Aiims Study 1

Emergency and Injury Care
at Secondary and Tertiary

Emergency and Injury Care at Secondary and Tertiary Level Centres in India
Level Centres in India

A Report of Current Status on
Country Level Assessment
Emergency and Injury
Care at Secondary
and Tertiary Level
Centres in India
A REPORT OF CURRENT STATUS ON
COUNTRY LEVEL ASSESSMENT
PROJECT REPORT SUBMITTED TO

NITI Aayog, New Delhi
This study was carried out with the financial support of

NITI Aayog, Government of India,
and conducted by
Department of Emergency Medicine,
JPNATC, AIIMS.
DISCLAIMER
Department of Emergency Medicine, JPNATC, AIIMS has received the
financial assistance under the Research Scheme of NITI Aayog (RSNA 2018)
to prepare this report. While due care has been exercised to prepare the
report using the data from various sources, NITI Aayog does not confirm
the authenticity of data and accuracy of the methodology to prepare the
report. NITI Aayog shall not be held responsible for findings or opinions
expressed in the document. This responsibility completely rests with the
Department of Emergency Medicine, JPNATC, AIIMS.
Copyright: © 2020 Department of Emergency Medicine, JPNATC, AIIMS,

New Delhi
All rights reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording or any information storage and retrieval system,
without permission in writing from the publisher.
This book and the individual contributions contained in it are protected
under copyright by the Department of Emergency Medicine, JPNATC,
AIIMS, New Delhi.
LIST OF
INVESTIGATORS AND
CONTRIBUTORS
S. No. Name Designation Organization

PRINCIPAL INVESTIGATOR
Department of Emergency
1 Dr Sanjeev Kumar Bhoi Professor Medicine, JPNATC,
AIIMS, New Delhi
CO-INVESTIGATORS
Professor &
2 Dr Praveen Aggrawal Medicine, AIIMS, New
HOD
Delhi
Associate
3 Dr Tej Prakash Sinha Medicine, JPNATC,
Professor
AIIMS, New Delhi
CONTRIBUTORS
Directorate General of
Deputy Director
4 Dr Tanu Jain Health Services, Nirman
General
Bhawan, New Delhi
iii
Emergency and Injury Care at Secondary
and Tertiary Level Centres in India
IFS, Chief
Conservator of Govt. of Arunachal
5 Dr S Rajesh Forests Pradesh
Former Director NITI Aayog, Govt. Of
(Health) India, New Delhi
National Institute of
Officer on
6 Dr K Venkatnarayan Transforming India (NITI)
Special Duty
Aayog
RESEARCH OFFICERS
7 Ms Dolly Sharma Research Officer
Medicine, JPNATC,
AIIMS, New Delhi
8 Dr Monica Sindhu Research Officer
iv
Foreword
Care of emergency and accident patients is of paramount importance in saving

lives, preventing disability and for achieving the intended health goals of the Nation.
However, accident and emergency services in India has witnessed uneven progress.
Given its extraordinary importance, it is time that India embarks on creating a world-
class, efficient, professional and integrated system, enabled by technology, for the care
any victim of accident, emergency or trauma in any part of the country.
To understand the imperatives in realizing this goal, NITI Aayog, jointly with
Ministry of Health & Family Welfare (MoHFW) conducted field visits and held multi-
stake holder meetings. It emerged from these deliberations that a pan-lndia study to
assess gaps in optimal delivery of emergency care services was a crucial starting point.
Accordingly, NITI Aayog commissioned Emergency Medicine Department, AllMS, New
Delhi to conduct a Nation-wide assessment of prevailing emergency care system in
India.
I am happy to note this study, which involved 100 Secondary and Tertiary level
health facility sites of government and private hospitals of all zones of the Nation,
has been completed. Besides highlighting the spectrum and load of emergency cases,
it brings out the prevailing gaps in ambulance services, health infrastructure, human
resources and equipment in the provision of optimal care. I complement the team for
conducting live observations of various processes involving efficiency of time-bound
procedures, patient satisfaction reports. Medico-legal burden, adherence to protocols
and data-entry operations.
My congratulations to the AllMS team for successful completion of the project and
the teams from NITI Aayog and Ministry of Health & Family Welfare for their useful
contribution In bringing out this timely report. The learnings from this study would be
useful for developing vision and plans toward creating world-class emergency care in
the country.
MESSAGE
Emergency conditions such as Acute coronary syndrome, stroke, respiratory diseases,

maternal and pediatric emergencies and injuries are the leading causes of death and
disabilities in India. Trauma is the leading cause of death among young, who often are
the sole bread earner of the family.
The landscape of emergency care includes timely access and acute care delivery to
critically ill and injured patients. Premature death and Disability Adjusted Life Years
(DALYs) can be prevented by establishing robust integrated emergency care system with
definitive care.
In this study, 100 healthcare facilities were randomly selected from 28 states and 2 union
territories of our Country and were assessed by team of assessors.
This study aims to find the available gaps in the emergency and injury care system in the
healthcare facilities, both in government and private sector. It also studied the linkages
between pre-hospital care and hospital care in India.
I strongly believe that the outcomes of this study will provide the policy inputs to improve
and strengthen the emergency care services at all tiers of the healthcare facilities in India.
I congratulate the researchers for conducting this very important study.
ACKNOWLEDGEMENT
ACKNOWLEDGEMENT
We wish to express our sincere gratitude to all who helped us to complete this project in an
efficient time-bound manner. This study was carried out by Department of Emergency Medicine,
JPNATC, AIIMS, with the financial support of NITI Aayog, Government of India.
At the outset, we like to thank Dr V K Paul, Member, National Institution for Transforming India
who provided useful insights in conceiving this study and guiding throughout various processes.
We would like to thank to Dr Madan Gopal, Sr. Consultant, NITI Aayog for his kind support and
co-operation both during this study and submission of its report.
This study would not have been possible without the continued support. dedication and constant
engagement of all our research staff and team of national assessors, especially given the limited
time frame.
We would also thank all the nodal officials and all the staff of various hospital sites, who were
immensely cooperative in providing the needful inputs for the study, whenever our team reached
out to them.
Our special thanks to the teams representing our key stakeholders from the Ministry of Health
and Family Welfare and NITI Aayog, for their valuable contribution and time.
Finally, we thank the God almighty for giving this opportunity to successfully conduct this study;
which we hope, would bear an important imprint for making key policy decisions to deliver
optimal emergency care for the Nation.
Team of Investigators
JPNATC
AIIMS, New Delhi
ix
TABLE OF CONTENTS
List of Investigators and Contributors iii

Foreword v
Message vii
Acknowledgement ix
Abbreviations xv
1. EXECUTIVE SUMMARY 1
1. Salient Findings of the Study 4
2. Key Recommendations 8
2. INTRODUCTION 11
3. REVIEW OF LITERATURE 15
1. Burden of Emergency Conditions in the South-East Asian Region 16
2. Burden in India 18
3. Current Status of Emergency Care in the India 19
4. WHO Emergency Care System Framework 20
5. Hospital Based Emergency Care in the Government Sector in India 22
6. Training 22
7. Academic Emergency Medicine 23
8. Gaps 23
8.1 Research and Development for Emergency Services 23
8.2 Organization and financing 24
4. AIMS AND OBJECTIVES 27
5. METHODOLOGY 31
6. OBSERVATIONS AND RESULTS WITH SUGGESTIONS 39
I. FIELD VISIT: ADMINISTRATIVE INTERVIEW/ONE YEAR DATA COLLECTION 39
1. Background Information of the Hospitals 39
2. Available Beds at Assessed Facilities 39
xi
3. Burden of Patients (OPD and Emergency) 41

4. Huge Mismatch between Emergency Beds & Burden of Emergency and Injury Cases: 44
5. Burden of Medico-legal Cases 46
6. Burden of Admissions through Emergency 48
7. Burden of Death of Trauma Patients 49
8. Burden of Patient’s Death due to Road traffic Injury 50
9. Burden of Brought Dead Patients 50
10. Blood Bank Services 51
11. Definitive Care Services 57
12. Ambulance Services 62
12.1 Available ambulances in hospitals 62
12.2 Hospital Ambulance Services 65
12.3 Use of Ambulances by Hospitals 67
12.4 Patient transfer in absence of hospital ambulance: 67
13. ED Protocol / SOP / Guidelines 68
14. Emergency care protocols 72
15. Measures ensuring Safety & Security in Hospitals 75
16. Disaster Management 78
17. Continuous Quality Improvement 82
18. Computerized Data Management System 87
19. Financing 92
20. Physical Infrastructure 96
21. Manpower in Emergency Department 98
22. Equipment and Supplies in ED 101
22.1 Biomedical Equipment 101
22.2 Compliance of critical available equipments 102
23. Point of Care Lab 107
24. Essential Medicines for Emergency 111
II. LIVE OBSERVATION 114
1. Disposition Time 114
2. Chest Pain 116
3. Stroke 120
4. Trauma 125
5. Incidence of Violence 128
5.1 Reason of Violence 128
5.2 Mitigation measures 129
6. Communication Skills in Emergency Department 130
7. Patient Satisfaction 131
8. Referral of the Patient 133
III. LIVE OBSERVATION (ONE DAY DATA OF EMERGENCY) 136
1. Burden of Patients (OPD and Emergency) 136
2. Disposition Summary 137
xii
Table of Contents
3. Spectrum of Diseases 138

3.1 Adult Patients 138
3.2 Pediatric Patients 140
IV. COMPARISON OF EMERGENCY CARE IN VARIOUS SYSTEMS 142
1. Hospitals with Academic Emergency Medicine (n=5) 142
2. Govt. Secondary care v/s Tertiary care Hospitals 146
3. Private Hospitals vs Government Hospitals 151
4. NABH accredited vs non-NABH accredited Hospitals 151
V. COMPLIANCE OF INDIVIDUAL HOSPITALS TO THE CHECKLIST 152
7. DISCUSSION 155
8. CONCLUSIONS 159
9. SUMMARY OF KEY SUGGESTIONS EMERGING FROM THE STUDY 163
10. SUGGESTED KEY POLICY RECOMMENDATIONS 169
11. REFERENCES 175
12. ANNEXURE 179
Annexure-I: List of Hospitals 181
Annexure-II: Study Tool 185
Annexure-III: List of Scientific Advisory Committee Members 224
Annexure-IV: Patient Information Sheet 226
Annexure-V: Confidentiality / Conflict of Interest Agreement Form for National Assessor 228
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital 230
Annexure-VII: List of National Assessors 242
Annexure-VIII: Contact Details of Hospitals 249
Annexure-IX: Comparative compliance of Hospitals among categories 256
xiii
ABBREVIATIONS
ACLS Advanced Cardiac Life Support

AIIMS All India Institute of Medical Sciences
ALS Advanced Life Support
AMBU Artificial Manual Breathing Unit
APTT Activated Partial Thromboplastin Time
ATLS Advanced Trauma Life Support
BLS Basic Life Support
Ca Calcium
CABG Coronary Artery Bypass Grafting
CCU Critical Care Unit
CD Communicable Disease
Cl Chlorine
CMO Chief medical officer
CT Computerized Tomography
DALYs Disability-Adjusted Life Years
DLC Differential Leucocyte Count
DNB Diplomat of National Board
DSA Digital Subtraction Angiography
ECG Electrocardiogram
ECS Emergency Care System
ED Emergency Department
EHR Electronic Health Record
EM Emergency Medicine
xv
EMS Emergency Medical Services

EMT Emergency Medical Technician
ER Emergency Room
ETAT Emergency Triage Assessment and Treatment
FFP Fresh Frozen Plasma
GDA General Duty Attendant
GDP Gross Domestic Product
GHE Global Health Estimates
HA Hospital Attendant
Hb Hemoglobin
Hct Hematocrit
HDU High Dependency Unit
HMRI Hai Medicare and Research Institute
ICU Intensive Care Unit
INDUSEM INDO-US Emergency Medicine
INR International Normalized ratio
IPD In-Patient Department
IPGMER Institute of Post-Graduate Medical Education and Research
ITU Intensive Treatment Unit
IV Intra-venous
JPNATC Jai Prakash Narayan AIIMS Trauma Centre
JR Junior Residents
K Potassium
LAMA Left Against medical Advice
LMA Laryngeal Mask Airway
LMICs Lower Middle Income Countries
MCI Medical Council of India
MLC Medico legal Cases
MO Medical Officer
Na Sodium
NABH National Accreditation Board for Hospitals & healthcare Providers
NCD Non-Communicable Disease
NITI Aayog National Institution for Transforming India
OPD Out Patient Department
OT Operation Theatre
xvi
Abbreviations
PALS Pediatric Advanced life Support

PCI Percutaneous Coronary Intervention
PEF Peak Expiratory Flowmeter
Pro-BNP N-terminal B-type Natriuretic Peptide
PT Platelet Transfusion
RBC Red blood Corpuscles
RTI Road Traffic Injury
SA Sanitary Attendant
SAC Scientific Advisory Committee
SD Standard Deviation
SEAR South East Asian Regions
SOP Standard Operating Procedures
SPSS Statistical Package for the Social Sciences
SR Senior Residents
SSG Sir Sayaji General
SSKM Seth SukhlalKarnani Memorial
STNM Sir ThutobNamgyal Memorial
TEG Thromboelastogram
TLC Total Leucocyte Count
Trop-I Troponin I
Trop-T Troponin T
U.S. United States
USG Ultrasound/Sonography
WHO World Health Organization
xvii
EXECUTIVE SUMMARY 01
TRIAGE
NO DELAY!!
Radial Pulse - Present / Absent;

RED Physiology Noisy Breathing/Stridor; Pulse<50 or >120/min;
Criteria >> A Angioedema
Active seizures C SBP <90 mm Hg or >220mm Hg;
Capillary refill >2 sec
(If any one of these mentioned Shock index > 1
vital criteria is present on the Talking incomplete sentence; Altered sensorium,
assessment) >> B RR<10 or >22/min;

SPO2 <90%
D Responding only to pain on AVPU-Scale of GCS < 12
C-Spine Injury with Single Breath count < 15
Non- Trauma Trauma

Symptoms/ History/ Exam finding based Injuries identified Mechanism of injury
1. Breathlessness / Pallor with Edema 1. Gun-shot wound 1. Fall from
2. Active Bleeding (Hematemesis, Hemoptysis, Epistaxis, 2. Major Vascular injury • >3 times height of patient
Hematuria, etc) 3. Stab wounds • >5 stairs
3. Active seizures (Head/Neck/Chest/Abdomen/Groin) 2. Roll over vehicle
4. H/o Fainting / Syncope 4. Multiple injuries 3. Co-passenger death
5. Fever with Delirium 5. Open fractures excluding fractures of 4. Ejection from vehicle
R 6. Poisoning with unstable vital sign
7. Snake / Scorpion bite
R hand and feet
6. Two or more long bone fracture
5. Railway track injuries
6. Steering wheel injury
E 8. Burn >20% BSA (Burn of special areas)
9. Hanging /Drowning / Electrocution / Heat Stroke
E 7. Pelvic fracture
8. Visible neck swelling
7. Prolonged extrication time from
vehicle
D D 9. Suspected sexual assault
10. Flail chest with paradoxical respiration
8. Roll over vehicle
9. Stuck between 2 heavy vehicles
11. Chest trauma with
• Surgical Emphysema
• Seat Belt Mark
• CCT Positive
12. Traumatic Amputation
Y Y
1. Minor Head Injury 1. Suspected abuse
1. Post-seizure stage
2. Open or closed fractures of hand & feet (Child/Women/Elderly)
2. Pain abdomen / Loose motions (>3episodes)
3. Isolated long bone fracture 2. Significant assault
E 3. Painful Bleeding P/R
4. H/o Bleeding E 4. GCS-15 with -
• Alcohol
L L
5. Pallor/ Known Anaemia for Transfusion
• Anticoagulant
6. Fever with Headache/ chest Pain / Jaundice
• LOC and vomiting
7. Fever in patient on chemotherapy / HIV Patients /
L Diabetic patients
8. Drug overdose, Poisoning with stable vital signs
L • Nasal & ENT bleed
• Limb Weakness
O 9. Painful swelling / wound

10. Headache, dizziness
O
W 11. Unable to pass stool
12.Unable to pass urine W
G
1. Minor symptoms of existing illness 1. Abrasions
G 2. Fitness urticaria / Skin rash
3. Fever
2. Lacerations
3. Isolated fracture of small bones of hand and foot
R 4. For medico-legal examination
5. Minor conditions and low risk conditions (cough, cold,
R 4. Contusions and Bruises
E etc.)
E
E E
N N
EXECUTIVE SUMMARY
01
Medical emergencies including Road Traffic Injuries are one of the major leading causes of deaths
in India. RTIs alone contribute to 1.5 Lakh deaths annually. Approximately 2 persons died of
heart attack every hour in 2015-16. Currently, Non Communicable Diseases alone account for
~62% of deaths in India and Communicable infections, Maternal, New born account for ~27%
of deaths. Most of these deaths present as emergency conditions. In fact, as per one estimate
more than 50% of deaths and 40% of total burden of disease in Low Middle Income Countries
could be averted with pre-hospital and emergency care. The global total addressable deaths and
DALYs that can be averted amount to 24.3 million and 1023 million lives respectively. In fact,
in South-East Asia alone, 90% of deaths and 84% of disability-adjusted life years (DALYs) are due
to emergency and trauma conditions.
Emergency care system in our country has seen uneven progress. Some states have done well,
while others are still in the budding stages. Overall, it suffers from fragmentation of services from
pre-hospital care to facility-based care in government as well as in the private sector. The system
also suffers from lack of trained human resource, finances, legislation and regulations governing
the system.
Absence of standalone academic department since its inception is another factor for the current
ails in the system.
In the light of the above, the present study was conducted. The study aimed to assess the prevailing
status of emergency and trauma care at government and private hospital settings of India to bring
out the existing gaps and provide a framework for further improvement and the needed policy
directions. Towards achieving this goal, a country-wide study of emergency and trauma care
services of 100 tertiary and secondary level hospitals in 29 States and 2 Union Territories from
5 regions of India was conducted.
The selected health facilities consisted of 20 hospitals each under the following categories: Govt.
Medical Colleges, Private hospitals>300 bed strength, Private hospitals<300 bed strength,
Government hospitals >300 bed strength and Government hospitals <300 bed strength. The
assessments were conducted by trained assessors, selected from all over country who followed
by the investigators and research team.
3
SALIENT FINDINGS OF THE STUDY

Case load
Emergency and injury cases annually accounted for 9-13% of all patients presenting to
a health facility and 19-24% of admissions in Govt Hospitals and 31-39% admissions
in Private Hospitals.
Live observations revealed that emergency cases accounted for 11-30% of all OPD
patients on a given day.
Spectrum of major medical conditions presenting at Emergency

Departments
During live observations conducted for 24 hours at the study centres, the following
were the most common spectrum of cases encountered at the EDs:
Adult patients (n=4677): Trauma and road-traffic injuries (24%), Fever (20%), Pain
Abdomen (16%), Respiratory Distress (11%), Chest Pain (9%), Pregnancy-related
(6%), altered mental status (5%), Poisoning (4%), Stroke (3%) and Snake bite (2%)
Pediatric patients (n=1403): Fever (31%), Diarrhoea (21%), Respiratory distress
(17%), Pain abdomen (14%), Trauma and road traffic injuries (9%), Seizures (4%),
altered mental status (2%), poisoning (1%) and Snake bite (1%).
Ambulance Services
Even though 91% of hospitals had in-house ambulances, trained paramedics needed to
assist ambulance services were present only in 34%.
Provision of specialized care during ambulance transport were largely poor: only 19%
hospitals had mobile Stroke/ STEMI (for heart attack) program, with only 4% having a
mobile Stroke unit.
Most of the hospitals lacked Pre-hospital arrival notification system, with larger
representation of Government over Private Hospitals.
Physical Infrastructure
Despite high patient load reporting to the EDs, the number of beds available at Emergency
Departments accounted for only 3-5% of total hospital beds.
Amongst the critical infra-related quality parameters assessed in the EDs, the following
were important deficiencies: absence of point of care lab (73%), demarcated triage area
(65%), police control room (56%), separate access for ambulance (55%) and adequate
spacing for emergency department (52%).
Overall, on a standard matrix of assessment, Private Hospitals ranked better than
Government Hospitals.
4
Executive Summary
Human Resource
Most of the hospitals lacked presence of general doctors, specialists and nursing staff
dedicated for Emergency Departments vis-à-vis the average footfall of patients, even
though, the hospitals as such, had sufficient overall numbers of required human resource.
Besides, when present, most of the EDs were manned by junior doctors rather than
specialists.
Equipment status
Compliance with availability of overall recommended biomedical equipment and critical
equipment were largely found satisfactory at all private hospitals (86-93%) and Govt
medical college hospitals (68%), with deficiencies found largely in smaller government
hospitals (45-60%).
Specifically, equipment deficiencies pertained largely to the category of Pediatric-care
(75%). Equipments pertaining to Airway, Breathing, Circulation and General categories
had deficiencies pertaining to a few sets of specific equipments (10-72%).
Essential Medicines
Since it is essential to have the complete list of all recommended emergency medicines
24*7 in the emergency departments, assessment done for this aspect revealed that only
9% of all hospitals, fulfilled this criterion.
Overall, Private colleges fared better in maintaining the recommended inventory of
recommended medicines (86-89%) compared to Govt Hospitals (52-72%).
Definitive Emergency Specialized Care

Amongst study of definitive care services, availability of emergency operative care
services (for trauma, non-trauma, orthopedic, neurosurgical, obstetric care) varied
between 47-60% depending on the type of services and hospital facility.
Similarly, critical care services (involving intensive care services such as ICU, HDU,
PICU, NICU, CCU, Neuro ICU) varied across hospital facilities, but were typically
largely deficient at smaller Govt Hospitals.
Many Govt Medical Colleges lacked common HDU (55%), Cardiac ICU (55%) and
Neuro ICU (55%). In addition, they also lacked facilities for Coronary Artery By-pass
Graft (55%), Cardiac Cath Labs (30%) and interventional radiology (40%).
Blood Bank services

An in-house 24*7 functional Blood Banks were available in 90% of Govt Medical
Colleges, 70% of Govt Hospitals with >300 beds and 35% of Govt Hospitals with <
300 beds. While in Private there were present in 85% of Hospitals with > 300 beds
and 65% of Hospitals <300 beds.
Most of the Hospitals did not have a dedicated Blood Bank in the Emergency Department
nor an existing standard protocol for massive blood transfusion.
5
Patient disposition time (Live observation)

The patient disposition time for the sickest group (Red zone) was high at Government
Medical Colleges (90 Minutes) vis-à-vis Private Hospital (15 minutes). The reasons for
this delay amongst others were due to: high patient load, lack of in-house specialists
in the ED, need for multiple cross referrals, with an overarching lack of a dedicated
department for emergency services.
On study of efficiency of various time-bound procedures that need to be conducted for
optimal management of Chest Pain, Stroke and Trauma; generally Private Hospitals fared
better than Government Hospitals. And amongst the latter, smaller hospitals fared worse.
Violence between relatives of the care-seekers and health care providers were noticed
22-47% of hospitals, with higher representations from Government Hospitals. The
reasons were largely due to delay in providing care in Government Hospitals and
failure of appropriate communication in the Private set-ups.
Most of the Private Hospitals and smaller Government Hospitals lacked facilities such
as presence of Police/ private security guards, to mitigate such violence episodes.
Patient Satisfaction (Live observation)

Patients availing emergency care at Private Hospitals were largely satisfied with the
services provided (65-82%) in contrast to Government Hospitals (31% to 65%)
MLC Burden
The burden of Medico-legal cases (MLC) was 2-9% of all admissions.
They were disproportionately more MLCs at Government Medical College Hospitals
than others (9% Vs 3%), probably due to higher selective transfer of such cases form
other hospitals to avoid procedural issues.
ED protocols, Quality measures and Disaster planning

Most of the Government Hospitals lacked SOPs/standard manuals for emergency care,
patient transfer-in/out and handling of death. Further, policies for triaging and disaster
management were found only in ~50% of Government Hospitals and were largely
present in Private Hospitals.
Specific protocols for definitive care for chest pain, suspected sepsis, stroke, trauma and
cardiac arrest were found lacking across the spectrum of hospitals, with a higher share
of Government Hospitals. Similar patterns were seen for Disaster management planning
and systems to enforce continuous quality improvements.
Computerized data entry systems

Though computerized electronic health records, patient registration system were present
at most of the hospitals; specific computerized systems for patient clinical examination
notes, lab investigation reports and for data retrieval for research were largely deficient
in the Government Hospitals.
6
Executive Summary
Most of the hospitals across the spectrum lacked trauma registry and systems for
surveillance of trauma and Emergency Care.
Financing
None of the Hospitals had funds dedicated for emergency care services. A few of the
Hospitals received funds as part for delivery of trauma-care. Of the zones, the Eastern
Zone was the worst afflicted in terms of receipt of funds from Central/ State Government.
On assessing funding for overall hospital services, Ayushman Bharat as the major funding
Scheme (53%) followed by NHM (15%), Other State, Central Government and PSU
Schemes (11% each)
Comparison of various Hospital set-ups

NABH accredited vs non-accredited Hospitals
Overall, NABH accredited Hospitals fared better on all counts that required maintenance
of rigour of quality and services to deliver optimal patient care and functioning of
systems.
Presence of ongoing academic program in Emergency Medicine

Hospitals conducting structured academic programs in the subject of Emergency
Medicine have comprehensive robust systems in place for efficient patient care services
including critical care and definitive care, tackling imminent disasters and continuous
quality improvement.
These systems also ensure effective communication skills amongst care givers and timely
delivery of care, translating into higher patient satisfaction levels.
Secondary Vs Tertiary level Government Hospitals

Secondary level Government Hospitals (District Hospitals) fared better than tertiary level
hospitals (Medical Colleges) in terms of having standard SOPs for management of cases,
mock-drills, regular audits, referral policies and better patient satisfaction responses.
However, most of them needed further strengthening of following services: Blood Bank
facilities and definitive care such as operative procedures and critical care.
Private Vs Government Hospitals

Private Hospitals fared better than the Government Hospitals in terms of having
emergency operative services, mock drills, training programmes, regular audits and
referral policies.
Private Hospitals also ensure effective communication skills amongst care givers and
timely delivery of care, translating into higher patient satisfaction levels.
7
KEY RECOMMENDATIONS
1. Develop a robust integrated emergency care service system which can comprehensively
address all medical. Surgical emergencies inclusive of trauma-related care.
2. Standardize protocols, SOPs for emergency care, inclusive of triage to have a common
optimal nation-wide policy.
3. Strengthen the prevailing pre-hospital services such that a world-class ambulance services
are made available 24*7, encompassing on-going definitive care through effective
paramedics, for all citizens of the country and, these should be optimally integrated
with hospital care with an efficient pre-hospital arrival system using latest Information
Technologies.
4. Create adequate space for emergency care systems at the prevailing health facilities
such that standardized emergency departments with recommended proportion of beds,
infrastructure, equipment, drugs and human resources become a norm.
5. Systems to ensure efficient handling of medical care during disasters need to be ensured
at all hospitals.
6. Expand Blood Bank related services such that even smaller Government Hospitals are
ensured timely availability of on-demand blood and its related products.
7. Upgrade all the prevailing emergency care services to meet the standardized norms,
with efforts made to accredit all the existing emergency departments. All medical
colleges should attain self-sufficiency in providing definitive care for all emergency-
related conditions.
8. Establish Academic Emergency Medicine departments to ensure continuous ongoing
medical education and development of skills for doctors, nurses and paramedics.
9. Create standalone Central/ State level efficient funding mechanisms to ensure continuous
upgradation of emergency related issues at all hospitals, with built-in mechanisms for
periodic assessments to check optimal delivery of services.
10. Develop mechanisms to ensure free treatment for emergency care services for all citizens
covering the minimal required period for early stabilization.
8
REVIEW OF LITERATURE 02
EMERGENCY CARE HUMAN RESOURCES FUNCTIONS

VEHICLES, EQUIPMENT, SUPPLIES,
INFORMATION TECHNOLOGIES
H
SYSTEM FRAMEWORK CLINICAL OR
OPERATIONAL
All around the world, acutely ill and injured people seek care every day.
PROTOCOLS INPATIENT
Frontline providers manage children and adults with injuries and infec-
tions, heart attacks and strokes, asthma and acute complications of
pregnancy. An integrated approach to early recognition and manage-
ment saves lives. This visual summary illustrates the essential functions
of a responsive emergency care system, and the key human resources,
equipment, and information technologies needed to execute them. The
reverse side adresses elements of governance and oversight. • Early critical care
• Early operative care
Ad
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DRIVER fer
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PROVIDER
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Handover
Triage Screening Registration
PROVIDER
BYSTANDER Reception of Patients
SCENE TRANSPORT FACILITY

• BYSTANDER RESPONSE • PATIENT TRANSPORT • RECEPTION
• DISPATCH • TRANSPORT CARE • EMERGENCY UNIT CARE
• PROVIDER RESPONSE • DISPOSITION
www.who.int/emergencycare · [email protected] • EARLY INPATIENT CARE
INTRODUCTION
02
The emergency care system and facility-based care in India are in its infancy. It suffers from the
fragmentation of services from pre-hospital care to facility-based care both in government as well
as in private sectors. The system also suffers from the lack of trained human resources, finances,
legislation, and regulations governing the system.
The facility-based care in tertiary care lacks trained human resources due to the stunted growth of
academic emergency medicine since its inception. The other allied disciplines such as emergency
nursing and emergency medical technician are yet to take shape. Hence it is important to assess
the existing gaps in facility-based emergency care and the linkages to the emergency care system
in a representative stratified multi-stage random sample of 100 healthcare facilities across India.
The study was a cross-sectional survey across the five regions of the country.
In the survey, a total of 100 healthcare facilities were assessed with the help of a Consensus-based
tool (predesigned pretested data collection tool) for the data collection.
The project aims at country-level assessment of the gaps and linkages in emergency and injury
care at government medical colleges, private hospitals and district hospitals of India. This study
proposes:
1. To describe the burden of emergencies and injuries in the country
2. To identify and describe current gaps and suggest interventions to strengthen the
emergency/injury care (Pre-hospital care, definitive care, referral and rehabilitation
services)
3. Suggesting strategies to strengthen the emergency/injury care at the tertiary center level
4. Identification of prospects on strengthening/ establishing academic Emergency Medicine
at Medical Colleges
The purpose of the report is to identify the gaps in emergency and injury care systems in healthcare
facilities as well as to find out the linkages between the pre-hospital care and facility-based care
system in our country. Based on the findings and outcomes from the study, suitable policies will
be made to strengthen the emergency and injury care at the national level.
11
REVIEW OF LITERATURE 03
REVIEW OF
LITERATURE
03
Emergency care can be defined as the delivery of time-sensitive interventions needed to avert
death and disability and for which delays of hours can worsen prognosis or render care less
effective.
All around the world, acutely ill and injured people seek care every day. Goal of an effective
emergency medical system should be to provide universal emergency care — that is, timely quality
emergency care should be available to all who need it.
However, there are many unfounded myths about emergency medical care, and these are often
used as a rationale for giving it a low priority in the health sector, especially in low- and middle-
income countries. These myths include equating emergency care to ambulances and focusing on
transport alone while neglecting the role of care that can be provided in the community and at
a health-care facility. Perhaps most common is the perception that emergency care is inherently
expensive; this myth focuses attention on the high-technology end of clinical care as opposed to
the strategies that are simple and effective. Efforts to improve emergency care, however, need not
lead to increased costs for many people around the world, emergency care is the primary point
of access to the health system, and is thus, essential to universal health coverage.
As per a study, injuries alone accounted for 14% of the burden of disease among adult in 2002.
It is thus challenging to define the burden of disease addressed by emergency medical systems.
Emergency medical system is a set of diseases encompasses of communicable infections, non-
communicable conditions, obstetrics and injuries. Patients with all these conditions may present
to the emergency medical system either in the acute stages (such as diabetic hypoglycaemia,
septicaemia, premature labour or asthma) or may present with conditions that are acute in their
natural presentation (such as myocardial infarction, acute haemorrhage or injuries)(1).
A recent study showed that all 15 leading causes of death and disability-adjusted life years (DALYs)
globally were the conditions with potential emergent manifestations.(2)
By ensuring early recognition of acute conditions and timely access to needed care, organized
emergency care systems save lives and amplify the impact of many other parts of the health
system. The World Bank Disease Control Priorities Project estimates that Emergency care system
(ECS) with sound organization, have the potential to address over half of deaths and a third of
disability in low- and middle-income countries. (3)
Simple, low-cost interventions to strengthen timely emergency care delivery can have dramatic
impact on clinical outcomes, and well-integrated emergency care has enormous potential to save
lives even with limited input of new material resources.
BURDEN OF EMERGENCY CONDITIONS IN THE SOUTH-EAST

ASIAN REGION
Despite tremendous improvement in health care delivery in the SEAR over recent decades, high
rates of injuries and cardiovascular emergencies, now among the leading causes of death, co-exist
with persistent high rates of infectious disease and maternal and infant mortality in some areas.
Timely, quality emergency care prevents death and disability from all of these conditions, but
ECS are still under-developed in many SEAR countries. 90% of deaths and 84% of DALYs were
attributable to emergency conditions with South-East Asia having the second highest burden of
emergency conditions (Figure1).
Figure 1: DALYs per 100,000 population attributable to emergency conditions, by etiology: separated by income
level (A) and region (B). Distribution of deaths was similar. NCDs, non-communicable diseases; CDs, communicable
diseases; DALYs, disability-adjusted life years(2)
**Source: Reference (2)
WHO has projected the rise in the burden of various diseases causing death in SEAR in 2015
and 2030 (Table 1).This projection shows a significant decrease in mortality from communicable,
maternal, perinatal and nutritional causes from 25.2% to 16.1%. However, there is a projected
rise in deaths due to non-communicable diseases (NCD) from 63.5% in 2015 to 72.5% in 2030,
which is a cause for concern.(4)
16
Review of Literature
Table 1: Projections of mortality by cause for 2015 and 2030(4)
Deaths (thousands) by cause projected to 2015 and 2030 in SEAR

Year 2015 2030
Population (thousands) 1920761 2205146
GHE 2012 cause category Deaths % Total Deaths % Total
All Causes 14851 100 18595 100
I. Communicable, maternal, perinatal 3748 25.2 2998 16.1
and nutritional conditions
II. Non-communicable diseases 9428 63.5 13472 72.5
A. Cardiovascular diseases 4159 28.0 5872 31.6
B. Respiratory diseases 1712 11.5 2561 13.8
C. Malignant neoplasms 1412 9.5 2310 12.4
D. Diabetes mellitus 434 2.9 690 3.7
III. Injuries 1676 11.3 2125 11.4
(Based on the GHE 2012 estimates of causes of death for 2011, the regional projections
of mortality by cause for years 2015 and 2030 were carried out in 2012. (4)
Injuries came at 6thin the list of common causes of death and are responsible for 11.3% of all
deaths in SEAR (Table 1). Road injuries are the commonest cause of death in SEAR increasing
from 24.7% to 28.9% from 2015 to 2030, respectively.(4) With 90% of deaths occurring in LMICs
which only account for 54% of the world’s vehicles, these deaths and injuries are unevenly
distributed.(5) Figure 2 illustrates country-specific road traffic fatality rates. Amongst people 15
to 29 years of age, road traffic injuries are the leading cause of death, and cost governments
approximately 5% of GDP in LMICs. Other notable areas of injuries are falls (18.5%) and self-
harm (19.4%) leading to deaths in SEAR (Table 2)(4).
Figure 2: Road traffic fatalities per 100,000 populations in SEAR(5)

17
BURDEN IN INDIA
The top five individual causes of disease burden in India were Communicable, maternal, perinatal
and nutritional conditions in 1990, whereas in 2016, three of the top five causes were Non-
communicable diseases(NCDs), showing a shift toward NCDs (Table 2). From 1990 to 2016 the
number of DALYs due to most NCDs increased. The increase in all-age DALYs rate between
1990 and 2016 was highest for diabetes (80·0% [95% UI 71·6–88·5]), ischaemic heart disease
(33·9% [24·7–43·6]), and sense organ diseases (mainly vision and hearing loss disorders; 21·7%
[20·1–23·3]). Of the individual NCDs that are in the top 30 leading causes of DALYs in 2016.(6)
Table 2: Percentage contribution of disease categories to total deaths

by age groups for all of India, 2016(6)
Year 2016
Population (thousands) 1324200
GHE 2012 cause category Total (%)
All Causes 100
I. Communicable, maternal, perinatal and nutritional conditions 27.5
II. Non-communicable diseases 61.8
A. Cardiovascular diseases 28.1
B. Respiratory diseases 10.9
C. Malignant neoplasms 8.3
D. Diabetes mellitus 6.5
III. Injuries 10.7
Data are % (95% uncertainty interval).
Figure 3: Percent of total DALYs by age groups in India, 2016(6)

The higher proportion of the total DALY burden relative to their proportion of the population
18
was observed in the age groups of younger than 5 years and 45 years or older. The age group
of younger than 5 years group constituted 8.5% of the population and had 17.6% of the DALYs.
The highest proportion of DALYs were in children younger than 5 years (83·4%) attributed to
Communicable, maternal, perinatal and nutritional conditions%), and the lowest was in the
50–54 years age group (14·7%).The proportion of DALYs due to Non-communicable diseases
was highest at 78·8% in the 65–69 years group and exceeded 50% in the 30–34 years group
(Figure 3).The proportion of total DALYs due to injuries was highest in the age groups from 15
years to 39 years(range 18·3–28·1%).(6)
CURRENT STATUS OF EMERGENCY CARE IN THE INDIA

Emergencies and accidents are common place in all parts of India. Though India is a developing
country, due to rapid economic growth and urbanization, it faces the ills of both an under-
developed as well as developed economy. Every day, India faces the dual challenges posed
by emergencies related to infections and communicable diseases and those related to chronic
diseases and trauma.
Pre-hospital care is being provided by the state government regulated ambulances in many states
by Emergency Management and Research Institute with a common toll-free number 108. The
command centre is however not situated or run by the government or the Emergency Departments.
108 do not provide any pre-hospital notification to the Emergency Departments.
Thus it is a rudimentary form of pre-hospital EMS that exists in India and needs modernization
and integration with the hospitals at state and national level. India also lacks a universal toll
free number and there are more than one numbers that lead to ambulance services for different
emergency conditions.
With more than 150,000 road traffic related deaths, 98.5% ‘ambulance runs’ transporting dead
bodies, 90% of ambulances without any equipment/oxygen, 95% of ambulances having untrained
personnel, most ED doctors having no formal training in EMS, misuse of government ambulances
and 30% mortality due to delay in emergency care, India portrays a mirror image of the U.S. of
the 1960s.
EMS has changed since the time it was commonly stated that, “EMS systems in India are best
described as fragmented.”(7) India has two different yet overlapping publicly funded ambulance
systems, with both popularly known by their helpline numbers, 108 and 102. Between them,
they have more than 17,000 ambulances across the union of 31 states and union territories. The
allocated federal fund for the ambulance services in 2013-2014 was $59 million.(8)
The provision of emergency services is enshrined in India’s Constitution. As per the Article 21 of
India’s Constitution “right to life”, if any hospital fails to provide timely medical treatment to a
person result’s in the violation of person’s “right to life”.(8) India always had a disproportionately
small health budget because of its ambitious growth aspiration and fastest growing population,
with one doctor for every 1,700 people and 21% of the world’s burden of disease.(9) In India
almost 23% of all trauma is transportation-related, with 13,74 accidents and 400 deaths every day
on roads. (10)The rest of the 77.2% of trauma is related to other events such as falls, drowning,
agriculture related, burns, etc.(11) According to World Health Organization, India has the highest
snakebite mortality in the world estimates it at 30,000 every year.(12)
19
WHO EMERGENCY CARE SYSTEM FRAMEWORK

The WHO info graphics below (Figure 4 a & b) are visual representations of the WHO Emergency
Care System Framework, designed to support policy-makers wishing to assess or strengthen
national emergency care systems. It is the result of global consultations with policy-makers and
emergency care providers across all regions, and provides a reference framework to characterize
system capacity, set planning and funding priorities, and establishes monitoring and evaluation
strategies.
Figure 4a illustrates the essential functions of an effective emergency care system, and the key
human resources, equipment, and information technologies needed to execute them (organized
by health systems building blocks).
Figure 4b info graphic complements this by locating critical governance and oversight elements—
including system protocols, certification and accreditation mechanisms, and key process metrics—
within the Framework. Also identified in the figure are essential overarching laws and regulations
that govern access to emergency care, ensure coordination of system components, and regulate
relationships between patients and providers.
(a)
20
(b)
Figure 4: WHO Emergency Care System Framework(13)
**Source: WHO info-graphics
Patients may
access any level
of care directly
Figure 5: Integrated Model: The roots feeding the Emergency Care System
21
HOSPITAL BASED EMERGENCY CARE IN THE GOVERNMENT

SECTOR IN INDIA
Definitive care for victims with emergencies is offered by government hospitals, corporate hospitals
and a large number of small clinics. Government hospitals generally offer free care, but the quality
of that care differs between centres. Most university hospitals provide a reasonable level of
emergency care. District hospitals often lack trained staff, adequate infrastructure, and supply of
consumables.(14) Triage is rarely practiced. As a result, impressive but non-life-threatening extremity
trauma may take precedence over bacterial meningitis or myocardial infarction.
There are no dedicated trauma surgeons and very few designated trauma centres in India.
Orthopedic surgeons lead the trauma response in 50% of facilities. (15) In the remainder; the
responsibility is not clearly defined. In the absence of defined roles amongst specialists, clinical
decisions are often delayed. Multi-system injury patients are at the greatest risk.
Typically, most of the “emergency care” in the hospitals in India is provided in areas known
as Casualty or Accident rooms. Formal education and specialty training in emergency care are
neither available nor mandatory for personnel involved in emergency care. These Causality/
Accident room physicians lack any specific training in emergency medicine.(14) Proceedings have
only recently been initiated to recognize Emergency medicine as a distinct medical discipline.
Residents posted in these ‘rooms’ often rotate from various specialties such as surgery, orthopedics,
and medicine and have little commitment towards patient management. These physicians are
often waiting to retake the All India Entrance Examination in the hope of securing postgraduate
position in established fields recognized by the MCI.(16) In some hospitals, emergency rooms
(ERs) are traditionally divided into separately run medical and surgical teams. With this division
it becomes very difficult to deliver quality, cost-effective care. In many hospitals, physicians
staffing the emergency rooms lack the resources and knowledge to manage the wide variety of
emergencies. They therefore function as ‘postal carriers’ who ‘deliver ‘victims to the respective
specialties. The most junior and inexperienced staff frequently treat the most seriously injured
patients.
TRAINING
Husum et al. have demonstrated that laypeople trained in first aid can effectively respond to
emergencies in a community within a high trauma burden (17, 18). In hospitals, most in-service
training for emergency care professionals is designed to address particular problems, such as
severe injuries, pediatric emergencies or obstetric emergencies. Yet because of the resource
constraints of low-income countries, the same personnel will be confronted with all of these
conditions. Unfortunately, few courses in emergency care have been rigorously evaluated(19, 20).
The Advanced Trauma Life Support course, a meticulously controlled training course in clinical
skills for doctors that was devised by the American College of Surgeons, has improved patients’
outcomes in some settings, although it may be too expensive for most low- and middle-income
countries, and it is clearly inappropriate for settings where most patients are not seen by doctors.
In a tertiary hospital in Trinidad and Tobago, mortality from injury fell by 50% after doctors
attended this course (21).Training in life-saving obstetric skills was found to contribute towards
reducing maternal deaths in Kebbistate, Nigeria, and in other sites where the intervention was
implemented(22,23).
22
Emergency Triage Assessment and Treatment (ETAT) training, part of WHO’s Integrated Management
of Childhood Illnesses strategy, has been used in many countries to improve pediatric emergency
care (24). Other examples of training courses are Primary Trauma Care (25), devised by the World
Federation of Societies of Anaesthesiologists, and Advanced Life Support in Obstetrics, devised
by the American Academy of Family Physicians (26).The above courses are used to standardize
protocol-based emergency care but evaluations of their outcomes are still awaited. The National
Trauma Management Course in India (27) costs US $50.00 per trainee and is taught by local
trainers. This course has now become a national training standard for immediate trauma care in
India. The courses described above are all examples used to show that even in the absence of
ambulances it is possible to improve emergency medical systems. Low-income countries need to
identify training models that are appropriate for their emergency care personnel, who may need
to take on a variety of roles, especially those working at middle-level facilities, who respond to
different types of emergencies.
ACADEMIC EMERGENCY MEDICINE

