Department of Paediatrics

SOPs

Dept. data last updated on :27/11/2021

NRC

DEPARTMENTOF PEDIATRICS

Jawaharlal Nehru Medical College

Aligarh Muslim University


Standard Operating Procedure

For

Nutritional Rehabilitation Centre (NRC) scheme of NHM

  1. Purpose: To admit SAM patients under supervision and to provide quality care to the admitted patients. It is also to ensure that SAM Patients achieved target weight (weight of admission + 15 % of admission weight )

  2. Scope: It will apply to all patient admitted (1) through OPD or (2) through word or (3) through RBSK.

  3. Responsibility: Co-oordinator, Unit heads and other qualified faculty of the respective units shall be responsible for executing the SOP and training of junior doctors and medical officer.

  4. Procedure: as listed in steps listed below: details in table given below.

    1. Admission of all patient through (1) through OPD or (2) through word or (3) through RBSK respective admitting unit as per schedule

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1.1    Detailed history and examination, preparing case file, obtaining first level of investigations.

1.2    Registration in NRA register by nursing officerand medical officer.

1.3    Bed allocation, provision of hospital linen as per hospital norms. Rest inpatient rules as per JNMCH guidelines and the Nutritional Rehabilitation Centre (NRC) Under Project guideline.

1.4    Visitors permitted during visiting hours as per the hospital norms. Maximum of two patient attendant allowed at all times except during ward rounds by team of doctors when only one attendant is permitted.

1.5    Daily ward rounds by unit consultants along with team of SR, and JRs and MO review of diagnosis and treatment and any interdisciplinary consultation. Evening rounds by JRs and SR and MO minimum duration of patient is 14 days for achieving target weight with guidance/visit of unit consultants.

1.6    Discharge/referral planning.

Infants less than 6 months of age


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  • Target weight gain i.e. 15% weight gain from the weight on admission (or weight on the day free of oedema)

  • No oedema (for last 10 days in facility based care in NRC and for last 14 days in the 60 days Programme)

  • No medical complication

    1. Process efficiency criteria

    2. No. of patient admitted annually-

  • (2016-192),(2017-178),(2018-224),(2019-183),(2020-74).

    1. Bed occupancy rate Under 5 Years-

  • (2016-67.6%),(2017-57.4%),(2018-73.6%),(2019-68.7%),(2020-24.9%)

    1. Percentage of discharge, death, LAMA, abscond and referral among inpatients.-

    1. No of complaint received regarding inpatients.-(2)

    2. Audit of complaints-(NIL)

SI.NO.

Activity

Responsibility

Record

4.1

Admission in NRC

  • Patient will be assigned to the admitting unit as per the schedule

  • Admission is made initially to pediatric Emergency ward either after pediatric OPD consultation or directly through casually

  • Patient referred from other hospital must also report to pediatric emergency for admission

  • Interdisciplinary transfer of patients within hospital may be made directly to PICU or pediatric wards.



4.2


Obtaining CADS NO. (hospital inpatient admission number) and visitor pass

  • Nurse on duty

  • Patient’s attendants

CADS Number

4.3

Initial assessment and treatment

  • The initial assessment for inpatient is documented immediately including condition at admission. Initial assessment includes

  • Treatment card is prepared and handed over to nursing officer for implementation.

  • Senior Resident on duty along with team of junior Residents and Medical Officer under guidance of consultants on call.

Case file

4.4






4.5




Bed allocation

  • Once stabilizer, the nursing officer allocates bed and provides linen and other essentials as provided by the hospital.

  • Hospital inpatient rules, visiting hours, etc. Are intimated



                                                                                 

  • Ward/PICU nursing officer

Ward admission register










4.6

Case Review

  • Daily ward rounds by unit consultants along with team of SR and JRs for review of diagnosis and treatment and any interdisciplinary consultation.

  • Evening rounds by JRs and SR with guidance/visit of unit consultants.

  • Any special instruction are given both in written and verbally to the team of doctor being handed over charge

  • Patient attendants are provided update on patient diagnosis, treatment, current status likely outcome daily.

