equipment are lesser in number and not adequate for the patient load. The warmer is not maintained properly and hence malfunctions sometimes. Shortage of space lots of babies are kept in one room and there is no space for the mother to stay with her baby.

K B Bhabha hospital

Shortage of nurses Shortage of on call doctors on call doctors are over worked and there is nobody to attend to outdoor patients if indoor patients are critical. There is no space for servants to wash clothes and gowns. There is no milk bank. There is no nursing station for relatives and patients to come and enquire about their babies. There is no patient and relative communication. inadequate space to dry clothes.

Intensive Paediatric Care Unit The total number of beds in the unit is 6. On a average occupancy averages around 70 75 %. Staff 1 resident per shift is on duty. Hence three residents are on call throughout the day during these three shifts. The sister in charge of the paediatric ward is common to the IPCU. There are 5 staff nurses allocated to the IPCU out of which two work in the morning and 1 each in the evening and the night. One sister is given off. 6 to 9 servants work in the morning, 6 to 9 in the evening and 2 in the night. Timings meal timings of patients are as follows : 9 am milk and bread; 12 pm lunch; 8 pm dinner. Rounds by doctors are taken during the morning time between 9 am to 11 am. Visitors are allowed between 4:30 pm and 6:30 pm. Function children below 13 years of age who are in a critical condition requiring constant medical attention are admitted to this unit. Equipment possessed by the department Ventilators Multiple monitors Lamps to provide phototherapy Steriliser Trays of equipment that maybe required for procedures like central lines, intubation

Records/registers maintained Records of septic patients Admissions register

K B Bhabha hospital

Transfer register Transfer to toher hospital regiser Call book Death book

These registers are stored for a minimum period of 5 years.

K B Bhabha hospital

CLINICAL DEPARTMENT II INTENSIVE CARE UNIT


Ideal Intensive care unit Location there are two school soft ought regarding where an ICU is to be located. One suggests that the ICUs should be in a centralised place, and be contagious with, or readily accessible to one another. Having intensive care facilities in a centralised place allows specially trained professionals and equipment instant access to patients in all clinical services when an emergency develops. The second school of thought favours that the location be dependent on the type of patients for e.g. a surgical ICU should be close to the operating rooms and the medical ICU should be near the medical ward to facilitate the concept of progressive care. ICU should be close to the emergency department, operating rooms, recovery rooms, respiratory therapy, laboratory and radiology and so located that the specialised cardiac team is able to respond promptly to the ICU emergency calls. The ICUs should be located away from heavy traffic and noise. The rule of thumb whilst determining the number of ICU beds is that the 10% of the total number of beds should be reserved for the ICU. There should be no more than 12 to 16 beds per ICU. A 6 bed unit is probably the most economical unit. Design Proximity of the nurses station to the patients room and serves to boost patients morale. Interior design should be planned to avoid depressing effects or over stimulation from certain colours and lighting. Live plants are refreshing. Staff must be specially trained for quick action in any emergency. Facilities and space requirements - Privacy is required for all adult beds since the unit will be serving both male and female patients. Curtains over the glass walls may be drawn when necessary. The entrance door to rooms should be at least 1.11 metres (3 feet 8 inches) preferable 1.21 metres (4 feet wide) for easy movement of beds and large equipment. The following items should be placed on the wall at the head end of each bed or on a free standing column : Medical gas outlets two for oxygen, one for compressed air and two for suction. Nurses call button Telephone outlet optional Electrical outlet for ceiling lights, dimmers, fluoroscopy equipment, high intensity lights for examination and treatment. Wall mounted blood pressure equipment (swivel type) with a cough basket for each bed. Recessed plastic pan below the medical gas module to hold vaccum bottles.