Academic emergency medicine is a recognized post-graduate program since 2009. Presently,
more than 28 medical colleges are offering a total of 60 seats, a diplomat of national board (DNB)
offering more than 120 residency seats in Emergency Medicine in a year. This number is highly
inadequate and not enough to cater the needs of even one state of India. Indo-US collaborative
INDUSEM played a major role in shaping the academic emergency medicine in India and now
in SEAR and rest of the world too.
Emergency Medicine (EM) is a new academic discipline in its infancy in India. Dedicated
emergency medicine faculty will be the keys for developing a national skilled emergency care
workforce. A strategy for integrated, coordinated trauma care and injury prevention activities must
be developed in India. Gujarat has become the first state to pass legislation addressing emergency
medical services.
Emergency Medicine (EM) Departments are the front line for the community during a disaster.
A disaster is defined as that time, when the need for staff, supplies and space exceed resources
due to an extraordinary stress on a community, e.g. earthquake, biological outbreak or terrorist
attack. As a result, Disaster Medicine has been, and continues to be, an important focus for
Emergency Medicine. The Emergency Department (ED) is the place to train, set standards for
response, and create a culture of preparedness not only for the Hospital but the community as
well. As the Emergency Department heads the Hospital’s Committee on Disaster Preparedness
by establishing protocols, conducting training, and facilitating exercises, they also create the
opportunity for a good relationship between the hospital administration and the community. This
proactive involvement validates the EM program and creates added value for those involved:
physicians, residents, and students, thus improving better patient care.(28)
GAPS
Research and Development for Emergency Services

As a neglected topic, emergency medical systems are part of the 10/90 gap in health research
whereby less than 10% of global research investment is spent on problems affecting 90% of the
23
world’s population(29). A review of the evidence on emergency medical systems as applicable to

low- and middle- income countries reveals many gaps in global knowledge. There is a need to
better understand the epidemiology of conditions that may be addressed by emergency systems
in these countries and to better understand which interventions may address them adequately.
Intervention trials in low- and middle-income countries are research priority in the field of
emergency medical systems. Well-designed, locally appropriate studies that establish effectiveness
are urgently needed, and they should include both those interventions that may be available in
high-income countries and newer interventions. Economic analysis is another area where research
is needed, especially in places where cost and cost–effectiveness information from low- and
middle-income countries is scant(30). These gaps reflect the need for a more systematic analysis
of the areas towards which research investments should be directed in order that systems can be
based on credible evidence.
Organization and financing

An emergency medical system must be sensitive to and meet the needs of the poor. Issues of
access to the system become critical because a lack of money often deters people from using
emergency services. Different means of achieving this financial protection need to be explored,
including community financing(31, 32).As a result, emergencies often lead to financial ruin for poor
families, and the implementation of some sort of financial protection for emergency health care
has not received adequate attention. Such protection would ensure that those with limited finances
are not deterred from using emergency services and that they do not get tipped into extreme
poverty by having to meet costs entirely out of their own pocket Community loan funds to cover
transportation and other requirements for emergencies, especially for obstetrics, have been used
in various setting, especially in Africa.(33, 34)
24
AIMS AND OBJECTIVES 04
AIMS AND OBJECTIVES
04
PRIMARY OBJECTIVE
1. To assess current status of facility based Emergency and Injury care in government
medical colleges & large private hospitals
SECONDARY OBJECTIVE
To assess the following:
1. Burden of emergency conditions including injuries
2. Assess the current status of Emergency and Injury care system linkages
a. Pre-hospital care (including intra-specific referral to ambulance services)
b. Hospital Care (Definitive care)
c. Measures of Academic Emergency medicine departments
27
METHODOLOGY 05
05
Methodology
METHODOLOGY
The study was initially proposed and approved for the assessment of 50 tertiary care centres
(government medical colleges and large private hospitals) and 50 secondary care centres (district
hospitals) of India.
In consultation with NITI Aayog, it was decided that the health facilities to be assessed be
categorized in 5 categories for the study purpose: Medical College more than 500-bed strength
(20), Government hospitals more than 300-bed strength (20), Government hospitals less than
300-bed strength (20), Private hospitals more than 300-bed strength (20) and Private hospitals
less than 300-bed strength (20).
Figure 6: Map showing hospitals (tagged red) selected for this study from different states and different zones
31
Selection of Healthcare Facilities
Finalization of Healthcare Facilities
Team formation of National Assessors
Development of Study Tool
Finalization of Study Tool through

Scientific Advisory Committee
Training of Assessors by tele /

video-conference
Field visit across country for

DATA COLLECTION
• One year data collection • Live data collection for 24 hours

• Based on administrative interview • Based on live observation
• Based on facility visit • Data collection of Specific
Diseases
Data Analysis Categorization : **

A) Hospital-wise
B) Zone-wise
C) NABH Accreditation-wise
Draft Report
Figure 7: (a) Flow chart of Methodology

**where applicable
The study was carried out in five regions of India (North, South, East, West, and North-East)
including 29 States and 2 Union Territories, from which a total of 100 private and government
healthcare facilities were randomly selected from each zone.
This cross-section study was undertaken in two phases:
32
Methodology
1. Scientific Advisory Committee (SAC) meeting for the finalization of the tool by the
experts of various health departments
2. Quantitative and qualitative data collection as a pilot testing from two hospitals
Pilot testing was followed by collecting of data from the 100 randomly selected healthcare facilities
by a team of 3 assessors. The assessment was done by conducting administrative interview, facility
visit and live observation of the healthcare facility.
1. Identification of potential healthcare facilities: While selecting the institutions for
assessment, we had discussed with the experts’ group. After a series of meetings and
discussions with the experts’ team, it was decided that there should be no overlapping
of healthcare facilities.
We identified 100 healthcare facilities from five regions of the country and contacted
the respective state health dignitaries to nominate a suitable nodal person for obtaining
information about the healthcare facilities to assess suitability. These healthcare facilities
were visited by the assessors’ team for assessment.
2. Finalization of the sites: We started the formal process of site selection from 20th May
2019. The process of selection took 2 weeks and by 3rd June 2019, the sites were
finalized.
3. Development of study tools, standard operating procedures:
Study tools: The study tool was developed and finalized after SAC meeting and
beta testing. The beta testing was done in two healthcare facilities (AIIMS, New
Delhi and Sri Sayaji General [SSG] Hospital, Gujarat) before the assessment being
conducted at the proposed healthcare facilities. The study tool was divided into
three major categories: lead assessor tool, live observation tool, and emergency
burden tool. These categories were further subdivided into sections: background
information of hospital, hospital services, ED protocol/SOP and guidelines, safety
and security, disaster management, quality improvement, data management system,
financing, physical infrastructure, manpower, equipments and supplies, point of
care lab in ED and hospital, and essential medicines.
Standard operating procedures /manual: The study operational manual for data
collection was developed and acted as a guide.
4. Establishment of governance structure and a project implementation: Scientific
Advisory Committee (SAC) members were identified, which included 22 national
experts from emergency and trauma, public health, research, and epidemiology. They
provided technical guidance in study tool development, protocol development, and
quality assurance.
5. Training of assessors: A tele/video-conference was organized every week to train the
assessors. Based on the received data from sites, the assessors were trained subsequently
for the challenges and the problems/issues faced by the other assessors’ team during
the assessment.
6. Data Collection: Healthcare facilities data were collected by a team of assessors (one
lead assessor and two co-assessors) at each site visit.
33
a. One Lead assessor (overall in-charge) was responsible for the conduct of survey and
major observations/assessment mainly through local administrator interview, data
source (hospital records) and site/facility visit, etc. He/she acted as a nodal person
for communication with the central project team at JPNATC, AIIMS, New Delhi.
b. Two other Co-Assessors were responsible for emergency department data collection
by live observation (mainly assessing the emergency department processes &
infrastructure [manpower, equipment, supplies, etc.]).
These assessors were trained for this study and were not blinded regarding the purpose
of the study. The assessors were trained with the study tool and assessors training manual
for the assessment of healthcare facilities. Data for the assessment of healthcare facilities
were obtained from face-to-face interviews with key staff at each facility.
The presence of supplies including medications and equipment was assessed through
direct observations. Assessors also checked the inventory of supplies in facilities which
allowed them to do so.
7. Definition and process of Live Data Recording: The assessment done by two Co-
assessors included continuous observation for 24 hours in healthcare facility without
any direct contact with patients admitted in the same premises. The live data recording
done by the Co-assessors was observation of the treatment process and procedures of
patients especially having three conditions: chest pain, stroke and trauma.
The process involved for live data collection (as per the data collection tool) was as
follows:
Arrival of the
Relevant
patient at Triage Resuscitation Investigation
healthcare facility
Final Disposal (Discharge/

Disposal Relevant
referral/ admission to general
Decision Consultation
ward/ to ICU/to OT/ to Cathlab)
8. Data analysis: Data collected from the health-facilities was entered using a Microsoft
Excel-based database. The analysis was done by using SPSS (Statistical Package for the
Social Sciences). The level of analysis for the assessment is the facility, and for overall
analysis it is category of the hospital.
Frequencies were computed for different sections of the study tool such as emergency
equipment, essential medicines and written protocols for the management whereas
median with IQR and minimum, maximum were computed to present the distribution
of continuous variables, for example, doctors per facility.
We had calculated the percentages of all essential equipment and medicines. We
assessed availability of equipments and essential medicines on three different scales:
50% or less (Score-0), 50% to 99% (Score-1), and 100% (Score-2).
34
Methodology
Figure 7b: Overall representation of strategy and procedures of Data Collection
35
OBSERVATIONS AND
Methodology
RESULTS WITH
SUGGESTIONS
06
37
06
Observations and Results with Suggestions
OBSERVATIONS
AND RESULTS WITH
SUGGESTIONS
I. FIELD VISIT: ADMINISTRATIVE INTERVIEW/ONE YEAR DATA

COLLECTION
We are presenting the observations based on the findings from both qualitative and quantitative
components of the assessment research.
1. BACKGROUND INFORMATION OF THE HOSPITALS

Out of 100 hospitals studied, 20 hospitals were medical colleges (more than 500 bedded), 20
hospitals were government hospitals (more than 300 bedded), 20 hospitals were government
hospitals (less than 300 bedded), 20 hospitals were private hospitals (more than 300 bedded) and
20 hospitals were private hospitals (less than 300 bedded).
Out of the 100 hospitals, NABH accredited hospitals were 28. There were only 5 hospitals that had
academic emergency medicine out of all 100 hospitals. Among all the assessed hospitals, 25 were
tertiary care government hospitals, 34 were secondary care (district) hospitals, 1 was secondary
care (trust) hospital and 40 were private hospitals (20 tertiary and 20 secondary care hospitals).
2. AVAILABLE BEDS AT ASSESSED FACILITIES:

The data of hospital bed strength was collected from each hospital such as hospital in-patient
beds and emergency beds separately. Out of 100 hospitals, 32 hospitals had triage beds and
follows triage policy.
The median [IQR] min-max of in-patient beds and emergency beds (the beds assigned for emergency
/ emergency department) for all categories of hospitals is shown in table 3 and represented in
figure 8.
39
Table 3: Overall Summary of available Beds in Hospitals: Emergency Department

Beds and Inpatient Beds
Total Inpatient beds
Emergency Department % of Emergency
Categories of in Hospital
n beds in Hospital Beds out of all
Healthcare Facilities Median [IQR] Min-
Median [IQR] Min-Max Beds at ED
Max
Medical Colleges 46 [28] 1233[1147]

20 3%
(>500 bed strength) 10-210 252-3500
Govt. Hosp. 17 [25] 418 [306]

20 4%
(>300 bed strength) 2-183 200-1079
Govt. Hosp. 5 [6] 145 [182]

20 4%
(<300 bed strength) 1-22 47-380
Pvt. Hosp. 15 [14] 467 [196]

19 4%
(>300 bed strength) 5-44 150-1000
Pvt. Hosp. 10 [4] 200 [54]

19 5%
(<300 bed strength) 3-15 48-400
*n: number of hospitals which shared data with assessor’s team, IQR: Interquartile range
As mentioned in table 3, the percentage of beds in the emergency department accounted for 3%
of all hospital beds in medical colleges, 4% in government hospitals (>300 beds strength), 4%
in government hospitals (<300 beds strength), 4% in private hospitals (>300 beds strength) and
5% in private hospitals (<300 beds strength).
In medical colleges, maximum number of emergency beds was observed at JIPMER, Pondicherry
(210 beds out of 2137 in-patient beds), while minimum number of emergency beds was observed
at Tomo Riba Institute of Health & Medical Sciences, Papumpare (10 beds out of 252 in-patient
beds).
In government hospitals (>300 beds), maximum number of emergency beds was observed at
Indira Gandhi Government General Hospital, Pondicherry (183 beds out of 626 in-patient beds),
while minimum was observed at District Hospital, Dhamtari (2 beds out of 200 in-patients beds).
In government hospitals (<300 beds), maximum number of emergency beds was observed at
District Hospital, Ganderal (22 beds out of 200 in-patient beds), while minimum was observed at
District Hospital, Bishnupur & District Hospital, Peren both had 1 bed out of 50 in-patients beds).
40
Figure 8: Overall representation of beds distribution in different categories of hospitals
The majority of hospitals did not have system for triage in their emergency department. Only 32
hospitals of all 100 hospitals had triage systems.
Systems for triage were present at 5 medical colleges (Government General Hospital, Guntur;
AIIMS, Bhopal; Rajiv Gandhi Government General Hospital, Madras Medical College; JIPMER,
Pondicherry and IPGMER & SSKM Hospital), 4 government hospitals more than 300 beds,
14 private hospitals more than 300 beds, 9 private hospitals less than 300 beds and
government hospitals less than 300 beds did not have any system for triage in their
hospital emergency or emergency department.
3. BURDEN OF PATIENTS (OPD AND EMERGENCY)

The annual census of the year 2018 (from 1st January 2018 to 31st December 2018) was collected
from all the hospitals, which includes number of patients visited in OPD, emergency, number
of medico-legal cases attended in emergency, number of admissions through emergency, etc.
In table 4, summary of patients visited in OPD and emergency at hospitals is reported with median
[IQR] and min-max (figure 9). The annual burden of patients visited in emergency department of
hospitals was calculated by dividing the total number of patients visiting in emergency with the
total number of patients visiting in the hospital (OPD + Emergency) and the median value of
percentage is reported in table.
41
Table 4: Summary of Patients visited in Emergency and OPD in different Categories

of Hospitals (1st Jan 2018 to 31st Dec 2018)
Emergency and Injury Care % of ED Patients
OPD Patients
Categories of Patients out of all
Healthcare Facilities Median [IQR] Median [IQR] patients visited
n n in hospital
Min-Max Min-Max
Medical Colleges 119461 [140435] 794860 [499481]
15 18 13%
(>500 bed strength) 3560-477845 146000-3382591
Govt. Hosp. 43001 [118984] 435229 [447465]
17 17 14%
(>300 bed strength) 4876-308883 22000-1463635
Govt. Hosp. 18738

224897 [145985]
16 [35140]1560- 18 15%
(<300 bed strength) 44400-743278
227364
Pvt. Hosp. 20861 [22118] 255000 [308000]
17 17 9%
(>300 bed strength) 3676-103524 28278-749145
Pvt. Hosp. 13800 [4908] 94292 [53143]
11 12 12%
(<300 bed strength) 3699-43304 7188-170938
In medical college, the burden of patients in emergency as well as in OPD were maximum at
SMS Medical College & Hospital and minimum at AIIMS, Bhopal (for emergency) and Regional
Institute of Medical Sciences, Imphal (for OPD).
In government hospitals >300 beds, the burden of patients in emergency as well as in OPD
were maximum at Indira Gandhi Government General Hospital, Puducherry and minimum at
District Hospital, Dhamtari (for emergency) and Southern Railways Hospital, Chennai (for OPD).
In government hospitals <300 beds, the burden of patients in emergency were maximum at Puri
District Headquarter Hospital and minimum at Sadar Hospital, Gaya; the burden of patients in
OPD was maximum at Government BDM Hospital, Kotputli and minimum at District Hospital,
Bishnupur, Manipur.
In private hospitals >300 beds, the burden of patients in emergency as well as in OPD were
maximum at Dr Ram Manohar Lohia Hospital, Lucknow and minimum at GNRC, Guwahati,
Assam. In private hospitals <300 beds, the burden of patients in emergency as well as in OPD
were maximum at Ramakrishna Mission Hospital, Arunachal Pradesh and minimum at Medeor
Hospital, Manesar.
The annual burden of patients who presented as emergency case, out of all patients visited the
hospital for the year 2018 were: 13% in medical colleges, 14% in government hospitals with more
than 300 beds, 15% in government hospitals with less than 300 beds, 9% in private hospitals
with more than 300 beds and 12% in private hospitals with less than 300 beds.
42
Figure 9: Comparison of Patients visited in OPD and Emergency in different Categories of Hospitals
(1st Jan 2018 to 31st Dec 2018)
*M. C.- Medical College, G. H.- Government Hospital, P. H.- Private Hospital, OPD- Out-patient Department
Data maintained regarding adult/pediatric patients were heterogenous across the studied hospitals.
Only 43 hospitals maintained OPD data of adult patients and 37 hospitals maintained data of
pediatric patients. Similarly, 36 hospitals maintained ED data of adult patients and 28 hospitals
maintained data of pediatric patients respectively.
In table 5, separate adult and pediatric patient’s data for OPD and emergency is reported with
median [IQR] and min-max.
43
Table 5: Summary of Patients visited in OPD and Emergency (Adult and Pediatric)
in different Categories of Hospitals (1st Jan 2018 to 31st Dec 2018)
Emergency and Injury care Patients OPD Patients
Categories of Adult Pediatric Adult Pediatric
Healthcare
Facilities Median [IQR] Median [IQR] Median [IQR] Median [IQR]
n n n n
Min-Max Min-Max Min-Max Min-Max
Medical 80418 737333
21849 61418
Colleges [141265] [694550]
9 6 [18019] 11 10 [37814]
(>500 bed 11961- 220097-
6429-130581 8900-445398
strength) 347264 2937193
Govt. Hosp. 23671 384335 46812

3650 [25872]
10 [12983] 9 10 [194085] 9 [41308]
(>300 bed
461-30204
strength) 7495-281011 21000-1388295 1000-127688
Govt. Hosp. 11809 149737 23035

687 [550]
6 [41883] 5 7 [129722] 6 [19350]
(<300 bed
311-22688
strength) 836-150007 5889-586632 1479-96725
Pvt. Hosp. 14326 220631 33106
2201 [3899]
7 [18854] 6 9 [331418] 7 [27192]
(>300 bed
225-13378
strength) 3667-32304 28278-872227 9293-52612
Pvt. Hosp. 10908
7555 [2234] 763 [248] 67096 [19035]
4 2 6 5 [11471]
(<300 bed
4800-8778 515-1011 30000-150534
strength) 3285-30431
In addition, the definition for pediatric age group also varied among the assessed hospitals. Out of
100 hospitals, 28 hospitals were following 0-12 years age for pediatric patients, 20 hospitals were
following 0-14 years age, 10 hospitals were following 0-15 years age, 1 was following 0-16 years
age, 11 were following 0-18 years age, and 30 hospitals did not have the details for the same.
4. HUGE MISMATCH BETWEEN EMERGENCY BEDS & BURDEN OF

EMERGENCY AND INJURY CASES:
Table 6 depicts the gap between the emergency beds and burden of patients in emergency, it is
clear that there is a huge mismatch between emergency beds and burden of emergency cases.
44
Table 6: Huge Mismatch between Emergency Beds & Burden of Emergency and
Injury Cases
% of Emergency and % of Emergency and
injury cases injury cases % of Available
Hospital Categories
Emergency Beds
(One Year) (One Day)
Medical Colleges 13% 17% 3%
Govt. Hosp.
14% 11% 4%
(>300 bed strength)
Govt. Hosp.
15% 11% 4%
(<300 bed strength)
Pvt. Hosp.
9% 10% 4%
(>300 bed strength)
Pvt. Hosp.
12% 30% 5%
(<300 bed strength)
Different categories of hospitals have only 3-5% available emergency beds while the yearly burden
of patients’ ranges from 9 to 15%, which is much more than the available beds. It may be because
the resources available in the healthcare facilities are either underutilized or over-utilized. By the
above observation, it is clear that the optimum utilization of resources is missing in the hospitals.
The burden of emergency cases at medical college was high compared to both district hospitals
and private hospitals. It may be because people are not utilizing secondary care hospitals due to
lack of quality of care (lack of facilities present in district hospitals when compared to medical
colleges).
About 65.9% populations belongs to rural areas (according to the World Bank collection of
development indicators in 2018), most of the rural population cannot afford private hospitals
due to high expenses.
As per current MCI guidelines, 35 emergency beds should be available in 500 bedded medical
college i.e., 7% emergency beds. Table 8 A depicts the recommended number of beds per
category of healthcare facility
1. For MBBS & PG Programme: To start PG programme, 7% emergency beds (below table) are
sufficient, but to provide the quality emergency services this bed strength is less.
Table 7: Beds per centre as per MCI

“Red” Triage beds/
No. Of UG “Yellow” “Green”
Minimum ICU category Trolleys (other
student category Beds/ category
Total beds beds beds/ than total beds/
intake Trolleys beds/Trolleys
Trolleys trolley)
50 30 6 4 15 5 3
100 35 7 5 16 7 3
150 40 8 6 18 8 4
200 45 9 7 20 9 4
50 or
>200 10 8 22 10 5
above
45
2. For optimal care/services: To provide optimal emergency care services, we need to increase
the number of emergency beds to 12% of all beds with addition of 10% as buffer beds
based on footfall. Secondly, needs to be developed cashless for emergency care and thirdly,
to provide quality of care as per the existing and expected footfall we need to strengthen
district hospitals by-
Upgrading them to medical college
Developing residency programme in DNB: where in PG residents rotate regularly at
district hospitals
Initiate programme based in centivization of government hospitals
3. Upgradation of medical colleges and district hospitals to cater the existing and expected
footfall to provide quality service.
DNB (Diplomate of National Board) Emergency Medicine Criteria: The hospital should be
200 bedded with 50 patients per day in emergency (Assumption- By developing residency
programme, the footfall of patients will increase).
*Note: Emergency Beds: The beds assigned for emergency department.
Buffer Beds: The beds under department of emergency for addressing surge capacity including ICU facility and it should
have separate beds for disaster.
5. BURDEN OF MEDICO-LEGAL CASES

Table 8 summarizes the annual number of medico-legal cases attended in emergency of different
categories of hospitals with median [IQR] and min-max. The annual burden of medico-legal cases
attended at hospitals emergency was calculated by dividing the total number of medico-legal
cases attended at emergency with the total number of patients visiting in the emergency and the
median value of percentage is depicted.
46
Table 8: Summary of Medico-legal cases attended at Emergency of different

Categories of Hospitals
Medico-legal Cases
% of MLC = Total MLC/
Hospital Categories Median [IQR]
n Total Emergency Pts.
Min-Max
15473 [16719]
Medical Colleges 13 8.7%
216-91354
Govt. Hosp. 2108 [4975]
18 3%
(>300 bed strength) 87-23728
Govt. Hosp. 1230 [1598]
15 6.4%
(<300 bed strength) 236-10049
Pvt. Hosp. 794 [1449]
14 3.6%
(>300 bed strength) 257-2986
Pvt. Hosp. 498 [927]
13 2.5%
(<300 bed strength) 71-1500
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range, MLC: Medico-legal cases
In medical colleges, maximum medico-legal cases in emergency were at Patna Medical College
& Hospital and minimum at New STNM Hospital, Sikkim.
In government hospital >300 beds, maximum medico-legal cases in emergency were at District
Hospital, Karim Nagar, Telangana and minimum at AIIMS, Patna.
In government hospital <300 beds, maximum medico-legal cases in emergency were at North
Goa District Hospital, Goa and minimum at District Hospital, Ganderbal.
In private hospital >300 beds, maximum medico-legal cases in emergency were at Dr Ram
Manohar Lohia Hospital, Lucknow and minimum at Cosmopolitan Hospitals Private Limited,
Kerala.
In private hospital <300 beds, maximum medico-legal cases in emergency were at Ruby General
Hospital, West Bengal and minimum at G G Hospital, Kerala.
Majority of district hospitals make more MLC’s when compared to medical college and private
hospitals. In district hospitals a dedicated CMO (Chief Medical Officer) is present, who makes
MLC cases. Preparation of MLC reports adds to the existing mandate of providing quality acute
care service by the emergency care provider.
Burden of Medico-legal cases on Emergency Department ranging between 2%-9%.
Suggestions for MLC:

These findings suggest higher burden of MLC’s at government hospitals. Amongst government
hospitals, the load is highest at medical colleges. Private hospital seems to have a disproportionally
lean load of MLC.
47
Suggestions to improve MLC related services; the following are suggested:

1. Ensure equitable distribution for MLC related services among both government and
private sector.
2. Dedicated EMO (Emergency Medical Officer) / Senior Resident (Forensic Medicine) to
deal with MLC documentation and representation to court.
3. Develop cadre of Forensic Nursing and post them in the emergency for round the clock
frontline medico-legal service.
4. Station an in-house police post for mitigating plausible violence and protection of
emergency care provider. This would aid in better co-ordination of MLC documentation
and legal service.
6. BURDEN OF ADMISSIONS THROUGH EMERGENCY

In addition, table 9 summarizes the annual number of admissions through emergency at different
categories of hospitals.
The annual burden of admissions through hospital emergency department was calculated by
dividing the total number of admissions through ED with the total number of patients visiting in
emergency department.
Table 9: Summary of Admissions through Emergency Department at different

Categories of Hospitals
Admissions through Emergency

% of patients
Hospital Categories Median [IQR] admitted of those
n visiting ED
Min-Max
31487 [23267]
Medical Colleges 14 22.2%
552-80315
Govt. Hosp. 6591 [13936]
15 19.4%
(>300 bed strength) 373-55293
Govt. Hosp. 1269 [4969]
12 23.8%
(<300 bed strength) 147-227364
Pvt. Hosp. 9877 [6749]
16 31%
(>300 bed strength) 195-31899
Pvt. Hosp. 4020 [4721]
14 39%
(<300 bed strength) 1236-9834
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range, ED: Emergency department
In medical college, maximum number of admissions through emergency was at Government

Medical College, Thiruvananthapuram and minimum at AIIMS, Bhopal.
In government hospital >300 beds, maximum admissions through emergency was at District
Hospital, Karim Nagar, Telangana and minimum at Deen Dayal Upadhyay Hospital, Himachal
Pradesh.
48
In government hospital <300 beds, maximum admissions through emergency was at Puri District
Headquarter Hospital, Orissa and minimum at Morigaon Civil Hospital, Assam.
In private hospital >300 beds, maximum admissions through emergency was at Dr Ram Manohar
Lohia Hospital, Lucknow and minimum at Central referral Hospital, Sikkim.
In private hospital <300 beds, maximum admissions through emergency was at Jaipur Golden
Hospital, Delhi and minimum at Ruban Memorial Hospital, Bihar.
 Government Hospitals - 19% to 24%

Admissions through emergency 
 Private Hospitals - 31% to 39%
Suggestions:
The number of admissions through emergency was high in district hospitals>300 beds than
medical colleges but they have less number of emergency beds to cater the existing footfall.
1. NABH Accreditation
2. District hospitals admits more patients in emergency than medical college, so
Upgrade them into medical college
Develop residency programme for emergency medicine
7. BURDEN OF DEATH OF TRAUMA PATIENTS

Table 10 depicts the annual number of death of trauma patients in emergency of different
categories of hospitals. It was compared with the total number of trauma patients (one day)
visited in emergency of all hospitals.
Table 10: Summary of Death of Trauma Cases in Emergency by Categories of Hospitals
Death of Trauma Patients Number of Trauma Patients visited in

(ONE YEAR) Emergency (ONE DAY)
Categories of Healthcare
Facilities Median [IQR] Median [IQR]
Total Pts
n n
Min-Max in one day Min-Max
Medical Colleges 11 266 [1172] 15 599 18 [25]

(>500 bed strength) 40-8067 1-210
Govt. Hosp. 8 12 [35] 18 175 5 [11]

(>300 bed strength) 1-234 1-45
Govt. Hosp. 9 8 [23] 19 130 5 [6]

(<300 bed strength) 1-66 1-40
Pvt. Hosp. 9 14 [26] 18 143 3 [10]

(>300 bed strength) 2-206 1-35
Pvt. Hosp. 7 3 [37] 17 60 3 [4]

(<300 bed strength) 2-797 1-20
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range
49
Death of trauma patients was high in medical college when compared to other categories of
hospitals. It may be assumed that the death of trauma patients was due to delay in definitive care
(beyond Golden Hour) and due to lack of trained human resources in emergency department.
Suggestion:
Develop a robust integrated emergency care system which includes injuries
8. BURDEN OF PATIENT’S DEATH DUE TO ROAD TRAFFIC INJURY

Table 11 depicts the annual number of patient’s death due to road traffic injury in emergency of
different hospital categories.
Table 11: Summary of Patient’s Death due to Road Traffic Injury by Categories of
Hospitals
Patient’s Death due to Road Traffic Injury

Facilities Median [IQR]
n
Min-Max
Medical Colleges 171 [527]
8
(>500 bed strength) 1-1013
Govt. Hosp. 21 [81]
10
Govt. Hosp. 11 [26]
5
Pvt. Hosp. 6 [19]
10
Pvt. Hosp. 6 [63]
7
It may be assumed that the patients of road traffic injury died due to lack of pre-hospital care,
lack of injury prevention and may be they are non-salvageable.
9. BURDEN OF BROUGHT DEAD PATIENTS

Table 12 summarizes the annual number of brought dead patients in emergency of different
hospital categories with median [IQR] and min-max.
50
Table 12: Summary of Brought Dead Patients in Emergency by

Different Category of Hospitals
Brought Dead Patients

Facilities Median [IQR]
n
Min-Max
Medical Colleges 204 [137]

7
Govt. Hosp. 129 [170]
11
Govt. Hosp. 23 [24]
8
Pvt. Hosp. 70 [105]
11
Pvt. Hosp. 25 [91]
8
It may be assumed that brought dead patients came to hospitals due to:
1. Failure to recognize, resuscitate and refer of sick patients either by bystander or
paramedic.
2. Probable non-salvageable patients.
Suggestions:
1. Develop and strengthen preventive emergency healthcare strategy such as National
Injury Prevention Programme
2. Develop a robust pre-hospital emergency care system including community
participation.
3. There should be installation of AED (Automated external Defibrillator) as a public access

device especially in mass gathering areas such as schools, shopping mall, railway station,
airport, religious gathering areas etc.
4. Implement good Samaritan law for all emergency conditions including injuries across
the country
10. BLOOD BANK SERVICES

Table 13 summarizes the hospital blood bank services for all categories of hospitals. As per the
51
assessment, 69 hospitals out of 100 had licensed in-house blood bank, out of which 66 hospitals
ran 24 X 7 services.
It was observed that 34 hospitals had a tie-up with an external blood bank facility, 57 hospitals
had separate component facility for packed cell (RBC), FFP, Platelet Cryoprecipitate, 57 hospitals
had availability of O- (Negative) blood in their hospitals (figure 10).
A. Hospital-wise comparison
It was observed that out of 20 medical colleges 18 had 24*7 blood bank service available in
hospital but one medical college (Tomo Riba Institute of Health & Medical Sciences, Papumpare)
did not have 24*7 blood bank facility while one medical college (B J Medical College & Sassoon
General Hospital, Pune) did not have in-house blood bank available but it had tie-up with other
blood bank.
Table 13: Summary of Hospital Blood Bank Services by Categories of Hospitals

Govt. Govt.
Pvt. hospitals Pvt. hospitals
Medical hospitals hospitals
(>300 bed (<300 bed
Hospital Blood Colleges (>300 bed (<300 bed
strength) strength)
Bank Services (n=20) strength) strength)
(n=20) (n=20)
(n=20) (n=20)
FC PC NC FC PC NC FC PC NC FC PC NC FC PC NC
Licensed in-house
18 1 1 14 3 3 7 5 8 17 0 2 13 1 6
Blood Bank
24*7 Blood Bank 18 1 1 14 3 2 7 1 5 17 0 2 13 1 6
Tie up with
external blood 7 1 2 6 4 1 6 3 4 6 0 5 9 3 3
bank
Separate
Component 16 1 2 6 6 6 6 2 8 16 1 3 13 1 6
Facilities
O Negative Blood
17 2 1 11 5 3 7 6 4 15 3 2 7 4 9
Availability
ED Blood Storage 4 1 14 1 2 17 5 3 9 4 1 15 6 0 14
ED Blood
Transfusion 6 0 13 3 1 15 3 2 13 10 2 8 10 1 9
Protocol
Massive Blood
Transfusion 7 0 13 2 1 16 4 1 13 9 0 11 8 0 12
Protocol
**FC: Full Compliance, PC: Partial Compliance, NC: Non-Compliance, ED: Emergency department
Out of 100 hospitals, 11 hospitals (Christian Institute of Health Sciences & Research, Dimapur;
District Hospital, Ganderbal; District Hospital Bishnupur; Shija Hospital & Research Institute,
Imphal; Birla CK Hospital, Jaipur; Fortis Hospital, Jaipur; Civil Hospital, Sec-22, Chandigarh; Bhopal
Fracture Hospital, Bhopal; Sadar Hospital, Gaya; Paras HMRI Hospital, Bihar and Coronation
Hospital, Dehradun)were found which neither has in-house licensed blood bank nor has any
tie-up with external blood bank facility.
52

Figure 10: Comparison of Hospital Blood Bank Services in Hospital Categories
The blood bank is under construction in Christian Institute of Health Sciences & Research,
Dimapur and District Hospital Bishnupur, while District Hospital, Ganderbal has only blood
storage. District Hospital, Dhamtari reported shortage of staff for blood bank.
**Blood Bank in the ED

It was observed that the majority of hospitals did not have facilities for storage of blood at ED.
Only 20 hospitals {10 government hospitals [6 district hospitals and 4 medical colleges], 10
private hospitals} had separate blood storage for ED.
Most of the hospitals did not have protocols for massive blood transfusion and ED blood transfusion
(Figure 10).
53
Best Practices for Blood Bank Services:

In the 300-500 bedded government hospital category–District Hospital Baramulla,
Jammu & Kashmir had 24x7 blood bank availability and also had separate ED blood
storage with separate component facility.
In the 100-300 bedded private hospital category- North Goa District Hospital had 24x7
blood bank availability and also had separate ED blood storage with separate component
facility.
6 district hospitals had separate blood storage

for ED:
District Hospital, Baramulla, J &K
District Hospital, Virajpet, Karnataka
Singtam District Hospital, Sikkim
District Hospital, King koti, Telangana
BDM District Hospital, Kotputli, Rajasthan
North Goa District Hospital, Goa
Only 4 medical colleges had separate blood

storage for ED:
B J Medical College, Pune
SMS Medical College & Hospital, Rajasthan
Patna Medical College & Hospital, Bihar
IPGMER & SSKM Hospital
Suggestions:
1. Blood bank services for 24*7 at all hospitals.
2. Blood storage facilities in the ED should be made mandatory for those medical college
and district hospitals (>300 beds) which deals with high volume major trauma cases,
emergency conditions requiring lifesaving blood transfusion services (e.g Massive upper/
lower gastrointestinal bleed, Massive hemoptysis, severe anaemia).
54
B. Zone-wise comparison:
Table 14 and figure 11 summarizes the blood bank services for hospitals in different zones of India.
55

Figure 11: Zone-wise Comparison of Hospital Blood Bank Services
It was observed that 5 hospitals in north zone neither had blood bank facility in hospital nor had
any tie-up with other blood bank. Similarly, 2 hospitals in east zone and 4 hospitals in north
east neither had blood bank facility in hospital nor had any tie-up with other blood bank. The
assessed hospitals of south zone and west zone had 24*7 available blood bank facilities either
in their hospital or had some tie-up with another blood bank facility.
Table 14: Zone-wise Summary of Hospital Blood Bank Services
North East
Hospital Blood Bank North (n=30) South (n=21) East (n=11) West (n= 16)
(n=22)
Services
NC PC FC NC PC FC NC PC FC NC PC FC NC PC FC
Licensed in-house
4 3 23 4 0 16 4 2 5 4 1 11 4 4 13
Blood Bank
24*7 Blood Bank 3 0 26 3 1 15 2 1 6 2 2 10 6 3 13
Tie up with external

6 3 12 4 1 6 1 1 4 0 3 3 4 3 8
blood bank
Separate Component
8 3 17 3 2 15 3 2 4 4 2 9 8 2 10
Facilities
O-ve Blood
6 6 18 2 2 16 1 5 3 4 2 9 7 4 10
Availability
ED Blood Storage 22 1 7 13 2 4 4 2 3 9 3 3 20 0 2
ED Blood
18 1 10 10 1 8 4 2 4 7 2 6 18 1 3
Transfusion Protocol
Massive Blood
19 1 9 11 1 8 7 0 3 8 1 6 19 0 3
Transfusion Protocol
**FC: Full Compliance, PC: Partial Compliance, NC: Non-Compliance, ED: Emergency Department
56
11. DEFINITIVE CARE SERVICES

Definitive care is the care that is rendered conclusively to manage patient’s condition, encompassing
the full range of preventive, curative acute, convalescent, restorative, and rehabilitative medical
care.
In this study the following categories were assessed: emergency operative services, intensive care
unit services and specialized care services.
i. Emergency Operative Services:

It was observed that 53% hospitals had emergency operative services for trauma patients, 58%
hospitals had emergency operative services for non-trauma patients, 57% hospitals had emergency
operative services for obstetrics patients, 61% hospitals had emergency operative services for
orthopedic patients, and 47% hospitals had emergency operative services for neurosurgical
patients (table 15 and figure 12).
In addition, only 14 medical colleges had emergency operative services for trauma patients, 5
medical colleges showed partial compliance while one medical college (New STNM Hospital,
Sikkim) did not had emergency operative services for trauma patients. Also, 4 medical colleges
(Guru Nanak Dev Hospital, GMC, TRIHMS, New STNM Hospital and Patna Medical College)
did not have emergency operative services for neurosurgical patients.
Table 15: Overall Summary of Emergency Operative Services by Hospital Category

Govt. hospitals Govt. hospitals Pvt. hospitals Pvt.hospitals
Medical
Emergency (>300 bed (<300 bed (>300 bed (<300 bed
Colleges
Operative strength) strength) strength) strength)
(n=20)
Services (n=20) (n=20) (n=20) (n=20)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
For Trauma
14 5 1 7 9 3 1 8 11 14 6 0 17 3 0
pts
For Non-
14 6 0 10 7 2 2 8 10 14 6 0 18 2 0
Trauma pts
For Obstetrics
14 2 0 10 6 3 7 10 3 12 6 1 14 3 1
pts
For
Orthopedic 15 4 0 9 6 4 4 7 8 15 5 0 18 1 1
pts
For
Neurosurgical 13 2 4 4 3 10 0 3 16 14 3 2 16 2 1
pts
*n: total number of assessed hospitals
57
Figure 12: Comparison of Hospital Emergency Operative Services in Hospital Categories
ii. Critical Care Services

An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit
(ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that
provides intensive treatment medicine.
Table 16: Overall Summary of Critical Care Services by Hospital Category
Govt. Hospitals Govt. Hospitals Pvt. Hospitals Pvt. Hospitals

Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Colleges
Definitive strength) strength) strength) strength)
(n=20)
Care Services (n=20) (n=20) (n=20) (n=20)
Common ICU 13 4 3 11 4 4 1 5 14 16 3 1 17 3 0
Common
5 4 11 5 4 8 0 2 18 14 3 2 14 2 3
HDU
Pediatric ICU 14 1 3 4 5 9 0 2 18 11 3 4 8 2 6
Neonatal ICU 13 2 3 6 5 7 4 5 11 12 3 3 12 3 2
Neurosurgical
8 3 7 4 1 11 0 0 19 12 3 4 8 5 5
ICU
Cardiac ICU 10 1 7 4 3 9 0 0 19 15 2 2 15 1 2
*n: total number of hospitals, ICU: Intensive Care Unit, HDU: High Dependency Unit
58
In this study, different types of ICUs were assessed. It was observed that majority of hospitals did
not had any common ICU as well as specialized types of ICU in their hospitals. A total of 58%
hospitals had common ICU, 38% had common HDU (High Dependency Unit), 37% hospitals
had pediatric ICU, 47% hospitals had neonatal ICU, only 32% hospitals had neurosurgery ICU,
and 44% hospitals had cardiac ICU were observed (table 16 and figure 13).