  • Patient attendants are closely involved in decision making regarding investigations treatment options or referral.

  • Consultant of the unit

  • Senior resident on duty along with team of junior residents.

Case file

4.7

Discharge or referral

  • Discharge or referral is planned a priori in consultant with patient or attendants.

  • For referral to higher centre a suitable referral letter is provided preferably after discussion with the doctor being referred to.

  • In case a patient leaves against medical advice or absconds, a LAMA or abscond form is filled

  • In case of mortality, a death certificate is issued stating the time and cause of death.

  • Consultant of the unit.

  • Senior resident on duty along with team of junior Residents.

  • Nursing officer

  • Medical Officer

Discharge ticket admission/discharge register

Case file

Dc book

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SOP FOR STORE AND INVENTORY



DEPARTMENT OF PEDIATRICS

Jawaharlal Nehru Medical College

Aligarh Muslim University


SOP # 4: Stores and Inventory



  1. Purpose: To provide guideline instructions for effective and efficient management of Receipt, Storage and Issue of goods, equipment, medicines, consumables, reagents, etc in the Department of Pediatrics.

  2. Scope: It covers all activities under the purview of equipment, goods and medicine/consumable that are procured and stored in the Department of Pediatrics

  3. Responsibility: (1) Over all responsibility: Chairperson, Department of Pediatrics (2) Specific: (a) Teacher in-charge store (b) Store-incharge

  4. Procedure: As given in table below





4. Procedure:

Sl.No.

Activity/Description

Responsibility

Ref. documents/ Record

4.1

Receipt of Items/Materials

  • Items are received from the concerned vendor/supplier/hospital store along with bill/challan/receipt.

  • The material received is intimated to Chairperson/Teacher in-charge store for verification.

Store incharge

Bill / Challan


4.2

Verification of Items

  • The materials received are verified with respect to complete specification such as quantity, quality, date of manufacture, date of expiry (as applicable), make etc.

  • In case of any discrepancy, it is informed to Chairperson/Teacher-in-charge and the necessary action is taken and the vendor/sender is informed accordingly.

Store incharge


Teacher-incharge

Purchase Order, Bill / Challan





Bill / Challan

4.3

Entry in Stock Register

  • The details of Ok materials are entered in Stock Register.

  • For medicines/ drugs/ other consumables including lab reagents/kits etc, procedure for Pharmacy Management is followed (batch number, date of manufacturing, expiry date, etc)

Store incharge

Stock Register



4.4

Storage of Items

  • The ok materials are stored/kept at identified location may be in store, almirah or at user place as required in a rack with a proper labeling of the medicine name.

  • The rejected materials are kept separately by identifying “Rejected”.

Store incharge

Bill / Challan

4.4.1

The safe storage facilities for vulnerable items such as spirit etc. are insured.

Store incharge



Sl.

No.

Activity/Description

Responsibility

Ref. documents/ Record

4.4.2

Storage of Seasonal Items

Items which are used for a particular season such as room heaters, coolers etc are kept separately and issued to the concerned person/section at the start of particular season or during need.



4.5

Issue of Items

Items are issued against duly filled Indent form and approved (by department head) which is received from the indenter. The indent form should be signed by the Unit head.

The record of issued items is maintained in the stock register at the store.

For issue of medicines/syringes/reagents, procedure for Pharmacy Management is followed.

Store incharge

Unit head

Indent Form, Stock Register, Pharmacy Management

4.6

Updation of Stock Register

After the issue of items, the Stock Register is updated accordingly.

Store incharge

Stock Register


4.7

Inventory Management As applicable,

The inventory of critical items are maintained as follow:

a)Calculation of Lead time, Reorder level, EOQ etc. (see terminology)

b) Maintenance of Buffer / Safety stock. This is done with the intimation/approval from Teacher-incharge/Chairperson

Store incharge

Teacher-incharge

Stock Register


4.8

Physical Verification

The physical verification of items is carried out periodically with respect to quantity, quality, Expiry, manufacturer, batch no. etc. The result of physical verification is intimated to the Chairperson for taking further necessary action, as applicable

Store incharge

Teacher-incharge

Physical Verification Record


4.9

Disposal of Obsolete Materials

The expired / condemned items are kept separately and record of such items are maintained (name, quantity, date of expired etc). These types of items are also received for disposal from various sections to which the goods were issued. The list of such items are prepared and sent to Chairperson/ Teacher incharge for intimation and approval from the competent authority (condemnation committee) for further action.