K B Bhabha hospital

All toilets in the private rooms and cubicles and on the non-cubicle side should allow wheel chairs. Toilets should be provided with grab bars and panic buttons with pull cords. In the non cubicles curtained area there should be a clear space of at least 1.37 metres between beds and 1.06 metres between the end bed of the wall. There should be a clear space of at least 0.9 metre between head end of the wall and 1.21 metre at the foot end to permit resuscitation procedures etc. In larger units, more than one nurses station may be needed to provide unobstructed view of the patients faces. For this reason, nowadays some hospitals design U shaped or semi-circular layouts. The central control station should be designed to seat 2 or 3 persons only. This will discourage staff from frequenting or idling in that area. All units need resuscitation equipment such as ventilators, blood gas analysers, infusion pumps and defibrillator with built in oscilloscope. One or more emergency carts also called crash carts, red carts or blue carts should be kept ready in each ICU immediately accessible to the ICU nursing station. Equipment and medical supplies are normally assembled on carts and kept ready to role at any time. The part should be replenished immediately after use. Considerable storage space is required to stock a large number of essential items like, dressing trays, catheterization kits, sterile gloves, etc. Provision should be made for a nourishment centre for ICU patients who are largely on liquids. Nourishment for staff who miss regular food hours because of emergencies should also be available. It is essential to provide for isolation rooms in each ICU for infected or potentially infected and critically ill patients. This is particularly necessary when it is not possible to provide single rooms for all patients. A soiled holding and work area with clinical sink and hand washing facilities. Soiled linen should be bagged in a different colour if it is infected linen with sufficient space left at the top to close completely and stored temporarily in the soiled holding area until picked up by laundry personnel. Storage for house keeping supplies with janitors closet, service sink and bed pan flushing facilities. Hand washing facilities for staff. Duty doctors name with sleeping accommodation and bath, toilet etc. there should be separate rooms for male and female doctors who are on regular resident or on call duty.

K B Bhabha hospital

Family waiting rooms with toilet and pay phone facilities. There should be a gowning area and storage for clean gowns, masks etc. Casual visiting should be discouraged in order to maintain high standards of cleanliness. Most ICUs, however, allow family members to visit one at a time for 5 to 10 mins, every one or two hours. A sign board which says patient needs rest usually helps the family understand this rule.

K B Bhabha hospital

CLINICAL DEPARTMENT III INTENSIVE CARE UNIT


Intensive Care Unit
This unit is officially a 10 bed ward for all patients and one bed is reserved for emergency situations. Average occupancy of the intensive care unit is almost 100 %. Staff Hierarchy

Doctors - 4

Sister In Charge - 1

Senior staff - 2

Staff nurses - 10

Servants - 6

The total strength of staff in the department is 23. 1 doctor is posted in the ICU every shift i.e. one in the morning, one in evening and one in the night. The sister in charge works in a general shift whilst two senior staff work in the mornings as well. 2 staff nurses are assigned to the ICU per shift. One sweeper and one ward boy are assigned to each shift. The doctors take rounds between 9:30 and 11:30. Relatives area allowed to visit the patients between 4 to 7 pm.

K B Bhabha hospital

Functions of the department Concentrate in one centralised area, The critically ill patients for close observation and skilled nursing care by specially trained personnel To enhance physicians ability to treat acutely ill patients through the use of centralised and highly skilled support personnel and specialised equipment. To provide close personal and monitor assisted surveillance of critically ill patients so that the readings and data relating to their physiological functions are available to professional staff to facilitate timely diagnosis, treatment and evaluation of care. To improve over all patient care on the patient floors by moving to the ICU the acutely ill patient whose treatment is often carried out at the expense of other patients. This way nurses can give more time to the less critically ill patients in the ward. The ICU provides care of post-surgical patients, emergency patients suffering from coma, shock, haemorrhage, convulsions, respiratory and other medical problems. The ICU cares for patients with acute cardiac conditions as well.

Equipment possessed 1portable electrocardiography machine 1 cardioscope 7 ventilators (Versa) Monitors for every bed Infusion pumps Pulse oximeter Central oxygen pipeline Defibrillator Oxygen cylinder Airway ventilation tubes Filters 1 weighing machine Refrigerator for medicines Trays for procedures like central lines 1 computer Central suction for every bed Lockers for every bed Bedside Iv stands Bedside buckets/pots for collecting urine/stool Suction catheters Various medicines and injections like low molecular weight injections

Records/registers maintained K B Bhabha hospital

Patient over book Nurse duty schedule Indent book for medicines and surgical disposables Special lecture book Outside doctors (neurology, cardiology etc.) visit book Outside investigations book Injections account book Bio medical waste book Monthly census book Internal Transfer book Transfer out to other hospitals book Death book Epidemic book this records details of epidemics if they have broken out at any point ECG record book

The registers are maintained in a continuous fashion. New registers are opened when the old one gets over. The old registers are sent to the seventh floor office once they get over. Epidemics are reported to the Medical Records Office on a daily basis. A daily census is also sent to the MRO along with a record of all the deaths.