Figure 13: Comparison of Hospital Critical Care Services by Category of Hospital
It was observed that 20 out of 3 medical colleges (TRIHMS, Sher-i-kashmir Institute of medical
Sciences and Patna medical College) did not have common ICU. 3 medical colleges (Guru
Nanak Dev Hospital, GMC, TRIHMS, and New STNM Hospital) did not have pediatric ICU and
3 medical colleges (Sher-i-kashmir Institute of medical Sciences, New STNM Hospital and IGMC,
Shimla) did not have neonatal ICU.
iii. Specialized Care Services

Other than ICU, hospitals have some specialized care services, which were also assessed. It was
observed that 43% hospitals had cardiac cath lab, 28% hospitals had intervention radiology,
only 17% hospitals had intervention neuroradiology service with DSA, 26% hospitals had facility
for emergency CABG services, and only 18% hospitals had facility for radiofrequency ablation
services (table 17 and figure 14).
59
Figure 14: Comparison of Hospital Specialized Care Services by Category of Hospitals
Table 17: Overall Summary of Specialized Care Services by Hospital Category

Govt. Govt. Pvt. Hospitals Pvt. Hospitals
Medical Hospitals Hospitals
Colleges (>300 bed (<300 bed (>300 bed (<300 bed
Specialized Care strength) strength)
Services (n=20) strength) strength)
(n=20) (n=20) (n=20) (n=20)
Cardiac Cath Lab 11 1 6 4 3 9 0 0 19 14 3 2 14 2 2
Intervention
Radiology
9 2 7 1 4 10 0 2 17 8 4 6 10 4 4
Intervention
Neuro Radiology 4 6 8 1 3 11 0 0 18 7 4 8 5 6 7
with DSA
Facility for
Emergency 4 3 11 2 3 10 0 0 18 9 5 5 11 4 3
CABG Service
Facility for
Radiofrequency 5 0 12 0 2 12 0 0 18 7 4 8 6 4 7
Ablation Service
*n: total number of assessed hospitals
60
Best Practices for Specialized Care Services at Hospitals
Cardiac Cath Lab:

1. Dr Shyam Prasad Mukharji Civil Hospital, Lucknow
2. Indira Gandhi General Hospital, Puducherry
3. Southern Railway Hospital, Chennai
4. District Hospital, Tenali*
Intervention Radiology*:
1. District Hospital, Baramulla
2. Puri District Hospital, Odisha
3. Indira Gandhi General Hospital, Puducherry
Intervention Neuroradiology service with DSA:

1. Indira Gandhi General Hospital, Puducherry*
Facility for Emergency CABG services:

1. District Hospital, Tenali
2. Southern Railway Hospital, Chennai
3. Indira Gandhi General Hospital, Puducherry*
*Facilities were present but not available for 24 hours due to lack of staff and equipments
Best Practices for Overall Definitive Care Services:

Overall the following hospitals had all compliance for defined definitive care
services, best practices were observed in Grant Medical Foundation Ruby Hall
Clinic, Shija Hospital & Research Institute, Manipal Hospital, Max Super Speciality
hospital, Ramakrishna Care Hospital and Primus Super Speciality hospital.
These hospitals had all types of emergency operative services, all types of ICU and
every specialized care services were observed in the above mentioned hospitals.
Suggestions:
1. Medical colleges should have all types of emergency operative, critical care and
specialized care services for 24*7.
2. District hospitals >300 beds should have trauma, non-trauma operative services, general
ICU (Intensive Care Unit), HDU (High Dependency Unit), NICU (Neonatal ICU) and
PICU (Pediatric ICU).
3. District hospitals <300 beds should have general operative services, general ICU
(Intensive Care Unit) / HDU (High Dependency Unit) and NICU (Neonatal ICU).
District hospitals may be upgraded into multi-speciality hospitals to improve the quality
of care.
61
12. AMBULANCE SERVICES
12.1 Available ambulances in hospitals
A. Hospital-wise comparison:
A total of 378 ambulances were recorded in 100 hospitals, out of which 315 were functional,
31 were non-functional and the data of 32 ambulances were not known.
Out of the 315 functional ambulances, 148 ambulances were ALS (Advanced Life Support), 97
ambulances were BLS (Basic life Support), and 70 ambulances were neither ALS nor BLS (other
transport vehicles).
Table 18: Summary of available Ambulances by Hospital Category
Govt. Govt.
Ambulance (>300 bed (<300 bed
Colleges (>300 bed (<300 bed
Services strength) strength)
(n=20) strength) strength)
(n=20) (n=20)
(n=20) (n=20)
Total Ambulances 119 56 54 91 58
Functional 86 (72%) 37 (66%) 47 (87%) 91 (100%) 54 (93%)
ALS 38 (44%) 21 (57%) 17 (36%) 40 (44%) 32 (59%)
BLS 24 (28%) 6 (16%) 6 (13%) 45 (49%) 16 (30%)
Other Transport
24 (28%) 10 (27%) 24 (51%) 6 (7%) 6 (11%)
Vehicles
Non-Functional 16 (13%) 5 (9%) 7 (13%) 0 (0%) 3 (5%)
Data Not Known 17 (14%) 14 (25%) 0 (0%) 0 (0%) 1 (2%)
*n: number of assessed hospitals, ALS: Advanced Life Support, BLS: Basic Life Support
Figure 15: Representation of available Ambulances Status by Category of Hospitals
62
Figure 16: Representation of types of Ambulances by Category of Hospitals
It was observed that ~48% of the ambulances were ALS of all the functional ambulances in
every category of hospital, and only 10% patients (red triaged patients) require ALS ambulances.
B. Zone-wise comparison
A total of 136 ambulances were found in north zone (n= 30), 82 ambulances were found in
south zone (n=21), 31 ambulances were found in east zone (n=11), 64 ambulances were found
in west zone (n=16), and 65 ambulances were found in north-east zone (n=22) of India (table
19 and figure 17, 18).
Table 19: Zone-wise Summary of available Ambulances in Hospitals
Hospital Ambulance North South East West North East

Services (n=30) (n=21) (n=11) (n=16) (n=22)
Total Ambulances 136 82 31 64 65

Functional 103 (76%) 69 (84%) 29 (94%) 55 (86%) 59 (91%)
ALS 33 (24%) 39 (48%) 17 (55%) 34 (53%) 25 (38%)
BLS 35 (26%) 25 (30%) 8 (26%) 18 (28%) 11 (17%)
Other Transport 68 (50%) 18 (22%) 6 (19%) 12 (19%) 29 (45%)
Vehicles
Non-Functional 6 (4%) 9 (13%) 2(7%) 9 (16%) 5 (8%)
Data Not Known 27 (20%) 4 (5%) 0 (0%) 0 (0%) 1 (2%)
Good Practice by using Bike Ambulance

It was found that Max Super Speciality Hospital, Chandigarh has 2 functional bike ambulances
which were used for patient transport.
63
Figure 17: Zone-wise Comparison of available Ambulances in Hospitals
Figure 18: Zone-wise Comparison of types of Ambulances in Hospitals
C. NABH Accreditation-wise comparison:

Table 20 and figure 19summarizes the number of ambulances on the basis of hospitals with
NABH accreditation and hospitals without NABH accreditation.

Figure 19: Comparison of available Ambulances with their types in NABH Accredited Hospitals and Non-NABH
Accredited Hospitals
64
Table 20: Summary of available Ambulances in NABH accredited and non-NABH

NABH Accredited Hospitals Non-NABH Accredited Hospitals
Hospital Ambulance Services
(n=28) (n=72)
Total Ambulances 121 32% 257 68%
Functional 118 98% 197 77%

ALS 59 49% 89 35%
BLS 54 45% 43 17%
Other Transport Vehicles 8 7% 125 49%
Non-Functional 3 2% 28 11%
Data Not Known 0 0% 32 12%
*n: number of hospitals
Suggestions:
As per MCI, number of in-hospital ambulances according to bed strength:
1. For > 300 beds, 1 ambulance should be present
2. For > 500 beds, 2 ambulances should be present
The in-hospital ambulances should be optimally utilized in the common resource pool of
EMS (Emergency medical Service) of the region as per requirement.
Regular maintenance of ambulances should be done.
The ALS ambulances can be used for mobile stroke unit as well as for STEMI programme.
12.2 Hospital Ambulance Services

It was observed that out of 100 hospitals, 91 had in-house ambulances. Only 18% hospitals get
a pre-hospital notification of ambulance arrival at the hospital. Trained paramedics were available
in 34% hospitals.
Mobile stroke unit was available in only 4% hospitals and Tele stroke/STEMI (ST-segment elevation
myocardial infarction) was available in 19% hospitals.
65
Figure 20: Comparison of Ambulance Services by Category of Hospitals
Table 21: Summary of Hospital Ambulance Services by Category of Hospitals

Govt. hospitals Govt. hospitals Pvt. hospitals Pvt. hospitals
Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Colleges
Ambulance strength) strength) strength) strength)
(n=20)
Services (n=20) (n=20) (n=20) (n=20)
Ambulances in
17 0 3 17 0 1 19 0 1 19 0 0 19 0 1
Hospital
Pre Hospital
1 5 13 0 3 16 2 5 13 9 4 6 6 6 8
Notification
Trained
Paramedics for 6 4 10 0 7 13 2 5 13 12 4 3 14 2 4
Ambulances
Mobile Stroke
1 0 19 0 1 18 0 0 20 1 0 18 2 1 16
Unit
Tele Medicine
7 1 11 3 2 15 2 1 16 3 2 13 4 0 15
Facility
*n=number of hospitals
66
12.3 Use of Ambulances by Hospitals

It was observed that mostly hospitals used the ambulances for inter-transfer of patients to other
hospitals,while a few number of ambulances used the ambulances to drop the patient (figure 21).
Figure 21: Overall representation of use of Ambulances by Hospitals
12.4 Patient transfer in absence of hospital ambulance:

It was found that in absence of hospital ambulance patient transfer takes place by private
ambulances in most hospitals, sometimes patient have to go by their own vehicles and sometimes
it takes place by 108 or 102 ambulances (figure 22).
Figure 22: Overall representation of Patient transfer in case hospital does not have ambulance services
It was observed that 6 hospitals (Christian Institute of Health Sciences & Research, Dimapur;
District Hospital, Baramulla, Jammu & Kashmir; Gauhati Medical College & Hospital; Government
General Hospital, Guntur; North Goa District Hospitaland IGMC, Shimla) does not have any
ambulances while 3 hospitals (Government Multispeciality Hospital, Sector 16, Chandigarh;
Apollo Hospitals, Chennaiand Deen Dayal Upadhyay Hospital, Shimla) did not share their
ambulance data with our assessor’s team.
67
Best Practices for Hospital Ambulance Services:

Primus Super Speciality Hospital is a private 138 bedded hospital and it have best hospital
ambulance services out of all 100 hospitals. It has mobile stroke unit as well as tele-
medicine facility.
Hospitals have GVK centre which is a Centralized ambulance services in Goa.
Mobile Stroke Unit was observed in Gauhati Medical College, Medeor Hospital, Sri
Ganga Ram Hospital, and Primus Super Speciality Hospital.
Note: It was found that some government hospitals did not have sufficient staff for ambulances
not even drivers. Jallianwala Bagh Matyr Memorial Hospital, Punjab and District Hospital,
Peroorkada, Kerala did not have manpower for ambulance.
North Goa District Hospital, Goa is running STEMI Programme by using tele-radiology. 6 hospitals
(Christian Institute of Health Sciences & Research, Dimapur; Synod Hospital, Aizawl, Mizoram;
Ramakrishna Mission Hospital, Arunachal Pradesh; District Hospital, Pasighat; Shija Hospital &
Research Institute, Imphal and Morigaon Civil Hospital, Assam) were found using tele-radiology
for various purpose such as for X-ray and CT scan.
Suggestions:
1. Create National Pre-hospital care guidelines.
2. Capacity building of existing paramedics by structured training program.
3. Creation of EMT (Emergency Medical Technician) course as a residency programme.
4. Dedicated job creation for EMT with performance based promotional ladder.
5. Establish Paramedic Council of India as regulatory body
13. ED PROTOCOL / SOP / GUIDELINES
In a healthcare facility, a protocol, also called a medical guideline, is a set of instructions which
describe a process to be followed to investigate a particular set of findings in a patient, or the
method which should be followed to control a certain disease.
It was observed that 41% hospitals had documented emergency manual, 30% hospitals had
documented policies and procedures for patient transfer in, 30% hospitals had documented
policies and procedures for patient transfer out, 57% hospitals gave discharge summary to patients,
58% hospitals had policy on handling cases of death, 44% hospitals had documented disaster
management plan, and only 41% hospitals had triage policy in ED.
68
Table 22: Summary of ED Protocol / SOP / Guidelines by Category of Hospitals

Medical
ED Protocol Colleges (>300 bed (<300 bed (>300 bed (<300 bed
/ SOP / (n=20) strength) strength) strength) strength)
Guidelines (n=20) (n=20) (n=20) (n=20)
Emergency
1 3 15 4 7 9 3 3 14 14 3 3 19 1 0
Manual
Policies and
procedures
1 4 15 2 7 11 3 3 14 13 0 7 11 6 3
for patient
transfer in
Policies and
procedures
1 5 14 1 9 10 2 6 12 13 2 5 13 6 1
for patient
transfer out
Discharge
Summary to 7 7 5 8 5 7 6 6 8 16 4 0 20 0 0
patients
Policy on
handling death 9 6 5 10 5 5 8 7 4 14 3 3 17 3 0
cases
Disaster
Management 6 2 12 5 5 10 5 3 10 14 1 5 14 2 3
Plan
Triage Policy
5 0 14 3 2 15 5 0 15 12 0 8 16 0 3
in ED
FIn medical college, only one hospital (IPGMER & SSKM Hospital) had emergency manual,
1 hospital (IPGMER & SSKM Hospital) had documented policies and procedures for patient
transfer in, 1 hospital (IPGMER & SSKM Hospital) had documented policies and procedures
for patient transfer out, 7 hospitals (Civil Hospital, Ahemdabad; Agartala Government Medical
College & G B Pant Hospital; Sher–I–Kashmir Institute of Medical Sciences, Srinagar, Government
General Hospital, Guntur; SMS Medical College & Hospital; AIIMS, Bhopal and IPGMER & SSKM
Hospital) gave discharge summary to patients, 9 hospitals had policy on handling cases of death,
6 hospitals had documented disaster management plan, and only 5 hospitals (AIIMS, Bhopal;
Rajiv Gandhi Government General Hospital, Madras Medical College; JIPMER, Pondicherry;
Government Medical College, Thiruvanananthapuram and IPGMER & SSKM Hospital) had triage
policy in ED (table 22 and figure 23).
It was observed that 7 district hospitals had documented emergency manual, 3 district hospitals had
documented policies and procedures for patient transfer in, 2 district hospitals had documented
policies and procedures for patient transfer out, 11 district hospitals gave discharge summary
to patients, 15 district hospitals had policy on handling cases of death, 9 district hospitals had
documented disaster management plan, and only 6 district hospitals (Jamanabai General Hospital,
Gujarat; Civil Hospital, Aizawl, Mizoram; District Hospital, Pasighat, Arunachal Pradesh; District
Hospital, Singtam, Sikkim; Southern Railways Hospital, Chennai and HNB Base Hospital,
Uttarakhand) had triage policy in ED.
69
Figure 23: Comparison of ED Protocol / SOP / Guidelines by Hospital Categories
70
Table 23: Zone-wise Summary of ED Protocol / SOP / Guidelines in Hospitals
North East
ED Protocol / SOP North (n=30) South (n=21) East (n=11) West (n= 16)
(n=22)
/ Guidelines
No Partial Yes No Partial Yes No Partial Yes No Partial Yes No Partial Yes
Emergency Manual 9 4 17 11 3 5 5 2 4 7 4 5 10 3 9
Policies and
procedures for 13 6 11 11 4 4 5 0 6 4 6 6 15 5 2
patient transfer in
Policies and
procedures for 12 6 12 9 5 6 5 1 5 5 7 4 11 8 3
patient transfer out
Discharge Summary
5 5 20 6 4 9 3 1 7 0 5 11 7 7 8
to patients
Policy on handling
3 7 20 4 3 12 2 1 8 2 4 10 6 9 6
death cases
Disaster
8 4 18 10 1 7 5 2 4 5 4 7 12 1 7
Management Plan
Triage Policy in ED 15 1 14 9 0 9 4 1 6 9 0 6 17 0 5
Figure 24: Zone-wise Comparison of ED Protocol / SOP / Guidelines in hospitals
71
C. NABH Acrcreditation-wise comparison:

Figure 25: Overall Comparison of ED Protocol / SOP / Guidelines in NABH accredited and
non-NABH Accredited Hospitals
14. EMERGENCY CARE PROTOCOLS
In Emergency Department, some emergency care protocols are present which have emergency
care protocol for different diseases. 38% hospitals had alert system for cardiac arrest, 16% had
alert system for trauma, 15% had alert system for chest pain, only 10% had for sepsis and 23%
had alert system for stroke (table 24 and figure 26).
Figure 26: Comparison of Emergency Care Protocols by Hospital Categories
72
In medical college, 2 hospitals (Rajiv Gandhi Government General Hospital, Madras Medical
College and IPGMER & SSKM Hospital) have alert system for cardiac arrest and for trauma, only
1 hospital (IPGMER & SSKM Hospital) have alert system for chest pain, for sepsis and for stroke.
In government hospitals >300 beds, 4 hospitals (District Hospital, Baramulla, J&K; Government
District Hospital, Tenali; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow and Government
Multispeciality Hospital, Sector 16, Chandigarh) have alert system for cardiac arrest, 1 hospital
(District Hospital, Baramulla, J&K) have alert system for trauma, 1 hospital (District Hospital,
Baramulla, J&K) have alert system for chest pain, only 1 hospital (District Hospital, Karim Nagar)
have alert system for sepsis and 2 hospitals (District Hospital, Baramulla, J&K and Government
District Hospital, Tenali) have alert system for stroke.
In government hospitals <300 beds, only 1 hospital (Dr Jogalekar Hospital, Pune) have alert
system for cardiac arrest, for trauma, for chest pain for stroke.
Table 24: Overall Summary of Emergency Care protocols by Category of Hospitals

Medical
Emergency Colleges (>300 bed (<300 bed (>300 bed (<300 bed
Care (n=20) strength) strength) strength) strength)
Protocols (n=20) (n=20) (n=20) (n=20)
Blue:
Cardiac 2 2 16 4 0 16 1 0 19 14 1 4 17 0 3
Arrest
Trauma 2 0 18 1 1 18 1 0 19 9 0 10 3 2 15
Chest Pain 1 0 18 1 0 19 1 0 19 5 2 12 7 3 9
Sepsis 1 0 18 1 2 17 0 0 20 4 0 15 4 2 13
Stroke 1 0 18 2 0 18 1 0 19 10 0 9 9 2 8
B. Zone-wise comparison:
Table 25 depicts the comparison of emergency care protocols at the assessed healthcare facilities.
Table 25: Zone-wise Summary of Emergency Care protocols in Hospitals
Emergency North East

North (n=30) South (n=21) East (n=11) West (n= 16)
Care (n=22)
Protocols No Partial Yes No Partial Yes No Partial Yes No Partial Yes No Partial Yes
Cardiac
12 0 18 12 1 7 7 0 4 9 1 6 19 1 1
Arrest
Trauma 24 1 5 15 0 5 8 1 2 12 1 3 21 0 0
Chest Pain 22 2 6 15 1 2 7 2 2 12 0 4 20 0 1
Sepsis 26 3 1 14 0 4 7 1 3 14 0 2 21 0 0
Stroke 20 1 9 12 0 6 7 1 3 12 0 4 20 0 1
73
Figure 27: Zone-wise Comparison of Emergency Care Protocols in Hospitals
C. NABH and non-NABH Accredited Hospitals comparison:

Figure 28 depicts the comparison of NABH and non-NABH accredited hospitals for the emergency
care protocols.

Figure 28: Overall Comparison of Emergency Care protocols in NABH accredited and non-NABH
Suggestions:
1. Develop standardized evidence based emergency care protocols (administrative and
clinical).
2. Development of academic residency programme.
3. Implementation of triage policy in each hospital.
74
4. NABH Accreditation.
5. Increase the scope of Good Samaritan Law from road traffic injuries to other time
sensitive conditions.
15. MEASURES ENSURING SAFETY & SECURITY IN HOSPITALS

Several safety aspects were assessed for Emergency Department which is mentioned in the below
tables and figure. It was observed that majority of hospitals did not have periodic training of staff
and periodic mock drill was also not conducted regularly.
Nearly all private hospitals had periodic training programmes in their hospitals while most of
the government hospitals including medical colleges did not have regular periodic training of
staff. Similarly, mock drill conducted in most of the private hospitals while mostly government
hospitals did not conduct mock drill.
These aspects also assessed according to hospital bed strength
a. Category wise (table 26and figure 29)
b. 5 Zones of our country (zone wise) (table 27 and figure 30)
c. NABH accredited and non-NABH accredited hospitals (figure 31).
Table 26: Overall Summary of measures ensuring Safety & Security by Category of Hospitals
Medical
Safety & Colleges (>300 bed (<300 bed (>300 bed (<300 bed
Security (n=20) strength) strength) strength) strength)
measures (n=20) (n=20) (n=20) (n=20)
Fire Safety 13 7 0 9 10 1 7 10 2 19 1 0 17 3 0
Building Safety 12 3 4 9 7 4 8 6 5 15 3 1 17 2 1
Electrical
12 7 1 10 7 3 11 6 3 19 1 0 19 1 0
Safety
Patient and
Provider 12 7 0 8 9 3 8 6 5 17 3 0 20 0 0
Safety
Chemical
9 10 1 7 7 5 8 8 3 20 0 0 18 1 0
Safety
Periodic
Training of 7 5 8 4 9 7 3 13 4 16 3 1 18 2 0
Staff
Periodic Mock
6 5 9 4 7 9 3 11 6 16 3 1 17 3 0
Drill
Police Post
Available in 15 2 3 15 0 5 5 4 11 4 3 13 2 2 16
Premises
Alarm
Bell/Code
3 7 9 4 2 13 2 2 16 14 1 5 16 2 1
Announcement
in ED
*n: number of hospitals, ED: Emergency Department
75
Figure 29: Comparison of measures ensuring Safety & Security by Hospital Categories
76

Figure 30: Zone-wise comparison of measures ensuring Safety & Security in Hospitals
77
Table 27: Zone-wise measures ensuring Summary of Safety & Security in Hospitals
North East
Safety & North (n=30) South (n=21) East (n=11) West (n= 16)
(n=22)
Security
Fire Safety 24 5 1 10 8 2 8 3 0 12 3 0 10 12 0
Building Safety 22 4 4 11 4 5 7 2 2 12 3 1 8 8 3
Electrical Safety 23 5 2 10 7 3 8 2 1 12 4 0 16 5 1
Patient and
22 7 1 10 7 2 6 2 3 9 6 1 16 4 1
Provider Safety
Chemical Safety 22 8 0 10 5 4 8 2 1 10 5 0 10 6 5
Periodic
Training of 18 7 5 9 3 8 3 7 1 10 6 0 8 8 6
Staff
Periodic Mock
18 6 6 7 2 11 3 6 2 10 5 1 7 9 6
Drill
Police Post
Available in 12 6 12 9 2 9 3 1 7 9 0 7 7 3 12
Premises
Alarm Bell/
Code
16 4 9 6 3 9 4 1 6 7 4 5 4 2 16
Announcement
in ED
*n=number of hospitals, ED=Emergency Department
C. NABH Accreditation comparison

Figure 31: Comparison of Safety & Security in NABH and Non-NABH Accredited Hospitals
78
16. DISASTER MANAGEMENT

Hospital disaster management provides the opportunity to plan, prepare and when needed enables
a rational response in case of disasters/ mass casualty incidents (MCI). Disasters and mass casualties
can cause great confusion and inefficiency in the hospitals.
The preparedness/readyness of hospitals for disaster management were analysed according to the
categories of hospitals as depicted in the below table and graph.

Figure 32: Comparison of preparedness/readyness for Disaster Management by Hospital Categories
It was observed that only 33 hospitals have documented disease outbreak management plan,
38 hospitals have surge capacity, only 14 hospitals (2 government hospitals: Government
Multispeciality hospital, Sector-16 and Dr Jogalekar Hospital) have separate decontamination
area for ED entrance, 35 hospitals have separate disease stock in ED, 32 hospitals conducted
drill and debriefing for disaster management, and 38 hospitals have system to redistribution of
patients to other hospitals during disaster.
79
Table 28: Summary of preparedness/readyness for Disaster Management by

Category of Hospitals
Govt. Govt.
(>300 bed (<300 bed
Disaster Colleges (>300 bed (<300 bed
strength) strength)
Management (n=20) strength) strength)
(n=20) (n=20)
(n=20) (n=20)
Disease
Management 4 4 12 7 4 9 2 7 11 13 3 4 7 7 6
Outbreak Plan
Surge Capacity 5 8 7 8 5 7 2 9 9 13 3 3 10 6 4
Separate
Decontamination 0 2 18 1 1 18 1 2 17 7 2 10 5 5 10
Area at ED entrance
Separate Disaster
4 2 14 7 1 12 2 5 13 11 2 7 11 5 4
Stock in ED
Drill and Debriefing
for Disaster 2 5 13 5 4 11 2 3 15 13 3 4 10 5 5
Management
Redistribution of pts
4 2 14 6 5 8 5 4 11 14 2 4 9 8 3
to other hospitals
Mostly healthcare facilities did not have separate decontamination area at ED entrance. Government
hospitals and medical colleges did not conducted drill and debriefing for disaster management.
The government healthcare facilities also lack the system for redistribution of patients to other
network hospitals during disaster (Zone wise-table 29 and figure 33).
Table 29: Zone-wise Summary of preparedness/readyness for Disaster Management in Hospitals

North East
Disaster North (n=30) South (n=21) East (n=11) West (n= 16)
(n=22)
Management
Surge Capacity 18 9 3 7 4 8 3 5 3 8 3 5 2 8 12
Separate
Decontamination 7 4 19 1 2 16 1 3 7 4 1 11 1 2 19
Area at ED entrance
Separate Disaster
14 5 11 8 2 10 5 2 4 3 4 9 4 3 15
Stock in ED
Drill and Debriefing
for Disaster 14 7 9 8 1 11 3 3 5 4 3 9 3 6 13
Management
Redistribution of pts
16 4 9 6 2 12 4 3 4 8 5 3 3 7 12
to other hospitals
80
It was observed during analysis that north-east was the weakest zone in disaster management in
all the required aspects as mentioned in table 29 and figure 33.
Figure 33: Zone-wise Comparison of preparedness/readyness for Disaster Management in Hospitals
C. NABH Accreditation comparison

In addition, it was also observed that the hospitals which were NABH accredited had good disaster
management system when compared with non-NABH accredited hospitals (figure 34).
Best Practices for preparedness/readiness for Disaster

Management
Fortis Hospital, Punjab, Government Multispecialty Hospital, Sector 16, Apollo Hospital, Paras
HMRI Hospital, Ramakrishna Care Hospital, Medeor Hospital, and Sri Ganga Ram Hospital
had all the required stocks and requirements needed for disaster management.
81

Figure 34: Overall Comparison of preparedness/readyness for Disaster Management in NABH
and Non-NABH Accredited Hospitals
Suggestions:
1. There should be standard protocols for implementation of in-hospital disaster management
plan
2. Implementation of hospitals preparedness for both external and internal disaster
management.
3. There should be separate decontamination area at entrance of emergency department.
4. Every hospital should have surge capacity with separate disaster stock in emergency
department.
5. There should be periodic drills and debriefing for disaster management.
6. Regular monitoring and evaluation of implementation of disaster management protocols
should be done by national disaster management authority.
17. CONTINUOUS QUALITY IMPROVEMENT

It is a process of creating an environment in which management and workers strive to create
constantly improving quality. The purpose of continuous quality improvement programs is to
improve health care by identifying problems, implementing and monitoring corrective action
and studying its effectiveness.
It was observed that 40% hospitals had dedicated staff for identification and loop closure, 52%
hospitals undergo regular audits, 42% hospitals had continuous education and training programs,
42% hospitals had key indicators for quality monitored, only 22% hospitals had quality indicators
for urgent and interventional procedures monitored, 50% hospitals had death review committee,
and 42% hospitals had central empowered hospital committee for continuous quality improvement
for emergency services.
Most of the government hospitals and medical colleges do not run continuous quality improvement
programmes and training while on the other hand; private hospitals showed good performance
in continuous quality improvement (table 30 and figure 35).
82
Table 30: Summary of Continuous Quality Improvement by Category of Hospitals

Govt. Govt. Pvt.
Pvt. hospitals
Medical hospitals hospitals hospitals
Colleges (<300 bed
Continuous Quality (>300 bed (<300 bed (>300 bed
(n=20) strength)
Improvement strength) strength) strength)
(n=20)
(n=20) (n=20) (n=20)
Dedicated Staff for
gap identification & 2 6 11 5 5 10 4 4 12 14 5 1 15 5 0
loop closure
Regular audits in
7 7 6 6 4 10 6 8 6 15 4 1 18 1 0
hospital
Continuous
Education and 4 7 9 6 7 7 1 9 10 14 4 2 17 3 0
Training programs
Key Indicators of
5 7 8 5 9 6 5 13 2 12 5 2 15 5 0
Quality Monitored
Quality Indicators
for urgent and
interventional 1 4 15 2 0 17 2 2 16 9 6 5 8 6 6
procedures
monitored
Death Review
6 6 8 6 4 10 4 5 11 16 2 2 18 0 2
Committee
Central Empowered
4 3 13 4 6 10 5 4 11 13 6 1 16 3 1
Hospital Committee
Out of 20 medical colleges, 2 hospitals (Civil Hospital, Ahmedabad and JIPMER Pondicherry) had
dedicated staff for identification and loop closure, 7 hospitals undergo regular audits, 4 hospitals
(Regional Institute of Medical Sciences, Imphal; Rajiv Gandhi Government General Hospital,
Madras Medical College; JIPMER, Pondicherry and IPGMER & SSKM Hospital) had continuous
education and training programs, 5 hospitals had key indicators for quality monitored, only 1
hospital (Gauhati Medical College & Hospital) had quality indicators for urgent and interventional
procedures monitored, 6 hospitals had death review committee, and 4 hospitals (Civil Hospital,
Ahemdabad; Rajiv Gandhi Government General Hospital, Madras Medical College; JIPMER,
Pondicherry and IPGMER & SSKM Hospital) had central empowered hospital committee for
continuous quality improvement for emergency services.
83
Figure 35: Comparison of Continuous Quality Improvement by Hospital Categories
Out of 20 government hospitals >300 beds, following were observed:

1. 5 hospitals had dedicated staff for identification and loop closure (Jallianwala Bagh
Matyr Memorial Hospital, Amritsar; District Hospital, Baramulla, J&K; Dr Shyam Prasad
Mukharji Civil Hospital, Lucknow; Government Multispeciality Hospital, Sector 16 and
Deen Dayal Upadhyay Hospital, H.P.)
2. 6 hospitals undergo regular audits (Jallianwala Bagh Matyr Memorial Hospital, Amritsar;
District Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow;
Government Multispeciality Hospital, Sector 16; HNB Base Hospital and Deen Dayal
Upadhyay Hospital, H.P.)
3. 6 hospitals had continuous education and training programs (Civil Hospital, Shillong; Dr
Shyam Prasad Mukharji Civil Hospital, Lucknow; Southern Railways Hospital, Chennai;
84
District Hospital, Baramulla, J&K, AIIMS, Patna and Deen Dayal Upadhyay Hospital,
H.P.)
4. 5 hospitals had key indicators for quality monitored (Civil Hospital, Shillong; District
Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow; Southern
Railways Hospital, Chennai and Deen Dayal Upadhyay Hospital, H.P.)
5. 2 hospitals had quality indicators for urgent and interventional procedures monitored
(District Hospital, Baramulla, J&K and Government Multispeciality Hospital, Sector 16)
6. 6 hospitals had death review committee (Jallianwala Bagh Matyr Memorial Hospital,
Amritsar; District Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital,
Lucknow; Government Multispeciality Hospital, Sector 16; AIIMS, Patna and Deen
Dayal Upadhyay Hospital, H.P.)
7. 4 hospitals had central empowered hospital committee for continuous quality
improvement for emergency services (Jallianwala Bagh Matyr Memorial Hospital,
Amritsar; District Hospital, Baramulla, J&K; AIIMS, Bhubneshwar and Government
Multispeciality Hospital, Sector 16)
Out of 20 government hospitals <300 beds, following were observed:

1. 4 hospitals had dedicated staff for identification and loop closure (Civil Hospital, Aizawl,
Mizoram; District Hospital, Ganderbal; Dr Jogalekar Hospital, Pune and District Hospital,
Singtam)
2. 6 hospitals undergo regular audits (Civil Hospital, Aizawl, Mizoram; District Hospital,
Pasighat; District Hospital, Singtam; District Hospital, King Koti; Dr Jogalekar Hospital,
Pune and North Goa District Hospital)
3. Only 1 hospital had continuous education and training programs (Dr Jogalekar Hospital,
Pune)
4. 5 hospitals had key indicators for quality monitored (Civil Hospital, Aizawl, Mizoram;
District Hospital, Singtam; District Hospital, King Koti; Dr Jogalekar Hospital, Pune and
North Goa District Hospital)
5. 2 hospitals had quality indicators for urgent and interventional procedures monitored
(North Goa District Hospital and Dr Jogalekar Hospital, Pune)
6. 4 hospitals had death review committee (Civil Hospital, Aizawl, Mizoram; District
Hospital, Pasighat; District Hospital, Singtam and North Goa District Hospital)
7. 5 hospitals had central empowered hospital committee for continuous quality
improvement for emergency services (Civil Hospital, Aizawl, Mizoram; District Hospital,
Singtam; District Hospital, King Koti; Dr Jogalekar Hospital, Pune and North Goa District
Hospital)
It was observed that North zone performed best out of all 5 zones in continuous quality
improvement while the rest of the zones performed below average (table 31 and figure 36).
85
Table 31: Zone-wise Summary of Continuous Quality Improvement in Hospitals
North North East

Continuous Quality South (n=21) East (n=11) West (n=16)
(n=30) (n=22)
Improvement
Dedicated Staff for gap
identification & loop 19 5 6 6 8 6 2 5 4 6 3 7 6 4 11
closure
Regular audits in hospital 22 5 3 8 4 7 4 4 3 6 6 4 10 6 6
Continuous Education
15 12 3 8 3 9 5 3 3 6 5 5 8 6 8
and Training programs
Key Indicators of Quality
17 9 3 6 10 4 4 5 2 7 5 4 8 9 5
Monitored
Quality Indicators for
urgent and interventional 11 5 13 3 3 14 2 4 5 4 3 9 1 3 18
procedures monitored
Death Review Committee 19 2 9 9 5 6 3 2 6 5 3 8 10 4 8
Central Empowered
18 4 8 7 4 9 4 5 2 6 5 5 6 3 13
Hospital Committee
Figure 36: Zone-wise Comparison of Continuous Quality Improvement in Hospitals
86

In addition, it was observed that NABH accredited hospitals had good performance in continuous
quality improvement when compared to non-NABH accredited (figure 37).

Figure 37: Overall Comparison of Continuous Quality Improvement in NABH and Non-NABH
NABH accredited healthcare facilities had regular audits in their facility, dedicated staff for
loop closure, runs training program cycles for skill development, had key indicators and quality
indicators for urgent and interventional procedures monitored. They had death review committee
to review the cause of patient’s death. Most of the NABH accredited hospitals followed the above
procedures for quality improvement.
Best Practices for Continuous Quality Management

Best practices for continuous quality management were observed in District Hospital,
Baramulla; Manipal Hospital; Fortis hospital, Jaipur; Max Super Speciality Hospital; Apollo
Hospital; Care Hospital; Yashoda Hospital, Malakpet; Paras HMRI Hospital; Ramakrishna Care
Hospital; Medeor Hospital and Artemis Hospital.
Suggestions:
1. There should be dedicated quality manager for gap identification and loop closure.
2. Develop a quality council among emergency care providers.
3. Mandatory Emerald certification under NABH.
4. Regular mortality and morbidity meeting.
5. Regular third-party audit of external agencies by using KPI and the funding of the
hospital should be linked with it.
6. Continuous training of quality council provider as well as manager.
18. COMPUTERIZED DATA MANAGEMENT SYSTEM

Healthcare data management is the process of storing, protecting, and analysing data pulled from
diverse sources. Managing the wealth of available healthcare data allows health systems to create
holistic views of patients, personalize treatments, improve communication, and enhance health
outcomes.
87
Out of 100 studied hospitals 52 hospitals did not had any electronic health record (EHR) and
other hospitals had EHR system.
Table 32: Summary of Data Management System by Category of Hospitals

Govt. Govt.
Colleges (>300 bed (<300 bed
Computerized Data (>300 bed (<300 bed
(n=20) strength) strength)
Management System strength) strength)
(n=20) (n=20)
(n=20) (n=20)
EHR 6 11 3 7 6 7 5 6 9 12 8 0 18 2 0
Patient Registration
15 2 3 17 0 3 10 2 8 20 0 0 20 0 0
System
Patient Clinical
2 1 17 3 1 16 0 1 19 6 5 9 6 5 9
Examination Notes
Patient Investigation Lab
10 3 7 7 4 9 4 3 13 16 2 2 18 1 1
Reports
Patient Radiological
12 3 5 10 2 8 3 5 11 18 2 0 16 2 2
Investigation Reports
Trauma Registry 2 5 13 3 5 12 1 2 17 6 3 11 7 5 7
Injury Surveillance
0 2 18 0 3 17 2 0 18 2 3 14 4 4 11
System
ED Surveillance System 1 3 16 0 4 16 1 1 18 9 1 10 7 3 9
Data Retrieval System 3 4 13 4 8 8 2 3 15 12 2 6 12 2 5
*n: number of hospitals, ED: Emergency Department, EHR: Electronic Health Record
In addition, it was also observed that 19 hospitals have trauma registry, only 8 hospitals have
injury surveillance system, 18 hospitals have emergency department surveillance system, and 33
hospitals have data retrieval system for quality improvement & research.
Out of 20 medical colleges, 6 hospitals had electronic health record (EHR), 15 hospitals had
computerized patient registration system, only 2 hospitals (AIIMS, Bhopal and IPGMER & SSKM
Hospital) had computerized patient clinical examination notes, 10 hospitals had computerized
patient investigation lab reports and 12 hospitals had computerized patient radiological
investigation reports.(Note: Though hospitals have answered yes for trauma registry but many of
them do not understood it’s meaning).
In addition, it was also observed that 2 hospitals (AIIMS, Bhopal and IPGMER & SSKM Hospital)
had trauma registry, none of them had injury surveillance system, 1 hospital (AIIMS, Bhopal) had
emergency department surveillance system, and 3 hospitals (Civil Hospital, Ahemdabad; AIIMS,
Bhopal and JIPMER, Pondicherry) had data retrieval system for quality improvement & research
(table 32 and figure 38).
88
Figure 38: Comparison of Data Management System by Hospital Categories
Out of 20 government hospital >300 beds, 7 hospitals had electronic health record (EHR),
17 hospitals had computerized patient registration system, only 3 hospitals (Dr Shyam Prasad
Mukharji Civil Hospital, Lucknow; AIIMS, Patna and Jai Prakash Narayan District Hospital, Bhopal)
had computerized patient clinical examination notes, 7 hospitals had computerized patient
investigation lab reports and 10 hospitals had computerized patient radiological investigation
reports.
89
In addition, it was also observed that 3 hospitals (AIIMS, Patna; Civil Hospital, Shillong and
HNB Base Hospital) had trauma registry, none of them had injury surveillance system and
emergency department surveillance system, and 4 hospitals (AIIMS, Bhubneshwar; District
Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow and Deen Dayal
Upadhyay Hospital, H.P.) had data retrieval system for quality improvement & research.
Out of 20 government hospital <300 beds, 5 hospitals had electronic health record (EHR), 10
hospitals had computerized patient registration system, none of them had computerized patient
clinical examination notes, 4 hospitals had computerized patient investigation lab reports and 3
hospitals had computerized patient radiological investigation reports.
In addition, it was also observed that 1 hospital (Puri District Headquarter Hospital, Orissa)
had trauma registry, 2 hospitals (Puri District Headquarter Hospital, Orissa and Dr Jogalekar
Hospital, Pune) had injury surveillance system, 1 hospital (Dr Jogalekar Hospital, Pune) had
emergency department surveillance system, and 2 hospitals (Civil Hospital, Aizawl, Mizoram
and Dr Jogalekar Hospital, Pune) had data retrieval system for quality improvement & research.
Computerized data management system found weak in government sector

especially in government hospitals less than 300 bed strength.
Trauma registry, injury surveillance system, emergency department surveillance system, and data
retrieval system for quality improvement & research were found weak in all categories of the
healthcare facilities (table 32 and figure 38).
Table 33: Zone-wise Summary of Data Management System in Hospitals
North East
North (n=30) South (n=21) East (n=11) West (n=16)
Data Management (n=22)
System
EHR 16 7 7 7 9 4 7 2 2 11 4 1 6 11 5
Patient Registration
25 0 5 17 0 3 9 0 2 14 1 1 16 3 3
System
Patient Clinical
4 4 22 2 5 13 4 2 5 5 2 9 1 1 20
Examination Notes
Patient Investigation
20 3 7 8 5 7 6 1 4 11 2 3 9 1 12
Lab Reports
Patient Radiological
15 5 10 12 2 6 7 1 3 10 3 3 13 4 4
Investigation Reports
Trauma Registry 5 10 15 2 4 14 6 1 4 4 2 9 1 2 19
Injury Surveillance
3 4 23 0 3 16 3 3 4 1 2 12 0 0 22
System
ED Surveillance
7 4 19 3 4 12 3 3 5 4 0 11 0 0 22
System
Data Retrieval
14 3 13 5 7 7 5 2 4 6 4 5 2 3 17
System
*n: number of hospitals, ED: Emergency department, EHR: Electronic Health Record
90
Figure 39: Zone-wise Comparison of Data Management System in Hospitals
Out of all five zones of India, north east was found weak in sector of computerized data
management system.
91

In addition, it was observed that data management is good in NABH Accredited Hospitals but
the data for research was found below average (figure 40).