Store incharge

Teacher-incharge

Condemnation committee

List of Obsolete/ Expired Items




Procedure for Stores and Inventory




  1. Process Efficiency Criteria:

Sl.No.

Activity Sl. No.

Activity/Description

Responsibility

1

4.4

Sending Rejected Items


The rejected items shall be sent within one month after rejection. If not sent due to some valid reason, the letter shall be sent to vendor/supplier.

2

4.8

Physical Verification


Physical Verification shall be done on yearly basis.



TERMINOLOGY

  1. Purchase order lead time is the number of days from when the department places an order for supplies, to when those items arrive.

  2. Reorder stock level: is the level of inventory at which a new purchase order should be placed. It is the fixed stock level that lies between the maximum and minimum stock levels.

  3. Economic order quantity (EOQ) is the ideal order quantity the department should purchase to minimize inventory costs such as holding costs, shortage costs, and order costs.



SOP FOR DEPARTMENT


DEPARTMENT OF PEDIATRICS

Jawaharlal Nehru Medical College

Aligarh Muslim University


SOP # 1: Administrative work in the Department of Pediatrics


  1. Purpose: To carry out all administrative work related to the department and to maintain all records and assist in all academic activities.

  2. Scope: This SOP shall apply for administrative and other tasks for the non-teaching staff of the Department of Pediatrics

  3. Responsibility: The Chairperson of the department shall assign responsibilities to the supervisory, clerical, and MTS staff of the department and review the progress from time to time. 

  4. Procedure

    1. To carry out administrative orders as per the Chairperson, Department of Pediatrics.

    2. Maintain attendance register of MBBS students/ Postgraduate trainees/ interns/ teaching and non-teaching staff.

    3. Typing of professional documents

    4. Provide duty rosters and schedules for academic activities.

    5. Assist in conduct of sessional and final examinations of MBBS and MD students

    6. Maintaining personal files of all staff and postgraduate students

    7. Maintaining leave record of all department employees and resident doctors

    8. Keeping records of finances and purchases.

    9. Arranging Board of Studies meetings, guest lectures, outreach activities

    10. Co-ordinating with other departments and higher offices for smooth functioning.


SOP FOR NICU

STANDARD OPERATING PROCEDURE

FOR

NEONATAL INTENSIVE CARE UNIT/ SPECIAL NEWBORN CARE UNIT


  1. Purpose

To admit the sick babies to NICU/ SNCU for management based on standard guidelines and to successfully discharge them after their management. It is also to ensure that neonates do not develop iatrogenic complications during their NICU/SNCU stay.

  1. Scope

This document covers the admission and discharge of neonates from NICU/SNCU, their management, and monitoring. It also covers the NICU/SNCU equipment maintenance as well as maintenance of records and their storage.

  1. Responsibility

Unit heads, the Sister-in-charge as well as other members of the unit shall be responsible for implementing the SOP. The resident doctors and the nursing staff will be trained for implementing the SOP during their posting in NICU.

  1. Procedure

This section enlists the various activities to be performed in the NICU/SNCU, the person responsible and the document that needs to be maintained (from which the performance of the activity can be verified).


S. No

Activity

Responsibility

Record

4.1

Admission and Discharge



4.1.1





4.1.2




4.1.3


The NICU/SNCU receives all the babies delivered in JNMCH as well as mother-baby dyads referred from the peripheral centres as well as private set ups.

The newborn on arrival in the NICU/SNCU shall be received by the staff on duty in the thermo-neutral environment.