Bio medical waste disposal The bio medical waste is disposed off in various coloured bags depending on the nature of the waste. Dry waste is deposited in a black bag whereas blood soiled items and blood as such are thrown in red bag. Needles and syringes are disposed of in a puncture proof container with hypochlorite solution. The servants allocated to each shift take the waste away. Linen Soiled linen from the ICU are sent to the laundry department twice a week on Mondays and Thursdays. Freshly laundered linen is received on Fridays. If patients gowns or bed sheets have been soiled then they are changed immediately. In all other cases bed sheets are changed daily. Problems faced by the department Inadequate number of ventilators is present in the ICU. The number of patients requiring ventilation far exceeds the available supply of ventilators. Outside medicines are sometimes brought in by patients. The quality and appropriateness of such medicines cannot be trusted. Shortage of staff places pressure on the existing staff.

K B Bhabha hospital

Shortage of beds the ward is officially a 10 bed unit with one bed reserved for emergency situations. However, in order to cope with the excessive patient load four other mobile beds are also placed in the unit. Shortage of servants cleanliness is a major problem because servants are in short supply. The shortage of servants prevents washing of the ward from being done twice a month. Fumigation is supposed to be done once every three months but that isnt done either.

Recommendations Purchasing more ventilators to deal with the existing patient demand Expanding the department by setting up another ICU at another floor containing at least 5 more beds. Strict protocols should be followed regarding fumigation and infection control Allocation of more servants should be done to the ICU as the chances of spreading infection is greatest in this department.

K B Bhabha hospital

CLINICAL DEPARTMENT IV OPERATION THEATRE


Ideal operation theatre (OT) Operating rooms should have walls and floor of impervious semi matt surface with anti static flooring. Tiles are no recommended. A mosaic floor with the least possible joints and with brass or copper stripes six inches apart both ways carries away static electricity. The operation theatre should be divided into three zones: the clean outer zone, the intermediate sub sterile are and the the inner sterile section. The outer zone the clean areas includes administrative, reception control area where personnel enter the department and patients are received and held or sent to appropriate holding areas of the inner zone. The intermediate area, the sub sterile area includes wok and storage areas where outside personnel deliver supplies and materials. In a completely integrated system, the post-operative recovery room may be located in this zone. The inner zone, the sterile area consists of the actual operation room and the scrub area. Various personnel have to be provided with lockers, lounges and toilet facilities. There should be a coffee room. A conference or classroom for meetings and in-service training programmes is necessary. The intermediate zone is also a good place for the doctors lounge where they can rest or wait in between cases and from where they can attend on post-operative patients without having to come out of the sub-sterile area. Surgical or post anaesthesia recovery rooms should have a nurses station with charting facilities, medication cabinet, hand washing facilities, clinical sink, provision for bedpan cleaning, storage space for stretchers, supplies and equipment. A clear space of at least 0.91 metre (3 feet) should be provided between patient beds and between the patient bed and the adjacent wall. The scrubbing area should be so located as to provide minimum travel to the operating room so that chances of contamination after the scrubbing procedures are eliminated. The types of scrub sinks and their positions should be such that there is a minimum of water splashing on nearby personnel, equipment or supply carts. Two scrub positions should be provided at the entrance to each operating room. The scrub sinks should be equipped with hot and cold mixer taps that are foot controlled. It is recommended that the surgical corridors are not less than 3.04 to 3.65 metres(10 to 12 feet) wide. They are often found lined with occupied stretchers for want of adequate holding area. In general hospitals the tendency is to have all major operating rooms as nearly identical as possible so that scheduling of various kinds of surgery is possible. Operating rooms must have a minimum clear area of 33.44 square metres(360 sq. feet) = 5.48 x 6.10 metres(18 feet x 20feet) excluding fixed cabinets and built in shelves. X ray illuminators which will handle at least two films at the same time and an emergency communication system that can be activated without the use of hands for contact with the surgical suite control section or the frozen section laboratory. K B Bhabha hospital