Figure 40: Comparison of Data Management System in NABH and Non-NABH Accredited Hospitals
Best Practices for Data Management System was observed in Ruban Memorial Hospital, Asian
Hospital, and Primus Super Speciality Hospital (with 100% score).
Suggestions:
1. Develop National Emergency Department Information System (EDIS)
2. Implement and integrate the computerized care delivery template which will serve as
clinical notes, registry and surveillance
3. It will use the data for quality improvement initiative and research
4. Develop various emergency conditions registries such as cardiac arrest, poisoning, snake
bite including trauma registry
19. FINANCING
Availability of dedicated funds for emergency department assessed for all hospitals. Out of 60
government healthcare facilities, only 2hospitals received sufficient central government funds,
13 did not received sufficient central government funds and the rest did not received any fund
at all for ED services.
It was observed that none of the hospitals received dedicated funds for emergency department
because of lack of dedicated emergency department in hospitals. Some hospitals received funds
from state such as funds for trauma.
92
Table 34: Overall Summary of Financing by Category of Hospitals

Govt. hospitals Govt. hospitals
Medical Medical Colleges
Financing for (<300 bed (<300 bed
Colleges with ED with Emergency
Emergency strength) strength)
Academics (n=3) Services (n=17)
Department (n=20) (n=20)
SF NSF NF SF NSF NF SF NSF NF SF NSF NF
Central Govt Funds
0 1 1 2 3 12 0 4 15 0 4 14
for ED Services
State Govt Funds for
2 0 1 3 7 7 5 7 7 3 7 8
ED Services
(**SF: Sufficient Funds, NSF: Not Sufficient Funds, NF: No Funds, n: number of hospitals)

Figure 41: Comparison of Financing by Hospital Categories
Out of 3 medical colleges with academic emergency department, 2 had received sufficient funds
from state government- a) funds for trauma (JIPMER, Pondicherry) b) funds from Government of
Gujarat(Civil Hospital, Ahmedabad).
Out of 17 medical colleges without academic emergency department, 2 hospitals (Regional
Institute of Medical Sciences, Imphal and AIIMS, Bhopal) had sufficient funds, 3 hospitals
(Government General Hospital, Guntur; Government Medical College, Thiruvanananthapuram
and Patna Medical College & Hospital, Patna) had funds but not sufficient and 12 hospitals had
no funds from central government.
Out of 100 hospitals from five zones of country, it was observed that east zone was the weakest
zone for receiving funds from government either state or central.
Table 35: Zone-wise Summary of Financing in Hospitals

North East
North (n=15) South (n=15) East (n=5) West (n=10)
Financing for ED (n=14)
SF NSF NF SF NSF NF SF NSF NF SF NSF NF SF NSF NF
Central Govt Funds
0 3 12 1 5 9 0 3 2 1 0 6 1 2 11
for ED Services
State Govt Funds
2 7 6 4 3 8 0 3 2 3 1 3 3 7 4
for ED Services
(* n= number of government hospitals in respective zones, ED= Emergency Department)
(**SF: Sufficient Funds, NSF: Not Sufficient Funds, NF: No Funds)
93
Figure 42: Zone-wise ccomparison of Financing in Hospitals
C. Status of funds
It was observed that some hospitals received funds on time others did not received on time and
in most of the hospital’s funds are not fully utilized as depicted in the below table and figure.
Table 36: Overall Summary of Financial Status by Category of Hospitals

Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Colleges
Financial Status strength) strength) strength) strength)
(n=19)
(n=15) (n=17) (n=10) (n=16)
Yes No Yes No Yes No Yes No Yes No
Full Utilisation
8 10 6 9 6 11 1 9 4 9
of Funds
Delay in Release
5 14 4 11 2 15 0 10 2 14
of Funds
(* n= number of government hospitals in respective zones)
94

Figure 43: Overall Comparison of Financial Status by Hospital Categories
D. Funding Schemes
The studied hospitals received funds from central and state government under several funding
schemes. Most of the funding schemes cover trauma care services and other hospital services.
From the entire studied funding schemes, one major funding scheme was Ayushman Bharat. Out
of 100 hospitals, 66 hospitals received funds from either state or central government.
Figure 44: Funding Schemes by Category of Hospitals
E. Ayushman Bharat (PMJAY)

Ayushman Bharat provides coverage for 35 hospitals in both government and private sector out of
100 hospitals. It covers 8 medical college, 9 government hospitals (>300 beds), 12 government
hospitals (<300 beds), 4 private hospitals (>300 beds), and 2 private hospitals (<300 beds) as
shown in figure 45.
Figure 45: Comparison of Ayushman Bharat Scheme by Category of Hospitals
95
Suggestions:
1. Protected funding for emergency and injury care services and for establishment of
residency programme in emergency medicine, emergency nursing and EMT (Emergency
Medical Technician) course.
2. Integration and aggregation of financial schemes for emergency and injury care.
3. Cashless scheme- Increase Ayushman Bharat scheme for all red-triaged patients in all
hospitals.
20. PHYSICAL INFRASTRUCTURE

In hospitals, patients seek medical treatment and staff members provide continuous support by
creating a healing environment with the support of appropriate physical aspects. A healthy hospital
environmental is found to have an impact on the quick recovery of diseases.
In this study, consensus based tool was developed which includes a checklist for physical
infrastructure of Emergency Department. The observations of physical infrastructure are given in
the table 37and figure 46.
Table 37: Summary of Physical Infrastructure by Hospital Categories

Govt. Hosp. Govt. Hosp. Pvt. Hosp. Pvt. Hosp.
Medical
Hospital (>300 bed (<300 bed (>300 bed (<300 bed
Colleges
Category strength) strength) strength) strength)
(n=20)
(n=20) (n=20) (n=20) (n=20)
Physical
55.5% 56% 53.5% 76% 74.5%
Infrastructure
Figure 46: Comparison of Physical Infrastructure for Emergency Department by Category of Hospitals
96
Out of 10 critical checklist points assessed for emergency department for all the hospitals, the
overall compliance was as follows:
Separate access for ambulance services (45%)
Designated area for ambulances (58%)
Demarcated triage area (35%)
Emergency department with adequate space (48%)
Dedicated minor OT (63%)
Point of care lab (26%)
Police control room (44%)
Smooth entry area with wheel chair, etc (63%)
Adequate waiting area (63%)
Safe drinking water (63%)
Other Standard for physical infrastructure emergency mainly defines the access to ER, parking, staff
service at doorstep, clinical services provided, facilities available, information display and facility
upkeep. The hospitals conformed to the parameters of easy and direct access to ER, designated
parking for ambulance, staff and public, but 37% hospitals parked vehicle in front of ER and 25%
hospitals showed partial compliance to this objective.
The hospitals (48%) showed compliance, 26% however partial compliance to parameter of
smooth entry to emergency like ramp for stretchers, canopy and availability of staff at entrance
to help patient with wheelchair and stretchers.
The patient care assistant of most government hospitals was found to attend only critical
and unattended patients from ambulances. The information board displaying services
being provided was found missing from 13% hospitals and 24% hospitals partially fulfilled
the requirement by exhibiting only partial information.
Similarly display of names of doctors and staff on duty, important telephone numbers along
with relevant information were found missing from most of the government hospitals. 51%
hospitals have adequate waiting area. Mostly hospitals had functional male and female
toilets but only 38% hospitals have functional toilets with wheel chair. Police post was
available in 56% of hospitals.
Out of 100 hospitals, 48 hospitals had designated emergency rooms, 29 hospitals did not
have proper designated emergency room and 23 hospitals did not have any emergency
room. Only 34 hospitals had demarcated area for triage.
Only 23 hospitals had isolation room in emergency. Similarly the point of care lab
was found in only 26 hospitals (6 medical colleges, 3 government hospital >300 beds, 1
government hospital <300 beds, 10 private hospitals >300 beds and 6 private hospitals <300
beds).
Out of 100 hospitals, no separate room was present for sexual assault victim in 64 hospitals,
no availability of forensic evidence kit for them in 58 hospitals and no counselling service
for sexual assault / domestic violence cases in 57 hospitals.
97
Suggestions:
1. Uniformity of name (Emergency/Emergency Medicine Department) in every hospital
for emergency / casualty / injury care etc.
2. The capacity and capability of ED should be standardizing based on the tier of facility,
footfall of patients and academic programme.
3. Availability of either point of care lab or hospital lab (24*7) for emergency services
4. Adequate space for ambulance drop zone.
5. There should be demarcated triage area.
6. There should be ICU in each hospital.
21. MANPOWER IN EMERGENCY DEPARTMENT

In Emergency Department, manpower plays a very crucial role in providing care to the patients.
It was observed that emergency department did not have adequate manpower that’s why the
quality of care is compromised in most of the government hospitals.
The manpower in emergency was recorded and it was observed that many government hospitals
had very less manpower in emergency. The percentage of manpower was calculated as per the
footfall of patients in emergency department as well as per emergency beds available in hospitals.
Table 38: Summary of Manpower in Emergency Department Category of Hospitals

Medical
Hospital (>300 bed (<300 bed (>300 bed (<300 bed
Colleges
Categories strength) strength) strength) strength)
(n=20)
(n=20) (n=20) (n=20) (n=20)
Doctors 3 7 15 12 50
Nurses 2 3 4 10 11
Technicians 1 6 6 11 17
Support Staff 3 4 10 14 22
98
Table 39: Detailed Summary of Manpower in Emergency Department by Category

of Hospitals
Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Colleges
strength) strength) strength) strength)
(n=20)
(n=20) (n=20) (n=20) (n=20)
Overall
100 patients in ED
100 patients in ED
100 patients in ED
100 patients in ED
100 patients in ED
% Per footfall of
% Per footfall of
% Per footfall of
% Per footfall of
% Per footfall of
Manpower in
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
Emergency
Min-Max
Min-Max
Min-Max
Min-Max
Min-Max
Faculty / 3 [3] 6 [7.7] 2 [3.7] 2 [2] 2 [4]
0.19 2.53 6.41 1.19 9.44
Consultant 1-8 1-39 1-33 1-138 1-80
Casualty 5.5
5 [6.5] 2 [4.2] 4 [2] 2 [5]
Medical [3.5] 0.23 0.46 1.27 1.80 1.71
Officer 1-16 1-12 1-13 1-9
1-20
1.5
Senior 8 [8] 7 [2.5] 3 [3]
0.43 1.57 0 0 [13] 1.50 6.79
Resident 2-20 3-18 1-20
1-30
9.5
Junior 7 [9.5] 1 [0] 4 [7] 5 [9]
[6.2] 0.81 1.10 0.39 2.72 14.47
Resident 2-30 1-1 1-167 2-26
2-24
Medical 4 [4] 4 [3.5] 6 [4] 4 [7.2] 2 [5]

0.23 0.51 3.09 2.40 3.76
Officer 1-51 3-9 1-8 1-11 1-18
6.5
5 [6] 12 [8] 4 [85] 22 [0]
Intern [3.7] 0.69 0.97 4.34 2.24 13.47
2-40 4-20 3-100 22-22
2-18
Nursing 3 [2] 2 [1] 1 [1.7] 2 [2] 1 [2]
officer 0.19 0.30 0.61 0.75 0.85
Incharge 1-33 1-18 1-10 1-4 1-4
Staff Nurse 21 17.5 15

12 [9] 7 [6.2]
/ Nursing [11.5] 2.25 3.25 3.09 [24.7] 8.94 [5.7] 10.24
officer 3-165 1-31
4-70 3-50 3-35
Radiology 4 [4] 3 [2] 1 [2] 3 [6] 2 [2]

0.32 1.79 0.55 0.72 4.14
Technician 1-4 1-6 1-4 1-18 1-10
Lab 3 [2] 3 [4] 3 [3.7] 9 [12] 3 [3]

0.20 1.29 2.28 2.67 5.52
Technician 1-18 2-12 1-12 1-31 1-12
OT 3 [5.5] 2 [0] 2 [1] 10 [3] 2 [2]

0.39 0.87 2.73 4.79 3.78
Technician 1-10 1-2 1-3 6-12 1-14
6.5
4 [0] 1 [0.5] 4.5 [2] 4 [4]
H.A. / G.D. A. [8.2] 0.92 1.30 2.46 4.60 8.05
4-4 1-2 3-10 1-12
1-19
99
12 7.5
Housekeeping 3 [3] 3 [1.5] 7 [3.5]
[20.2] 0.57 1.20 3.72 4.08 [8.5] 3.27
Staff 1-20 1-4 2-152
2-60 3-20
6
6 [6.5] 3 [1] 3 [0.5] 5 [3.5]
EMT 0.46 1.67 0.65 [15.2] 2.60 3.67
2-27 1-30 1-16 1-30
2-55
8.5
4 [5] 3 [2.7] 4 [3] 4 [3]
Security [10.5] 1.03 0.97 1.07 2.25 3.24
1-30 1-6 2-25 1-10
2-83
4.5
Registration 3 [3.5] 3 [3.5] 2 [2.5] 3 [1]
0.26 0.50 0.88 [3.7] 2.04 2.49
Staff 1-19 1-35 1-5 1-10
1-22
1.5
4 [0] 4 [0] 3 [0] 4 [2]
Any Other 0.33 [0.5] 0.13 1.52 0.78 4.70
4-4 4-4 3-3 2-6
1-2
(*n-number of hospitals, GDA- General Duty Assistant, SA- Sanitary Attendant, HA- Housekeeping Attendant)
Note: A total of 357 staff members including doctors were recorded for Civil Hospital,
Ahemdabad (Medical College) in ED.
21.1 Other Specialist / Super Specialist Available in Hospital

In this study, the number of specialist and super specialist were also recorded for the whole
healthcare facility. It was observed that the hospitals were having adequate number of specialist
and super specialist in the hospital (Annexure VI) but the number of doctors in the emergency
department was not enough.
The median of consultants as well as residents was found high in medical colleges during OPD
hours. Emergency department is manned by junior doctors for caring of the sickest patients even
though the hospitals had adequate specialists.
21.2 Discussion for Manpower in Emergency

Table 40 depicts the gaps in manpower present in emergency or emergency department for the
existing annual footfall. There are several gaps like, less number of available emergency beds
and manpower, to manage patients in emergency department.
100
Table 40: Comparison of Emergency Cases and Manpower in categories of Hospitals

Emergency and Injury Care Patients % of % of
% of
Emergency Emergency
Healthcare Bed Available
and injury and injury
Facilites Strength n Median IQR Min-Max Emergency
care Patients care Patients
Beds
(One Year) (One Day)
Medical 3560-
<500 15 119461 140435 13% 17% 3%
colleges 477845
Government 876-
>300 17 43001 118984 14% 11% 4%
Hospitals 3088834
Government 1560-
<300 16 18738 35139 15% 11% 4%
Hospitals 227364
Private 3676-
>300 17 20161 22118 9% 10% 4%
Hospitals 103524
Private 4800-
<300 11 13800 4908 12% 30% 5%
Hospitals 8778
Suggestions:
1. Round the clock physical posting of Consultants/Faculty in emergency department for
providing quality acute care.
2. Rotatory posting of doctors and nursing students from different disciplines including
interns for a defined period in emergency under the administrative control of ED.
3. Creation of dedicated post of doctors, nurses and paramedics for emergency department.
4. Establish academic emergency medicine, emergency nursing and EMT.
5. Capacity building of emergency care providers.
22. EQUIPMENT AND SUPPLIES IN ED
22.1 Biomedical Equipment

It assesses the availability of the equipment in accordance with the scope of service, inventory
maintenance and periodic inspection & calibration of equipment. It was observed that the
equipments are available according to the available services in 69 hospitals and the inventory
and log books are maintained properly in 67 hospitals. The records of periodically inspection
and calibration were found in 66 hospitals out of 100 (Table 41). Figure 47 illustrates the above-
mentioned points by category of hospitals.
Table 41: Summary of Biomedical Equipment by Category of Hospitals

List of equipments
Biomedical Medical equipment Periodically inspected &
according to available
Equipment inventory and log book calibrated equipment Record
services
Yes 69 67 66
Partial 20 23 18
No 6 5 11
101
Figure 47: Compliance of Biomedical Equipment by Hospital Categories
It was observed that the equipments and supplies for ED were mostly present in private hospitals
in comparison with the government hospitals as shown in the figure 48.
22.2 Compliance of critical available equipments

It was observed that most of the hospitals had all resuscitation/airway management equipments
but basic items like cervical collar, pelvic binder and bed-sheets, broselow tape, fluid warmer
were missing from most of the hospitals. It was also observed that only 59% hospitals had mobile
resuscitation beds, 39% hospitals had transport ventilators, 43% had Laryngeal Mask Airway, 50%
hospitals had vaginal speculum, and only 24% hospitals had capnography.
In addition, 28% hospitals had incubators, 28% hospitals had emergency cricothyroidotomy kit,
25% hospitals had emergency thoracotomy set, 23% hospitals had emergency decompressive
craniotomy set, only 17% hospitals had emergency thrombectomy sets, and 25% hospitals had
phototherapy unit (table 42).
102
Figure 48: Comparison of Equipments and Supplies present in ED by Category of Hospitals i) on the basis of
Percentage range ii) Ranking on the basis of Overall Performance
Table 42: Overall Summary of Equipments and Supplies list in ED for 100
Healthcare Facilities by Category
Govt. Govt. Pvt. Hospitals Pvt. Hospitals
Medical Hospitals Hospitals
Equipments& strength) strength)
Supplies in ED (n=20) strength) strength)
(n=20) (n=20) (n=20) (n=20)
Mobile bed for
10 2 8 10 4 6 4 2 14 17 1 2 19 0 1
resuscitation
Crash cart 12 5 3 11 5 4 11 5 4 17 2 1 19 0 1
Hard cervical
9 0 11 5 3 12 3 0 16 16 0 4 16 1 3
collar
Oxygen supply
15 2 3 15 0 5 4 1 15 19 1 0 18 0 2
by pipeline
Oxygen cylinder 18 1 1 19 1 0 19 0 1 19 1 0 20 0 0
Suction machine 16 3 0 19 1 0 18 1 1 18 2 0 20 0 0
Multipara
15 12 4 13 1 6 9 4 7 18 1 1 18 1 1
monitor
Simple/transport
10 3 7 12 1 7 7 3 10 16 1 3 19 0 1
monitor
Defibrillator 13 5 2 13 2 5 8 6 6 18 1 1 18 1 1
All types of
11 3 6 10 5 4 9 5 6 17 3 0 18 2 0
forceps
Transport
7 1 12 4 1 15 2 2 16 14 2 4 13 2 5
ventilator
AMBU bag 17 2 1 15 5 0 16 2 2 18 2 0 17 1 1
103
Suprapubic
8 4 8 4 1 15 2 1 17 14 1 5 13 0 7
cathetor
Light source 10 1 9 12 2 6 12 2 6 16 1 3 18 1 1
Stethoscopoe 14 3 3 18 0 1 19 1 0 18 1 1 19 0 0
Oropharyngeal
14 3 3 14 4 2 10 4 6 20 0 0 19 0 1
airway blades
LMA (Lanryngeal
9 0 11 3 2 15 2 1 16 15 0 5 14 0 6
Mask Airway)
Tourniquet 12 1 7 12 2 6 9 0 11 16 1 3 19 0 0
Pelvic binder &
bed-sheets with 6 4 10 2 3 15 4 1 15 12 0 8 13 0 7
clips
Needle holder
and suture 15 3 2 17 1 1 13 6 1 19 1 0 20 0 0
material
Vaginal speculum 8 3 9 6 3 10 9 3 8 13 2 5 14 0 5
Ryles tubes 13 6 1 13 7 0 13 6 1 19 1 0 18 0 2
Foley’s catheter 13 5 2 13 7 0 12 7 1 19 1 0 18 0 2
Laryngoscope 14 6 0 15 4 1 12 5 3 19 1 0 18 1 1
Endotracheal
14 6 0 16 4 0 10 6 4 18 2 0 19 0 1
tubes
Chest tubes with
11 5 4 7 4 8 3 3 14 18 1 1 16 1 3
water seal drain
Blood pressure
17 2 1 17 2 1 17 3 0 19 1 0 20 0 0
monitor
ECG machine 17 3 0 17 2 1 17 1 2 20 0 0 20 0 0
Ultrasonic
12 3 5 10 4 5 7 2 11 15 2 3 18 0 2
nebulizer
IV cannula and
16 2 2 15 5 0 19 1 0 19 1 0 19 1 0
IV infusion sets
Syringes and
disposable 17 2 1 19 1 0 20 0 0 20 0 0 19 1 0
needles
Broselow tape 1 2 16 0 1 18 2 1 16 11 0 9 10 0 10
Protoscope 14 1 5 8 1 11 8 2 10 16 1 3 15 0 5
Fluid Warmer 3 2 15 3 0 17 2 4 14 7 2 11 10 0 10
Dressing sets 6 4 0 17 2 1 11 5 4 19 1 0 20 0 0
Personal
protecting 11 8 1 14 4 2 10 7 2 18 2 0 18 1 1
equipments
Central line of all
9 3 8 2 5 12 2 2 16 16 3 1 17 1 2
sizes
Capnography 5 3 12 2 1 16 1 2 17 8 3 9 9 1 10
104
Infusion pump
and syringe 10 2 8 7 1 12 5 1 14 18 2 0 19 0 1
drivers
Spine board with
sling & scotch 5 2 13 6 2 12 1 1 17 13 0 7 16 0 4
tape all sizes
Splints for all
9 8 3 5 10 5 3 7 10 14 3 3 15 3 2
fractures
Non-invasive
and invasive 10 2 8 3 4 13 3 2 15 16 3 1 15 1 4
ventilators
Incubators 9 2 7 2 1 17 1 2 17 8 3 9 9 2 9
Emergency
Cricothyroidotomy 7 1 12 2 1 17 1 2 17 8 2 10 11 1 8
kit
Emergency
7 0 13 2 1 16 1 0 19 8 1 11 8 2 10
Thoracotomy set
Emergency
Decompressive 7 1 11 2 1 17 1 0 19 6 3 11 8 2 10
craniotomy sets
Emergency
Thrombectomy 4 0 15 0 2 18 0 0 20 7 1 12 6 2 11
sets
Phototherapy
9 2 7 1 1 17 3 2 15 5 3 12 8 2 10
unit
*n-number of hospitals, AMBU- Artificial Manual Breathing Unit, ECG- Electrocardiography, IV- Intravenous, ED-Emergency
Department
105
All hospital emergency departments should 3. Circulation equipments:

ensure 100% availability of all these Multipara monitor (68%)
equipments:
Transport monitor (39%)
1. Airway equipments:
Pelvic binder or bed-sheets with clips
Laryngeal Mask Airway (43%) (37%)
Endotracheal tubes (76%) Fluid warmer (25%)
AMBU bag (84%) Portable Ultrasound machine (36%)
Transport ventilator (39%) Central line of all sizes (44%)
Laryngoscope (77%) Infusion pumps and syringe driver

(58%)
Oropharyngeal airway blades
(75%) Defibrillator (68%)
Capnography (24%) 4. General equipments:
Emergency Cricothyroidotomy kit Mobile bed for resuscitation (59%)

(28%) Crash cart (70%)
Peak Expiratory Flow (16%) ED blood storage (18%)
2. Breathing equipments: Hard cervical collar (48%)
Emergency Thoracotomy set (25%) Spine board with slings (40%)
Chest tube with seal drain (53%) 5. Pediatric equipments:
Ultrasonic nebulizer (61%) Broselow tape (24%)
Oxygen cylinder (93%) Phototherapy Unit (25%)
Oxygen supply by pipeline (70%) Incubators (28%)
Suction machine (90%)

Non-invasive and invasive ventilator
(45%)
Suggestions:
1. All essential equipments and supplies should be present in emergency department of
every hospital.
2. There should be dedicated staff for maintenance of equipments in emergency.
3. There should be dedicated training of staff regarding the maintenance of equipments
(how to use and maintain).
4. Maintain checklist of supplies and equipments, they should be checked before end of
every shift and beginning of every shift
5. Maintain a checklist of non-functional equipments and consumed supplies and should
be communicated during handovers
106
23. POINT OF CARE LAB

Point of care lab for ED was observed in only 18 hospitals out of all 100 hospitals. Most of the
hospitals performed these tests in emergency labs:
1. Random blood sugar (74%)
2. Pregnancy test (56%)
3. Urinary ketones (49%)
4. Hemogram (46%)
5. Electrolyte (44%)
6. Blood urea & serum creatinine (44%)
Point of care lab and hospital labs did not perform the entire listed test of annexure-4 of study
tool. D-dimer, Pro-BNP, plasma ketones, toxicology screening-urinary, serum osmolality, urine
osmolality, TEG and PEF also did not performed by most of the hospitals as shown in table 43,
44 and figure 49.
Figure 49: Overall Compliance of Point of Care Lab for ED & Hospital
Best Practices for Point of Care Lab in ED: It was observed that only 2 hospitals performed
all types of laboratory investigations for emergency department; Ramakrishna Care hospital
and Primus Super Speciality Hospital.
107
Table 43: Summary of Point of Care Lab by Category of Hospitals

Medical Colleges (>300 bed (<300 bed (>300 bed (<300 bed
Point of care lab in (n=20) strength) strength) strength) strength)
ED (n=20) (n=20) (n=20) (n=20)
Hemogram- Hb,
Hct, TLC, DLC, 10 0 8 8 0 8 9 0 10 9 3 7 10 0 7
Platelet
Random blood Sugar 16 0 3 13 0 4 14 1 4 17 0 2 14 0 3
Coagulation profile:
3 0 11 5 1 10 6 0 13 7 2 9 10 0 7
PT, APTT, INR
Electrolytes: Na, K,
9 0 10 7 0 9 7 1 11 11 2 6 10 0 7
Cl,Ca
Blood Urea & Serum
11 0 8 6 0 9 8 0 11 8 3 7 10 0 7
Creatinine
Blood Gas Analysis 6 2 11 6 1 9 1 1 17 13 2 4 11 0 6
Cardiac enzymes,
7 3 9 4 1 11 5 0 14 11 4 3 11 0 6
Trop-I, Trop-T
Serum Amylase 7 1 11 5 0 10 2 2 15 5 3 10 10 0 7
D-Dimer 1 1 16 2 0 13 1 0 18 6 2 10 9 0 8
Pro-BNP 0 1 17 2 0 13 1 0 18 4 2 12 10 0 7
Urinary ketones 9 1 9 9 0 8 7 1 11 12 2 5 12 0 5
Plasma Ketones 1 1 16 2 0 13 0 0 19 4 2 12 7 0 10
Toxicology
0 0 18 0 0 15 0 0 19 0 2 16 4 0 13
Screening-Urinary
Serum osmolality 1 0 17 3 0 12 0 0 19 3 2 13 8 0 9
Urine osmolality 1 0 17 2 0 13 0 0 19 3 2 13 9 0 8
Pregnancy test 10 2 7 9 0 7 13 0 6 13 1 4 11 0 6
Thromboelastogram
0 0 19 0 0 14 0 0 19 1 2 16 2 1 14
(TEG)
Peak Expiratory
0 0 19 0 1 14 0 0 19 6 1 11 10 0 7
Flowmeter
Microscopy: Thin &
3 1 13 6 0 10 8 0 11 7 2 9 10 0 7
Thick Smear
Rapid Diagnostic
6 0 12 5 1 10 8 0 11 7 2 9 10 0 7
Test (Malaria)
CSF: Microscopy &
4 1 12 3 1 11 2 1 16 6 2 10 9 0 8
Gram staining
Portable USG 4 1 12 3 1 11 0 1 18 15 1 4 14 0 4
Echocardiography 7 0 10 4 1 11 2 0 17 13 2 4 13 1 4
Portable X ray 11 1 7 7 1 7 3 4 12 17 1 2 13 2 3
CT Scan 10 0 7 7 0 8 3 0 14 8 3 8 10 0 7
*n-number of hospitals, ED-Emergency Department, Hb- Hemoglobin , Hct- Hematocrit, TLC- Total Leukocyte Count,
DLC- Differential Leukocyte Count, PT- Prothrombin Time, APTT- Activated partial thromboplastin time, INR- International
Normalized Ratio, BNP- Brain Natriuretic Peptide, USG- Ultrasonography, CT- Computerized Tomography
108
Table 44: Overall Summary of Hospital labs by Category of Hospitals

Hospital Labs (n=20) strength) strength) strength) strength)
(n=20) (n=20) (n=20) (n=20)
Hemogram- Hb, 19 0 1 19 0 0 19 0 0 16 0 1 15 0 0
Hct, TLC, DLC,
Platelet
Random blood Sugar 17 0 2 17 0 2 18 0 1 15 0 2 14 0 1
Coagulation profile: 17 0 3 13 2 4 11 0 8 18 0 0 15 0 0
PT, APTT, INR
Electrolytes: Na, K, 17 0 2 17 0 2 15 0 4 17 0 0 15 0 0
Cl,Ca
Blood Urea & Serum 19 0 0 18 1 0 17 0 2 17 0 0 15 0 0
Creatinine
Blood Gas Analysis 12 1 6 10 1 8 1 1 17 16 0 1 14 0 1
Cardiac enzymes, 11 4 4 9 4 6 6 0 13 17 0 1 14 0 1
Trop-I, Trop-T
Serum Amylase 16 1 2 12 1 5 6 1 12 17 0 1 15 0 0
D-Dimer 10 0 10 4 0 14 1 0 18 15 1 2 14 0 1
Pro-BNP 8 0 12 4 0 14 1 0 18 14 1 3 14 0 1
Urinary ketones 14 2 3 16 0 3 14 1 4 17 0 0 14 0 1
Plasma Ketones 10 1 9 6 1 11 2 0 17 13 0 5 11 0 4
Toxicology 7 1 12 2 0 16 1 0 18 11 1 6 6 1 9
Screening-Urinary
Serum osmolality 8 1 11 5 0 13 1 0 18 15 0 3 14 0 1
Urine osmolality 8 2 10 8 0 10 1 1 17 15 0 3 15 0 0
Pregnancy test 18 0 1 17 0 2 18 0 1 17 0 1 14 0 1
Thromboelastogram 3 0 16 1 0 16 1 0 18 9 0 8 4 0 11
(TEG)
Peak Expiratory 4 1 14 5 0 13 2 0 17 15 0 3 9 0 6
Flowmeter
Microscopy: Thin & 18 1 1 18 1 0 16 2 1 18 0 0 15 0 0
Thick Smear
Rapid Diagnostic 16 0 3 18 1 0 17 0 2 18 0 0 14 0 1
Test (Malaria)
CSF: Microscopy & 14 2 4 13 1 4 4 2 13 18 0 0 14 0 1
Gram staining
Portable USG 13 2 5 7 1 10 2 1 16 13 1 2 12 0 3
Echocardiography 18 1 1 9 1 9 2 1 16 16 1 0 14 0 1
Portable X ray 14 2 2 10 3 5 4 6 9 15 0 1 14 0 1
CT Scan 16 1 1 10 0 8 6 0 11 17 0 0 13 0 2
*n-number of hospitals, ED-Emergency Department, Hb- Hemoglobin, Hct- Hematocrit, TLC- Total Leukocyte Count,
DLC- Differential Leukocyte Count, PT- Prothrombin Time, APTT- Activated partial thromboplastin time, INR- International
Normalized Ratio, BNP- Brain Natriuretic Peptide, USG- Ultrasonography, CT- Computerized Tomography
109
Figure 50: Comparison of Point of Care Lab for ED & for Hospital on % basis of compliance
110
Suggestions:
All healthcare facilities should have either basic point of care lab in emergency department or
emergency lab in hospital for 24*7
24. ESSENTIAL MEDICINES FOR EMERGENCY

Out of 100 hospitals only 9 hospitals had all essential medicines required at emergency
department. In addition, it was found that only 11 hospitals had essential medicines used in
resuscitation out of all 100 hospitals.
Most of the hospitals did not have essential drugs used for emergency. The checklist contains
101 essential medicines required in emergency department. Out of these 101 medicines, 30
medicines are categorized as resuscitation medicines (medicines used in resuscitation).
We had calculated the percentages of all essential equipment and medicines. The availability of
essential medicines was calculated on three different scales: 50% or less (Score-0), 50% to 99%
(Score-1), and 100% (Score-2).
For resuscitation medicines, the scoring was based on two scales: the score was zero if even
one drug was missing from list (Score 0) and the score was two if all 30 medicines were present
(Score-2). Resuscitation drugs should be must in all hospitals.
Essential Medicines: The medicines that “satisfy the priority health care

needs of the population”. These are the medications to which people
should have access at all times in sufficient amounts. (WHO)
Other essential
Resuscitation Medicines (n=30): The medicines
medicines (n=71):
which are used during resuscitation process.
The essential
medicines other
Resuscitation Medicine Package: It is a package
than resuscitation
of 30 medicines. Even if one drug is deficient at
medicines included in
time of assessment, the score is zero.
this category
Only 2 None of the

9 private
medical government 9 private hospitals
hospitals have
colleges have hospitals have have complete
complete
complete complete package of
package of
package of package of resuscitation
resuscitation
resuscitation resuscitation medicines
medicines
medicines medicines
Figure 51: Chart of Essential medicines for Hospitals
111
Most of the hospitals did not have essential drugs used for emergency especially in government
hospitals when compared to the private ones. Not all private hospitals had all the enlisted drugs
for emergency as in annexure (figure 51).
Table 45: Overall Summary of Essential Medicines for Emergency:

Medical
Essential Medicines/ (>300 bed (<300 bed (>300 bed (<300 bed
Colleges
Drugs for Emergency strength) strength) strength) strength)
(N=20)
(N=20) (N=20) (N=20) (N=20)
Resuscitation Drugs 2 (10%) 0 (0%) 0 (0%) 3 (15%) 6 (30%)
Other Essential Drugs 72% 71% 63% 86% 87%
Only 2 medical colleges (Government Medical College, Thiruvanananthapuram and AIIMS, Bhopal)
had complete package of resuscitation drugs, other than these none of the government hospitals
had complete package of resuscitation drugs out of 60 hospitals.
For private hospitals >300 beds, 3 hospitals (Grant Medical Foundation Ruby Hall Clinic,
Pune; Kasturi Medical College & Hospital and Fortis Hospital, Jaipur) had complete package of
resuscitation drugs.
For private hospitals >300 beds, 6 hospitals (Bhailal Amin General Hospital; Birla CK Hospital,
Jaipur; Charak Hospital & Research Centre, Lucknow; Ruban Memorial Hospital; Ramakrishna
Care Hospital and Primus Super Speciality Hospital) had complete package of resuscitation drugs.

Figure 52: Comparison of Essential Medicines for Emergency by Category of Hospitals i) on the basis of Percentage
range ii) on the basis of Overall Performance/Compliance
Overall the small private hospitals performed best out of the 5 category of hospitals. Only 2
medical colleges have all essential medicines out of all 60 government hospitals.
112
Suggestions:
1. Complete package of resuscitation medicines should be present in all hospitals for 24*7
2. Other essential medicines should also be present in all hospitals for 24*7
3. During third party audits, if any essential drug is missing from the resuscitation package
then the license of the hospital may be cancelled
Best Practices for Essential Medicines in ED

100% compliance was observed in following hospitals for essential medicines which
are required for emergency department:
Medical College: AIIMS, Bhopal, Government Medical College,
Thiruvanananthapuram
Private Hospital: Grant Medical Foundation Ruby Hall Clinic, Kasturi Medical
College & Hospital, Fortis Hospital, Jaipur, Birla CK Hospital, Ruban Memorial
Hospital, Ramakrishna Care Hospital, and Primus Super Speciality Hospital
113
II. LIVE OBSERVATION
1. DISPOSITION TIME
The time from entry of patient at emergency department to admission/transfer-out/discharge is
disposition time.
Ideally for time sensitive conditions (STEMI, stroke, trauma, cardiac arrest), patients should be
immediately seen after arrival in emergency department. For red triage, patient should be seen
within 10 min; for yellow triage, patient should be seen within 30 min and for green triage,
patient should be seen within 4 hours after arrival in emergency.
Ideal disposition time for red triage patients should be within 6 hours, for yellow triage patients
should be within 12 hours.
Table 46: Summary of Disposition Time of Patients Visited in Emergency Department

Medical
Disposition time (>300 bed (<300 bed (>300 bed (<300 bed
Colleges
(in minutes) strength) strength) strength) strength)
(n=20)
(n=20) (n=20) (n=20) (n=20)
Red triaged 90 [686] 30 [44] 17 [31] 45 [102] 15 [20]

patients 7-4680 5-1440 5-60 6-240 5-48
Yellow triaged 200 [307] 90 [315] 120 [121] 120 [210] 30 [63]
patients 12-1440 10-3060 8-360 7-1920 10-225
Green triaged 60 [214] 45 [145] 46 [188] 75 [91] 32 [162]

patients 6-1450 1-720 10-900 4-575 7-420
*n-number of hospitals, Median [IQR] Min-Max
Figure 53: Chart of Disposition time of Patients by Hospitals Category
114
The disposition time of red triaged patients was high in medical colleges with median of 90
minutes and low in private hospitals (<300 beds) with median of 15 minutes.
For yellow triaged patients the disposition time was high in medical college with median of 200
minutes and low in private hospitals (<300 beds) with median of 30 minutes.
Similarly, for green triaged patients it was high in private hospitals (>300 beds) with a median
of 75 minutes and low in private hospitals (<300 beds) with median of 32 minutes.
The disposition time of red triaged patients was high in medical college. It was due to various
factors observed as such:
1. Lack of emergency care provider
2. High patient load
3. Need of multi-speciality reviews
4. Multiple investigations being conducted
5. Lack of dedicated department leads todelayed decision making from definitive care/
disposal
6. Not availability of buffer beds for addressing surge capacity under emergency department
7. Mismatch between available emergency beds and patient load and manpower
8. Not availability of triage policy in most of the hospitals
Figure 54: Comparison of Disposal Time of Patients visited in Emergency by Hospital Category
Suggestions:
1. Implementation of triage policy in all hospitals (Prioritization of patient)
2. Adequate manpower should be present in hospitals as per footfall of patients and
emergency beds
3. Optimum utilization of resources
4. There should be a dedicated emergency nurse coordination (ENC) system
5. Empowered hospital committee comprising of members of emergency department and
allied medical and surgical speciality to address the issues and challenges pertaining to
emergency department
115
2. CHEST PAIN
In this study, a total of 201 patients of chest pain were observed by our assessor’s team from all
zones and categories of our country.
Percutaneous coronary intervention (PCI) is a non-surgical procedure used to treat narrowing
(stenosis) of the coronary arteries of the heart found in coronary artery disease. PCI is also used
in people after other forms of myocardial infarction or unstable angina where there is a high risk
of further events.
Firstly, 53% hospitals did not have triage. Secondly, ECG was not performed within 10 min in
30% hospitals. Some hospitals don’t even have ECG machine. Thirdly, Door to needle was not
performed 54% hospitals within 30 minutes. Lastly, Door to PCI was also absent in 68% hospitals.

Figure 55: Overall Comparison of Chest Pain Management by Category of Hospitals
*N=Number of red patients of chest pain, 65 patients were observed from 20 Medical Colleges, 33 patients were observed
from 20 Govt. Hosp. (>300 bed strength), 34 patients were observed from 20 Govt. Hosp. (<300 bed strength), 44 patients
were observed from 20 Pvt. Hosp. (>300 bed strength) and 25 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
The management of chest pain was observed best in the private hospitals (<300 beds) among
all the categories of healthcare facilities as shown in table 47 and figure 55. Overall door to PCI
was not done in most of the hospitals.
116
Table 47: Summary of Chest Pain Management by Category of Hospitals: N (%)

Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Chest Pain Colleges
Management (N=65 Pts)
(N=33 Pts) (N=34 Pts) (N=44 Pts) (N=25 Pts)
22 43 14 19 27 28 16 24
Triage 7 (21) 1 (4)
(34) (66) (42) (58) (79) (64) (36) (96)
Door to ECG 37 26 23 10 16 17 39 24
5 (11) 1 (4)
(<10 min) (59) (41) (70) (30) (48) (52) (89) (96)
Door to Needle 17 23 14 20 16 12 18
8 (36) 1 (5) 2 (10)
(<30 min) (42) (58) (64) (95) (57) (43) (90)
Door to PCI 16 12 16 11 18 10
6 (27) 5 (29) 0 (0) 5 (33)
(<90 min) (73) (71) (100) (38) (62) (67)
*N=Number of red patients of chest pain, 65 patients were observed from 20 Medical Colleges, 33 patients were observed
from 20 Govt. Hosp. (>300 bed strength), 34 patients were observed from 20 Govt. Hosp. (<300 bed strength), 44 patients
were observed from 20 Pvt. Hosp. (>300 bed strength) and 25 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
Figure 56: Chart of Chest Pain Management of patients by Category of Hospitals
In addition, it was observed that the east zone performed best and the north zone performed
worst out of all zones.
In the east zone, 35 patients of chest pain had observed in 11 different hospitals and 17 patients
managed within the timeframe.
Similarly, 47 patients of chest pain had observed in 11 different hospitals of north zone and only
3 patients managed within the timeframe.
117
Table 48: Zone-wise Summary of Chest Pain Management in Hospitals: N (%)
North (N=47 South (N=48 East (N=35 West (N=44 North East
Chest Pain Pts.) Pts.) Pts.) Pts.) (N=27 Pts.)
Management
16 31 17 25 10 27 17 10 17
Triage 31 (65)
(34) (66) (35) (71) (29) (61) (39) (37) (63)
Door to ECG 34 13 26 26 38 15 12
21(45) 8 (24) 5 (12)
(<10 min) (72) (28) (55) (76) (88) (56) (44)
Door to
19 14 17 13 10
Needle (<30 9 (32) 28 (67) 6 (26) 7 (47) 8 (53)
(68) (33) (74) (57) (43)
min)
Door to PCI 18 17 10
3 (14) 8 (20) 32 (80) 6 (26) 3 (75) 1 (25) 1 (9)
(<90 min) (86) (74) (91)
*N=Number of red patients of chest pain, 47 patients were observed from 30 hospitals of north zone, 48 patients were
observed from 21 hospitals of south zone, 35 patients were observed from 11 hospitals of east zone, 44 patients were observed
from 16 hospitals of west zone and 27 patients were observed from 22 hospitals of north-east zone
Figure 57: Zone-wise Comparison of Chest Pain Management in Hospitals
*N=Number of red patients of chest pain, 47 patients were observed from 30 hospitals of north zone, 48 patients were
observed from 21 hospitals of south zone, 35 patients were observed from 11 hospitals of east zone, 44 patients were observed
from 16 hospitals of west zone and 27 patients were observed from 22 hospitals of north-east zone
118
C. NABH Accreditation-wise comparison:

Also, it was observed that NABH accredited hospitals performed better than non-NABH accredited
hospitals for management of chest pain (table 49 and figure 58).
Table 49: Overall Summary of Chest Pain Management in NABH accredited and
non-NABH accredited hospitals: N (%)
NABH Accredited Hospitals Non-NABH Accredited Hospitals

Chest Pain Management (Pt.= 49) (Pt.= 152)
Yes No Yes No
Triage 38 (78) 11 (22) 57 (37) 95 (63)

Door to ECG (<10 min) 44 (90) 5 (10) 95 (64) 54 (36)
Door to Needle (<30 min) 22 (69) 10 (31) 38 (38) 61 (62)
Door to PCI (<90 min) 16 (52) 15 (48) 16 (24) 52 (76)

Figure 58: Overall Comparison of Chest Pain Management in NABH accredited and non-NABH accredited hospitals
Factors affecting Chest Pain Management:

1. Lack of manpower (such as ECG technician)
2. Lack of training
3. Lack of supplies (such as ECG machine)
4. Lack of infrastructure
5. Lack of policy
Suggestions for Management of Chest pain:

1. Upgrade them for thrombolysis.
2. Adequately trained emergency care provider.
3. All district hospitals must have ECG machine and technician.
4. Establish Tele-ECG and Tele-Medicine programme.
5. Resuscitate patient in district hospital and refer them to other higher government hospital.
6. Develop a STEMI Programme by Hub and Spoke Model (figure 59)
7. Develop PCI centres in multi-speciality hospitals
119
Figure 59: Hub and Spoke model for Thrombolysis near home – STEMI
Requirements for STEMI Hub and Spoke Model:

1. MOU (Memorandum of Understanding) with Local Government
2. Training
3. Supplies
4. Consent of patient
5. Governance
6. Budget Allocation
7. Cashless care in all hospitals for red triaged patients
Best practice in District Hospitals for Thrombolysis

1. District Hospital, Baramulla, J&K
2. North Goa District Hospital, Goa
3. Jai Prakash Narayan District Hospital, Bhopal
4. Southern Railway Hospital, Madras
3. STROKE
A stroke is a medical condition in which poor blood flow to the brain results in cell death. There
are two main types of stroke: ischemic, due to lack of blood flow, and haemorrhagic, due to
bleeding. Both result in parts of the brain not functioning properly.
120
The management of stroke was observed best in the small private hospitals and worst observed in
small government hospitals among all the categories of healthcare facilities due to lack of facilities
as shown in table 50 and figure 60.
Figure 60: Comparison of Stroke Management by Category of Hospitals
*N=Number of red patients of stroke, 50 patients were observed from 20 Medical Colleges, 17 patients were observed from
20 Govt. Hosp. (>300 bed strength), 14 patients were observed from 20 Govt. Hosp. (<300 bed strength), 25 patients were
observed from 20 Pvt. Hosp. (>300 bed strength) and 20 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
The management of stroke was also not observed well in district hospitals due to lack of
thrombolysis and CT scan machine.
Door to Doctor was achieved within 10 minutes in 79% hospitals. But Door to CT completion
was not performed within 25 minutes in 47% hospitals. Door to CT reading was not achieved
within 45 minutes in 52% hospitals. Door to thrombolysis was absent in 74% hospitals as shown
in figure 61.
121
Table 50: Summary of Stroke Management by Category of Hospitals: N (%)

Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Stroke Colleges
Management (N=50 Pts)
Door to Doctor 38 12 15 20 18
2 (12) 9 (64) 5 (36) 5 (20) 2 (10)
(<10 min) (76) (24) (88) (80) (90)
Door to CT
16 31 10 12 19 17
Completion 6 (37) 1 (8) 6 (24) 2 (11)
(34) (66) (63) (92) (76) (89)
(<25 min)
Door to CT
15 33 10 12 15 10 17
reading 6 (37) 1 (8) 1 (6)
(31) (69) (63) (92) (60) (40) (94)
(<45 min)
Door to
32 9 14
Thrombolytic 6 (16) 6 (40) 9 (60) 0 (0) 7 (33) 6 (50) 6 (50)
(84) (100) (67)
(<60 min)
Door to First 20 11
6 (23) 6 (50) 6 (50) 1 (10) 9 (90) 5 (31) 8 (73) 3 (27)
Pass (<90 min) (77) (69)
*N=Number of red patients of stroke, 50 patients were observed from 20 Medical Colleges, 17 patients were observed from
Figure 61: Chart of Stroke Management of patients by Hospital Category
In addition, it was observed that the east zone performed best and the north zone performed
worst out of all zones (table 51 and figure 62).
122
Table 51: Zone-wise Summary of Stroke Management in Hospitals: N (%)
Stroke Pts.) Pts.) Pts.) Pts.) (N=24 Pts.)
Management
Door to Doctor 18 33 10 18 11 20
1 (5) 6 (25) 5 (31) 4 (17
(<10 min) (95) (77) (23) (75) (69) (83)
Door to CT
10 22 21 17 12
Completion 9 (47) 7 (29) 6 (46) 7 (54) 9 (42)
(53) (51) (49) (71) (57)
(<25 min)
Door to CT
12 23 20 18 17
reading (<45 6 (33) 6 (25) 6 (46) 7 (54) 5 (23)
(67) (53) (47) (75) (77)
min)
Door to
34 16 6 16
Thrombolytic 3 (27) 8 (73) 6 (15) 6 (27) 0 (0) 0 (0)
(85 (73) (100) (100)
(<60 min)
Door to First Pass 25 15 4
3 (30) 7 (70) 7 (22) 6 (29) 0 (0) 1 (13) 7 (87)
(<90 min) (78) (71) (100)
*N=Number of red patients of stroke, 19 patients were observed from 30 hospitals of north zone, 43 patients were observed
from 21 hospitals of south zone, 24 patients were observed from 11 hospitals of east zone, 16 patients were observed from
16 hospitals of west zone and 24 patients were observed from 22 hospitals of north-east zone
Figure 62: Zone-wise Comparison of Stroke Management in Hospitals

*N=Number of red patients of stroke, 19 patients were observed from 30 hospitals of north zone, 43 patients were observed
from 21 hospitals of south zone, 24 patients were observed from 11 hospitals of east zone, 16 patients were observed from
16 hospitals of west zone and 24 patients were observed from 22 hospitals of north-east zone
123
C. NABH Accreditation-wise comparison

Also, it was observed that NABH accredited hospitals performed better than non-NABH accredited
hospitals for management of stroke (table 52 and figure 63).
Table 52: Overall Summary of Stroke Management in NABH accredited and non-
NABH accredited hospitals: N (%)
NABH Accredited Hospitals (N=28) Non-NABH Accredited Hospitals
Stroke Management (Pts.= 31) (N=72) (Pts.= 95)
Yes No Yes No
Door to Doctor
24 77% 7 23% 76 80% 19 20%
(<10 min)
Door to CT Completion
23 77% 7 23% 40 44% 50 56%
(<25 min)
Door to CT reading
23 79% 6 31% 35 38% 56 62%
(<45 min)
Door to Thrombolytic
10 43% 13 57% 15 21% 57 79%
(<60 min)
Door to First Pass
10 56% 8 44% 16 28% 41 72%
(<90 min)

Figure 63: Overall Summary of Stroke Management in NABH accredited and non-NABH accredited hospitals
Factors affecting Stroke Management:

1. Lack of manpower
2. Lack of training
3. Lack of supplies (such as CT Scan machine)
4. Lack of infrastructure
5. Lack of policy
Best Practice for CT Scan in District Hospitals:

District Hospital, Tenali
Deen Dayal Upadhyay Hospital, Shimla
Morigaon Civil Hospital, Assam
124
Suggestions:
1. Thrombolysis near home – Hub and Spoke Model (figure 59)
2. Develop Tele-stroke programme
3. Stroke management by PPP (Public-Private Partnership) model in district hospitals
4. TRAUMA
It was observed that trauma management was good in private hospitals when compared to the
government ones as shown in table 53and figure64, because the disposal of patients was delayed
in government hospitals.
Table 53: Summary of Trauma Management by Category of Hospitals: N (%)

Govt. Govt. Pvt. hospitals Pvt. hospitals
Trauma Management strength) strength)
(N=57 Pts) strength) strength)
Door to Resuscitation time 34 23 20 10 12 19 12
9 (43) 5 (21) 0 (0)
(<15 min) (60) (40) (67) (33) (57) (73) (100)
26 26 20 16 11 10
time in Head Injury 9 (31) 2 (11) 5 (31) 2 (17)
(50) (50) (69) (89) (69) (83)
(<45 min)
Disposal Time (in minutes) 185 150 60 62 30
*N=Number of red patients of trauma, 57 patients were observed from 20 Medical Colleges, 30 patients were observed from
Figure 64: Comparison of Trauma Management by Hospital Categories

*N=Number of red patients of trauma, 57 patients were observed from 20 Medical Colleges, 30 patients were observed from
125
Table 54: Zone-wise Summary of Trauma Management in Hospitals: N(%)
Pts.) Pts.) Pts.) Pts.) (N=17 Pts.)
Trauma Management
Door to Resuscitation 26 17 25 17 15 20 6 8
1 (6) 9 (53)
time (<15 min) (60) (40) (60) (40) (94) (77) (23) (47)
Door to CT
Completion time in 11 26 20 21 11 3 13 8 3 11
Head Injury (<45 (30) (70) (49) (51) (79) (21) (62) (38) (21) (79)
min)
Disposal Time
498 635 — 103 110
(in minutes)
*N=Number of red patients of trauma, 43 patients were observed from 30 hospitals of north zone, 42 patients were observed
from 21 hospitals of south zone, 16 patients were observed from 11 hospitals of east zone, 26 patients were observed from 16
hospitals of west zone and 17 patients were observed from 22 hospitals of north-east zone.
Figure 65: Zone-wise Comparison of Trauma Management in Hospitals
*N=Number of red patients of trauma, 43 patients were observed from 30 hospitals of north zone, 42 patients were observed
from 21 hospitals of south zone, 16 patients were observed from 11 hospitals of east zone, 26 patients were observed from 16
hospitals of west zone and 17 patients were observed from 22 hospitals of north-east zone.
126
C. NABH Accreditation comparison:

Table 55: Summary of Trauma Management in NABH accredited and non-NABH
accredited hospitals
NABH Accredited Hospitals (N=28) Non-NABH Accredited Hospitals
Trauma Management (Pt.= 37) (N=72) (Pt.= 107)
Yes No Yes No
Door to Resuscitation time
29 78% 8 22% 65 61% 42 39%
(<15 min)
time in Head Injury 17 63% 1 37% 41 41% 59 59%
(<45 min)
Disposal Time (in minutes) 74 395

Figure 66: Comparison of Trauma Management in NABH accredited and non-NABH accredited hospitals
Best Practice for CT Scan in District Hospitals:

1. District Hospital, Tenali
2. Deen Dayal Upadhyay Hospital, Shimla
3. HNB Base Hospital, Shimla
Factors affecting Trauma management:

1. Lack of staff
2. Lack of policy
3. Lack of training
4. Lack of resources (such as CT Scan machine)
Suggestions:
1. Adequate staff
2. Training
127
5. INCIDENCE OF VIOLENCE
During assessment, incidence of violence was observed in the hospital and assessors noted the
observation in the given study tool. In the given table 56 and figure 67 the ratio of incidence of
violence is shown by category of hospitals.
Table 56: Summary of incidence of Violence by Hospital Categories: N (%)

Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Live Colleges
Observation (n=15)
(n=17) (n=18) (n=18) (n=16)
Incidence of 11 10 14
7 (47) 8 (53) 6 (35) 8 (44) 4 (22) 5 (31) 11 (69)
Violence (65) (56) (78)
Figure 67: Representation of Incidence of Violence Observed by Category of Hospitals
5.1 Reason of Violence

It was also observed during live observation about the reason of violence incident in hospitals.
The reason of violence was found either communication failure or care delay.
Figure 68: Representation of the reason of Violence by Category of Hospitals
128
5.2 Mitigation measures

Mitigation measures were also recorded like availability of security guard in hospital, availability
of police in hospital and availability of anti-violence mitigation policy.
Table 57: Summary of Mitigation measures available by Category of Hospitals: N (%)

Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Mitigation Colleges
measures (N=20)
(N=20) (N=20) (N=20) (N=20)
Private security 12 10 15 13
2 (14) 8 (53) 7 (47) 6 (37) 1 (6) 2 (13)
guard (86) (63) (94) (87)
Private Security 10 2
1 (9) 8 (80) 2 (20) 4 (43) 3 (57) 14 (0) 9 (18) 2 (82)
Guard 24*7 (91) (100)
13 10
Police Available 1 (7) 9 (60) 6 (40) 7 (47) 8 (53) 4 (29) 7 (54) 6 (46)
(93) (71)
Police Available 11
1 (8) 7 (78) 2 (22) 5 (63) 3 (37) 5 (56) 4 (44) 4 (50) 4 (50)
Guard 24*7 (32)
Anti-violence
11 11
mitigation policy 6 (46) 7 (54) 1 (8) 2 (15) 7 (64) 4 (36) 9 (64) 5 (36)
(92) (85)
available
Figure 69: Representation of Mitigation measures available by Category of Hospitals
129
6. COMMUNICATION SKILLS IN EMERGENCY DEPARTMENT

During/after treatment of any patient, the health care provider/staff/nurses communicate with the
patient/patient attendant/relative to inform them about the condition of patient. It was observed
that sometimes the health care provider/staff/nurses did not communicate properly with the
patient/patient attendant/relative.
For knowing the way of communication, assessor’s team observed the communication between
hospital staff and patient during live observation and the summary of communication skills is
shown in table 58 and figure 70.
Table 58: Summary of Communication Skills in Emergency Department by

Category of Hospitals: N(%)
Govt. Govt. Pvt. Pvt.
Medical hospitals hospitals hospitals hospitals
Communication Skills in ED Colleges (>300 bed (<300 bed (>300 bed (<300 bed
(n=20) strength) strength) strength) strength)
(n=20) (n=20) (n=20) (n=20)
Full content with empathy and
7 (44) 9 (50) 8 (47) 16 (89) 13 (93)
share decision making
Full content with empathy and
2 (13) 4 (22) 6 (35) 2 (11) 0 (0)
no share decision making
Full content with no empathy 3 (19) 5 (28) 1 (6) 0 (0) 1 (7)
Minimal Communication and
4 (25) 0 (0) 2 (12) 0 (0) 0 (0)
inappropriate behaviour
*n- number of hospitals
Figure 70: Representation of Communication Skills in Emergency Department of Hospital Category
Suggestions:
1. Create a cadre of emergency nurse coordinator (ENC) from the existing pool of nursing
officers with defined roles and responsibility.
2. Training of staff on communication skills from under-graduate level (for doctors, nurses
and paramedics).
3. Establish a concept of shared decision making.
130
7. PATIENT SATISFACTION
During live observation by assessor’s team for 24 hours, 3-5 random patients from each triage
category (red, yellow and green) were asked few questions about the care (in terms of satisfaction)
provided in the hospital.
Table 59: Summary of Patient Satisfaction by Category of N(%) Hospitals N(%)

Medical (>300 bed (<300 bed (>300 bed (<300 bed
Patient Colleges (n=20) strength) strength) strength) strength)
Satisfaction (n=20) (n=20) (n=20) (n=20)
Red Yellow Green Red Yellow Green Red Yellow Green Red Yellow Green Red Yellow Green
Triage Triage triage Triage Triage triage Triage Triage triage Triage Triage triage Triage Triage triage
Extremely
1 (6) 1 (7) 0 (0) 3 (21) 2 (13) 3 (20) 1 (8) 2 (15) 5 (36) 4 (24) 5 (26) 7 (39) 2 (18) 3 (23) 4 (29)
satisfied
Very
6 (40) 6 (40) 5 (33) 3 (22) 6 (40) 6 (40) 3 (23) 4 (31) 4 (29) 7 (41) 9 (47) 5 (28) 7 (64) 7 (54) 6 (43)
satisfied
Moderately
4 (27) 4 (27) 5 (33) 7 (50) 7 (47) 4 (27) 5 (38) 4 (31) 3 (21) 5 (29) 3 (16) 4 (22) 2 (18) 2 (15) 3 (21)
satisfied
Slightly
3 (20) 3 (20) 4 (27) 1 (7) 0 (0) 2 (13) 4 (31) 3 (23) 2 (14) 1 (6) 2 (11) 2 (11) 0 (0) 0 (0) 1 (7)
satisfied
Not at all
1 (7) 1 (6) 1 (7) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (8) 0 (0)
satisfied
Figure 71: Chart of Patient Satisfaction by Hospitals Categories
*Note: Patient satisfaction was individually observed and calculated for red, yellow and green triaged patients. The percentage
in brackets shows extremely satisfied and very satisfied patients/ patient attendant from the level of care provided by healthcare
facility
131
Figure 72: Representation of Triaged Patient Satisfaction for care provided by Hospital Categories
132
Suggestions
1. Establish a suggestion box in the hospital, especially within the emergency department
premises.
2. Establish patient information display system.
3. Train emergency care providers on communication skills including grief counselling
and shared decision making.
8. REFERRAL OF THE PATIENT

During live observation, referral of patient was observed. Organization referral policy was checked.
It was also observed that the hospital provides proper arrangement to the patient or not and the
patient was assisted with any assistance or not from the hospital during referral.
It is clear from the table 60 and figure 73 that 55%hospitals have some referral policy, 53%
hospitals provide proper arrangement to patients and assistance was provided in only 49%
hospitals during referral.
Table 60: Summary of Referral of Patient by Hospital Categories: N (%)

Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Referral of Colleges
Patients (n=20)
(n=20) (n=20) (n=20) (n=20)
Any referral 11 11 12 15 15
2 (15) 7 (39) 5 (29) 3 (17) 1 (6)
policy (85) (61) (71) (83) (94)
Any proper 10 10 17 14
3 (23) 8 (44) 9 (53) 8 (47) 1 (6) 1 (7)
arrangement (77) (56) (94) (93)
Any assistance 10 10 15 15
4 (31) 9 (69) 8 (44) 7 (41) 2 (12) 1 (6)
during referral (56) (59) (88) (94)
133
Figure 73: Graphically representation of Referral of Patient by Category of Hospitals
Suggestions:
1. Develop National Forward and Backward Referral Policy with safe transport integrated with
local EMS system
a. Hub and Spoke Model (figure 74)
b. Structured referral protocols
c. There should be informed transfer.
There should be a Standard Referral back policy (Standard Forward & Backward Policy) and it
has to be in the form of hub and spoke model. In this policy, there should be a MOU of tertiary
care centres with mid-level government hospitals with multi-speciality district hospitals as well
as with private hospitals (cashless scheme).
In this policy, the referral should be on the basis of lack of facilities in secondary care. The tertiary
care should mandate to admit all red triaged patients as well as yellow triaged patients.
In case of fully utilized tertiary care centres, they need to admit patients through emergency then
they need to stabilize the patients and then they can transfer the stabilized yellow patient to other
middle level government hospital for further care to cater the load.
The red triaged patients need to admit through emergency in tertiary care then after stabilization
of patient transfer it either to ICU (who require ventilator) or HDU (who do not need ventilator).
It will vacant the red triaged beds in emergency and be available for other patients.
134
Figure 74: Hub and Spoke Model for National Forward and Backward Referral Policy
Requirements:
1. MOU with Government and EMS
2. There should be trade-off between tertiary and secondary care system for management
of complex cases which are resource intensive in tertiary care with cases, which can
be stabilized in secondary care centres.
3. Optimal utilization of all tiers of healthcare system based on capacity and capabilities.
135
III. LIVE OBSERVATION

(One Day Data of Emergency)
1. BURDEN OF PATIENTS (OPD AND EMERGENCY)

One day data (24 hours data either of previous day or same day) was collected by assessor’s team
from registration desk of the hospital containing information regarding total visits of patients in
hospital both OPD and emergency, admissions/transfer-out/discharge, death etc.
The burden of patients needing emergency came in 24 hours was 23% in medical colleges, 8%
in government hospitals more than 300 beds, 13% in government hospitals less than 300 beds,
6% in private hospitals more than 300 beds and 25% in private hospitals less than 300 beds as
shown in table 61.
The comparison of patients in OPD and emergency is represented in figure 75 for different
categories of hospitals.
In medical college, the burden of patients needing emergency for 24 hours was maximum at
SMS Medical College & Hospital and minimum at AIIMS, Bhopal.
In government hospitals >300 beds, the burden of patients in emergency was maximum at Indira
Gandhi Government General Hospital, Puducherry and minimum at District Hospital, Dhamtari
(for emergency) and Southern Railways Hospital, Chennai (for OPD).
In government hospitals <300 beds, the burden of patients in emergency was maximum at Puri
District Headquarter Hospital and minimum at Jamanabai General Hospital, Gujarat.
In private hospitals >300 beds, the burden of patients in emergency was maximum at Dr Ram
Manohar Lohia Hospital, Lucknow and minimum at Fortis Hospital, Rajasthan.
In private hospitals <300 beds, the burden of patients in emergency was maximum at Primus
Super Speciality Hospital, Delhi and minimum at Jaipur Golden Hospital, Delhi.
Table 61: Summary of number of patients at OPD and Emergency during Single day (24 hours)
Total Emergency and Injury OPD Patients other than % of ED
care Patients emergency cases Patients out
Hospital Categories of all patients
Median [IQR] Median [IQR] visited in
n n
Min-Max Min-Max hospital
446 [376] 1942 [1374]
Medical Colleges 16 15 17%
55-7450 250-7545
Govt. Hosp. 103 [92] 1223 [1095]
19 18 11%
(>300 bed strength) 22-769 54-5164
Govt. Hosp. 103 [103] 820 [1261]
15 14 11%
(<300 bed strength) 15-960 40-2769
Pvt. Hosp. 57 [87] 988 [1184]
18 17 10%
(>300 bed strength) 22-315 27-3460
Pvt. Hosp. 25 [24]
16 14 102 [332] 22-476 30%
136
Figure 75: Comparison of Patients visited in OPD and Emergency in different Categories of Hospitals (ONE DAY)
*M. C.- Medical College, G. H.- Government Hospital, P. H.- Private Hospital, ED- Emergency department, OPD- Out patient
visit department
2. DISPOSITION SUMMARY
The disposition of patients in emergency department was also recorded by the team of assessors.
In this, number of admissions, LAMA (Leave against Medical Advice), discharge, Death in ED for
24 hours was recorded by the team. The summary of the patient disposal from ED is shown in
table 62 by categories of healthcare facilities.
137
Table 62: Summary of Disposition of Patients at emergency department (24 hours)

by Category in the Healthcare Facilities: Median (% per total ED Visits)
Medical
(>300 bed (<300 bed (>300 bed (<300 bed
Colleges
Disposition of Median Median Median Median Median
Patients from ED (% Out (% Out (% Out (% Out (% Out
n of total n of total n of total n of total n of total
ED ED ED ED ED
visits) visits) visits) visits) visits)
66 24.5 14 13.5
Total Admissions 16 16 16 15 21(37%) 15
(15%) (24%) (13%) (54%)
LAMA 19 3.5 (1%) 19 3 (3%) 19 3.5 (3%) 18 1 (2%) 18 3 (12%)
55 50 17 22.5
Discharge 15 15 15 15 15 6.5 (26%)
(12%) (49%) (17%) (39%)
Death 18 2 (0%) 18 1.5 (1%) 17 1 (1%) 16 1 (2%) 16 1 (4%)
Death due to Trauma
/ injury / Road traffic 15 2 (0%) 14 1 (1%) 16 3 (3%) 13 0 (0%) 13 1 (4%)
accidents
*n: Number of Hospitals, ED: Emergency department, LAMA: Leave against medical advice
3. SPECTRUM OF DISEASES
According to World Health Organization a state in which normal procedures are suspended and
extra-ordinary measures are taken is termed as emergency condition.
The spectrum of diseases present at ED were assessed for adult (10 diseases) and pediatric patients
(9 diseases) separately. Most of the hospitals maintained separate data for adult and pediatric,
while others did not have pediatric patient data.
3.1 Adult Patients

In table 63, the summary of adult diseases reported at the emergency department for all categories
of hospitals is depicted.
138
Table 63: Summary of Spectrum of Diseases for Adults by Category of Hospitals

(n=20) (n=20) (n=20) (n=20)
Spectrum
of Diseases
(% Out of total
(% Out of total
(% Out of total
(% Out of total
(% Out of total
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
for Adults
ED visits)
ED visits)
ED visits)
ED visits)
ED visits)
Min-Max
Min-Max
Min-Max
Min-Max
Min-Max
N N N N N
5.5 3 [4.5] 4 [4.2]

3 [4.2] 2 [2.5]
Chest Pain 144 [10.2] 1.23 85 2.91 51 2.91 84 7.02 40 8
1-28 2-15 1-13 1-15
1-46
5 [5] 1 [1] 3 [3] 2 [1.5] 1 [1.5]
Stroke 75 1.12 19 0.97 25 2.91 30 3.51 14 4
1-42 1-10 1-9 1-9 1-5
Altered 18 [25] 3 [3] 2 [1] 1 [1]

3 [1.5]
Mental 136 4.04 59 2.91 20 2.91 27 3.51 16 4
1-70 1-17 1-5 1-6 1-4
Status
Trauma/ 5
Road traffic 18 [25] 4.5 [6] 3 [10] 3 [4]
599 4.04 175 [10.5] 4.85 130 4.37 143 5.26 60 12
accident/ 1-210 1-40 1-35 1-20
injuries 1-45
6.5 6.5
Respiratory 9 [21] 4 [9] 4 [4]
165 2.02 144 [8.2] 6.31 62 3.88 83 [4.5] 11.40 41 16
Distress 2-40 1-17 1-7
1-38 2-22
Pain in 13 [13] 7 [7.5] 15 [17] 8 [5] 3 [4]

232 2.91 164 6.80 161 14.56 123 14.04 48 12
Abdomen 2-72 1-36 1-27 2-18 1-11
2.5 2 [3.5] 3 [4.7] 1 [0]
1 [0.5]
Poisoning 67 [6.7] 0.56 115 1.94 6 0.97 20 5.26 3 4
1-79 1-3 1-6 1-1
1-30
1 [4] 4 [2] 1 [0.5] 4 [2] 1 [0]
Snake Bite 38 0.22 24 3.88 4 0.97 10 7.02 1 4
1-21 2-10 1-2 1-5 1-1
11.5
8 [24] 12 [15] 6 [7] 4 [7]
Fever 206 1.79 262 [12.7] 11.17 251 11.65 148 10.53 65 16
1-36 2-80 1-42 1-13
1-72
26 [25] 4.5 [3] 2 [2] 1.5

Pregnancy 2 [0.7]
200 5.83 41 4.37 15 1.94 43 3.51 3 [0.5] 6
related 1-140 2-10 1-5 1-30 1-2
*n: number of hospitals, N: total number of patients recorded in 24 hours from district hospitals, IQR: Interquartile range
It was observed that the trauma care (1101 patients) accounted for the maximum number
of patients visiting in hospital emergency department followed by those with complaints
of fever (932 patients).
139
In medical colleges, the trauma care accounted for the maximum number of patients visiting in
hospital emergency department followed by those with complaints of pain in abdomen.
In government hospitals >300 beds, the maximum number of patients visiting in hospital
emergency department accounted for complaints of fever followed by those of trauma care
patients.
In government hospitals <300 beds, the maximum number of patients visiting in hospital
emergency department accounted for complaints of fever followed by those with complaints of
pain in abdomen.
In private hospitals (both >300 beds and <300 beds), the maximum number of patients visiting
in hospital emergency department accounted for complaints of fever followed by those of trauma
care patients.
3.2 Pediatric Patients

In table 64, the summary of pediatric diseases reported for all categories of hospitals is depicted.
Amongst pediatric patients, it was observed that the maximum number of patients visiting in
hospital emergency department accounted for complaints of fever (443 patients) followed by
those of diarrheal diseases (290 patients).
Table 64: Summary of Spectrum of Diseases for Pediatrics in all Categories of Hospitals
Spectrum (n=20) (n=20) (n=20) (n=20)
of Diseases
(% Out of total
(% Out of total
(% Out of total
(% Out of total
(% Out of total
for
Median (IQR)
Median (IQR)
Median (IQR)
Median (IQR)
Median (IQR)
ED visits)
ED visits)
ED visits)
ED visits)
ED visits)
Min-Max
Min-Max
Min-Max
Min-Max
Pediatrics Min-Max
N N N N N
6 2
Respiratory 4 [5.5] 2 [1] 1 [3.7]
115 [11.5] 1.35 47 3.88 11 1.94 28 1.75 35 [14.5] 8
Distress 1-21 1-3 1-18
1-35 2-31
3.5 2
Diarrheal 3 [2] 3 [2] 2 [2]
86 [11.7] 0.78 34 2.91 35 2.91 29 3.51 106 [26.5] 8
Disease 1-7 2-9 1-16
1-25 1-101
Altered 1.5 1 [0] 1.5 1 [0]

3 [2]
Mental 19 [1.5] 0.34 2 0.97 3 [0.5] 1.46 6 5.26 1 4
1-1 1-5 1-1
Status 1-7 1-2
Trauma/
Road 6 [5] 2 [2] 4 [3] 1 [1] 3 [6.5]
traffic 43 1.35 16 1.94 34 3.88 11 1.75 18 12
1-10 1-5 1-17 1-4 1-14
accident/
injuries
140
2 [4] 1.5
1.5 [1] 2 [0.2] 1 [1]
Seizure 29 0.45 12 1.46 7 1.94 10 1.75 3 [0.5] 6
1-10 1-5 1-2 1-5
1-2
Pain in 2 [4] 2 [1] 3 [2.5] 2 [1.2] 15 [0]

102 0.45 33 1.94 20 2.91 24 3.51 15 60
Abdomen 1-12 1, 12 1-5 1-12 15-15
4 [0.5] 2 [0] 2 [0]

Poisoning 13 0.90 0 0 0.00 0 0 0.00 2 3.51 2 8
4-5 2-2 2-2
1 [0.5] 2 [1] 1 [0]
Snake Bite 4 0.22 0 0 0.00 4 1.94 1 1.75 0 0 0
1-2 1-3 1-1
6 3 [4] 2 [2]
2 [2.5] 5 [10]
Fever 159 [23.5] 1.35 70 2.91 35 1.94 67 8.77 112 8
1-26 1-11 1-21 1-105
1-47
*n: number of hospitals, N: total number of patients recorded in 24 hours from district hospitals, IQR: Interquartile range
In medical colleges, the maximum number of patients visiting in hospital emergency department
accounted for complaints of fever followed by those with respiratory distress.
In government hospitals >300 beds, the maximum number of patients visiting in hospital
emergency department accounted for complaints of fever followed by those with respiratory
distress.
In government hospitals <300 beds, the maximum number of visiting in hospital emergency
department patients accounted for complaints of fever and diarrheal disease followed by those
of trauma patients.
In private hospitals (both >300 beds and <300 beds), the maximum number of patients visiting
in hospital emergency department accounted for complaints of fever followed by those with
diarrheal patients.
141
IV. COMPARISON OF EMERGENCY CARE IN VARIOUS SYSTEMS
1. HOSPITALS WITH ACADEMIC EMERGENCY MEDICINE (N=5)

In this study, 5 medical colleges were selected which have academic emergency medicine in
their Post-Graduation programme.
The following observations were obtained during assessment from these hospitals with
academic emergency medicines:
Strengths at Hospitals with Academic Emergency Medicine:

1. They have 24*7 blood bank facility available (figure 76)
2. Adequate manpower in emergency
3. Definitive care services were observed well with proper ICU facilities in hospitals
with academic emergency medicine (figure 77)
4. They have disaster management plan with surge capacity, also conduct drill and
debriefing (figure 78)
5. Majority of them have triage policy
6. They conduct continuous education and periodic training programs for staff to
improve quality (figure 79)
7. They have dedicated staff for gap identification and loop closure.
8. They have key indicators for quality monitored.
9. They have computerized data management system (figure 80)
10. They have good communication skills in ED with satisfaction of majority of patients
(figure 83)
11. They have referral policy due to tie-up with local EMS system (figure 84)
Need to improve:
1. Emergency care protocols were missing (figure 84)
2. Lack of separate decontamination area (figure 78)

Figure 76: Summary of Hospital Blood bank in hospitals with academic emergency medicine and without academic
emergency medicine
142

Figure 77: Summary of Definitive Care Services in hospitals with academic emergency medicine and without
academic emergency medicine
143
Figure 78: Summary of Disaster Managementin hospitals with academic emergency medicine and without
Figure 79: Summary of Continuous Quality Improvement in hospitals with academic emergency medicine and
without academic emergency medicine
144

Figure 80: Summary of Computerized Data Management System in hospitals with academic emergency
medicine and without academic emergency medicine
Figure 81: Summary of Communication Skills in ED in hospitals with academic emergency medicine and without

Figure 82: Summary of Referral Policy in hospitals with academic emergency medicine and without
145

Figure 83: Summary of Emergency Care Protocols in hospitals with academic emergency medicine
and without academic emergency medicine
2. GOVT. SECONDARY CARE V/S TERTIARY CARE HOSPITALS

Out of 100 hospitals, 34 were district hospitals (secondary care centres) and 25 were government
tertiary care centres from various states of our country. The following observations were obtained
during assessment from district hospitals:
Strengths
50% have 24*7 blood bank facility available (figure 84)
Some of hospitals (6) have separate ED blood storage (figure 85)
25% have 24*7 emergency operative services (figure 86)
Compliance for ED protocol/SOP/guidelines were good, when compared to tertiary care
government hospitals (figure 87)
Some of them conducted periodic mock drill and training of staff (figure 88)
Regular audits conducted in mostly district hospitals
Communication in ED and patient satisfaction of district hospitals were good, when
compared to tertiary care government hospitals
Majority have good referral policy with assistance during referral (figure 89)

Figure 84: Summary of Hospital Blood Bank in Secondary Care Centres
146

Figure 85: Summary of Hospital Blood protocols in Secondary Care Centres

Figure 86: Summary of Emergency Operative Services in Secondary Care Centres
147
Figure 87: Summary of ED Protocols / SOP / Guidelines in Secondary Care Centres
Figure 88: Summary of Continuous Quality Improvement in Secondary Care Centres
148

Figure 89: Summary of Referral Policy in Secondary Care Centres
Need to improve:
Lack of blood transfusion protocols (figure 85)
Lack of common ICU with PICU and NICU (figure 90)
Lack of computerized data management system (figure 91)

Figure 90: Summary of Critical Care Services in Secondary Care Centres
149
Figure 91: Summary of Computerized Data Management System in Secondary Care Centres
**Note: Comparison of District Hospitals >300 beds and <300 beds has done as a separate study
150
3. PRIVATE HOSPITALS VS GOVERNMENT HOSPITALS

In this study, 60 hospitals were government hospitals and 40 hospitals were private hospitals
out of 100 hospitals. The following observations were obtained during assessment from these
hospitals were as follows:
Government Private hospitals

Key point of checklist Figure
hospitals (n=60) (n=40)
Blood bank facility availability 65% 75% 10
ED and massive blood transfusion protocol 17% 25% 10
Emergency operative services 37% 77% 12
Periodic mock drill 15% 57% 29
Periodic training programs for staff 18% 77% 29
Regular audits 32% 82% 35
Communication in ED 40% 72% 71
Referral policy 42% 75% 74
4. NABH ACCREDITED VS NON-NABH ACCREDITED HOSPITALS

In this study, 28 hospitals were NABH accredited out of 100 hospitals; all NABH accredited
hospitals were private. The following observations were obtained during assessment from these
hospitals having NABH Accreditation:
Strength
They have 24*7 blood bank facility available.
They have ED and massive blood transfusion protocols.
They have good definitive care services.
They have all types of ED protocols/SOP/guidelines with triage (figure 25).
These hospitals conduct continuous education and periodic training programs for staff
(figure 37).
Periodic mock drill also conducted in these hospitals (figure 31).
Majority have computerized data management system (figure 40).
Management of time sensitive conditions is good as compared to non-NABH accredited
hospitals (figure 58, 63, 67)
They also have referral policy
151
V. C
OMPLIANCE OF INDIVIDUAL HOSPITALS TO
THE CHECKLIST
A checklist encompasses the following parameters was checked for all the hospitals studied. The
details are attached as Annexure VII.
The hospitals which scored 75% or above were found satisfactory and marked green, the score
of 50% to 74% requiring improvement was marked yellow and score of less than 50% in an area
were marked red. The areas in red suggested the need for an intervention on priority.
152
DISCUSSION 07
153
07
Discussion
DISCUSSION
This study is the first cross-sectional stratified multi stage comprehensive assessment of emergency
and trauma care facilities using consensus based study tool in India. We found significant gaps
in whole system at various levels.
According to Medical Council of India, each hospital must have 5% emergency beds. It was
observed that all hospitals have an average of 3%-5% emergency beds. On the other hand, the
annual burden of patients visited in emergency is 10-30%, which is much more than the available
emergency beds present in hospitals.
A major concern was that only a few facilities at any level of care had ED blood storage, protocols
for massive blood transfusion and ED blood transfusion. A major gap in definitive care services
was that nearly all government hospitals (<300 bed strength) do not have common ICU.
Another major concern was the lack of protocols/SOP/guidelines for emergency department.
Nearly all government hospitals and medical colleges do not have emergency care protocols
(alert system for different diseases) and most of the government hospitals and medical colleges
do not have alarm bell/code announcement in ED.
The major gaps in disaster management in the healthcare facilities assessed were lack of separate
decontamination area in ED, separate disaster stock in ED, absence of drill and debriefing for
disaster management and the system for redistribution of patients to other network hospitals
during disaster was present in few hospitals. The quality indicators for urgent and interventional
procedures monitored were found missing at most of the hospital at any levels of care.
Also, gaps were observed in data management systems: most of the government hospitals and
medical colleges do not have trauma registry systems; while ~40% private hospitals have trauma
registry system. Nearly all government hospitals and medical colleges do not have injury and ED
surveillance system and most of the private hospitals also do not have injury and ED surveillance
system.
A major concern was lack of-provision of allocated budget (Central/ State Government) to finance
emergency care systems were observed at nearly all facilities at all tiers. The available few
allocated budget at a few locations pertained specifically for delivery of goals related to trauma
155
care.
There were lack of optimal availability of human resource, essential medicines, critical care
equipments and supplies at various levels. Of these, the most critical gaps were scarcities related
to doctors, paramedics, adherence to essential drug list at ED and essential emergency care
equipments such as cervical collar, transport ventilator, resuscitation medicines, etc. Many of the
frequently absent equipment were inexpensive items, which would save lives in many emergency
conditions.
Amongst the issues related to human resource, it was found that most of the hospitals had adequate
number of general duty doctors and specialists; deficiencies still prevailed in the emergency
department. This was probably due to lack of importance given to the emergency care services as
a separate standalone independent unit/department. Further, most of the posted doctors at the ED
were the most junior doctors, with least experience, that too on a rotational basis-corroborating
further with the aforementioned facts. The recent MCI mandate to develop standalone EDs at all
Medical Colleges should at least partially address these issues. But a larger change in attitude of
administrators, policy makers and doctors is required to bring about significant changes.
Additionally, major gaps were found in physical infrastructure both within and in immediate outside
surrounding areas of emergency departments that could be easily rectified with minimal budget.
These gaps such as independent direct access to ambulance services from the ED and demarcated
area for triage amongst others would be able to save lives by improving efficiency of delivery of
care. Most of these could be achieved by minimally altering the prevailing infrastructures.
Of the prevailing gaps in the infrastructure, lack of availability of a separate 24*7 point of care lab
for ED was prevalent at most of the health facilities. This is a critical deficiency, since availability
of timely lab results is crucial for management of patients with medical emergency conditions,
wherein time is of paramount importance.
The strengths of this study were the fact that this was the first systematic study of prevailing facility
based emergency and trauma care services in the country. The study has been conducted in a
robust manner covering all zones of the country by assessors trained in pre-specified standardized
tools in an unbiased way. The health facilities assessed covered all possible strata and levels of
care.
There are a few limitations to the study. First, most of the information of the healthcare facilities
was obtained from the direct interviews with one or two administrative official per facility.
However, this was partially compensated by live observations by the assessors. Second, most of
the facilities did not have inherent electronic data systems to capture historic information and
these had to be culled from other sources and by Delphi methods.
156
CONCLUSIONS 08
Discussion
157
08
Conclusions
CONCLUSIONS
Facility-level physical infrastructure, human resource, equipment & supplies, point of care lab
and essential medicines gaps existed in the current emergency care system at different healthcare
levels in India. Gaps in financing, protocols, blood bank, etc also existed in the current emergency
care system different healthcare facilities.
Gaps also existed between pre-hospital care and definitive care services, proper linkage should
be there. A major gap is lack of academic emergency medicine department at different healthcare
levels in India. All these gaps are likely to compromise the provisions of quality emergency care.
These findings point towards the implementation of a comprehensive programme of emergency
care system reforms in the country of India.
159
KEY SUGGESTIONS 09
Conclusions
161
09
Summary Of Key Suggestions Emerging from the Study
SUMMARY OF KEY
SUGGESTIONS
EMERGING FROM
THE STUDY
HEADING SUGGESTIONS
We need to increase the emergency beds (12% emergency beds +10%
buffer beds) as per the existing and expected footfall.
Develop Cashless emergency care scheme for all red triaged patients
because of out of pocket expenditure during emergency conditions
Huge Mismatch between
Emergency Beds & Burden To provide quality of care as per the existing and expected footfall we
of Emergency and Injury need to strengthen district hospitals by-
Cases Upgrade them into medical college
Develop residency programme (DNB)
Initiate incentivization and decentivization according to the performance
of hospital
Develop Forensic Nursing in nursing college / dedicated EMO (Emergency
Medical Officer) / Senior Resident (Forensic Medicine) to deal with MLC
Burden of Medico-legal documentation and representation to court
Cases In-house or nearby police post for mitigating violence and protection
of emergency care provider and for better co-ordination of MLC
documentation and legal service
But for running acute care services, we need blood bank services for
24*7 in all hospitals.
Hospital Blood Bank Majority of district hospitals have blood bank however the round the
Services clock service is missing in many of them, due to lack of staff.
Emergency blood storage is mandatory for those medical college and
district hospitals (>300 beds) which deals with more trauma cases
163
HEADING SUGGESTIONS
Medical colleges should have all types of emergency operative, critical
care as well as specialized care services for 24*7
District hospitals >300 beds should have trauma, non-trauma operative
services, general ICU (Intensive Care Unit), HDU (High Dependency
Hospital Definitive Care Unit), NICU (Neonatal ICU) and PICU (Pediatric ICU).
Services District hospitals <300 beds should have general operative services,
general ICU (Intensive Care Unit) / HDU (High Dependency Unit) and
NICU (Neonatal ICU).
District hospitals may be upgraded into multi-speciality hospitals to
improve the quality of care
The in-hospital ambulances should be optimally utilized in the common
resource pool of EMS (Emergency medical Service) of the region as per
requirement.
Regular maintenance of ambulance should be done.
Hospital Ambulance The ALS ambulances can be used for mobile stroke unit as well as for
Services STEMI programme.
Creation of EMT (Emergency Medical Technician) course as a residency
programme
Dedicating job creation
Paramedic Council
Development of academic residency programme
Implementation of triage policy in each hospital
ED Protocols / SOP /
Guidelines NABH Accreditation
Increase the scope of Good Samaritan Law from road traffic injuries to
other time sensitive conditions
There should be standard protocols for implementation of in-hospital
disaster management plan
Implementation of hospitals prepared for disaster management for both
external and internal
Establish academic emergency medicine
Disaster Management There should be separate decontamination area at entrance of emergency
Every hospital should have surge capacity with separate disaster stock in
emergency
There should be drill and debriefing for disaster management
Regular monitoring and evaluation of implementation of disaster
management should be done from NDMA
There should be dedicated quality manager for gap identification and loop
closure
Develop a quality council among emergency care providers
Continuous Quality Mandatory Emerald certification under NABH

Improvement Regular mortality and morbidity meeting
Regular third party audit of external agencies by using KPI and the
funding of the hospital should be linked with it
Continuous training of quality council provider as well as manager
164
HEADING SUGGESTIONS
Develop National Emergency Department Information System (EDIS)
Implement and integrate the computerized care delivery template which
Computerized Data will serve as clinical notes, registry and surveillance
Management System It will use the data for quality improvement initiative and research
Develop various emergency conditions registries such as cardiac arrest,
poisoning, snake bite including trauma registry
Protected funding for emergency and injury care services and for
establishment of residency programme in emergency medicine,
emergency nursing and EMT (Emergency Medical Technician) course
Financing Integration and aggregation of financial schemes for emergency and injury
care
Cashless scheme- Increase Ayushman Bharat scheme for all red-triaged
patients in all hospitals to save out of pocket expenditure
Uniformity of name (Emergency/Emergency Medicine Department) in
every hospital for emergency / casualty / injury care etc.
The capacity and capability of ED should be standardize based on the tier
of facility, footfall of patients and academic programme
Physical Infrastructure Availability of either point of care lab or hospital lab (24*7) for
emergency services
Adequate space for ambulance drop zone
There should be demarcated triage area
There should be small ICU in each hospital
Rotator posting of doctors and nursing students from different disciplines
including interns for a defined period in emergency
Manpower in Emergency Creation of dedicated post for emergency department of doctors, nurses
Department and paramedics
NABH Accreditation
Establish academic emergency medicine, emergency nursing and EMT
All essential equipments and supplies should be present in every hospital
to improve the quality of care
There should be dedicated staff for maintenance of equipments in
emergency
Equipments and Supplies There should be dedicated training of staff regarding the maintenance of
in ED equipments (how to use and maintain)
Maintain checklist of supplies and equipments, they should be checked
before end of every shift and beginning of every shift
Maintain a checklist of non-functional equipments and consumed supplies
and should be communicated during handovers
All healthcare facilities should have either basic point of care lab or
Point of Care Lab
emergency lab in hospital for 24*7
165
HEADING SUGGESTIONS
Complete package of resuscitation medicines should be present in all
hospitals for 24*7
Essential Medicines for
Other essential medicines should also be present in all hospitals for 24*7
Emergency
During third party audits, if any essential drug is missing from the
resuscitation package then the license of the hospital may be cancelled
It should be a sovereign department
Implementation of triage policy in all hospitals (Prioritization of patient)
Entry to Admission/
Transfer-out/Discharge Adequate manpower should be present in hospitals as per footfall of
Time of Patients Visited in patients and emergency beds
Emergency Department
Optimum utilization of resources
There should be a dedicated emergency nurse coordination (ENC) system
Upgrade them for thrombolysis
Adequate trained emergency care provider
All district hospitals must have ECG machine and technician
Use Tele-ECG and Tele-Medicine programme
Chest Pain Management
Resuscitate patient in district hospital and refer them to other higher
government hospital
Develop a STEMI Programme by Hub and Spoke Model
Develop PCI centres in multi-speciality hospitals
Thrombolysis near home – Hub and Spoke Model
Develop Tele-stroke programme
Stroke Management
Stroke management by PPP (Public-Private Partnership) model in district
hospitals
Dedicated emergency nurse coordinator (ENC)
Communication Skills in
Emergency Department Training of staff on communication skills from under-graduate level (for
doctors, nurses and paramedics)
Develop National Forward and Backward Referral Policy with safe
transport integrated with local EMS system
Hub and Spoke Model
Referral of the Patient
Structured referral protocols
There should be informed transfer
NABH Accreditation
Burden of Death of Develop a robust integrated emergency care system which includes injuries
Trauma Patients
Develop preventive emergency healthcare strategy such as National Injury
Prevention Programme
Burden of Brought Dead Developing a robust emergency injury care initiative
Patients
There should be installation of public access device of AED (Automated
external Defibrillator) as a national policy in mass gathering areas such as
schools, shopping mall, railway station, etc.
166
KEY POLICY
10
RECOMMENDATIONS
167
10
Suggested Key Policy Recommendations
SUGGESTED
KEY POLICY
RECOMMENDATIONS
These findings were suggestive for the following suggestions:

1. Develop a robust integrated emergency care system including injuries: The current
policy focus (which is predominately trauma-centric) should be leveraged to deliver
comprehensive emergency and trauma care services in an integrated manner, without
losing the gains achieved in delivery of trauma care services through-out the Nation.
2. Standardize the Protocols / SOP and Guidelines including Triage: The policies, protocols
and guidelines for emergency department should be standardized across all EDs in the
country, irrespective of their levels of care. The key for achieving this is a availability of
standardized universal emergency-care manual at the point of care. This manual should
contain- information for management of all anticipated emergency medical conditions
with updated SOPs, protocols and flow charts. Specific focus should also be given for
critical issues such as triage, handling of critical equipments, norms for optimal care
delivery. If feasible, these should also be available in a ready-to-use handy app format,
which can be downloaded on a mobile phone.
3. Adequate Space allocation for Emergency and Injury Care: Adequate space should be
allotted for emergency department in each hospital as per the footfall. The critical needs
for establishment of such a department should be met at all hospitals.
4. Develop Standardize Emergency Department: There is a need to develop a blue print
for a standalone standardized department of emergency medicine for various levels of
care, for the Nation. These norms need to be adapted after a consensus is achieved.
5. Establish Academic Emergency Medicine departments: This is the need of the hour to
ensure continuous ongoing medical education and development of skills for doctors,
nurses and paramedics. Further, development of such departments will be the key to
enhance research to provide further policy directions.
6. Continuous Training and Skill Development of ED Staff: There should be capacity
building of doctors, nurses and paramedics. The emergency care providers should be
trained for life saving skills with structured courses such as: ACLS, BLS, PALS, ATLS or
169
NELS, Point of care emergency ultrasound; with periodic refresher courses, to ensure
continuous skilling of defined core competencies.
7. Accreditation of all Emergency and the health facility for providing quality care: There
should be accreditation of all EDs and health facility for delivering and improving the
quality care. Regular quality checks on a specified format should be ensured to enhance
the performance of emergency care.
8. Upgradation and maintenance of existed Emergency and Health facility: The ED is like
a mini-hospital and in itself requires separate wide variety of resources. The availability
of resources should be supported with optimum utilization for maximum output. The
management of staff for 24 hours in right number should be a policy and same should be
followed for equipments and medicines. An effort should be made to integrate the EMS
with pre-hospital notification, so that the patients could be transferred to appropriate
health facility based on the level care needed for the underlying disease condition.
9. Pooling of Ambulances (Integration and aggregation of ambulances): The in-hospital
ambulances should be optimally utilized as a common resource pool for providing EMS
services for the entire -local region, as per requirement.
10. Optimization of Resources (manpower, infrastructure, supplies and medicines): Since
many of the gaps in optimization of resources needed for optimal emergency care
services can be achieved with minimal budgetary requirements, it is recommended
that phasing of the needs be done, so as to achieve early low hanging fruits. Some of
these examples include reallocation of available human resources, minimal alteration
of existing infrastructure to provide access to ambulance vehicles and creation of a
demarcated area for triaging.
11. Protected Funding for Emergency and Injury Care as well as for developing academic
department / DNB Emergency Medicine: Separate budget head needs to be created
for emergency care services. One option is to augment the prevailing funds for trauma
care to encompass overall emergency care delivery.
12. Cashless care for all red triaged patients in all hospitals: Policy for caring of all
emergency conditions for all citizens of the Nation for the initial critical period to
ensure early clinical stabilization is a way forward to achieve Health for all and SDGs.
NOTE: To carry forward the above recommendations, it is suggested that in the first phase, these
may be implemented at 30 existing facilities which have a functional emergency department and
trauma care facility. The lessons learnt from this endeavour can act as template to give further
directions.
170
PHASE-I SUGGESTED KEY POLICY RECOMMENDATIONS

Uniformity of name–Emergency or Emergency Medicine Department
Create an empowered Hospital Committee, which have composition of different
disciplines and headed by Hospital in-charge/Medical Superintendent. The member
secretary should be Head of the Emergency Department.
Reorganize of the existing emergency department for comprehensive management of all
emergency conditions, at all tiers of healthcare facilities depending on the anticipated
footfall of patients.
Initiate Quality Improvement (QI) programmes.
Implement triage policy.
Initiate processes to capture data related to emergency care at each hospital.
Ensure 24*7 availability of adequate dedicated emergency staff such as doctors, nurses
and paramedics.
Optimize infrastructure and supplies from within the available resources and create a
roadmap for futuristic needs with timelines.
Ensure on-going training and skilling of doctors, nurses and paramedics.
Develop standardized care delivery template for time sensitive conditions.
Develop a robust pre-hospital care system linked with facility based emergency care
services.
Create a separate protected fund/ budget to address the immediate concerns regarding
critical supplies and equipment’s needs of the Emergency Department.
171
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173
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177
ANNEXURES 12
References
179
12
Annexure-I: List of Hospitals
ANNEXURE-I:
LIST OF HOSPITALS
Government Private
Government Private
S. Medical Hospital less Hospital
Zone State Hospital more Hospital less
No. College than 300 more than
than 300 beds than 300 beds
beds 300 beds
Sher-i-Kashmir
District District
Institute of
Jammu & Hospital Hospital
1 Medical - -
Kashmir Hospital, Ganderbal,
Sciences,
Barahmulla Ganderbal
Srinagar
District
Hospital
Himachal (Deen Dayal
2 IGMC, Shimla - - -
Pradesh Upadhyay
Hospital),
Shimla
Guru Nanak Shivam
Jallianwala
Dev Hospital Hospital,
NORTH Bagh Martyr’s Fortis
& Govt. Multi Super
ZONE 3 Punjab Memorial - Hospital,
Medical Speciality
Civil Hospital, Mohali
College, Hospital,
Rambagh
Amritsar Hoshiarpur
Coronation
HNB Base
4 Uttarakhand - Hospital, - -
Hospital
Dehradun
RML Charak
Utttar Civil Hospital-
5 - - Hospital, Hospital
Pradesh Lucknow
Lucknow Dubagga
Government Civil Max
Superspeciality Hospital Superspeciality
6 Chandigarh - -
Hospital, Sector-22, Hospital,
Sector-16 Chandigarh Mohali
181
SMS Medical Hari Baksh Govt. BDM Fortis Birla Hospital-

7 Rajasthan College & Kanwatia Hospital, Hospital, CK Birla,
Hospital, Jaipur Hospital, Jaipur Kotputli Jaipur Jaipur
Yashoda
Indian Spinal
hospital,
Injuries Centre
Kaushambi
Medeor
Asian
Hospital,
Hospital
8 Delhi - - - Manesar
Sri Ganga Jaipur Golden
Ram Hospital Hospital
Primus Super
Artemis
Speciality
Hospital
Hospital
GMERS
BJ Medical Jamanabai Parul Bhailal Amin
Medical
College & Government Sewasharam General
1 Gujarat College &
Civil Hospital, Hospital, Hospital, Hospital,
Hospital, Gotri,
Ahemdabad Mandvi Vadodara Vadodara
Vadodara
Sri Seva
BJ Medical Medical Grant
College & foundation Medical
2 Maharashtra Sassoon - Dr Jogalekar Foundation -
General Hospital, Ruby Hall
Hospital, Pune Shirwal, Clinic, Pune
Pune
WEST
Jai Prakash
ZONE Bhopal
District
Madhya Fracture
3 AIIMS, Bhopal Hospital, - -
Pradesh Hospital,
Shivaji Nagar,
Bhopal
Bhopal
District Ramkrishna
District
Hospital, CARE
4 Chhattisgarh - Hospital, -
Tikarpara, Hospital,
Dhamtari
Raipur Pachpedhi
North Goa
Goa Medical District
5 Goa - - -
College, Panaji Hospital,
Mapusa
Ruban
Sadar Paras HMRI
Memorial
1 Bihar PMCH, Patna AIIMS Patna Hospital, Hospital,
Hospital
Gaya Patna
Patliputra
EAST District
Capital
ZONE AIIMS, Headquarter Care Hospital,
3 Orissa - Hospital,
Bhubneshwar Hospital, Bhubneshwar
Bhubneshwar
Puri
IPGMER & Ruby General
4 West Bengal - - -
SSKM Hospital
182
Annexure-I: List of Hospitals
Central
New STNM- Singtam
Referral
1 Sikkim Govt- medical - District -
Hospital,
college, Sikkim Hospital
Gangtok
TomoRiba
Institute of BakinPertin Ramakrishna
Arunachal Health & General Mission
2 - -
Pradesh Medical Hospital, Hospital,
Sciences, Pasighat Itanagar
Papumpare
Gauhati
Nemcare
Medical Morigaon GNRC
Superspecialty
3 Assam College and - Civil Hospital,
Hospital,
Hospital, Hospital Guwahati
Guwahati
Guwahati
Civil Hospital
4 Meghalaya - - - -
Shillong
Christian
NORTH
EAST District Institute
ZONE 5 Nagaland - - Hospital, - of Health
Peren Science and
Research
Shija Hospital
District & Research
6 Manipur RIMS, Imphal - Hospital, - Institute,
Bishnupur Lamphelpat,
Imphal
Tripura
Agartala medical
Gomti
Government college&
District
7 Tripura Medical - BRAM -
Hospital,
College & G B Teaching
Udaipur
Pant Hospital Hospital,
Agartala
Synod
Civil
Zoram Medical Hospital
8 Mizoram - Hospital, -
College (Presbyterian
Aizawl
Hospital)
183
District District Yashoda

Hospital, Hospital, Hospital,
1 Telangana - -
Karim Nagar, King Koti, Malakpet,
Hyderabad Hyderabad Hyderabad
Mysore
Medical
College Victoria Government Manipal
2 Karnataka & Krishna Hospital, Hospital, Hospital, -
Rajendra Bengaluru Virajpet Bengaluru
Hospital,
Mysuru
Guntur
Lalitha Super
Medical Government Kasturi
Specialty
Andhra college & District Medical
3 - Hospital,
Pradesh Government Hospital, College &
Kothapet,
General Tenali Hospital
SOUTH Guntur
Hospital
ZONE
Trivandrum District District Cosmopolitan
4 Kerala Govt Medical Hospital, Hospital, Hospitals Pvt G G Hospital
College Neyyattinkara Peroorkada Ltd
Madras
Railway
Hospital,
Madras
Madras Apollo
5 Tamil Nadu Medical - -
(Southern Hospital
College
Railway
Headquarters
Hospital)
Indira Gandhi
Government
JIPMER,
6 Pondicherry General - - -
Pondicherry
Hospital,
Pondicherry
184
Annexure-II: Study Tool
ANNEXURE-II:
STUDY TOOL
Section A: Background Information of the Hospital:
Date of Inspection:
Name of the Name of Inspection Team Member:

1.
hospital: 1.
Address of the 2.
2.
hospital: 3.
Government/Non Govt. (Trust/society/
Corporate/…………………... Specify)
Type of Health
3. Large Tertiary( >500 Beds) /
Care Facility
Secondary (300-500 Beds) /
Secondary (100-300 Beds)
4. Total no of Total no. of beds in Emergency care Red (ESI:1-2)
Inpatient area
Beds in the Yellow (ESI: 3-4)
hospital Green (ESI: 5)
5. Total number of patients visited in hospital outpatient Adult Pediatric

department (OPD ) (During 1st Jan 2018 to 31st Dec 2018) (Age - 0 to …..)
6. Total number of patients visited in emergency (During 1st Adult Pediatric

Jan 2018 to 31st Dec 2018) (Age - 0 to …..)
185
7. Total number of death of trauma patients in emergency Adult Pediatric

department (During 1st Jan 2018 to 31st Dec 2018) (Age - 0 to …..)
8. Total number of patient’s death due to road traffic injury in Adult Pediatric
emergency department (During 1st Jan 2018 to 31st Dec (Age - 0 to …..)
2018)
9. Total number of patients which are brought dead to the Adult Pediatric
hospital (During 1st Jan 2018 to 31st Dec 2018) (Age - 0 to …..)
10. Total number of Medicolegal cases attended in Emergency

(During 1st Jan 2018 to 31st Dec 2018)
11. Total Number of admissions through Emergency (last 1yr)
Section-B: Hospital Services
1. BLOOD BANK(SCORE- 1: Full Compliance, 2: Partial Compliance, 3: Non

Compliance)
REMARKS
S.No. OBJECTIVE ELEMENTS Check point SCORE
(If any)
Does the facility have a licensed in- Admin Interview/
1. SCORE
house blood bank? Facility Visit
If yes, does the blood bank available Admin Interview/
2. SCORE
for 24x7? Facility Visit
If no, any tie up with external Blood Admin Interview/
3. SCORE
bank facility? Facility Visit
Does the emergency have separate Admin Interview /

4. component facility: Packed cell (RBC), Blood bank Visit/ SCORE
FFP, Platelet, Cryoprecipitate? Stock Register
Does the facility have 0-Negative Blood bank Visit/

5. SCORE
Blood availability? Stock Register
Facility available in
6. ED Blood storage SCORE
ED
7. ED Blood Transfusion Protocol Written protocol SCORE
8. Massive Blood Transfusion Protocol Written protocol SCORE
186
Definitive Care Services (Score: 1-No, 2- Partial, 3- Yes)

*NOTE: Question no 12 to 16 is not applicable for district hospital
S. REMARKS
OBJECTIVE ELEMENTS Check point SCORE
No. (If Any)
Emergency operative services for Admin interview / 24 hours
1. Trauma patients available facility/OT Register
SCORE
Emergency operative services

Admin interview / 24 hours
2. for Non-Trauma (Surgical,
available facility/OT Register
SCORE
Orthopedics etc.) patients
Emergency operative services for Admin interview / 24 hours
3. Obstetrics patients available facility/OT Register
SCORE
Elective Operative services for Admin interview / OT

4. Orthopedic patients facility/OT Register
SCORE
Elective Operative services for Admin interview / OT

5. neurosurgical patients facility/OT Register
SCORE
Common Intensive care services Admin interview / facility/

6. (ICU) Facility Register
SCORE
Common High dependency Unit Admin interview / facility/

7. (HDU) Facility Register
SCORE
Admin interview / facility/

8. Pediatric ICU
Facility Register
SCORE

9. Neonatal ICU
Facility Register
SCORE

10. Neurosurgery ICU
Facility Register
SCORE

11. Cardiac Intensive care Unit
Facility Register
SCORE

12. Cardiac Cath lab*
Facility Register
SCORE

13. Intervention Radiology*
Facility Register
SCORE
Intervention Neuroradiology Admin interview / facility/

14. service with DSA* Facility Register
SCORE
Facility for Emergency CABG Admin interview / facility/

15. services* Facility Register
SCORE
Facility for Radiofrequency Admin interview / facility/

16. ablation services* Facility Register
SCORE
187
Hospital Ambulance Services(Score: 1-No, 2- Partial, 3- Yes)
REMARKS
SN. OBJECTIVE ELEMENTS Check point SCORE
(if any)
Do you have ambulances Admin interview /
1. SCORE
in your hospital? Facility/Ambulance visit
If Yes, total number of Admin interview /
2. NUMBERS
ambulances. Facility/Ambulance visit
Total Number of Functional-

Functional ambulances Admin interview / Numbers
3.
and Non-Functional Facility/Ambulance visit Non-functional-
ambulances. Numbers
ALS- (Numbers
Number of BLS/ALS only)
Admin interview/
4. (Advance life support)
Ambulance visit BLS- (Numbers
ambulances.
only)
Pick up the patient/
Drop Patient /
Intra-transfer of
For what purpose, hospital Admin interview/
5. patient in hospital
uses these ambulances? Ambulance driver
/ Inter transfer of
patient to other
hospital
If hospital doesn’t have
any ambulance, then how
6. you transfer patient from Admin interview COMMENT
your hospital to other
hospital?
Do you get Pre-Hospital
Notification (Prior Admin interview /
7. information about patient’s Paramedic/Ambulance SCORE
condition is communicated driver/Patient Interview
to ED)?
Does the ambulance is
manned with appropriately
Admin interview /
8. trained paramedics as per SCORE
Paramedic Interview
the level of ambulance
services?
Do you have mobile stroke Admin interview /
9. SCORE
unit? Mobile stroke unit visit
a) Do you have Tele-
Medicine facility? Admin interview /
Tele-stroke facility a. YES/NO
b) If no, did you start this
facility in coming days? visit (whether the b. SCORE
10. facility is mentoring
c) If Yes, how are you the thrombolysis in at c. COMMENT
using it for patient care? district hospital via tele d. sSCORE
d) Does it have minimum technology platform)
requirements?
188
Section-C: Ed Protocol/Sop and Guidelines (Score: 1-No, 2- Partial,

3- Yes)
Remarks
SN. OBJECTIVE ELEMENTS Check Point SCORE
(If any)
a. Do you have documented
Emergency Manual at the Protocol /SOP and
point of care? procedures for emergency
SCORE
b. If yes, only documented/ care are documented and
1. implemented? operations in ED must SCORE REMARKS
be guided by them (e.g.
c. If implemented, off-on SCORE
Clinical Protocol/Treatment
implemented/regular?
guidelines.)
d. If no, what is the protocol?
e. Do you have documented
Triage protocol /SOP and
triage guidelines and
protocol? procedures for emergency
2. care are documented and SCORE REMARKS
f. If no, how you manage operations in ED must be
patients in emergency
guided by them
department?
g. Do you have documented
policies and procedures
which guide the transfer Outside patients are
of patients into the admitted only after proper
organization? SCORE
referral by a doctor with
3. h. If yes, only documented/ prior communication SCORE REMARKS
implemented? depending on the services
SCORE
provided and bed
i. If implemented, off-on
availability.
implemented/ regular?
j. If no, what is the protocol?
k. Do you have documented
policies and procedures
which guide the transfer-out/
referral of stable and unstable
patients after stabilization to Documentation of referrals,
another facility in appropriate SCORE
advance communication,
4. manner with documentation? written orders by treating SCORE d) REMARKS
l. If yes, only documented/ doctor and consent of the
SCORE
implemented? attendant/patient taken.
m. If implemented, off-on
implemented/ regular?
n. If no, what is the protocol?
Discharge with regard
a. Do you give discharge
summary to all patients? to LAMA, DAMA, MLC,
5. Abscond (Clearly mentions SCORE b) REMARKS
b. If no, which procedure you the treatment given, name
follow?
of the treating doctor etc.)
189
a. Do you have policy on

handling cases of death
(outside and inside hospital) To make MLC, intimate
6. mentioned in manual? police, dead body hand SCORE b) REMARKS
over etc.
b. If no, how you manage death
cases?
a. Do you have documented
disaster management plan?
7. SCORE b) REMARKS
b. If no, which procedure you
follow?
Is there a triage policy/system at
your emergency department? If
Yes then: YES/ NO
a. Are you using triage? a) SCORE
b. Is there a dedicated triage Verify written SOP &
8. b) SCORE
nurse? Interview
c) SCORE
c. Is there a colour triage band
available? d) SCORE
d. Is there any regular audit of
your triage system?
Do you have alert system: code Verify written SOP &
9. SCORE
Blue? Interview
Do you have alert system: Verify written SOP &
10. SCORE
Trauma? Interview
Do you have alert system: Chest Verify written SOP &
11. SCORE
Pain? Interview
Verify written SOP &
12. Do you have alert system: Sepsis? SCORE
Interview
Verify written SOP &
13. Do you have alert system: Stroke? SCORE
Interview
Section-D: Safety & Security (Score: 1-No, 2- Partial, 3- Yes)

S. No. Objective Elements Check Point Score Remarks (If Any)
Admin interview/smoke detectors, fire

1. Do you have fire safety? extinguishers (class A, B , C or ABC SCORE
type) Sign postings, Fire exits etc.
Do you have building
2. Admin Interview SCORE
safety?
Do you have electrical Admin interview/UPS, Generators for
3. SCORE
safety? monitors and ventilators etc.
Do you have patient and
4. Side rails, window grills, etc. SCORE
provider safety?
Regular sterilization, safety hazard
Do you have chemical
5. specially PEP, Pre-exposure SCORE
safety?
immunization such as swine flow, etc.
190
a) Do you have periodic

training of staff? (Every 6
months ) Admin interview/Response time
6. measured and corrective measures SCORE
b) Do you have periodic taken (Record maintained)
mock drill? (Every 6
months )
Do you have police
5 post available within the Admin interview/Facility visit SCORE
premises?
Do you have alarm bell
Admin interview/ Facility visit/Security
in Emergency/ Code
6 system is in place in case of violence, SCORE
announcement available
mass situation in ED
for extra help?
Section-E: Disaster Management (Score: 1-No, 2- Partial, 3- Yes)

S.
Objective Elements Check Point Score Remarks
No.
Admin interview/ See Plan
Do you have disease outbreak document [e.g. for Dengue,
1 SCORE
management plan? malaria etc. and other community
emergencies]
Admin interview/ Facility visit
[Triage area is marked, expansion
Do you have surge capacity in
2 of care area, line of authority is SCORE
your hospital?
clear, internal communication
system]
Do you have separate Admin interview/ Facility visit
3 decontamination area at ED [Provision for flexible and YES/NO
entrance? expandable facility]
Do you have separate disaster
stock in ED? Admin interview/ Facility visit
SCORE
4 [Medical supplies, manpower,
If yes, for how many patients NUMBER
medicines etc.]
(e.g. 50, 100)?
Does drill is conducted and
document [Role and responsibility
5 debriefing is done for disaster SCORE
of staff in disaster is checked and
management?
recorded]
Do you have system to
redistribution of patients to
6 document [Prior plan for increased SCORE
other network hospitals during
load of patients]
disaster?
191
Section-F: Continuous Quality Improvement (Score: 1-No,

2- Partial, 3- Yes)
Remarks
S.No. Objective Elements Check Point Score
(If Any)
Admin interview
Do you have dedicated staff (Dedicated staff can be: Patient
1. for gap identification and loop safety nurse, Infection control nurse, SCORE
closure? Emergency nurse coordinators,
Quality manager)
Admin interview
Do you have regular audits in [Death audits and post event
2. SCORE
your hospital? analysis etc./
Clinical audit]
Do you have continuous
education and training Admin interview
3. programs cycles for (Trainings like- ACLS, BLS, ATLS, SCORE
professional development and etc.)
skill improvement?
Admin interview
Do you have key indicators of [Key Indicators are Mortality rate,
4. SCORE
quality monitored? Referral rate, Return to ER, LAMA,
Absconding rate]
Are quality indicators for Admin interview
urgent and interventional [e.g. 1. MI- (Door to needle -30
procedures monitored? mins thrombolysis, door to balloon
5. SCORE
(% of patients receiving time 90 mins PCI) 2. Stroke: (door
interventions is documented, to needle time 60 mins) 3. Trauma
at-least 50%) resuscitation (30 min of arrival) ]
Do you have death review

6. Admin interview SCORE
committee?
Do you have Central
Empowered Hospital
7. committee for continuous Admin interview SCORE
quality improvement of
Emergency services?
192
Section-G: Data Management System (Score: 1-No,

2- Partial, 3- Yes)
Remarks
S.No. Objective Elements Check Point Score
(If Any)
Do you have Integrated Computerized EHR
1. (Registration, Clinical care, Lab, Radiology, Admin interview SCORE
Others and Disposal)?
Do you have Computerized Patient
Registration system?
Do you have Computerized Patient clinical
examination notes?
Do you have Computerized Patients
investigation Lab reports?
Do you have Computerized Patients
radiological investigation reports?
6. Do you have Trauma registry? Admin interview SCORE
7. Do you have Injury Surveillance system? Admin interview SCORE
Do you have Emergency Department

Surveillance system?
Do you have data retrieval system for Quality
Improvement & Research?
Section-H: Financing (Score: 1-No Funds, 2-Not Sufficient,

3-Sufficient)
Sn. Objective Elements Check Point Score Remarks
Do you have Central Govt. funds for

Emergency and Trauma services?
Do you have dedicated State Govt. funds
for Emergency and Trauma services?
If funds are available, which health
NAME THE
3. protection schemes are covering your Admin interview —
SCHEME
emergency care system?
Full Utilization of funds (Annual
utilization)?
5. Is there any delay in release of funds? Admin interview SCORE
193
ANNEXURE-1: PHYSICAL INFRASTRUCTURE
1. OUTSIDE EMERGENCY (SCORE: 1-NO, 2- PARTIAL, 3- YES)

S.N. Objective points Check point Score
Adequate Signage on the major road and

Does the hospital have easy and
boundary of the Hospital, E.D Board is
1. direct access to the Emergency Score
prominently
Department?
displayed with illumination in night facility
Does the access road of hospital is
2. Can pass three ambulances at a time Score
wide enough?
Does the vehicles parked on
3. the way /in front of emergency People are using as parking lot Score
department?
Does the hospital have separate Sufficient space for Ambulance offloading and
4. Score
access for ambulance services? turn-around
No vehicles parked on the way/in front of
Does the hospital have designated emergency
5. parking area for Ambulance, Staff Score
and Public? parking, “No Parking Board” placed outside
emergency
Entrance have a canopy, ramp for stretchers
Does the hospital have smooth entry and wheelchairs
6. area with adequate wheel chair, Score
trolley and stretcher bay? with Demarcated space for trolleys and
wheelchair
Does the hospital have patient
attendant at the entrance of hospital Staff Responds with a wheel chair, stretcher,
7. Score
to help the patient with the wheel trolley promptly
chair, stretcher, etc.?
Unidirectional flow, separate entrance, no
8. Seamless flow of the patient Score
crisscross.
Does the services provided to
9. the patients are clearly defined, signage/ boards Score
displayed prominently?
Does the names of the doctors and

10. nursing staff on shift/duty/call are Score
displayed and updated?
numbers including emergency no, ambulance,

Is important Telephone numbers are
11. blood bank, police, referral centers etc. Score
displayed in hospital?
displayed
Does all relevant information is
Service charges/ User charges are displayed
displayed for the patients and
on a board/printed on pamphlet/ personally
12. visitors including user charges Score
counseled, enquiry counter/Help desk/
wherever applicable at the time of
registration counter / designated staff.
procedure/ investigation/admission?
194
13. Do you have adequate waiting area? It has comfortable seating , information board Score
Do you have safe drinking water
14. 24hrs drinking water facility Score
facility?
Do you have functional male toilets?
Do you have functional female
Male toilet, Female toilet, Toilet for differently
toilets?
15. able with ( at least 1 wheelchair accessible Score
Do you have functional toilets for W.C and wash basins present)
differently able person with wheel
chair?
Building is painted, plastered, no cracks and
Do you have clean facility and is
16. seepage visible and furniture fixtures clean and Score
that maintained adequately?
intact with no junk around
Do you have Cafeteria facility for
17. Score
the family members/ attendants?
18. Do you have police control room? Score
Do you have Emergency Registration
19. Score
Counter?
Do you have ambulance driver’s
20. Ambulance drivers Score
room?
Remarks (if any):
2. INSIDE EMERGENCY (SCORE: 1-NO, 2- PARTIAL, 3- YES)
SN Objective Elements Check Point Score

Do you have emergency department Admin interview / 1000 m2 per 100patient
with adequate space as per patient load daily load (NQAS standards),Corridors are
1. Score
(Circulation space and open space)? broad enough (2-3m) for easy movement
of stretcher and Trolley
Does your department has proper layout 1.Resuscitation Area(Red)
and demarcated areas as per Triage?
2. 2.Observation Area(Yellow) Score
3 Ambulatory Area (Green)
Do you have demarcated station for Preferably in the center from where all
3. Score
doctors and nurses? beds are visible
4. Do you have demarcated plaster room? Score
Do you have dedicated Isolation rooms Negative pressure and separate AHUe.g.
5. Score
(Emergency Infections)? Swine flu/Ebola pts.
6. Do you have dedicated minor OT? Score
Do you have provision for Emergency
7. Score
OT?
195
8. Do you have point of care lab? Designated lab area in emergency Score
Do you have linkage to other facility on Radiology department, OT, Lab etc.
9. Score
the same floor?
Do you have separate room for As per One stop Centre
10. examination of rape / sexual assault Score
victim?
Do you have availability of sexual assault Kit has protocols and guidelines for
11. Score
forensic evidence kit? collection of forensic evidence.
Do you have counselling services for
12. Score
Sexual assault / domestic violence cases?
Do you have demarcated area for
13. Score
keeping dead bodies?
Do you have availability of clean utility
14. Score
room?
Do you have availability of dirty utility
15. Score
room?
Do you have store? Storage to refrigerate, keep equipment &
16. Score
Emergency supplies
Do you have curtains/screens at point of Privacy and dignity of patients maintained.
17. care? Score
Do you have demarcated duty room for

18. Score
doctors?
Do you have demarcated duty room for
19. Score
nursing staff?
196
ANNEXURE-2: MANPOWER IN EMERGENCY
Private Govt. Hospitals Medical Colleges
S.N. Category More More

Less than Less than Govt. Private
than 300 than 300
300 beds 300 beds Medical Medical
beds beds
1. Faculty/Consultant
2. CMO (casualty medical
officer)
3. SR ( Senior Residents )
4. JR ( Junior Residents)
5. MO (medical officer)
6. Intern
7. Nursing officer In charge /
Team leader
8. Staff Nurse/ Nursing Officer
9. Radiology technician/
Radiographer
10. Lab Technician
11. OT. Technician
12. H.A*/ GDA*/ Orderly
13. SA*/ Housekeeping staff
14. EMT
15. Security
16. Registration staff
17. Any other
GDA-General Duty Assistant, SA- Sanitary Attendant HA- Hospital Attendant

*
Other Specialist/ Super Specialist

Empanelled
24x7 Physically
S.N. Specialty Designation Timings On-Call (As and when
present
Required)
1. Medicine Consultant
Resident
2. General Surgery Consultant
Resident
3. Pediatrics Consultant
Resident
197
Gynecology&
4. Consultant
Obstetrics
Resident
5. Orthopedics Consultant
Resident
6. Radiology Consultant
Resident
7. Anesthesia Consultant
Resident
8. Critical care Consultant
Resident
9. Ophthalmology Consultant
Resident
10. ENT Consultant
Resident
11. Psychiatry Consultant
Resident
12. Dermatology Consultant
Resident
Forensic
13. Consultant
Medicine
Resident
14. Lab Medicine Consultant
Resident
Transfusion
15. Medicine/ Blood Consultant
Bank
Resident
16. Cardiology Consultant
Resident
CTVS (Cardiac
17. Consultant
Surgery)
Resident
18. Neurology Consultant
198
Resident
19. Neurosurgery Consultant
Resident
20. Plastic Surgery Consultant
Resident
Maxillofacial
21. Consultant
Surgery
Resident
22. Gastroenterology Consultant
Resident
23. Nephrology Consultant
Resident
24. Urology Consultant
Resident
25. Neuro Radiology Consultant
Resident
26. Pediatric Surgery Consultant
Resident
27. Neonatology Consultant
Resident
28. Hematology Consultant
Resident
29. Oncology Consultant
Resident
199
ANNEXURE-3: EQUIPMENTS & SUPPLIES IN ED
BIO MEDICAL EQUIPMENT (SCORE: 1-NO, 2- PARTIAL, 3- YES)

S.N. OBJECTIVE ELEMENT Check points SCORE
Do you have list of equipment in accordance with its

1. SCORE
scope of services available?
Logs are maintained for
Do you have medical equipment inventory and log operational
2. SCORE
book?
and maintenance purposes
Do you have periodically inspected and calibrated
3. SCORE
equipment record?
EQUIPMENTS & SUPPLIES IN ED (SCORE: 1-NO, 2- PARTIAL, 3- YES)

S. No. 24x7 availability of Score Remarks
1. Do you have mobile bed for Resuscitation? Score Remarks
2. Do you have crash cart (specialized cart for resuscitation)? Score Remarks
3. Do you have Hard Cervical collar? Score Remarks
4. Do you have Central Oxygen Supply through pipeline? Score Remarks
5. Do you have Oxygen cylinder? Score Remarks
6. Do you have suction machine? Score Remarks
7. Do you have Multipara Monitor (To monitor Heart rate, BP,

Score Remarks
SPO2[Essential] ECG, Respiration Rate [Desirable] etc)?
8. Do you have simple monitor/transport monitor? Score Remarks
9. Do you have defibrillator with external pacer? Score Remarks
10. Do you have Toothed Forceps, Kocher Forceps, Magill’s forceps,

Score Remarks
Artery forceps?
11. Do you have transport ventilator? Score Remarks
12. Do you have AMBU Bag for adult and Paediatric? Score Remarks
13. Do you have suprapubic catheter? Score Remarks
14. Do you have light source to ensure visibility (lamp and flash light)? Score Remarks
15. Do you have stethoscope? Score Remarks
16. Do you have oropharyngeal airway adult and pediatric blades? Score Remarks
17. Do you have LMA? Score Remarks
18. Do you have tourniquet? Score Remarks
19. Do you have pelvic binder or bed sheets with clips? Score Remarks
20. Do you have needle holder and suture material (absorbable and non
Score Remarks
absorbable)?
200
21. Do you have vaginal speculum? Score Remarks
22. Do you have different sizes of Ryles tube? Score Remarks
23. Do you have different sizes of Foley’s catheter? Score Remarks
24. Do you have laryngoscope with all sized blades? Score Remarks
25. Do you have Endotracheal Tubes of all sizes? Score Remarks
26. Do you have Laryngeal Mask Airway (LMA)? Score Remarks
27. Do you have Chest Tubes with Water seal drain? Score Remarks
28. Do you have Blood Pressure monitor? Score Remarks
29. Do you have ECG machine? Score Remarks
30. Do you have ultrasonic nebulizer? Score Remarks
31. Do you have IV cannula and IV infusion sets? Score Remarks
32. Do you have syringes and disposable needles? Score Remarks
33. Do you have broselow tape? Score Remarks
34. Do you have proctoscope? Score Remarks
35. Do you have fluid warmer? Score Remarks
36. Do you have dressing sets (Alcohol based solution, Betadinesolution

Score Remarks
gauze, roller, adhesive tape)?
37. Do you have personal protecting equipment’s (Apron, glove, face

Score Remarks
mask, eye protection)?
38. Do you have central line of all sizes? Score Remarks
39. Do you have capnography? Score Remarks
40. Do you have Infusion pump and Syringe Drivers? Score Remarks
41. Do you have spine board with sling and scotch tapes all sizes? Score Remarks
42. Do you have splints for all types of fracture? Score Remarks
43. Do you have non-invasive and invasive ventilators? Score Remarks
44. Do you have incubators? Score Remarks
45. Do you have emergency cricothyroidotomy kit? Score Remarks
46. Do you have emergency thoracotomy set? Score Remarks
47. Do you have emergency decompressive craniotomy sets? Score Remarks
48. Do you have emergency thrombectomysets? Score Remarks
49. Do you have phototherapy unit? Score Remarks
Remarks (if any):
201
ANNEXURE-4: POINT OF CARE LAB

(SCORE: 1-NO, 2- PARTIAL, 3- YES)
S. No. Point of Care Lab In ED In Hospital Remarks

1. Hemogram- Hb, Hct, TLC, DLC, Platelet Score Score Remarks
2. Random Blood Sugar Score Score Remarks
3. Coagulation Profile: PT, APTT, INR Score Score Remarks
4. Electrolytes: Na, K, Cl, Ca Score Score Remarks
5. Blood Urea & Serum Creatinine Score Score Remarks
6. Blood Gas Analysis Score Score Remarks
7. Cardiac enzymes, Trop-I, Trop-T, Score Score Remarks
8. Serum Amylase Score Score Remarks
9. D-dimer, Score Score Remarks
10. Pro-BNP Score Score Remarks
11. Urinary Ketones Score Score Remarks
12. Plasma Ketones Score Score Remarks
13. Toxicology screening- Urinary Score Score Remarks
14. Serum osmolality Score Score Remarks
15. Urine osmolality Score Score Remarks
16. Pregnancy test Score Score Remarks
17. Thromboelastogram (TEG) Score Score Remarks
18. Peak expiratory Flowmeter Score Score Remarks
19. Microscopy: Thick & Thin smear (For Malaria parasite & Score Score Remarks
Gram staining)
20. Rapid diagnostic test for Malaria (Card test) Score Score Remarks
21. CSF: Microscopy & Gram staining Score Score Remarks
22. Portable USG (Bed side/Point of Care) Score Score Remarks
23. Echocardiography Score Score Remarks
24. Portable X-ray (Bed side/Point of Care) Score Score Remarks
25. CT scan Score Score Remarks
Remarks (if any):
202
ANNEXURE-5: ESSENTIAL MEDICINES FOR EMERGENCY

(SCORE: 1-NO, 2- PARTIAL, 3- YES)
S. No. Drug Name Score S. No. Drug Name Score

1. Oxygen medicinal gas Score 27. Phenobarbitone Score
2. Thiopentone sodium Score 28. Phenytoin Score
Lignocaine hydrochloride (Jelly
3. Score 29. Amoxicillin + Clavulanic acid Score
sterile)
4. Lignocaine hydrochloride (Inj.) Score 30. Ampicillin sodium Score
5. Atropine Score 31. Benzathine penicillin Score
6. Diazepam Score 32. Cefotaxime Score
7. Diclofenac Score 33 Ceftriaxone powder Score
8. Ibuprofen Score 34. Amikacin Score
9. Paracetamol (Tablet) Score 35. Ciprofloxacin Score
10. Paracetamol (Syrup) Score 36. Gentamycin sulphate Score
11. Paracetamol (Inj.) Score 37. Metronidazole Score
12. Morphine sulphate Score 38. Heparin sodium Score
13. Tramadol hydrochloride (Tablet) Score 39. Ethamsylate Score
14. Tramadol hydrochloride (Inj.) Score 40. Vitamin K Score
15. Cetrizine Score 41. Plasma volume exppander Score
16.. Pheniramine maleate Score 42. Diltiazem Score
17. Dexamethasone disodium Score 43. Glycerinetrinitrate Score
18. Hydrocortisone sodium Succinate Score 44. Glycerinetrinitratenitroglycerine Score
19. Adrenaline Score 45. Isosorbidemononitrate Score
20. Charcoal activated Score 46. Isosorbidedinitrate Score
21. Antisnake venom Score 47. Adenosine phosphate Score
22. Calcium gluconate Score 48. Dobutamine Score
23. Naloxone hydrochloride Score 49. Dopamine hydrochloride Score
24. Pralidoxime (PAM) Score 50. Streptokinase Score
25. Lorazepam Score 51. Potassium permanganate Score
26. Magnesium sulphate Score 52. Silver sulfadiazine Score
53. Calamine lotion Score 78. Xylometazoline Score
54. Povidone iodine (Solution) Score 79. Glycerine Score
55. Povidone iodine (Ointment) Score 80. Oxytocin Score
56. Furosemide Score 81. Haloperidol Score
57. Mannitol Score 82. Alprazolam Score
58. Rantidine Score 83. Aminophylline Score
59. Metoclopramide hydrochloride Score 84. Ipratropium bromide – aerosol Score
203
60. Prochlorperazine Score 85. Salbutamol sulphate Score

61. Ondansetron Score 86. Etophylline + Theophylline Score
62. Promethazine hydrochloride Score 87. Budesonide Score
63. Promethazine Score 88. Glucose/dextrose Score
Glucose with sodium chloride/
64. Hyiscine butyl bromide Score 89. Score
saline
65. Glycerine saline Score 90. Potassium chloride Score
66. Oral rehydration salts Score 91. Ringer lactate Score
67. Insulin (soluble) Score 92. Sodium bicarbonate Score
68. Intermediate-acting insulin (Lente) Score 93. Sodium chloride Score
69. Anti-Rabies Immunoglobulin Score 94. Water for injection Score
70. Tetanus vaccine Score 95. Artesunate Score
71. Anti-Rabies vaccine Score 96. Artemether Score
72. Neostigmine Score 97. Quinine (Dihydrochloride) Score
73. Ciprofloxacin Score 98. Chloroquinine phosphate Score
74. Atropine sulphate Score 99. Amiodarone Score
75. Tropicamide + Phenylepherine Score 100. Digoxin Score
76. Sodium carboxymethyl cellulose Score 101. Pantoprazole Score
77. Saline Score
Remarks (if any):
204
LIVE OBSERVATION
1. Name of the hospital: Name of Inspection Team Member:
1.
2. Type of Health Care District Hospital

Facility 2.
Tertiary Care
3.
Apex Tertiary Car Date of Inspection:
INITIAL ASSESSMENT AND REASSESSMENT

(Score: 1-No/Never, 2- Partial, 3- Yes (24X7 basis)
S.N. Objective Elements Check Point Score
1. Does the emergency department priorities initial Time: Red – 10 mins, Yellow- 30
SCORE
assessment of the patient? mins, Green- 4 hours of arrival
2. Does the hospital staff record all treatment,
Direct Observation & Patient
assessment and reassessment details in patient SCORE
records (Only few samples)
record sheet?
3. Record the disposition time of patients from their Red Yellow Green
arrival to departure from hospital [in minutes]. P1: P1: P1: P6:
Disposal Disposal Disposal Disposal
Minimum number of patients to be recorded:
Time Time Time Time
Red Yellow Green Disposal Time
P2: P2: P2: P7:
(Emergency
>500 beds 5 5 10
Department) Disposal Disposal Disposal Disposal
300-500 2 2 5 = Arrival time Time Time Time Time
beds (Registration time)
P3: P3: P3: P8:
to Admission/
100-300 2 2 5 discharge/ transfer Disposal Disposal Disposal Disposal
Beds out time Time Time Time Time
P4: P4: P4: P9:

Time Time Time Time
P5: P5: P5: P10:

Time Time Time Time
1. CHEST PAIN
Instructions: Please, score YES/ NO below the objective elements (check points) in the table.
If No, than reason should be score for the categories provided below based on scale (1-5). The
scale score for each category will be as follows:
205
a. Manpower (Score 1-5) – 1: Minimal manpower, 2: Inadequate manpower in all shifts, 3:

Inadequate manpower in some shifts, 4: Adequate manpower with coverage5: Adequate
manpower available for 24*7
b. Training (Score 1-5) –1: None, 2: Only few are trained, 3:Only doctors are trained, 4: Mostly
staff are trained, 5: All are trained
c. Supply (Score 1-5)–1:No supply available, 2: Minimal Supply available, 3: Inadequate supply
available only in some shifts, 4: Inadequate supply available on 24*7 basis, 5: Adequate
supply available for 24*7
d. Infrastructure (Score 1-5)–1: No infrastructure and no tie up with other facilities, 2: Not
having any infrastructure but tie up with other facilities, 3: Infrastructure available but
not functioning at all, 4: Infrastructure available but functioning only for limited hours, 5:
Infrastructure available for 24*7
e. Policy (Score 1-5)–1: No policy available, 2: Some policy is available but not standard, 3:
Organizational policy in place but not in use, 4: Organizational policy in place but sometime
in use, 5: Organizational policy in place and in use
Objective Elements Patient 1
Triage (Red) YES/ NO

Policy or
If No, than score the Manpower Training Supplies Infrastructure
Guidelines
reasons
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Door to ECG (<10min) YES/ NO
Policy or
Guidelines
reasons
Door To
YES/ NO
Needle(<30min)
Policy or
Guidelines
reasons
Door to PCI; wire
YES/ NO
crossing (<90min)
Policy or
Guidelines
reasons
206

Policy or
Guidelines
reasons
Policy or
Guidelines
reasons
Door To Needle(<30min) YES/ NO
Policy or
Guidelines
reasons
Door to PCI; wire crossing
YES/ NO
(<90min)
Policy or
Guidelines
reasons

Policy or
Guidelines
reasons
Policy or
Guidelines
reasons
Policy or
Guidelines
reasons
207

YES/ NO
(<90min)
Policy or
Guidelines
reasons

Policy or
Guidelines
reasons
Policy or
Guidelines
reasons
Policy or
Guidelines
reasons
YES/ NO
(<90min)
Policy or
Guidelines
reasons

Policy or
Guidelines
reasons
Policy or
Guidelines
reasons
208

Policy or
Guidelines
reasons
YES/ NO
(<90min)
Policy or
Guidelines
reasons
2. STROKE
209

Door to Doctor (<10min) YES/ NO
Policy or
Guidelines
reasons
Door to CT completion
YES/ NO
(<25min)
Policy or
Guidelines
reasons
Door to CT reading (<45
YES/ NO
min)
Policy or
Guidelines
reasons
YES/ NO
(<60 min)
Policy or
Guidelines
reasons
Door to first pass
YES/ NO
(<90min)
Policy or
Guidelines
reasons

Policy or
Manpower Training Supplies Infrastructure
If No, than score the reasons Guidelines
YES/ NO
(<25min)
Policy or
210
Door to CT reading (<45 min) YES/ NO

Policy or
Door to Thrombolytic (<60
YES/ NO
min)
Policy or
Door to first pass (<90min) YES/ NO
Policy or

Policy or
Guidelines
reasons
YES/ NO
(<25min)
Policy or
Guidelines
reasons
Door to CT reading
YES/ NO
(<45 min)
Policy or
Guidelines
reasons
YES/ NO
(<60 min)
Policy or
Guidelines
reasons
211

Policy or
Guidelines
reasons

Policy or
Guidelines
reasons
YES/ NO
(<25min)
Policy or
Guidelines
reasons
Door to CT reading
YES/ NO
(<45 min)
Policy or
Guidelines
reasons
YES/ NO
(<60 min)
Policy or
Guidelines
reasons
Policy or
Guidelines
reasons
212

Policy or
Guidelines
reasons
YES/ NO
(<25min)
Policy or
Guidelines
reasons
Door to CT reading
YES/ NO
(<45 min)
Policy or
Guidelines
reasons
YES/ NO
(<60 min)
Policy or
Guidelines
reasons
Policy or
Guidelines
reasons
3. TRAUMA (RED CATEGORY)

213

YES/ NO
(<15min)
Policy or
If No, than reason Guidelines
Door to CT completion time
YES/ NO
in Head Injury (<45min)
Policy or
Disposal time (Arrival time
to Admission/Transfer out/ YES/ NO
Death declaration time)
Policy or
214

YES/ NO
(<15min)
Policy or
YES/ NO
Policy or
Policy or

YES/ NO
(<15min)
Policy or
YES/ NO
Policy or
Policy or
215

YES/ NO
(<15min)
Policy or
YES/ NO
Policy or
Policy or

YES/ NO
(<15min)
Policy or
YES/ NO
Policy or
Policy or
216
Incidence of Violence
Is there any violence with patient or healthcare provider observed?
1.1. If yes, than violence observed (please tick) was: (1) Verbal (2) Physical (3) Both
1.2. Please tick the reason of the violence that was observed; (1) Communication Failure
(2) Care Delay (3) Inappropriate Care (4) Inappropriate Behavior of healthcare
professional
1.3. Mitigation measures available:
Private Security Guard Yes/No
If yes, Available for 24*7 basis Yes/No
Police Available Yes/No
If yes, Available for 24*7 basis Yes/No
Anti-violence mitigation policy available Yes/No
Communication in Emergency Department

Mention the type of communication followed by the healthcare providers/staff/nurses with the
patients in emergency department (Please tick below).
1. Full content with empathy and share decision making
2. Full content with empathy and no share decision making
3. Full content with no empathy
4. Minimal communication and inappropriate behaviour
5. No communication at all
Patient Satisfaction
Perform one interview with patient or relative of the patient and please ask the following questions:
1. For Patient in Red Triage;
1.1. Does the patient/relative is satisfied with the emergency department services? Yes/No
If yes, please ask the patient satisfaction level based on the scale:
Extremely Very Moderately Slightly Not at all

Satisfied Satisfied Satisfied Satisfied Satisfied
If not satisfied, reason ............................................