The identification band will be tied on the wrist and foot print will be taken. The CADS number of the bay will be obtained and entered in the case-sheet


Doctor

Nursing staff


4.1.4



4.1.5



The newborn will be admitted based on the assessment at triage area

The file of the baby will be completed with details of relevant history and examination

Doctor


Admission register

4.1.6





4.1.7




4.1.8



4.1.9




4.1.10



All newborns discharged shall receive a discharge summary

All discharge formalities shall be

completed as soon as discharge

summary is prepared

All the babies will undergo eye screening by examination of red reflex and hearing evaluation by oto-acoustic emission.

The preterm/ low birth weight babies shall be regularly screened for the retinopathy of prematurity.

All the babies who have NICU stay shall be registered in the District Early Intervention Centre and will be regularly followed.

The data entry operator of the NICU shall ensure the follow-up of discharged babies

Doctor

Nursing staff

Discharge sheet

Discharge register

4.1.11

All neonatal deaths shall be certified as per standard guidelines.

Formalities after neonatal death shall be completed as soon as death is certified

Doctor on duty

Nursing staff

Doctor Death register/Death

certificates/Newborn

case record

Nurse Death register

4.2

Clinical case management



4.2.1



4.2.2




4.2.3




4.2.4



4.2.5





4.2.6

All the babies coming to NICU will be triaged based on the clinical signs.

The clinical assessment, investigative plan and treatment shall be completed within 1 hour of admission

All newborns shall be managed as per the standard clinical protocols and the details of all treatment given is documented

All newborns shall be monitored

regularly on a standard monitoring chart

The relevant investigations required for management will be sent to the labs. Consent from the parents will be sought wherever indicated

Reports of the investigations done will be recorded in the case-sheets

Doctor on duty

Nursing staff


4.3

Visitor/Parent Entry in NICU/SNCU





Entry of parents/visitors into NICU/SNCU shall be regulated as per unit/hospital policy


Nurse Visitor policy

document


4.4

Newborn Referral




All newborns who need to be

transported shall be stabilized before transport and will have a proper referral document


Doctor


Transport

protocol

4.5

Infection Control



4.5.1




4.5.2




4.5.3

All personnel entering and handling newborns shall follow standard hand

hygiene practices

Regular cleaning of bassinets, equipment, walls and surfaces will be done as per the standard protocol

The biomedical waste will be disposed based on standard guidelines

Doctor/Nurse Hand hygiene protocol


4.6

NICU/SNCU Maintenance




An inventory of all items in the NICU/SNCU(equipment, furniture, disposables, drugs, etc) shall be maintained



Nursing Sister

Stock books

4.7

NICU/SNCU Records/Storage




Newborn case records after

death/discharge shall be stored in an appropriate medical records unit


Doctor/Nurse


Medical records

register


NICU/SNCU data as per guidelines shall be recorded and updated in the computer

Date Entry

Operator/Doctor


Computer database


Process efficiency criteria


Year 2019

Year 2020

Number of babies admitted annually


1227

1089

Bed occupancy rate


65% to 195%

45% to 165%

Percentage of discharge, deaths, LAMA, abscond and referral


Deaths  309

LAMA – 9

Abscond zero

Referral 3

Deaths  305

LAMA – 20

Abscond zero

Referral 2

Number of complaints received regarding admitted babies


---

---

Audit of complaints


---

---




SOP for IPD



DEPARTMENT OF PEDIATRICS

Jawaharlal Nehru Medical College

Aligarh Muslim University


SOP # 3: Pediatric Inpatient Department (IPD) services


  1. Purpose: To admit patients for detailed evaluation under supervision and to provide quality care to the admitted patients.

  2. Scope: It will apply to all patients admitted (1) through OPD or (2) through Pediatric Emergency or (3) transferred from other departments such as Pediatric Surgery, ENT, Ophthalmology, Dermatology, Orthopedics, etc.