Number of Operating rooms the old rule of thumb is one major room for every 50 beds. In addition to major rooms the general hospital will require one or more minor operating rooms a scopy room and a fracture room. It has been found that an average primary and secondary hospital of more than 400 beds with a balanced mix of specialists can perform 1000 to 3000 procedures per operating room in a year. Facilities and space requirement Control station should be so located as to permit visual observation of all traffic into and tithing the department ORs supervisor office Operating rooms as required Pre-operative holding area Post-operative recovery area. Sterilizing facilities high speed autoclaves/flash sterilizers conveniently located to serve all operating rooms. Medical storage with refrigeration facilities. Scrub facilities An enclosed soiled workroom with a clinical sink, work computer, waste receptacle and linen hamper. This room can also be used for soiled holding. Fluid waste disposal facilities Clean workroom/clean supply room Medical gas storage facilities for reserve gas cylinders. Anaesthesia workroom for cleaning, testing and storing anaesthesia equipment with work counter and sink Equipment storage room Staff clothing change area for all categories of staff namely doctors, nurses, technicians and orderlies separate for men and women with lockers, toilets and hand washing facilities. Staff lounge and toilet facilities. May be combined for male and female personnel, but preferably separate for doctors and nurses. Should be so located that the doctors and nurses can have access to recovery room without leaving the sub-sterile area. Dictation and report preparation area accessible from the doctors lounge. Storage area for portable X ray equipment, stretchers, other items of equipment and materials Janitors closet with service sink and storage space for housekeeping equipment, supplies etc Laboratory for preparation and examination of frozen sections. This can be done in the main lab if the distance and time needed do not delay the completion of surgery. Provision for refrigerated blood bank Consultation and conference room. Administrative and clerical area for clerical work, scheduling, etc Family waiting rooms outside the operating room complex. Privacy is essential

K B Bhabha hospital

Operation Theatre
The OTs in Bhabha hospital are situated at three different places in the hospital. The surgical and orthopaedic OT is situated on the ground floor of the main hospital building. The gynaecology and ENT/ophthalmology OT is situated on the second floor of the main hospital building right next to the labour ward. The minor OT aka known as the septic OT is located in a separate building which also houses the water pump. Functions of the OT All gynaecology surgeries like C sections, hysterectomies, Tubal Ligation etc. is carried out in the gynaecology OT. Emergency surgeries like Lower Section C Section can be carried out at any time in the day. All ENT surgeries and ophthal surgeries are conducted in the ENT OT. All surgical cases like laparotomy, hydrocele, hernia, Incision and drainage, pancreatitis, laparoscopic cholecystectomy etc are carried out in the the surgical OT. Orthopaedic cases like fracture fixation are scheduled in the orthopaedic OT. Nail removal, small lipomas, Incision and drainage and biopsy are carried out in the /minor OT. The minor OT also has a Non Scalp Vasectomy room where vasectomies are carried out. All septic cases are done in the minor OT. OT schedule The surgical and orthopaedic OTs have two operation theatres out of which one is the main one and the other is the side OT. On Mondays and Tuesdays orthopaedic cases are carried out in the OT. Wednesdays and Thursdays are allocated to the surgical team. The next two days are given to either speciality on a case wise basis. The OT list is prepared one day in advance. The patients from the OPD are admitted, investigated and those whose admission records are complete are posted for the next day. The register is signed by the Assistant Medical officer, matron and the Sister In Charge. Elective cases are taken in the morning generally whereas emergency cases are carried put in the evening and the night.