2. For Patient in Yellow Triage;
2.1 Does the patient/relative is satisfied with the emergency department services? Yes/No
217


3. For Patient in Green Triage;
3.1 Does the patient/relative is satisfied with the emergency department services? Yes/No

Referral of the Patient

What is the referral policy of patient in the organization? Please answer (Yes/No) the following
questions:
1. Is there any referral policy in the organization? Yes/No
2. Is there any proper arrangement of patient referral? Yes/No
3. Is there any assistance during the patient referral? Yes/No
3.1. If Yes, type of assistance
(1) Technician (2) Nurse (3) Doctor (4) Other
(If other, please specify ............................................)
Details of the patient to be filled by registration desk for last

24 Hours
Health Facility Name: Time: Date:
Total Patients visited in Hospital for last 24 Adult- Pediatric-

Hours (please write the cut off
age)
Numbers
Total Number of Patients visited in Emergency Adult- Pediatric-
Department for last 24 Hours (please write the cut off
age)
Numbers
Total admissions in emergency department Adult- Pediatric-
(please write the cut off
Numbers
age)
218
Total Leaving Against Medical Advice (LAMA) Adult- Pediatric-

from emergency department (please write the cut off
age)
Numbers
Total discharge from emergency department Adult- Pediatric-
Numbers
age)
Total Death in emergency department Adult- Pediatric-
Numbers
age)
Total Death in emergency department- Adult- Pediatric-
Trauma/Injury/Road Traffic Accidents (please write the cut off
age)
Numbers
219
Adult Patients Pediatric Patients

(Please tick one check box for one patient) (Please tick one check box for one patient)
1. Chest Pain Patients 1. Respiratory distress
2. Stroke 2. Diarrheal disease
3. Altered Mental status 3. Altered Mental status
220

4. T
rauma/ Road Traffic Accidents/ 4. T
rauma/ Road Traffic Accidents/
Injuries Injuries
5. Respiratory Distress 5. Seizure
6. Pain abdomen 6. Pain abdomen
221

7. Poisoning 7. Poisoning
8. Snake Bite 8. Snake Bite
9. Fever 9. Fever
222
Adult Patients
(Please tick one check box for one patient)
10. Pregnancy Related
223
ANNEXURE-III:
LIST OF SCIENTIFIC ADVISORY
COMMITTEE MEMBERS
S.
Name of Member Designation E-mail ID
No.
Professor & Head of
Dr. Prof. Anurag Department of Surgical
1. [email protected]
Srivastava Disciplines, AIIMS, New
Delhi
Professor, Department of
Dr. Prof. Ashish
2. Internal Medicine, PGIMER, [email protected]
Bhalla
Chandigarh
Dr. Prof. Ashok Department of Neonatology,
Deorari AIIMS, New Delhi
Vice President (Research&
Policy), Public Health
Dr. Prof. D. Foundation of India
Prabhakaran Executive Director of Centre
for Chronic Disease Control
New Delhi
Dr. Prof. Deepak
5. Neurosurgery, JPNATC, [email protected]
Agarwal
New Delhi
Department of Epidemiology
WHO Collabrating Centre
Dr. Gururaj [email protected], guru@
6. for Injury Prevention &
Gopalakrishnan nimhans.kar.nic.in
Safety Promotion Centre for
Public Health
224
Annexure-III: List of Scientific Advisory Committee Members
S.
Name of Member Designation E-mail ID
No.
Dr. Jayaraj Professor & Head of
7. Mymbilly Department of Emergency [email protected]
Balakrishnan Medicine, KMC, Mangalore
Department of Pediatrics,
Dr. Jayashree
8. Advanced Pediatrics Centre, [email protected]
Muralidharan
PGIMER, Chandigarh
Professor Ex- HOD,
Dr. Prof. Department of Neurology,
9. Kameshwar AIIMS, New Delhi, Chief [email protected]
Prasad Neurosciences Centre,
AIIMS, New Delhi
Orthopedist, Department of
Dr. Mathew
10. Orthopedics, St. Stephen’s [email protected]
Varghese
Hospital
Dr Prof.
Executive Director, INCLEN
11. Narendra K. [email protected]
Trust International
Arora
Advisor, Public Health
12. Dr. Nobhojit Roy Planning, NHSRC, MoHFW, [email protected]
Government of India
Department of Non-
communicable Diseases and
Dr. Patanjali Dev Environment Health (NDE)
Nair WHO Regional Officer for
South-East Asia,
I.P. Estate, New Delhi
Professor & Head of
Dr. Prof. Rajesh Department of Orthopedics,
Malhotra AIIMS, New Delhi Chief of
JPNATC, New Delhi
Dr. Prof. Shakti
15. Hospital Administration, [email protected]
Gupta
AIIMS, New Delhi
Dr. Prof. Vivek
16. Orthopedics, JPNATC, [email protected]
Trikha
AIIMS, New Delhi
Senior Advisor, NITI Aayog,
17. Dr. Yogesh Suri [email protected]
New Delhi
225
ANNEXURE-IV:
PATIENT INFORMATION
SHEET
Study Title: “A country-level Gap Analysis of the current status of emergency and injury care
at secondary and tertiary care centres in India”
SUBJECT INFORMATION SHEET & INFORMED CONSENT

DOCUMENT
Purpose of the study: This study is being conducted as a country level assessment of emergency
and injury current status of facility based Emergency and Injury care in prefixed 50 government
medical colleges (75%), large private hospitals (25%) and 50 district hospitals in India. Department
of Emergency Medicine JPN Apex Trauma Centre, AIIMS, New Delhi is conducting this national
level assessment in collaboration with NITI Aayog and Ministry of Health and Family Welfare,
New Delhi. This project is introduction of current status of emergency and injury care at tertiary
care (both public and private) and district hospitals through gap analysis in India. This project is
documenting the current status of emergency and injury care in the tertiary care and district health
care facilities through collection of data sets from the hospitals including live data recording of
de-identified clinical cases for 24 hours.
Participation: For the study, we have received the administrative approval from state and district
authorities. As the concerned health staff of the health facility, we wish to obtain your feedback on
few aspects of emergency and injury care. Thus, we are inviting you to participate in the project.
Study Procedures:
For the participation, you will be asked to sign a consent form and one copy of the
signed consent form will be given to you.
Then the assessor shall discuss with you on few issues related to the emergency and
injury care.
The information and opinion shared by you shall be treated as confidential. Your
identifiers shall not be collected.
226
Annexure-IV: Patient Information Sheet
Duration of participation: Your participation for this study is limited to one time contact only
and shall end with end of the interaction. No further contact shall be required.
Data collection during contact: The assessors shall collect the practices followed and opinions
related to emergency and injury care at your facility. The assessors shall use a guide to collect
the information and the process is expected to take about 2 days.
Risks and Benefit: Your identification shall not be collected and used in analysis. The information
shared by you shall be treated as confidential and shall not be shared with any identifier with the
administration or any other person. There is no financial benefit to you. But your participation shall
assist understanding the current gaps for strengthening and expanding the linkages of emergency
and injuries care at national level.
Confidentiality: Your identification and information shared by you will be treated as confidential.
All information collected will be labeled with a unique ID and not with your name or any other
identifying information. All project documents and records will be kept under lock and key or
computers with passwords under supervision of the Investigators. This information may be looked
at ethics committee members reviewing the study.
Compensation for participation: There will be no monetary compensation provided for
participation in this study.
Contact details: If you have a concern about any aspect of participation, contact the investigator(s)
from the hospital or related to the project. Their telephone numbers and address are listed below.
Name and address of responsible persons:

Dr Sanjeev Kumar Bhoi Dr. Tej Prakash Sinha
Principal Investigator Co-Investigator
Professor Associate Professor
Department of Emergency Department of Emergency
Medicine JPN Apex Trauma Medicine JPN Apex Trauma
Centre, AIIMS, New Delhi Centre, AIIMS, New Delhi
Email:[email protected] Email:[email protected]
227
ANNEXURE-V:
CONFIDENTIALITY /
CONFLICT OF INTEREST
AGREEMENT FORM FOR
NATIONAL ASSESSOR
In recognition of the fact, that I………………….(Name and Designation),and his/her

affiliation……………herein referred to as the “Undersigned”, has been engaged as a National
Assessor of the AIIMS, has been asked to assess a national project titled “A country level assessment
of current status of emergency and injury care at secondary and tertiary level centers in India”
to be conduct by Department of Emergency Medicine JPN Apex Trauma Centre, AIIMS, New
Delhi funded by the NITI Aayog.
This Agreement thus encompasses any information deemed Confidential or Proprietary provided
to the Undersigned in conjunction with the duties as a National Assessor. Any written information
provided to the Undersigned that is of a Confidential, Proprietary, or Privileged nature shall be
identified accordingly.
As such, the Undersigned agrees to hold all Confidential or Proprietary trade secrets (“information”)
in trust or confidence and agrees that it shall be used only for contemplated purposes, shall not
be used for any other purpose or disclosed to any third party. Written Confidential information
provided shall not be copied or retained. All Confidential information (and any copies and notes
thereof) shall remain the sole property of the Department of Emergency Medicine JPN Apex
Trauma Centre, AIIMS, New Delhi.
The Undersigned agrees not to disclose or utilize, directly or indirectly, any Confidential or
Proprietary information belonging to a third party in fulfilling this agreement. Furthermore, the
Undersigned confirms that his/her performance of this agreement is consistent with the institute’s
policies and any contractual obligations they may have to third parties.
The Undersigned will immediately disclose to the Principal Investigator of project, any actual or
potential conflict of interest that he/she may have in relation to any particular and to abstain from
any participation in the project.
When a National Assessor has a conflict of interest, the assessor should notify the Principal
Investigator and except to provide information requested by the Principal Investigator.
228
Annexure-V: Confidentiality / Conflict of Interest Agreement Form for National Assessor
AGREEMENT ON CONFIDENTIALITY AND CONFLICT OF INTEREST

Please sign and date this Agreement, if the Undersigned agrees with the terms and conditions
set forth above. The original (signed and dated Agreement) will be kept on file in the custody
of the JPNATC, Department of Emergency (WHO collaborated Centre) AIIMS. A copy will be
given to you for your records.
In the course of my activities as a National Assessor for this countrywide project for onsite
assessments, I may be provided with confidential information and documentation (which we
will refer to as the “Confidential Information”). I agree to take reasonable measures to protect the
Confidential Information; subject to applicable legislation, including the Access to Information Act,
not to disclose the Confidential Information to any person; not to use the Confidential Information
for any purpose outside the mandate, and in particular, in a manner which would result in a
benefit to myself or any third party; and to return all Confidential Information (including any
minutes or notes I have made as part of my duties) to the Principal Investigator upon termination
of my functions as a National Assessor.
Whenever I have a conflict of interest, I shall immediately inform the Principal Investigator not
to count me toward a quorum for candidate.
Upon signing this agreement, I agree to take reasonable measures and full responsibility to keep
the information as confidential.
I, …………………………………., have read and accept the aforementioned terms and conditions
as explained in this Agreement.
_____________________ _____________________
Undersigned Principal Investigator
(National Assessor)
_____________________ _____________________
Date & Place Date &Place
229
ANNEXURE-VI:
OVERALL SUMMARY OF OTHER
SPECIALIST / SUPER SPECIALIST
AVAILABLE IN HOSPITAL
{MEDIAN [IQR] MIN-MAX} BY
CATEGORY OF HOSPITALS
Govt.
Department
Designation
Govt. Hosp. Pvt. Hosp. Pvt. Hosp.

Medical Hosp.
(<300 bed (>300 bed (<300 bed
Timings Colleges (>300 bed
strength) strength) strength)
(N=20) strength)
(N=20) (N=20) (N=20)
(N=20)
During OPD Hours
12 [7] 2-21 4 [2] 1-7 2 [2] 1-8 4.5 [4] 2-11 4 [2] 2-6
only
24 x 7 Physically
Consultant
3 [1] 1-3 3 [0] 1-3 2 [1] 1-3 3 [0] 3-5 3 [0] 3-3
Present
On Call during
3 [0] 3-3 3 [0] 1-3 3 [0] 3-4 3 [0] 3-3 3 [0] 2-3
Non-OPD Hours
Empanelled / As and
0 3 [0] 3-3 0 5 [0] 5-5 0
Medicine
when required
During OPD Hours 14 [18] 10.5 [10.2]
5 [5] 2-15 3 [1] 2-4 4.5 [3.5] 1-6
only 4-64 1-15
24 x 7 Physically
3 [0] 2-3 3 [1] 1-3 2.5 [0.5] 2-3 3 [0] 3-5 3 [0] 3-3
Resident
Present
On Call during
3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 0
Non-OPD Hours
Empanelled / As and
0 5 [0] 5-5 0 0 0
when required
During OPD Hours 6.5 [5.7]
12 [8] 2-24 6 [3] 1-9 2 [2] 1-6 3 [2.5] 1-4
only 2-11
General Surgery
24 x 7 Physically
Consultant
3 [1] 1-3 3 [1] 2-4 3 [0.5] 2-3 3 [0] 3-7 3 [0] 3-3
Present
On Call during
3 [0] 3-3 3 [0] 1-3 3 [0] 3-3 3 [0] 3-3 3 [0.7] 1-3
Non-OPD Hours
Empanelled / As and
0 3 [0] 3-3 0 3 [0] 3-3 0
when required
230
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
During OPD Hours 20 [22] 14 [5.5]

4 [7] 2-14 2 [2.5] 1-6 3 [1] 2-6
only 2-53 4-15
General Surgery
24 x 7 Physically
3 [0] 3-3 3 [1] 1-3 1 [0] 1-1 3 [0] 3-6 3 [0] 3-3
Resident
Present
On Call during
3 [0] 3-3 2 [0] 2-2 0 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
6 [1] 2-10 3 [4] 1-9 2 [1] 1-6 3 [2.5] 1-7 3 [1] 1-5
only
24 x 7 Physically
Consultant
2 [1] 1-3 2 [2] 1-3 2 [0] 2-2 3 [0] 3-7 3 [0] 3-3
Present
On Call during
3 [0] 3-3 3 [1] 1-3 3 [0] 3-3 3 [0] 3-3 3 [0.5] 1-3
Non-OPD Hours
Empanelled / As and
0 3 [0] 3-3 0 2 [0] 2-2 3 [0] 3-3
Pediatrics
when required
During OPD Hours
7 [6] 2-20 6 [2.5] 4-9 4 [1.5] 1-4 8.5 [0.5] 8-9 3.5 [0.5] 3-4
only
24 x 7 Physically
3 [0] 3-3 3 [0.5] 1-3 2 [1] 1-3 3 [0] 3-8 3 [0] 3-3
Resident
Present
On Call during
3 [0] 3-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours 8 [10.7]
3 [2.5] 1-7 2 [1] 1-10 5 [2.7] 1-18 3 [0.7] 3-6
only 1-16
24 x 7 Physically
Consultant
2 [1] 1-3 3 [0.2] 2-3 3 [0.2] 2-3 3 [0] 3-7 3 [0] 3-3
Present
On Call during
Gynaecology & Obstetrics
3 [0] 3-3 3 [1] 1-3 3 [0] 3-7 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 3 [0] 3-3 0 10 [0] 10-10 3 [0] 3-3
when required
During OPD Hours 9 [9.5] 10 [4.5]
5 [1.5] 2-8 4 [1] 1-5 3.5 [0.5] 3-4
only 1-33 2-11
24 x 7 Physically
3 [0] 3-4 3 [0.5] 2-3 3 [0.5] 2-3 3 [0] 3-10 3 [0] 3-3
Resident
Present
On Call during 1.5 [0.5]
3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 0
Non-OPD Hours 1-2
Empanelled / As and
0 0 0 0 0
when required
231

3 [4] 1-6 1 [2] 1-5 4.5 [4.2] 1-8 2 [1.5] 1-4
only 2-14
24 x 7 Physically
Consultant
3 [1] 1-3 3 [0.2] 2-3 2 [1] 1-3 3 [0] 3-9 3 [0] 3-3
Present
On Call during
3 [0] 3-3 3 [1] 1-3 3 [0] 2-3 3 [0] 3-3 3 [0] 2-3
Non-OPD Hours
Empanelled / As and
Orthopedics
0 3 [0] 3-3 0 4 [0] 4-4 0

when required
During OPD Hours
3 [11] 1-38 6 [2] 5-9 0 7.5 [1.5] 6-9 2 [1] 1-3
only
24 x 7 Physically
3 [0] 3-4 3 [1.5] 1-3 1 [0] 1-1 3 [0] 3-5 3 [0] 3-3
Resident
Present
On Call during
3 [0] 3-3 0 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
1.5 [1] 1-4 1 [1.5] 1-4 3 [1.5] 1-4 1.5 [1.7] 1-5
only 1-16
24 x 7 Physically
Consultant
3 [0] 3-3 2 [1] 1-3 3 [0] 3-3 3 [0] 3-4 3 [0] 3-3
Present
On Call during
3 [0] 3-3 3 [0.5] 1-3 2 [1] 1-3 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 3 [0] 3-3 0 0 0
Radiology
when required
During OPD Hours 7 [9.7] 6.5 [3.5]
2 [0] 2-2 1 [0] 1-1 4 [1] 3-5
only 1-16 3-10
24 x 7 Physically
3 [0] 3-5 2 [2] 1-3 1 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Resident
Present
On Call during
3 [0] 3-3 0 0 3 [0] 3-3 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours 11 [9.5] 7.5 [5.2]
4 [5.5] 1-10 2 [2.2] 1-7 3 [4.5] 1-11
only 2-39 3-23
24 x 7 Physically
Consultant
Anesthesia
3 [0] 3-3 3 [0] 1-4 3 [1] 1-3 3 [0] 3-5 3 [0] 3-3
Present
On Call during
3 [0] 3-3 3 [0.5] 1-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 3 [0] 3-3 0 0 0
when required
232
During OPD Hours 10 [22.7] 6.5 [5.5] 6.5 [3.5]

2 [1.5] 1-4 6 [2] 6-10
only 1-45 2-9 3-10
24 x 7 Physically
Anesthesia
3 [0] 3-4 3 [1] 1-4 2 [1] 1-3 3 [0] 3-8 3 [0] 3-3
Resident
Present
On Call during
3 [0] 3-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
3 [2.5] 1-6 4 [4] 1-7 3 [0] 1-4 3 [3] 1-13
only 1-4
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 1-3 3 [0] 3-3
Present
On Call during
3 [0] 3-3 2 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
Critical Care
0 0 0 0 0
when required
0 2 [0] 2-2 4.5 [1.5] 3-6 4 [1] 3-5
only 1-6
24 x 7 Physically
3 [0] 3-3 3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
Resident
Present
On Call during
3 [0] 3-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
3 [3] 1-10 2 [1] 1-5 1 [2.2] 1-5 3 [2.5] 1-5 2 [1.5] 1-6
only
24 x 7 Physically
Consultant
3 [0] 3-3 2 [2] 1-3 2.5 [0.5] 2-3 2 [1] 1-3 3 [0] 3-3
Present
On Call during
3 [0] 3-3 3 [0] 3-3 3 [0] 3-6 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Ophthalmology
Empanelled / As and
0 0 0 4 [0] 4-4 0
when required
5 [2] 1-5 0 2 [0] 2-2 2 [0] 2-2
only 1-22
24 x 7 Physically
3 [0] 3-3 3 [0.5] 1-3 1 [0] 1-1 3 [0] 3-3 0
Resident
Present
On Call during
3 [0.2] 2-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
233

2 [1.5] 1-4 1 [1.5] 1-6 3 [2] 1-6 2 [0.5] 1-3
only 1-10
24 x 7 Physically
Consultant
3 [0] 3-3 1 [1] 1-3 2 [0] 2-2 3.5 [0.5] 3-4 3 [0] 3-3
Present
On Call during
3 [0] 3-3 3 [0] 1-3 3 [0] 3-3 3 [0] 3-3 3 [0] 2-3
Non-OPD Hours
Empanelled / As and
0 0 0 1 [0] 1-1 0
when required
ENT
During OPD Hours

4 [7] 1-23 2 [1.5] 1-4 0 4 [2] 2-6 3 [0] 3-3
only
24 x 7 Physically
3 [0] 3-3 3 [0] 1-3 2 [0] 2-2 3 [0] 3-3 0
Resident
Present
On Call during
3 [0.2] 2-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
2 [0.5] 1-3 1 [0] 1-4 3 (1.5] 1-5 2 [2] 1-3
only 1-5
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 2 [1] 1, 3 0

Present
On Call during
3 [0] 1-3 3 [0] 1-3 3 [0] 1-3 3 [0] 3-3 3 [0] 1-3
Non-OPD Hours
Empanelled / As and
Psychiatry
0 0 0 0 3 [0] 3-3
when required
During OPD Hours 2.5 [3] 2.5 [0.5]
0 4.5 [2.5] 2-7 0
only 1-10 2-3
24 x 7 Physically
3 [0] 3-3 3 [0.5] 1-3 0 3 [0] 3-3 0
Resident
Present
3 [0.5] 1-3 0 3 [0] 3-3 0
Non-OPD Hours 2-3
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
3 [5.5] 1-7 2 [1.5] 1-4 1 [0.2] 1-4 2 [0.7] 2-3 3 [1] 1-3
only
24 x 7 Physically
Dermatology
Consultant
3 [0] 3-3 3 [1] 1-3 0 2.5 [0.5] 2-3 3 [0] 3-3

Present
On Call during
3 [0] 1-3 3 [0] 1-3 3 [0.5] 1-3 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 0 0 5 [0] 5-5 0
when required
234

6 [6] 2-14 0 2.5 [0.5] 2-3 0
only 3-4
24 x 7 Physically
Dermatology
3 [0] 3-3 3 [1] 1-3 1 [0] 1-1 3 [0] 3-3 0

Resident
Present
3 [0.5] 1-3 0 0 0
Non-OPD Hours 2-3
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
2 [9] 1-10 1 [2] 1-6 1 [0] 1-1 3 [2] 1-4 0
only
24 x 7 Physically
Consultant
3 [0] 3-3 3 [1] 1-3 0 3 [0] 3-3 0

Present
On Call during
3 [0] 1-3 3 [0] 1-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Forensic Medicine
Empanelled / As and
0 3 [0] 3-3 0 0 0
when required
1 [0] 1-1 0 1 [0] 1-1 0
only 1-6
24 x 7 Physically
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
Resident
Present
3 [1] 1-3 0 0 0
Non-OPD Hours 2-3
Empanelled / As and
0 0 0 0 0
when required
2 [0] 2-2 4 [5.5] 3-25 2 [1] 1-5 2 [0] 1-3
only 1-11
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3

Present
On Call during
3 [0] 3-3 3 [0] 3-3 3 [0.5] 3-4 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Lab Medicine
Empanelled / As and
0 3 [0] 3-3 0 0 0
when required
During OPD Hours
1 [0] 1-1 0 1 [0] 1-1 0 3 [0] 3-3
only
24 x 7 Physically
3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Resident
Present
On Call during
0 0 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
235
During OPD Hours

2 [2.2] 1-4 1 [2] 1-4 1 [0.5] 1-5 1 [1.5] 1-4 1 [1] 1-4
only
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 3 [1.5] 1-3 3 [0] 3-3
Present
Transfusion Medicine / Blood Bank
On Call during
3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 1-3 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
0 1 [0] 1-1 0 3 [0] 3-3
only 1-4
24 x 7 Physically
3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3 0
Resident
Present
On Call during
3 [0] 3-3 0 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
2 [3] 1-6 4 [2] 2-6 3 [1] 2-4 3 [2] 1-11 1 [1.5] 1-4
only
24 x 7 Physically
Consultant
0 0 0 0 0
Present
On Call during
3 [0] 1-3 3 [0.5] 1-3 0 3 [0] 3-3 3 [0] 1-3
Non-OPD Hours
Empanelled / As and
Cardiology
0 3 [0] 3-3 0 1 [0] 1-1 0

when required
During OPD Hours
6 [0] 6-6 0 0 4 [0] 4-4 3 [0] 3-3
only
24 x 7 Physically
3 [0] 3-3 3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
Resident
Present
3 [1] 1-3 0 0 3 [0] 3-3
Non-OPD Hours 2-3
Empanelled / As and
0 0 0 0 0
when required
1 [0] 1-1 1 [0] 1-1 3 [2] 1-6 1.5 [1.2] 1-3
CTVS (Cardiac Surgery)
only 1-5
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3

Present
On Call during
3 [0] 3-3 3 [0.5] 1-3 1 [0] 1-1 3 [0] 1-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 3 [0] 3-3 0 0 0
when required
236
During OPD Hours

6 [0] 6-6 1 [0] 1-1 0 3 [0] 3-3 3 [0] 3-3
CTVS (Cardiac Surgery)
only
24 x 7 Physically
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
Resident
Present
On Call during
3 [1] 1-3 0 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
0 1 [0] 1-1 3 [0] 2-3 2 [0.5] 2-3
only 1-4
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 3 [0.2] 3-4 3 [0] 3-3

Present
On Call during
3 [0] 1-3 3 [0.5] 1-3 1 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
Neurology
0 3 [0] 3-3 0 1 [0] 1-1 3 [0] 3-3

when required
0 0 4 [0] 4-4 3 [0] 3-3
only 1-6
24 x 7 Physically
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
Resident
Present
On Call during
3 [1] 1-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
3 [2.2] 2-5 1 [0] 1-1 2 [0] 2-2 3 [1] 2-4 2 [2] 1-3
only
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 3 [1] 1-3 3 [0] 3-3

Present
On Call during
3 [0] 1-3 3 [0.5] 1-3 1 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Neurosurgery
Empanelled / As and
0 3 [0] 3-3 0 0 0
when required
1 [0] 1-1 0 4 [0] 4-4 0
only 1-3
24 x 7 Physically
3 [0] 3-3 3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
Resident
Present
On Call during
3 [0] 3-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
237
During OPD Hours

3 [2.7] 1-5 1 [0] 1-1 1 [0] 1-1 1 [1] 1-3 2 [1] 1-3
only
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 2.5 [0.5] 2-3 3 [0] 3-3
Present
On Call during
3 [0] 1-3 3 [0.5] 1-3 1 [0] 1-1 3 [0] 3-3 3 [0] 1-3
Non-OPD Hours
Plastic Surgery
Empanelled / As and
0 3 [0] 3-3 0 2 [0] 2-2 0
when required
During OPD Hours
2.5 [3] 1-4 1 [0] 1-1 0 0 2.5 [1.5] 1-4
only
24 x 7 Physically
3 [0] 2-3 3 [0] 3-3 0 3 [0] 3-3 0
Resident
Present
On Call during
3 [0] 3-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
2 [0] 2-2 1 [0] 1-1 1 [0.5] 1-3 1 [0.2] 1-2
only 1-2
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 1 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Present
On Call during
3 [0] 1-3 2 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Maxillofacial Surgery
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
0 2 [0] 2-2 0 0 0
only
24 x 7 Physically
3 [0] 3-3 1 [0] 1-1 0 3 [0] 3-3 0
Resident
Present
On Call during
2 [1] 1-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
2 [0] 2-2 2 [0] 2-2 1 [2] 1-4 1 [2] 1-5
only 1-5
Gastroenterology
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 3 [0.5] 3-4 3 [0] 3-3

Present
On Call during
3 [0] 1-3 3 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 0 0 4 [0] 4-4 0
when required
238
During OPD Hours 10 [0] 10-

2 [0] 2-2 0 1 [0] 1-1 3 [0] 3-3
only 10
Gastroenterology
24 x 7 Physically
3 [0] 3-3 0 0 3 [0] 3-3 0
Resident
Present
On Call during
3 [0] 3-3 2 [0] 2-2 0 0 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
1 [1] 1-3 2 [0] 2-2 1 [0] 1-1 2 [2] 1-4 2 [2.5] 1-5
only
24 x 7 Physically
Consultant
3 [0] 3-3 0 0 3 [0.2] 2-3 3 [0] 3-3

Present
On Call during
3 [0] 1-3 3 [0] 1-3 1 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
Nephrology
0 3 [0] 3-3 0 1 [0] 1-1 0

when required
During OPD Hours
3 [1] 2-4 1 [0] 1-1 0 0 0
only
24 x 7 Physically
3 [0] 3-3 3 [0] 3-3 0 3 [0] 3-3 0
Resident
Present
On Call during
3 [0] 3-3 2 [0] 2-2 1 [0] 1-1 0 2 [1] 1-3
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
3 [2.5] 1-4 1 [0] 1-1 1 [0] 1-1 3 [0.7] 1-3 1 [1] 1-3
only
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Present
On Call during
3 [0] 1-3 3 [0.5] 1-3 0 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 0 0 1 [0] 1-1 0
Urology
when required
During OPD Hours
3 [3.2] 1-8 1 [0] 1-1 0 0 0
only
24 x 7 Physically
3 [0] 3-3 0 0 3 [0] 3-3 0
Resident
Present
On Call during
3 [0] 3-3 3 [0] 3-3 0 0 0
Non-OPD Hours
Empanelled / As and 2.5 [0.5]
0 0 0 0
when required 2-3
239
During OPD Hours

0 0 0 2 [1] 1-3 0
only
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
Present
On Call during
2 [1] 1-3 1 [0] 1-1 0 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Neuro Radiology
Empanelled / As and
0 3 [0] 3-3 0 0 0
when required
During OPD Hours
0 0 0 0 0
only
24 x 7 Physically
3 [0] 3-3 0 0 3 [0] 3-3 0
Resident
Present
On Call during
0 0 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
2 [2.2] 1-4 1 [0] 1-1 0 1 [1] 1-3 1 [1] 1, 3
only
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3

Present
On Call during
3 [0] 1-3 3 [0.5] 1-3 0 3 [0] 3-3 3 [0] 2-3
Non-OPD Hours
Pediatric Surgery
Empanelled / As and
0 0 0 1 [0] 1-1 0
when required
1 [0] 1-1 0 0 0
only 1-8
24 x 7 Physically
3 [0] 3-3 3 [0] 3-3 0 3 [0] 3-3 0
Resident
Present
3 [0] 3-3 0 0 0
Non-OPD Hours 2-3
Empanelled / As and
0 0 0 0 0
when required
1 [0] 1-1 0 3.5 [1.2] 2-4 1 [0.5] 1-3
only 1-2
24 x 7 Physically
Neonatology
Consultant
3 [0] 3-3 3 [0] 3-3 0 3 [0.5] 1-3 3 [0] 3-3

Present
On Call during
3 [0] 3-3 2 [1] 1-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
240
During OPD Hours

2 [0] 2-2 0 0 0 0
only
24 x 7 Physically
Neonatology
3 [0] 3-3 0 0 3 [0] 3-3 0

Resident
Present
On Call during
3 [0] 3-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
3 [0] 3-3 0 2.5 [1.7] 1-5 2 [1] 1-3
only 1-2
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0.5] 2-3 0 3 [0] 3-3 3 [0] 3-3

Present
On Call during
3 [0] 3-3 2 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
Hematology
0 0 0 0 0
when required
During OPD Hours
4 [0] 4-4 1 [0] 1-1 0 0 0
only
24 x 7 Physically
3 [0] 3-3 0 0 3 [0] 3-3 0
Resident
Present
On Call during
0 2 [0] 2-2 0 0 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
During OPD Hours
1 [0.5] 1-2 0 1 [0] 1-1 2 [2.2] 1-4 1 [3.5] 1-8
only
24 x 7 Physically
Consultant
3 [0] 3-3 3 [0] 3-3 0 3 [0.5] 1-3 3 [0] 3-3

Present
On Call during
3 [0] 1-3 3 [0.5] 1-3 0 3 [0] 3-3 3 [0] 3-3
Non-OPD Hours
Empanelled / As and
0 0 0 5 [0] 5-5 0
Oncology
when required
During OPD Hours
6 [0] 6-6 0 0 0 2 (0) 2, 2
only
24 x 7 Physically
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
Resident
Present
On Call during
2 [1] 1-3 2 [0] 2-2 0 0 0
Non-OPD Hours
Empanelled / As and
0 0 0 0 0
when required
241
Annexure-VII:
List of National
Assessors
S.N. Name Designation State Email

Senior Resident , Dept of
Emergency Medicine, JSS
1 Dr Adarsh S B Medical College, JSS Academy Karnataka [email protected]
of Higher Education, Mysuru,
Karnataka
MD, Emergency Medicine,
2 Dr Ajay Puducherry [email protected]
JIPMER, Puducherry
Professor, Dept of Emergency
3 Dr Ajit Baviskar Medicine, DY Patil Medical Maharashtra [email protected]
college
HOD, Dept of Emergency
Dr Ajith
4 Medicine, MOSC kolenchery, Kerala [email protected]
Venugopalan
Ernakulam
Dr Akilan Assistant Professor, Department
5 Tamil Nadu [email protected]
Elangovan of Emergency Medicine
Junior Resident, Dept of
Dr Amit Kumar
6 Emergency Medicine, JPNATC, Delhi [email protected]
Singh
AIIMS, New Delhi
Associate Professor and
HOD, Dept of Trauma and
7 Dr Anil Kumar Patna [email protected]
Emergency Medicine, AIIMS
Patna
chetan91_sharma@rediffmail.
8 Dr Ankit Sharma Trauma and Emergency Orissa
com
Medicine, AIIMS Bhubaneswar
Dr Apoorva drapoorvagomber@gmail.
9 Pathology, RML Hospital, New Delhi
Gomber com
Delhi
242
Annexure-VII: List of National Assessors
Associate Professor, Dept

10 Dr Arun Prasad of Trauma and Emergency Patna [email protected]
Medicine, AIIMS Patna
MD, Community Medicine,
11 Dr Arushi Ghai Delhi [email protected]
AIIMS, New Delhi
Associate Professor/ CNO
12 Dr Ashok Kumar Rajasthan [email protected]
AIIMS, Jodhpur
Dept of Trauma and
Dr Awaneesh
13 Emergency Medicine, AIIMS Uttarakhand -
Katiyar
Rishikesh
Dr Bharat Assistant Professor, Dept
14 Bhushan of Trauma and Emergency Uttarakhand [email protected]
Bhardwaj Medicine, AIIMS Rishikesh
Assistant Professor, Dept
Dr Bharat
15 of Trauma & Emergency Rajasthan [email protected]
Choudhary
(Pediatrics), AIIMS, Jodhpur
Junior Resident, JPNATC,
16 Dr Bharath G Delhi [email protected]
AIIMS, New Delhi
Junior Resident, JPNATC,
17 Dr Brunda R L Delhi [email protected]
AIIMS, New Delhi
Senior Resident, Dept of
Dr Chandra chandraprakashpatlauni@
18 Emergency Medicine, AIIMS Delhi
Prakash gmail.com
New Delhi
Dr Cyril G Emergency department, District
19 Kerala [email protected]
Cherian Hospital, Aluva, Ernakulum
Consultant Surgeon & Nodal
Officer for Trauma Care
20 Dr D Srikanth Kerala [email protected]
Emergency, Trivandrum District
Hospital
Dr Debayan Sinha Junior Resident, SSKM
21 West Bengal [email protected]
Roy Hospital, Calcutta
Junior Resident, AIIMS, New
22 Dr Deepti Delhi [email protected]
Delhi
Professor of Surgery & HOD
Dr Dipak Kumar dipakkumarsarma@hotmail.
23 of Emergency Medicine, Govt. Assam
Sharma com
Medical college, Guwahati
Senior Resident, Department of
24 Dr Gaurav Kumar Emergency Medicine, AIIMS, Delhi [email protected]
New Delhi
Junior Resident, Dept. of
Dr Ghanashyam ghanashyam.timilsina@gmail.
25 Emergency Medicines, Delhi
Timilsina com
JPNATC, AIIMS, New Delhi
Dr Gummadidala
26 Emergency Medicine, AIIMS, Delhi [email protected]
Manoj kumar
New Delhi
243

Dr Harshad of Anaesthesia, Incharge of
27 Maharashtra [email protected]
Dongare Emergency Dept, SSMF Dr
Jogalekar Hospital Shirwal
1st Year, PGT, GMCH, kalyanborah1987@gmail.
28 Dr Kalyan Bora Assam
Guwahati com
Senior Resident, Dept
29 Dr Kishen Goel of Critical Care, AIIMS Orissa [email protected]
Bhubaneswar
Assistant Professor and
30 Dr Linu Sekhar Incharge, Sree Gokulam Kerala [email protected]
Medical college, Trivandrum
31 Dr M Sukumar Emergency Medicine, JPNATC, Delhi [email protected]
AIIMS, New Delhi
Assistant Professor, Dept of
Dr Madhu
32 Medical College, JSS Academy Karnataka [email protected]
Srinivasarangan
Karnataka
Associate Professor, Dept of
Dr Mahaveer
33 Trauma & Emergency, AIIMS, Rajasthan [email protected]
Singh Rodha
Jodhpur
manoj.ortho@aiimsbhopal.
34 Dr Manoj Nagar of Trauma and Emergency MP
edu.in
Medicine, AIIMS Bhopal
Consultant Anaesthesia in
Dr Manzoor Critical Care, Directorate of
35 Kashmir [email protected]
Ahmed Rather Health Services, Jammu &
Kashmir
Senior Resident, Dept. of
36 Dr Mayuri Mhatre Emergency Medicine, MGM Maharashtra [email protected]
Medical College, Navi Mumbai
Dr Md Sabah
37 of Internal Medicine, AIIMS Chhattisgarh [email protected]
Siddiqui
Raipur
Dr Md Sharjeel Junior Resident, SSKM
38 West Bengal [email protected]
Khan Hospital, Calcutta
Dr Meenaloshni
39 Junior Resident Delhi [email protected]
Jayaseelan
Dr Megha
Register, ICU, Joglekar dr.meghasolasakar@gmail.
40 Yashwant Maharashtra
Hospital, Shirwal com
Solasakar
Provisional Assistant Professor,
Dr Midhun
41 Govt Medical College, Kerala [email protected]
Mohan N
Kozhikode
244
HOD and Consultant, Dept of