  3. Responsibility: Unit Heads and other qualified faculty of the respective units shall be responsible for executing the SOP and training of junior doctors

  4. Procedure: As listed in steps listed below; details in table given below.

    1. Admission of all patients through OPD or directly in pediatric emergency under respective admitting units as per schedule

    2. Patient’s attendants directed to obtain CADS number and visitor pass.

    3. Detailed history and examination, preparing case file, obtaining first level of investigations

    4. Transfer of patient along with case-file and treatment card to the Pediatric Ward/PICU for further evaluation and management

    5. Registration in IPD register by nursing officer

    6. Initial evaluation and stabilization in ward treatment room. Initiation of any emergent treatment required after transfer.

    7. Bed allocation, provision of hospital linen as per hospital norms. Rest inpatient rules as per JNMCH guidelines.

    8. Visitors permitted during visiting hours as per the hospital norms. Maximum of two patient attendants allowed at all times except during ward rounds by team of doctors when only one attendant is permitted.

    9. Daily ward rounds by unit consultants along with team of SR and JRs for review of diagnosis and treatment and any interdisciplinary consultation. Evening rounds by JRs and SR with guidance/visit of unit consultants

    10. Discharge/referral planning

  5. Process efficiency criteria

    1. No. of patients admitted annually

    2. Bed occupancy rate

    3. Percentage of discharge, deaths, LAMA, abscond and referral among inpatients

    4. No of complaint received regarding inpatients.

    5. Audit of complaints



  1. Procedure

  • Patients will be assigned to the admitting unit as per the schedule

  • Admission is made initially to Pediatric Emergency Ward either after pediatric OPD consultation or directly through casualty

  • Patients referred from other hospitals must also report to Pediatric emergency for admission

  • Interdisciplinary transfer of patients within hospital may be made directly to PICU or Pediatric ward.

  • Consultants, Senior Resident or Junior Residents posted in respective units or in Pediatric Emergency as per notified schedule

  1. (hospital inpatient admission number) and visitor pass

  • Nurse on duty

  • Patient’s attendants

Initial assessment and treatment

  • The initial assessment for inpatient is documented immediately including condition at admission. Initial assessment includes patients’ history, physical examination and establishing a provisional diagnosis.  Any emergent treatment required is provided and initial investigations suggested Case file is written and a plan of care documented.

  • Treatment card is prepared and handed over to nursing officer for implementation

  • Senior Resident on duty along with team of Junior Residents under guidance of consultant on call.



  • Patient is to be transferred to Ward after stabilization in emergency as assessed by Senior Resident

  • A pre-transfer note must be added in the case-file documenting the vitals and status of patient along with any special instructions during transfer

  • Transfer to the Ward/ PICU should be made by Ward attendant under supervision of junior resident doctor or nurse. Emergency supplies required during transfer should be ready.

  • Senior Resident on duty along with team of Junior Residents

  • Nursing officer

  • Ward attendant

Registration in IPD register

  • The Ward/PICU nursing officer must register the patient in IPD register on arrival and record date and time or arrival

  • Ward/PICU nursing officer

Initial evaluation in treatment room

  • Patients are initially evaluated in Ward treatment room, treatment card and case file is reviewed and any emergent treatment need is provided.

  • Senior Resident on duty along with team of Junior Residents

  • Ward/PICU Nursing officer

Bed allocation

  • Once stabilized, the nursing officer allocates bed and provides linen and other essentials as provided by the hospital

  • Hospital inpatient rules, visiting hours, etc are intimated

  • Ward/PICU nursing officer




Case review

  • Daily ward rounds by unit consultants along with team of SR and JRs for review of diagnosis and treatment and any interdisciplinary consultation.

  • Evening rounds by JRs and SR with guidance/visit of unit consultants

  • Any special instructions are given both in written and verbally to the team of doctors being handed over charge

  • Patient attendants are provided update on patient diagnosis, treatment, current status and likely outcome daily.

  • Patient attendants are closely involved in decision making regarding investigations, treatment options or referral

  • Consultant of the unit.

  • Senior Resident on duty along with team of Junior Residents

Discharge or referral

  • Discharge or referral is planned a priori in consultation with patient or attendants

  • For referral to higher centre a suitable referral letter is provided preferably after discussion with the doctor being referred to

  • In case a patient leaves against medical advice or absconds, a LAMA or Abscond form is filled

  • In case of mortality, a death certificate is issued stating the time and cause of death

  • Consultant of the unit.