OT timings In the surgical and orthopaedic OT surgeries start at 8 am. The induction time is only till 1 pm after which no cases are induced. Surgeries may last up to 2:30 pm. All infected cases are taken at the end of a normal list. In the gynaecology OT cases begin at 9 am. Induction time lasts up to around 12:30 although cases may continue up till 2 pm. The minor OT is open for patients from 8 am to 1:30 pm although staff remain in the OT till 4 pm i.e.till the time the OPD gets over. The patients from the surgical OPD are sent to the minor OT. The patients require to present the OPD paper and the surgery is carried out by the surgical resident doctor. Entry of every patient who comes in to the minor OT is made in an entry book. The K B Bhabha hospital

average number of cases seen in minor OT is around 20 per day. On Tuesdays the load may increase up to 40 cases. Staff in the OT Surgical/orthopaedic OT - The sister in charge of the surgical and orthopaedic OT is Sister Anita. She works in a general shift from 8 am to 4 pm. The sister in chage of the orthopaedic OT works from 7 am to 3 pm. There are 7 staff nurses in total out of which 2 work in the morning, 1 in the evening and 1 in the night. Two OT assistants work during the morning. 1 dresser works in the morning only along with 1 ward boy, 1 sweeper and 1 attendant. From 1 pm to 9 pm 1 ward boy is stationed in the OT for autoclaving. From 1 pm to 9 pm one ward boy is also working in the OT to wash the OT. Minor OT 1 sister in charge, 1 staff nurse, 1 ward boy, 1 dresser and 1 medical intern are posted in the minor OT in the morning. Surgical house men and registrars come and go as per the patient load. OT cleaning procedures The OTs are swept and mopped four times in a day. Fumigation of the OT is done once every month and a swab is taken of the floor, ceilings and walls is taken and sent to Cooper hospital. The results from Cooper are received within 3 days after every surgery, the surgical bed is carbolized with Bacilocid and the sheets are changed. If a high risk patient has been operated his/her gowns and other clothing are soaked for twelve hours in a solution containing 1% hypochlorite and water. Transfer control arrangements Half an hour before this surgery is scheduled, the ayah/ward boy brings the patient to the OT. Post-op once the patient is declared to have recovered from the effects of anaesthesia by the anaesthetist he/she is sent to the respective ward bythe OTs hamal. Equipment possessed by the OTs Surgical OT/orthopaedic OT Boyles apparatus 3 Cautery machine Suction machine Autoclave 1 Special table for orthopaedic case C arm Laparoscopic trolley and carbon dioxide for the same Lockers for sisters and doctors Minor OT 2 autoclaves Big machines

K B Bhabha hospital

Small instruments like artery forceps, tooth forceps, scalpels, and test tubes Suture materials Local anaesthetics

Gynaecology/ENT OT All types of scopes for laparascopy 3 autoclaves 1 steriliser 1 refrigerator

Protocol for autoclaving and sterilisation of equipment An entry of all trays that are received from different departments is made in an entry book. Each autoclave machine has the capacity to handle 3 big drums and 1 small drum containing instruments. 1 round of autoclaving is done in the morning. At noon two machines are operated and three rounds are sun. only 2 machines can be used at one time together. All equipment is stored in drums with a label that is put on them before sterilisation. The label changes colour if autoclaved properly. The date of the last autoclaving session is mentioned on the label. Any drum that has been autoclaved can be used for up three days although 48 hours is the ideal time period. Records/registers maintained Emergency surgery book Routine surgery book Doctors book Servants duty book Nurses duty book Anaesthesia register Log book OT list/schedule Medical and surgical indent book Entry book for the minor OT

Problems faced by the department Because the surgical and orthopaedic OT is combined there are less number of days and hours for both specialities. Shortage of servants Washing of clothes is problematic as there is enough area and because the department is a closed one it is difficult to dry them. The minor OT is understaffed with only one intern working throughout the day.

K B Bhabha hospital

No room is allocated to the servants in the Gynaecology OT. They are forced to change their clothes and eat food in the autoclave room. No supply of drinking water in the autoclave room. The servants have to go outside and fill water to drink. There are no lockers allocated to the servants in the OTs. Interdepartmental and intradepartmental conflicts.