Dr Mohameed haneef_farook@rediffmail.
42 Emergency Medicine, Medical Kerala
Haneef M com
Trust Hospital, Ernakulam
Medical Officer (Academics),
Dr Monesh
43 Symbiosis Institute of Health Maharashtra [email protected]
Bhandari
Sciences
3rd Year, PGT, GMCH,
44 Dr Nazrul Islam Assam [email protected]
Guwahati
45 Dr Nidhi Kaeley Emergency Medicine, AIIMS Uttarakhand [email protected]
Rishikesh
Assistant Professor/ ANS AIIMS,
46 Dr Nipin Kalal Rajasthan [email protected]
Jodhpur
47 Dr Nirjala Devi Junior Resident, JNIMS, Imphal Manipur [email protected]
Senior Resident , Dept of
48 Dr Nisarg S Medical College, JSS Academy Karnataka [email protected]
Karnataka
49 Dr Nitin Borker Chhattisgarh [email protected]
Pediatric Surgery, AIIMS Raipur
50 Dr Nitin Kashyap Chhattisgarh [email protected]
CTVS, AIIMS Raipur
Dr Paresh
51 Medical Officer, Goa Goa [email protected]
Mahabal
Medical Officer, UPHC,
52 Dr Prabin Manipur [email protected]
Kakching, Imphal
53 Dr Prawal Shrimal Emergency Medicine, JPNATC, Delhi [email protected]
AIIMS, New Delhi
Senior Resident, Emergency
54 Dr R. Surendar Puducherry [email protected]
Medicine, JIPMER, Puducherry
55 Dr Rachana Emergency Medicine, KMC Karnataka [email protected]
Mangalore
Dr Rajeshwari Consultant, Emergency and drrajeshwarivhora@gmail.
56 Maharashtra
Vhora Critical Care, Global Hospital com
Dr Ramkaran Associate Professor, Dept of
57 Rajasthan [email protected]
Chaudhary surgery, AIIMS, Jodhpur
Dr Ravindra Register, ICU, Vishwaraj
58 Maharashtra [email protected]
Vishwakarma Hospital, Pune
Emergency Medicine, SSG
59 Dr Rina Parikh Gujarat [email protected]
Hospital and Medical college,
Baroda
245

60 Dr Ritin Mohindra Emergency Medicine, AIIMS Delhi [email protected]
New Delhi
MD, Emergency Medicine,
61 Dr Sakshi Yadav Delhi [email protected]
AIIMS, New Delhi
Dr Sangeeta
62 of Trauma and Emergency Orissa [email protected]
Sahoo
saurabh.criticalcare@
63 Dr Saurabh Saigal Anesthesia and Critical Care, MP
aiimsbhopal.edu.in
AIIMS Bhopal
Dr Shandeep Medical Officer, Medical
64 Manipur [email protected]
Singh Directorate, Lamchel, Imphal
Dr Shivasheesh
65 Trauma and Emergency Orissa [email protected]
Rath
Emergency Medicine, SSG
66 Dr Shreyas Patel Gujarat [email protected]
Hospital and Medical college,
Baroda
Dr Subhankar
Paul
AIIMS, New Delhi
Dr Sudhanshu Senior Resident, Emergency, sudhanshu.mgmc@gmail.
68 MP
Agarwal AIIMS, Bhopal com
69 Dr Suprith C Emergency Medicine, JPNATC, Delhi [email protected]
AIIMS, New Delhi
Senior Resident, Dept. of
Dr Suvan Kanti
70 Emergency Medicine, GMCH, Assam [email protected]
Chowdhury
Guwahati
71 Dr Tanmay Dutta Orthopedics, SSKM Hospital, West Bengal [email protected]
Calcutta
Junior Resident, Department of
Dr Vignan
Kappagantu
AIIMS, New Delhi
Assistant Professor and Surgical
Arunachal
73 Dr Y. Tato Specialist, TRIHMS Hospital [email protected]
Pradesh
Naharlagun
Dr. Bansi Dilip Intern Doctor, SSG Hospital
74 Gujarat [email protected]
bhai Trambadia and Medical college, Baroda
Dr.Bhumiben Intern Doctor, SSG Hospital
Mukeshbhai Patel and Medical college, Baroda
246
Dr. Himanshu
Intern Doctor, SSG Hospital Himanshupatel9061@gmail.
76 Rameshchandra Gujarat
and Medical college, Baroda com
Patel
Dr. Hiren
Intern Doctor, SSG Hospital
77 Dahyabhai Gujarat [email protected]
and Medical college, Baroda
Vaghela
Dr. Krunal Kumar Emergency Medicine, SSG krunalpancholi90@gmail.
78 Gujarat
Pancholi Hospital and Medical college, com
Baroda
Assistant Professor, Dept.
Dr. Madhur
79 of Trauma Surgery, AIIMS, Uttarakhand [email protected]
Uniyal
Rishikesh
Dr. Malay
80 Mukeshbhai Gujarat [email protected]
Rathod
Dr. Mihir Haresh Intern Doctor, SSG Hospital
kumar Patel and Medical college, Baroda
82 Dr. Shivani Patel Gujarat [email protected]
Dr. Shreya Rajiv Intern Doctor, SSG Hospital
Dholakia and Medical college, Baroda
Dr.Sojitra Amit
84 kumar Ramnik Gujarat [email protected]
bhai
Dr.Tapan Jitendra Intern Doctor, SSG Hospital
kumar Patel and Medical college, Baroda
Tutor, Emergency & Trauma
care Technology, SRM Medical
86 Mr A. Ahamed Tamil Nadu [email protected]
College Hospital & Research
Centre, Kattankulathur
Nursing officer, Dept of
Mr Arun kumar arunthekkumkovil@gmail.
87 Trauma & Emergency, AIIMS Chhattisgarh
TA com
Raipur
88 Mr Aswin S Pillai Trauma & Emergency, AIIMS Chhattisgarh [email protected]
Raipur
Senior Nursing Officer,
Mr Bhanwar Lal
89 Department of Emergency Rajasthan [email protected]
Dewna
Medicine, AIIMS, Jodhpur
Nursing Officer, Department of
Mr Dheeneshbabu
Lakshminarayanan
New Delhi
dinodinesh.s1991@gmail.
91 Mr Dinesh Sridhar Emergency Medicine, AIIMS, Delhi
com
New Delhi
247
Manager-Clinical Operations,
92 Mr J Jayamurugan SRM University Hospital, Tamil Nadu [email protected]
Potheri, Chennai
Senior Nursing Officer,
Mr Prakash prakashjpmmahala@gmail.
93 Incharge Emergency Medicine, Uttarakhand
Mahala com
AIIMS, Rishikesh
Nursing Officer, WHO CC for
Emergency & Trauma Care,
94 Mr Rashad Delhi —
SEAR, JPNATC, AIIMS, New
Delhi
Mr Sreekanth Sreekanthvijayan4@gmail.
95 Trauma & Emergency, AIIMS Chhattisgarh
Vijayan com
Raipur
96 Mr Srinivas SHRI Emergency Medicine, AIIMS, Delhi [email protected]
New Delhi
Staff Nurse, General Hospital, Email_suneeshbadari@gmail.
97 Mr Suneesh S Kerala
Neyyattinkara com
Mr Vikas Nursing Tutor/ ANS, AIIMS,
98 Rajasthan [email protected]
Choudhary Jodhpur
99 Mrs Jincy Jose Trauma & Emergency, AIIMS Chhattisgarh [email protected]
Raipur
Staff Nurse, Gr1, General
100 Mrs Pratibha S L Kerala [email protected]
Hospital, Neyyattinkara
101 Ms Isha Kaushik Emergency Medicine, AIIMS, Delhi [email protected]
New Delhi
Public Relation Officer,
102 Ms Nirmal Thakur Department of Emergency Delhi [email protected]
Medicine, AIIMS, New Delhi
Ms Ramandeep
kaur
New Delhi
Nursing Officer, WHO CC for
Emergency & Trauma Care,
104 Ms Roopa Rawat Delhi [email protected]
SEAR, JPNATC, AIIMS, New
Delhi
Nursing Officer, Dept. of
Ms Stephy stephykennady95@gmail.
105 Emergency Medicines, Delhi
Kennady com
JPNATC, AIIMS, New Delhi
106 Ms. Varsha Devi Delhi [email protected]
pediatrics, AIIMS, New Delhi
Pulimela Aswan
107 Nursing Officer, AIIMS, Raipur Chhattisgarh [email protected]
Kumar
248
Annexure-VIII: Contact Details of Hospitals
ANNEXURE-VIII:
CONTACT DETAILS OF
HOSPITALS
S. No. State Hospital Name Contact Person Email ID

Sher-i-Kashmir Institute
of Medical Sciences, - [email protected]
Srinagar
Jammu & cmobaramulla123@gmail.

1. District Hospital, Dr B.A.Chalkoo
Kashmir com
Barahmulla Dr Syed Masood
[email protected]
District Hospital,
- [email protected]
Ganderbal
Dr Mukand Lal [email protected]

IGMC, Shimla
(Principal)
Himachal
2.
Pradesh dirhealthdhs@gmail.
District Hospital, Shimla Dr Ganga Sharma com(DHS)
[email protected]
(DME)
Govt. Medical College, [email protected],
Dr Shiv Charan
Amritsar [email protected]
Jallianwala Bagh Martyr’s
Dr Varun Joshi
Memorial Civil Hospital, -
(Admin)
Rambagh, Amritsar
3. Punjab
bhavna.ahuja@
Fortis Hospital, Mohali Dr Sunil
fortishealthcare.com
Shivam Multi Super Navtej Bassa
Speciality Hospital, [email protected]
Hoshiarpur
249
medicalsuprintendent@
01346 244706
HNB Base Hospital gmail.com
Sandeep (AO)
[email protected]
4. Uttarakhand
Dr S K Gupta
Coronation Hospital, [email protected]
(CMO)
Dehradun [email protected]
Dr Ramola (CMS)
Dr Ashok Kumar
Civil Hospital, Lucknow -
Singh (CMO)
Dr A S Tripathi
5. Uttar Pradesh (Q/A) [email protected],
RML Hospital, Lucknow
[email protected]
Admin Block
Charak Hospital, Manik Kumar

-
Lucknow Saxena
Government
Dr Satbir -
Superspeciality Hospital
6. Chandigarh Civil Hospital, Sec-22 Dr Mandeep -
Max Superspeciality
Lalit Kumar Sharma
Hospital -
Dr Sudhir Bhandari
SMS Medical College & (Principal) principalsmsmc@rajasthan.
Hospital Dr D S Meena gov.in
(MS)
Hari Baksh Kanwatia Dr Harashwardhan

[email protected]
Hospital, Jaipur (MS)
7. Rajasthan District Hospital, Dr. Rati Ram bdm.hospitalkotputli@gmail.
Kothputli Yadav (PMO) com
Dr. Shri Kant shrikant.swami@

Fortis Hospital, Jaipur
Swami (MS) fortishealthcare.com
Dr. Ajeet Singh
Birla Hospital- CK Birla,
(Senior Consultant [email protected]
Jaipur
in EM)
250
dean-bjmc-ahm@gujarat.
gov.in
B J Medical College,
-
Vadodara [email protected]
[email protected]
GMERS Medical College [email protected]

-
and Hospital, Gotri [email protected]
8. Gujarat cdmo.health.jamnabai@
Jamanabai Hospital -
gmail.com
[email protected]
ParulSevashram Hospital, [email protected]
-
Vadodara
medical@paruluniversity.
ac.in
Bhailal Amin General
- [email protected]
Hospital, Vadodara
Dr. Satyanarayan- [email protected]

BJ Medical College, Pune
(MS) [email protected]
Sri Seva Medical
9. Maharashtra foundation Dr Jogalekar - [email protected]
Hospital, Shirwal, Pune
Grant Medical
Foundation Ruby Hall - [email protected]
Clinic, Pune
AIIMS, Bhopal - -
Jai Prakash District
Madhya - [email protected]
10. Hospital, Bhopal
Pradesh
Bhopal fracture hospital, [email protected]
-
Bhopal [email protected]
District Hospital,
Dr. Ravi Tiwari -
Tikarpara, Raipur
District Hospital,
11. Chhattisgarh Dr. P.C. Thakur [email protected]
Dhamtari
Ramkrishna CARE Dr. Sujoy Das dr.tanushree.sidharth@
Hospital, Pachpedhi Thakur (HOD) carehospitals.com
Dr Rajesh Patil
Goa Medical College, [email protected]
Panaji Dr. S M Bandekar
[email protected]
(Dean)
12. Goa
Shailendra Munz
North Goa District
Dr. Geeta -
Hospital, Mapusa
Kakodkar (MS)
251
principalsoffice@rediffmail.
com
PMCH, Patna -
info@patnamedicalcollege.
com
AIIMS, Patna - [email protected]
13. Bihar Sadar Hospital, Gaya - -
Paras HMRI Hospital,

- [email protected]
Patna
Ruban Memorial
Hospital, Patliputra
info@aiimsbhubaneswar.
AIIMS, Bhubneshwar
edu.in
District Headquarter Dr. Narahari

-
Hospital, Puri Moharana (CMO)
Dr Ashok K
14. Orissa
Capital Hospital, Pattnaik (Director)
[email protected]
Bhubneshwar Dr Narayan Sethi-
(MS)
Care Hospital, leads.BBSR@carehospitals.

-
Bhubneshwar com
Dr Manimoy
IPGMER, SSKM Hospital,
Bandopadhyay [email protected]
Kolkata
(Director)
15. West Bengal
Ruby General Hospital,
Dr Sujoy Ranjan [email protected]
Kolkata
New STNM, Arithang,

Dr N Senga -
Gangtok, Sikkim
Singtam District Hospital,

16. Sikkim - -
Sikkim
Central Referral Hospital, Bunty Agarwal

-
Gangtok (Admin)
TRIHMS, Papumpare [email protected]
Bakin Pertin General

Arunachal Dr Y Darang -
17. Hospital, Pasighat
Pradesh
Ramakrishanan Mission [email protected]
-
Hospital, Itanagar [email protected]
252
Gauhati Medical College superintendentgmch@gmail.

-
and Hospital, Guwahati com
Morigaon Civil hospital, jtdhsmorigaon2017@gmail.
-
Guwahati com
18. Assam
GNRC Hospital,
- [email protected]
Guwahati
Nemcare Superspecialty
- [email protected]
Hospital, Guwahati
Civil Hospital Shillong,
19. Meghalaya - [email protected]
Meghalaya
District Hospital, Peren, Dr Hatlhing
-
Nagaland Hangsing
20. Nagaland Christian Institute of
Health Science and Dr Clement -
Research
[email protected]
RIMS, Imphal -
[email protected]
District Hospital,
21. Manipur - -
Bishnupur
Shija Hospital &
Research Institute, Meitei - [email protected]
longol, Imphal
[email protected]
Agartala Government
Dr Sukomal Sarkar [email protected]
Medical College
[email protected]
22. Tripura Gomti District Hospital,

- -
Udaipur
Tripura medical college&
BRAM Teaching Dr Anarsh [email protected]
Hospital, Agartala
director@mimerfalkawn.
Zoram Medical College Dr Debbie
edu.in
Dr John
Civil Hospital, Aizawl -
23. Mizoram Zohmingthanga
preshospital_durtlang@
Synod Hospital rediffmail.com
Dr Zothua
(Presbyterian Hospital)
[email protected]
District Hospital, Karim disthospitalkarimnagar@

-
Nagar gmail.com
District Hospital, King

24. Telangana - -
Koti, Hyderabad
Yashoda Hospital, Dr Ajith Singh dr.ajithsingh@yashodamail.

Malakpet, Hyderabad (Medical Admin) com
253
Mysore Medical College,

- -
Mysore
victoriahospitalbangalore@
Victoria Hospital, ymail.com
-
25. Karnataka Bengaluru
[email protected]
Govt. Taluk Hospital,

- [email protected]
Virajapet
Manipal Hospital - [email protected]
Guntur Medical College,

- [email protected]
Guntur
District Hospital Tenali - -
Kasturi Medical College

26. Andhra - [email protected]
& Hospital
Pradesh
Lalitha Super Specialty
[email protected]
Hospital, Kothapet, -
Guntur
Dr Thomas [email protected],
Trivandrum medical Mathew (Principal)
college
Dr Sharmath (MS) [email protected]
Neyyatinkara General
- [email protected]
Hospital
dmhperoorkkada@gmail.
27. Kerala District Model com
Hopital, Perooraada, -
Trivantapuram [email protected].
in(DHS)
ceo@cosmopolitanhospitals.
Cosmopolitan Hospital, Ashok P Menon in
Trivandrum (CEO) coo@cosmopolitanhospitals.
in
G G Hospital,
- [email protected]
Trivandrum
Dr R Jayanthi
(Dean) [email protected] ,
Madras Medical college
Dr Narayanasamy- [email protected]
(MS)
28. Tamil Nadu nirmala.deviv1959@gmail.
Southern Railway Dr Nirmala com
Headquarters Hospital (Medical Director)
[email protected]
Apollo Hospital, Greams
- [email protected]
Road, Chennai
254
Dr Rakesh [email protected],
JIPMER Pondicherry Aggarwal (Director) ashok1956badhe@gmail.
com
29. Pondicherry
Indira Gandhi Vizeacoumary
[email protected]
Government General (Deputy Director)
Hospital, Pondicherry Dr Simon (HOD)
casualty@primushospital.
Primus Super Speciality Dr Subrata Gorai com
Hospital, Chanakyapuri (MS)
[email protected]
Medeor Hospital,
Mr Shastry [email protected]
Manesar
Yashoda Hospital, dranujagarwal@rediffmail.

Dr Anuj (MS)
Kaushambi com
Indian Spinal Injury Dr H S Chhabra [email protected]

Centre (Medical Director) [email protected]
30. Delhi Dr Hilal Ahmed

Asian Hospital [email protected]
(Director)
Dr Reena Kumar
(Addl Director
Sri Ganga Ram Hospital Medical) [email protected]
Dr Sucheta (ED
Head)
Dr Sumit Ray
sumit.ray@artemishospitals.
Artemis Hospital (Chief of Medical
com
Services)
Jaipur Golden Hospital - [email protected]
255
ANNEXURE-IX: COMPARATIVE
COMPLIANCE OF HOSPITALS
AMONG CATEGORIES
256
COMPARATIVE OF COMPLIANCE AMONG MEDICAL COLLEGE
ED Protocol/ Continuous Data Equipment Essential
S. Hospital Safety & Disaster Physical Overall
Name of Hospitals SOP/ Quality Management Financing & Supplies medicine
No. Services Security management Infrastructure Compliance
Guidelines Management System in ED in ED
Civil Hospital,
1 66% 21% 94% 67% 71% 50% 75% 56% 92% 88% 68%
Ahemdabad
Agartala Government
2 Medical College & G 41% 17% 39% 0% 21% 39% 38% 76% 23% 67% 36%
B Pant Hospital
Guru Nanak Dev
3 Hospital, GMC, 45% 13% 28% 0% 7% 0% 38% 78% 30% 16% 26%
Amritsar, Punjab
Tomo Riba Institute
4 if Health & Medical 22% 0% 56% 0% 14% 17% 38% 56% 36% 35% 27%
Sciences, Papumpare
B J Medical College
5 & Sassoon General 57% 13% 72% 0% 7% 28% 50% 88% 56% 63% 43%
Hospital, Pune
Sher - I - Kashmir
6 Institute of Medical 57% 21% 56% 42% 50% 22% 38% 61% 63% 51% 46%
Sciences, Srinagar
Regional Institute of
7 Medical Sciences, 48% 13% 83% 25% 29% 28% 63% 92% 35% 43% 46%
Imphal
Gauhati medical
8 62% 29% 50% 33% 43% 50% 38% 78% 60% 62% 51%
College & Hospital
Mysore Medical
9 College & Krishna 40% 0% 33% 0% 7% 39% 0% 51% 34% 58% 26%
Rajendra Hospital
Annexure-IX: Comparative compliance of Hospitals among categories
257
258
10 New STNM Hospital 36% 0% 50% 0% 29% 44% 38% 47% 55% 77% 38%
Government General
11 52% 17% 44% 0% 14% 33% 13% 58% 55% 77% 36%
Hospital, Guntur
SMS Medical College
12 74% 13% 50% 42% 0% 39% 38% 69% 88% 91% 50%
& Hospital
13 Goa Medical College 72% 25% 83% 17% 57% 44% 25% 81% 49% 78% 53%
14 AIIMS, Bhopal 53% 25% 89% 17% 7% 89% 50% 44% 100% 100% 57%
Rajiv Gandhi
Government General
15 69% 46% 100% 75% 79% 44% 75% 93% 82% 95% 76%
Hospital, Madras
Medical College
16 JIPMER, Pondicherry 72% 33% 89% 67% 86% 78% 25% 69% 70% 83% 67%
Government Medical
17 College, Thiruva 57% 33% 78% 42% 43% 17% 75% 67% 80% 100% 59%
nananthapuram
Patna Medical College
18 36% 8% 22% 8% 29% 6% 38% 92% 59% 89% 39%
& Hospital
IPGMER & SSKM
19 91% 100% 89% 67% 86% 83% 38% 81% 92% 98% 83%
Hospital
20 IGMC, Shimla 60% 4% 78% 8% 21% 6% 38% 71% 72% 87% 45%
0 to 49% 50 to 74% 75 to 100%

COMPARATIVE OF COMPLIANCE AMONG GOVERNMENT HOSPITALS MORE THAN 300 BEDS
ED
Safety Continuous Data Equipment Essential
S. Hospital Protocol/ Disaster Physical Overall
Name of Hospitals & Quality Management Financing & Supplies medicine
No. Services SOP/ management Infrastructure Compliance
Security Management System in ED in ED
Guidelines
GMERS Medical
1 48% 29% 56% 50% 14% 33% 0% 88% 72% 79% 47%
College & Hospital
Civil Hospital,
2 21% 50% 78% 67% 29% 22% 0% 72% 58% 26% 42%
Shillong
Jallianwala Bagh
3 Matyr Memorial 31% 29% 78% 42% 79% 0% 38% 57% 41% 53% 45%
Hospital, Amritsar
Zoram Medical
4 21% 4% 22% 0% 0% 0% 13% 55% 52% 53% 22%
College
District Hospital,
5 Baramulla, Jammu 47% 71% 100% 92% 100% 72% 38% 74% 53% 74% 72%
& Kashmir
Victoria Hospital,
6 66% 4% 33% 8% 29% 39% 25% 76% 44% 59% 38%
Bangalore
District Hospital,
7 43% 21% 0% 0% 0% 0% 63% 67% 27% 56% 28%
Karim Nagar
Government
8 District Hospital, 50% 50% 56% 17% 21% 39% 63% 85% 48% 80% 51%
Tenali
Hari Baksh
9 19% 0% 28% 8% 7% 17% 50% 68% 34% 67% 30%
Kanwatia Hospital
Dr Shyam Prasad
10 Mukharji Civil 38% 29% 72% 50% 71% 50% 25% 64% 33% 78% 51%
Hospital, Lucknow
259
260
Government
Multispeciality
11 28% 58% 100% 100% 93% 50% 25% 82% 49% 61% 65%
Hospital, Sector
16
Jai Prakash
12 Narayan District 26% 29% 72% 67% 7% 56% 75% 65% 60% 87% 54%
Hospital, Bhopal
Southern Railways
13 52% 38% 61% 83% 21% 61% 38% 60% 58% 69% 54%
Hospital, Chennai
AIIMS,
14 41% 33% 67% 0% 36% 50% 75% 90% 71% 61% 52%
Bhubneswar
Indira Gandhi
Government
15 48% 0% 33% 17% 21% 33% 50% 65% 49% 88% 40%
General Hospital,
Pondicherry
16 AIIMS, Patna 62% 25% 67% 17% 57% 83% 0% 66% 94% 94% 57%
General Hospital,
17 19% 8% 22% 17% 29% 11% 38% 72% 45% 65% 33%
Neyyatinkara
District Hospital,
18 26% 21% 39% 17% 7% 28% 0% 67% 40% 60% 31%
Dhamtari
HNB Base
19 33% 21% 39% 42% 36% 44% 0% 75% 76% 73% 44%
Hospital
Deen Dayal
20 17% 8% 78% 42% 79% 61% 25% 66% 58% 79% 51%
Upadhyay Hospital
0 to 49% 50 to 74% 75 to 100%

COMPARATIVE OF COMPLIANCE AMONG GOVERNMENT HOSPITALS LESS THAN 300 BEDS
ED
Continuous Data Equipment Essential
S. Hospital Protocol/ Safety & Disaster Physical Overall
Name of Hospitals Quality Management Financing & Supplies medicine
No Services SOP/ Security management Infrastructure Compliance
Management System in ED in ED
Guidelines
Jamanabai General
1 21% 38% 44% 0% 36% 28% 63% 81% 37% 72% 42%
Hospital
Gomti District
2 26% 8% 61% 8% 14% 28% 50% 60% 32% 62% 35%
Hospital
District Hospital,
3 7% 17% 28% 0% 14% 0% 50% 83% 27% 16% 24%
Peren, Nagaland
Civil Hospital,
4 28% 54% 83% 67% 86% 39% 75% 61% 57% 62% 61%
Aizawl, Mizoram
District Hospital,
5 33% 21% 56% 8% 43% 17% 38% 53% 31% 56% 36%
Pasighat
Dr Jogalekar
6 38% 83% 67% 83% 86% 78% 0% 86% 94% 50% 67%
Hospital
District Hospital,
7 17% 25% 67% 33% 36% 28% 38% 85% 55% 82% 47%
Ganderbal
District Hospital,
8 Bishnupur, 10% 8% 22% 25% 21% 11% 63% 63% 24% 50% 30%
Manipur
Morigaon Civil
9 14% 8% 33% 25% 0% 39% 0% 69% 33% 63% 28%
Hospital, Assam
Government
10 33% 4% 28% 8% 29% 0% 25% 57% 43% 70% 30%
Hospital Virajpet
District Hospital,
11 28% 21% 56% 17% 71% 0% 25% 76% 53% 66% 41%
Singtam
261
262
District Hospital,
12 41% 13% 50% 0% 43% 44% 0% 73% 70% 57% 39%
King Koti
Govt. BDM
13 28% 17% 22% 8% 21% 0% 38% 74% 37% 29% 27%
Hospital, Kotputli
North Goa District
14 31% 21% 83% 8% 79% 33% 0% 60% 51% 83% 45%
Hospital
Civil Hospital,
15 7% 13% 67% 50% 21% 0% 38% 81% 53% 49% 38%

Sector 22
Puri District
16 Headquarter 34% 0% 72% 50% 43% 56% 63% 69% 61% 55% 50%
Hospital, Orissa
Sadar Hospital,
17 9% 0% 17% 0% 14% 0% 0% 44% 27% 40% 15%
Gaya
District Hospital,
18 21% 8% 28% 0% 21% 33% 0% 73% 42% 53% 28%
Peroorkada
District Hospital,
19 21% 38% 72% 33% 21% 0% 0% 76% 41% 59% 36%
Raipur
Coronation
20 Hospital, 14% 21% 22% 58% 7% 6% 63% 58% 31% 68% 35%
Dehradun
0 to 49% 50 to 74% 75 to 100%

COMPARATIVE OF COMPLIANCE AMONG PRIVATE HOSPITALS MORE THAN 300 BEDS
ED Protocol/ Continuous Data Equipment Essential
S. Hospital Safety & Disaster Physical Overall
Name of Hospitals SOP/ Quality Management Financing & Supplies medicine
No Services Security management Infrastructure Compliance
Guidelines Management System in ED in ED
Parul Sewasharam
1 52% 13% 78% 42% 50% 44% 0% 87% 90% 92% 55%
Hospital
Tripura Medical
2 College & BRAM 52% 21% 78% 50% 79% 39% 25% 76% 37% 76% 53%
Teaching Hospital
Synod Hospital,
3 38% 13% 50% 0% 7% 33% 0% 91% 88% 83% 40%
Aizawl, Mizoram
Grant Medical
4 Foundation Ruby 91% 100% 89% 92% 93% 89% 0% 89% 90% 100% 83%
Hall Clinic
GNRC, Guwahati,
5 40% 21% 61% 50% 57% 33% 0% 91% 42% 54% 45%
Assam
Manipal Hospital,
6 86% 83% 89% 67% 100% 56% 0% 96% 88% 70% 74%
Bangaluru
Central Referral
7 62% 8% 67% 8% 71% 44% 13% 87% 72% 94% 53%
Hospital, Sikkim
Kasturi Medical
8 59% 38% 78% 17% 57% 44% 0% 89% 66% 100% 55%
College & Hospital
Fortis Hospital,
9 33% 92% 100% 83% 100% 94% 0% 84% 100% 100% 79%
Jaipur
Dr Ram Manohar
10 45% 38% 100% 67% 86% 44% 25% 63% 58% 67% 59%
Lohia Hospital
Fortis Hospital,
11 86% 92% 89% 100% 86% 50% 0% 70% 76% 98% 75%
Punjab
263
264
Apollo Hospitals,
12 76% 96% 94% 100% 100% 94% 0% 72% 85% 87% 80%
Chennai
Capital Hospital,
13 52% 54% 72% 92% 43% 83% 38% 94% 65% 80% 67%
Orissa
Yashoda Hospital,
14 83% 83% 89% 67% 100% 83% 0% 79% 100% 89% 77%
Malakpet
15 Paras HMRI Hospital 41% 96% 89% 100% 100% 67% 0% 93% 92% 97% 78%
Cosmopolitan
16 Hospitals Privatre 76% 38% 78% 25% 79% 56% 0% 85% 89% 91% 62%
Limited
Yashoda Hospital,
17 66% 75% 83% 75% 64% 67% 0% 76% 79% 91% 68%
Kaushambi
18 Asian Hospital 88% 67% 94% 92% 93% 100% 0% 87% 96% 84% 80%
Sri Ganga Ram
19 84% 100% 89% 100% 93% 67% 0% 93% 94% 81% 80%
Hospital
20 Artemis Hospital 84% 92% 89% 83% 100% 78% 0% 75% 94% 92% 79%
0 to 49% 50 to 74% 75 to 100%

COMPARATIVE OF COMPLIANCE AMONG PRIVATE HOSPITALS LESS THAN 300 BEDS
ED Protocol/ Safety Continuous Data Equipment Essential
S. Hospital Disaster Physical Overall
Name of Hospitals SOP/ & Quality Management Financing & Supplies medicine
No Services management Infrastructure Compliance
Guidelines Security Management System in ED in ED
Bhailal Amin
1 74% 63% 89% 83% 93% 72% 0% 92% 78% 98% 74%
General Hospital
Christian
Institute of
2 Health Sciences 21% 33% 61% 25% 93% 56% 0% 84% 67% 77% 52%
& Research,
Dimapur
Shivam Hospital,
3 Hoshiarpur, 50% 38% 83% 17% 93% 44% 13% 86% 61% 66% 55%
Punjab
Ramakrishna
Mission Hospital,
4 43% 46% 78% 42% 86% 44% 0% 84% 78% 97% 60%
Arunachal
Pradesh
Shija Hospital
& Research
5 62% 42% 72% 33% 79% 33% 25% 85% 22% 71% 52%
Institute, Meitei
longol, Imphal
Nemcare
6 Superspeciality 79% 67% 89% 50% 36% 56% 50% 89% 80% 85% 68%
Hospital, Assam
Lalitha Super
7 Speciality Private 55% 75% 83% 25% 86% 89% 25% 88% 67% 94% 69%
Hospital
Birla CK Hospital,
8 41% 75% 78% 58% 79% 78% 0% 84% 100% 100% 69%
Jaipur
265
266
Charak Hospital
9 & Research 59% 67% 94% 83% 93% 50% 0% 73% 98% 98% 72%
Centre, Lucknow
Max Super
10 Speciality 86% 75% 89% 50% 100% 56% 13% 84% 92% 96% 74%
Hospital
Bhopal Fracture
11 26% 67% 78% 17% 57% 67% 38% 97% 96% 68% 61%
Hospital, Bhopal
Care Hospital,
12 69% 79% 89% 75% 100% 78% 0% 82% 73% 93% 74%
Orissa
13 G G Hospital 62% 83% 89% 67% 79% 67% 0% 77% 82% 93% 70%
Ruban Memorial
14 57% 88% 89% 50% 79% 100% 0% 77% 99% 100% 74%
Hospital
Ramakrishna Care
15 93% 75% 89% 100% 100% 94% 100% 80% 100% 100% 93%
Hospital
Ruby General
16 53% 63% 78% 42% 79% 72% 25% 92% 76% 83% 66%
Hospital
Indian Spinal
17 62% 67% 89% 83% 93% 72% 0% 78% 90% 86% 72%
Injuries Centre
18 Medeor Hospital 76% 92% 89% 100% 100% 56% 0% 67% 88% 74% 74%
Jaipur Golden
19 74% 71% 83% 92% 86% 50% 0% 84% 83% 79% 70%
Hospital
Primus Super
20 Speciality 100% 100% 100% 75% 86% 100% 100% 72% 92% 100% 93%
Hospital
0 to 49% 50 to 74% 75 to 100%

MASTER SHEET DEPICTING COMPLIANCE AMONG HOSPITAL CATEGORIES
Government Government Private Hospitals
Private Hospitals Overall
S.No. Area of Concern Medical College Hospitals more than Hospitals less than more than 300
less than 300 beds Compliance
300 beds 300 beds beds
1 Hospital Services 56% 37% 23% 65% 62% 49%
ED Protocol/ SOP/
2 22% 26% 21% 61% 68% 40%
Guidelines
3 Safety & Security 64% 55% 49% 83% 84% 67%
4 Disaster management 26% 37% 24% 66% 58% 42%
Continuous Quality
5 35% 37% 35% 78% 85% 54%
Management
Data Management
6 38% 37% 22% 63% 67% 45%
System
7 Financing 42% 32% 31% 5% 19% 26%
8 Physical Infrastructure 70% 71% 69% 84% 83% 75%
Equipment & Supplies
9 62% 53% 45% 80% 81% 64%
in ED
10 Essential medicine in ED 73% 68% 57% 86% 88% 74%
0 to 49% 50 to 74% 75 to 100%

267
268
MASTER SHEET DEPICTING OVERALL COMPLIANCE OF INDIVIDUAL HOSPITAL AMONG ALL
CATEGORIES
S. Government Hospital (more Government Hospital Private Hospital Private Hospital (less
Zone State Medical College
No. than 300 beds) (less than 300 beds) (more than 300 beds) than 300 beds)
Sher-i-Kashmir District Hospital Hospital, District Hospital
Jammu & Institute of Medical Barahmulla, Jammu & Kashmir Ganderbal, Ganderbal
1 - -
Kashmir Sciences, Srinagar
(46%) (72%) (47%)
District Hospital,Shimla (Deen

Himachal Dayal Upadhyay Hospital)

2 IGMC, Shimla (45%) - - -
Pradesh
(51%)
Guru Nanak Dev
Jallianwala Bagh Martyr’s Shivam Multi
Hospital & Govt. Fortis Hospital,
Memorial Civil Hospital, Super Speciality
3 Punjab Medical College, - Mohali
Rambagh, Amritsar Hospital, Hoshiarpur
Amritsar
(75%)
(45%) (55%)
NORTH (26%)
ZONE
4 Haryana - - - - -
Coronation Hospital,
HNB Base Hospital
5 Uttarakhand - Dehradun - -
(44%)
(35%)
RML Hospital, Charak Hospital

Utttar Civil Hospital- Lucknow Hardoi road, near
6 - - Lucknow
Pradesh (51%) Safed Masjid,
(59%) Dubagga (72%)
Government Superspeciality Civil Hospital Max Superspeciality
7 Chandigarh - Hospital, Sector-16 Sector-22, Chandigarh - Hospital, Mohali
(65%) (38%) (74%)
Birla Hospital- CK
SMS Medical College Hari Baksh Kanwatia Hospital, Govt. BDM Hospital,
Fortis Hospital, Jaipur Birla, Shanthi Nagar,
8 Rajasthan & Hospital, Jaipur Shastri Nagar, Jaipur Kotputli, Rajasthan
Jaipur
(79%)
(50%) (30%) (27%)
(69%)
Yashoda Hospital, Indian Spinal Injuries
Kaushambi Centre
(68%) (72%)
Medeor Hospital,
Asian Hospital
Manesar
(80%)
(74%)
9 Delhi - - -
Sri Ganga Ram Jaipur Golden
Hospital Hospital
(80%) (70%)
Primus Super
Artemis Hospital
Speciality Hospital
(79%)
(93%)
BJ Medical College GMERS Medical College & Jamanabai Government Parul Sewasharam Bhailal Amin General
1 Gujarat & Civil Hospital, Hospital, Gotri, Vadodara Hospital, Mandvi Hospital, Vadodara Hospital, Vadodara
Ahemdabad (68%) (47%) (42%) (55%) (74%)
BJ Medical College Sri Seva Medical Grant Medical
WEST & Sassoon General foundation Dr Jogalekar Foundation Ruby
2 Maharashtra Hospital, Pune - Hospital, Shirwal, Pune Hall Clinic, Pune -
ZONE
(43%) (67%) (83%)
Jai Prakash District Hospital, Bhopal Fracture
Madhya AIIMS, Bhopal
3 Shivaji Nagar, Bhopal - - Hospital, Bhopal
Pradesh (57%)
(54%) (61%)
269
270
District Hospital,
District Hospital, Dhamtari, Ramkrishna CARE
Tikarpara, Raipur,
4 Chhattisgarh - Chhattisgarh - Hospital
Chhattisgarh
(31%) (93%)
(36%)
Goa Medical College, North Goa District
5 Goa Panaji - Hospital, Mapusa - -
(53%) (45%)
Paras HMRI Hospital, Ruban Memorial

PMCH, Patna AIIMS Patna Sadar Hospital, Gaya
Patna hospital patliputra
1 Bihar
(39%) (57%) (15%)
(78%) (74%)
District Headquarter Capital Hospital, Care Hospital,
EAST AIIMS, Bhubneshwar
3 Orissa - Hospital, Puri Bhubneshwar Bhubneshwar
ZONE
(52%)
(50%) (67%) (74%)
Ruby General
IPGMER & SSKM
4 West Bengal - - - Hospital
(83%)
(66%)
New STNM- Govt-
Singtam District Central Referral
medical college,
1 Sikkim - Hospital hospital, Gangtok -
Sikkim
(41%) (53%)
(38%)
Tomo Riba Institute Bakin Pertin General
NORTH Ramakrishna Mission
Arunachal of Health & Medical Hospital, Medog,
EAST 2 - - Hospital, Itanagar
Pradesh Sciences, Papumpare Pasighat
ZONE
(60%)
(27%) (36%)
Nemcare
Gauhati Medical GNRC Hospital,
Morigaon Civil Hospital Superspecialty
3 Assam College and Hospital, - Guwahati
Hospital, Guwahati
Guwahati (51%) (28%)
(45%)
(68%)
Civil Hospital Shillong,
4 Meghalaya - Meghalaya - - -
(42%)
Christian Institute of
District Hospital, Peren,
Health Science and
5 Nagaland - -- Nagaland - - Research
(24%)
(52%)
Shija Hospital &
District Hospital,
RIMS, Imphal Research Institute,
6 Manipur -- Bishnupur - Imphal
(46%)
(30%)
(52%)
Tripura medical
Agartala Government
Gomti District Hospital, college& BRAM
Medical College & G
7 Tripura -- Udaipur Teaching Hospital, -
B Pant Hospital
Agartala
(35%)
(36%)
(53%)
Zoram Medical College Civil Hospital, Aizawl Synod Hospital
8 Mizoram - -
(22%) (61%) (40%)
District Hospital, Karim Nagar, District Hospital, King Yashoda Hospital,
1 Telangana - Hyderabad Koti, Hyderabad Malakpet, Hyderabad -
(28%) (39%) (77%)
SOUTH Mysore Medical
ZONE College & Krishna Government Hospital, Manipal Hospital,
Victoria Hospital, Bengaluru
2 Karnataka Rajendra Hospital, Virajpet Bengaluru -
Mysuru (38%)
(30%) (74%)
(26%)
271
272
Guntur Medical Lalitha Super Specialty
Government District Hospital, Kasturi Medical
Andhra college & Government Hospital, Kothapet,
3 Tenali - College & Hospital
Pradesh General Hospital Guntur
(51%) (55%)
(36%) (69%)
Trivandrum Govt District Hospital, Cosmopolitan
District Hospital, Neyyattinkara G G Hospital
4 Kerala Mediacl College Peroorkada Hospitals Pvt Ltd
(33%) (70%)
(59%) (28%) (62%)
Madras Railway Hospital,

Madras (Southern Railway Apollo Hospital
Madras Medical
5 Tamil Nadu Headquarters Hospital) - -
College (76%) (80%)
(54%)
Indira Gandhi Government
JIPMER, Pondicherry General Hospital, Pondicherry
6 Pondicherry - - -
(67%)
(40%)
0 to 49% 50 to 74% 75 to 100%

A Report of Current Status on Country Level Assessment
Phone Number: 011-26731068

Email: [email protected]
Office: Room No. 117, First Floor, Department of
Emergency Medicine, JPNATC, AIIMS, Ring Rd.,
Raj Nagar, New Delhi-110029
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Emergency and Injury Care

at Secondary and Tertiary

Level Centres in India

PROJECT REPORT SUBMITTED TO

This study was carried out with the financial support of

Copyright: © 2020 Department of Emergency Medicine, JPNATC, AIIMS,

S. No. Name Designation Organization

7 Ms Dolly Sharma Research Officer

8 Dr Monica Sindhu Research Officer

Care of emergency and accident patients is of paramount importance in saving

Emergency conditions such as Acute coronary syndrome, stroke, respiratory diseases,

List of Investigators and Contributors iii

3. Burden of Patients (OPD and Emergency) 41

3. Spectrum of Diseases 138

ACLS Advanced Cardiac Life Support

EMS Emergency Medical Services

PALS Pediatric Advanced life Support

Radial Pulse - Present / Absent;

vital criteria is present on the Talking incomplete sentence; Altered sensorium,

assessment) >> B RR<10 or >22/min;

Non- Trauma Trauma

O 9. Painful swelling / wound

SALIENT FINDINGS OF THE STUDY

Spectrum of major medical conditions presenting at Emergency

Definitive Emergency Specialized Care

Blood Bank services

Patient disposition time (Live observation)

Patient Satisfaction (Live observation)

ED protocols, Quality measures and Disaster planning

Computerized data entry systems

Comparison of various Hospital set-ups

Presence of ongoing academic program in Emergency Medicine

Secondary Vs Tertiary level Government Hospitals

Private Vs Government Hospitals

EMERGENCY CARE HUMAN RESOURCES FUNCTIONS

Triage Screening Registration

BYSTANDER Reception of Patients

SCENE TRANSPORT FACILITY

disability in low- and middle-income countries. (3)

BURDEN OF EMERGENCY CONDITIONS IN THE SOUTH-EAST

**Source: Reference (2)

Table 1: Projections of mortality by cause for 2015 and 2030(4)

Deaths (thousands) by cause projected to 2015 and 2030 in SEAR

**Source: Reference (4)

Figure 2: Road traffic fatalities per 100,000 populations in SEAR(5)

Table 2: Percentage contribution of disease categories to total deaths

**Source: Reference (6)

Figure 3: Percent of total DALYs by age groups in India, 2016(6)

CURRENT STATUS OF EMERGENCY CARE IN THE INDIA

WHO EMERGENCY CARE SYSTEM FRAMEWORK

HOSPITAL BASED EMERGENCY CARE IN THE GOVERNMENT

ACADEMIC EMERGENCY MEDICINE

Research and Development for Emergency Services

world’s population(29). A review of the evidence on emergency medical systems as applicable to

Organization and financing

Selection of Healthcare Facilities

Finalization of Healthcare Facilities

Team formation of National Assessors

Development of Study Tool

Finalization of Study Tool through

I. FIELD VISIT: ADMINISTRATIVE INTERVIEW/ONE YEAR DATA

4. HUGE MISMATCH BETWEEN EMERGENCY BEDS & BURDEN OF