  • Senior Resident on duty along with team of Junior Residents

  • Nursing officer


Procedure of Patient admission and discharge

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SOP for OPD



DEPARTMENT OF PEDIATRICS

Jawaharlal Nehru Medical College

Aligarh Muslim University


SOP # 2: Pediatric OPD and Sub-Specialty clinics


  1. Title: SOP for Pediatric OPD and Sub-Specialty Clinics

  2. Scope: It will apply to all patients registered in OPD

  3. Purpose: OPD Services are preventive, diagnostic, curative and rehabilitative; also admitted patients after discharge will need treatment and rehabilitation until they are fully recovered.

  4. Responsibility: Unit Heads/qualified doctors on duty shall be responsible for executing the SOP and training junior doctors. All follow-up patients after discharge from the hospital shall receive consultation by the Faculty or Senior Resident; or if there is no SR, the senior most Junior resident on duty with guidance from faculty.

  5. Procedure: Under various subheads as given in table below

    1. Priliminary registration of the patient at the OPD Registration desk by reception/registration staff and issue of Treatment card.

    2. Patient reports to pediatric OPD. Registration staff provides Pediatric OPD registration number and further guidance

    3. Anthropometry record by OPD registration staff or trainee doctor

    4. Assignment to one of the consultation rooms manned by team of physicians

    5. The consultation may result in either of the following outcomes: Brief discussion & disposal, treatment prescription, review with investigations, referral to specialist/clinic, or inpatient admission

    6. After  the consultation, the  provisional diagnosis and outcome (as in # 5.5 above) are recorded by OPD staff.

  6. Process efficiency criteria

    1. No. of new and old patients seen per OPD.

    2. No of complaint received regarding registration problems.

    3. Audit of complaints





  1. Procedure:


S.No.

Activity

Responsibility

Document/Record

5.1

Registration in OPD hall

  • The registration counter opens from 8.00 a.m to 11.30 a.m or as notified by the hospital from time to time

  • Preliminary OPD registration is done in the Registration Hall of the OPD. The OPD reception must display the Room number for registration.

  • Color coded directional lines may be laid down.

  • It should also have boards displaying the room number of the officers to contact in case of any grievance. It should also have a box to put any feedback

  • Patients and attendants must stand in a queue and security guards/OPD staff should guide the public in maintenance of discipline and avoid queue jumping.

  • A patient shall become eligible for obtaining medical help of this hospital only after getting himself/herself registered.

Registration worker,

Social Worker,








Security guards and OPD staff

Treatment card with stamped registration number

5.2

Pediatric OPD registration

  • Pediatric OPD waiting area shall board displaying various rooms. All OPD rooms to be numbered for the convenience of patient

  • The Pediatric OPD registration worker shall stamp the Pediatric OPD registration number and provide further guidance.

OPD Reception Staff,

MS/OPD Nurse in-charge/Care-taker

Pediatric OPD Registration number and date on Treatment card

S.No.

Activity

Responsibility

Document/Record

5.3

Anthropometry record

  • Weight record for all patients on each clinic visit and height/ length record 6-monthly.

  • Other parameters are recorded as required

  • Weight record by registration staff

  • Junior resident/intern

  • Record on treatment card

5.4

Assignment to a consultation room

  • Registered patients are given sequential number and assigned to a consultation room

  • University students/employee and Medical Attendance Scheme (MAS) beneficiary staff shall be given priority.

  • Registration staff

  • Pediatric OPD support staff

  • Prominent signboards and maps at appropriate places

5.5

Consultation

  • Consultation will be provided alternately to general patients and university student/employee

  • The doctor may see seriously ill patient out of turn.

  • Qualified doctors including Senior Resident doctor on duty

  • Postgraduate trainee doctors in consultation with consultatnt/SR

  • OPD staff

5.6

Post-consultation record

  • Record of patients seen along with provisional diagnosis

  • Reporting of notifiable conditions

  • OPD support staff

  • Record register

Procedure of patient flow in OPD

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