Recommendations Based on the old rule of thumb, one operation theatre is required for every 50 beds. On this basis one more OT complex should be established with at least three operating rooms. The OT complex should be made a centralised department. This prevents duplication of staff and equipment in both OTs. The minor OT should be relocated to a position close to the OPD. This would prove to be more convenient for the patients requiring minor surgeries. At least two interns should be posted in the minor OT during the mornings. Lockers should be installed and given to the class IV staff and they should be located in a convenient easily accessible situation.

Performance analysis the total number of major and minor surgeries both elective and emergence for the year 2011 are listed below in a tabular format.

K B Bhabha hospital

Month Day and evening sessions Jan

Surgical Gynaec Ophthal ENT

Orthopaedics Total

Major Minor Major Minor

31 21 26 23 39 15 15 18 56 9 18 20 39 46 27 59 27 32 41 52

45 17 47 31 40 44 57 82 31 16 85 40 43 20 47 22 17 26 67 7

27 8

25 12

46 1 26 8

174 Major - 273 59 99 62 168 Major 248 77 Minor - 196 80 119 186 Major 312 49 Minor 118 126 69 162 Major 272 195 Minor 284 110 89 115 Major 246 87 131 139 Minor 226 minor 121

Feb

Major Minor Major Minor

27 7

21 8

41 3 8 19

March

Major Minor Major Minor

33 10

22 14

44 3 23 9

April

Major Minor Major Minor

60 4 0 1 52 2

10 29 2 7 7 27 3 2

10 60 34 22 12 28 21 78

May

Major Minor Major Minor

K B Bhabha hospital

June

Major Minor Major Minor

40 16 14 41 12 25 53 17 42 11 10 35 27 5 10 18 23 6 10 26 23

48 17 47 35 31 24 49 33 44 12 49 13 19 8 77 23 26 8 31 13 31

18 7

29 13

33 1 17 16

168 Major 246 54 Minor 146 78 92 110 60 139 65 137 Major 216 28 79 65 86 Major 184 16 Minor 71 98 55 81 Major 255 36 Minor 75 74 39 125 Major 232 Minor 93 Major 249 Minor 125

July

Major Minor Major Minor

10 2

15 7

42 2 37 15

August

Major Minor Major Minor

0 0 0 0 2 1 0 0 10 1

7 0 0 0 10 2 0 0 10 3

44 5 20 17 28 0 11 14 12 18 33 0

September Major Minor Major Minor October Major Minor Major Minor November Major

19

13

39

K B Bhabha hospital

Minor Major Minor December Major Minor Major Minor

31 13 17 40 17 22 12

11 86 17 20 11 61 20

1 8 16

56 Minor 106 107 50 134 Major 229 45 Minor 87 95 42

25 6

13 6

36 5 12 10

Total number of Major surgeries conducted 2616 Total number of minor surgeries conducted 1648 Total number of surgeries conducted in the minor OT 7118

K B Bhabha hospital

General analysis of the hospital for the year 2011:


Average length of stay : 5.49 days
ANNUAL 205194 336713 541907 18839 97342 25516 1943 27459 2233 689 292 2616 1648 7118 11382 49599 33987 9605 8632 18237 DAILY AVERAGE 684 1122 1806 52 266 70 5 75 6 2 8 7 5 19 31 136 93 26 24 50

O.P.D. ATTENDANCE

NEW OLD TOTAL MEDICO LEGAL CASES EMERGENCY OPD GENERAL WARD ICU WARD TOTAL NORMAL LSCS TOTAL MAJOR MINOR EMERGENCY TOTAL TOTAL X-RAY FILMS TOTAL PATIENTS ROUTINE EMERGENCY TOTAL ROUTINE EMERGENCY TOTAL ROUTINE EMERGENCY TOTAL NO. OF REFERENCES NO. OF TRANSFERS OUT NO. OF TRANSFERS IN TOTAL TOTAL

CASUALTY ATTENDANCE

ADMISSIONS

DELIVERIES

SURGERY

6 7

X-RAY USG

C.T.SCAN

E.C.G.

10

AMBULANCE CALLS

11 12 13

HEARSE CALLS DEATHS INCOME

4800 2935 7735 631 145 180 681 818 Rs.32,94,550

16 8 24 2 1 1 2 2 Rs. 9001

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