DEPARMENTAL OPERATION POLICIES

INTENSIVE CARE UNIT/CORONARY CARE UNIT/HIGH DEPENDENCY WARD

LOCATION

In Hospital Banting ,Intensive Care Unit(ICU),Coronary Care Unit (CCU) and High
Dependency Ward( HDW) at new building opened up on 1.10.209. Located near the
Management block.

Objective

To provide care for the management of critically ill patient who require monitoring and
life support system.

Scope of Service.

provision of facilities for the management of critically ill patient who require intensive
monitoring and life support system.

The ICU/CCU/HDW shall operate 24 hours a day.The units shall operate as a multi
discipline.

Anaesthetist shall be in charge of the Intensive Care Unit and High Dependency
Ward.
Physian shall be in charge of the Coronary Care Unit.

The organization chart as follow .

Policy Description :

5.1 The unit shall operate as a multi disciplinary general ICU,CCU,HDW.

5.10 All female patients examined by male medical officer,shall be chaperoned by a female
staff.

5.11 All treatment ordered should be recorded in the patients case notes.

5.12 Drugs prescribed to patients shall be accordance with the approved list of drugs of the
Ministry Of Health.

5.2 The unit shall not segregate patients by class or sex.

5.3- All admission and discharge from icu,ccu,hdw shall be the responsibility of the
anaesthetist.

5.4 Patients shall be admitted through the admission room,casualty or wards.

5.5 All medical and surgical emergencies may be admitted directly to icu,ccu,hdw and the
admission formalities attended to subsequently.

5.6 Patients who are terminally ill with involvement of multi organ system or poor prognosis
shall not be admitted to the icu,ccu,hdw.

5.7. Isolation room in ICU,CCU,HDW shall be used for immuno-compromised patients

requiring intensive care and isolation treatment.

5.8- The criteria for admission to the ICU,CCU,HDW may include the following :

5.8.1 . Surgical Disorder

5.8.1.1 Post Operative Complication.

5.8.1.2 Severe Burns

5.8.1.3 Shock.

5.8.2. Medical

5.8.2.1 Acute Respiratory Failure From Either Infection/Drug Overdose,Airway

Disease/Severe Asthma.

5.8.2.2 Acute Cardiar Failure/Acute Pulmoanry Oedema.

5.8.2.3 Cardiac Arrythmias.

5.8.2.4 Acute Myocardial Infarction.

5.8.2.5 Shock Either Hypovolemic Septicaemia,Cardigenic Or D.I.V.C

5.8.2.6 Endocrine Emergencies.

 5.8.2.7- Acute Renal Failure.

5.8.2.8 Status Epilepticus Requiring Muscle Relaxant.

5.8.3 O& G Disorder.

5.8.3.1-Eclampsia.

5.8.3.2-D.I.V.C

5.8.3.3- Post operative complication.

5.8.3.4- Post partum haemorrhage.

5.8.4 Paediatric Cases above 12 year old.

5.8.4.1 Patients needing ventilatory support.

5.8.4.2 Dengue haemorrhagic fever wiht shock.

5.8.4.3 Status epilepticus/asthmaticus.

5.8.4.4 Patients requiring close monitoring of haemodynamic functions eg.

Myocarditis,severe C.C.F/arrythmias.

5.9 All admission shall be attended to immediately by the respective medical officer and
respective specialist informed.Cases shall be reviewed regularly.

5.10. An emergency trolley shall be made available at all times.The content of the trolley be
checked regularly and replenished accordingly.

5.11. All patients admitted shall be oriented on the facilities available inthe ward e.g. the
nurse call system,etc The patients shall also be made aware of the rules and regulations of
the hospital e.g no smoking,visiting hours.

5.12. Police cases shall be under the custody of the police at all time.

5.13. The ICU/CCU/HDW shall maintain a record og the all inpatients.

5.14. A daily midnight census of patients shall be carried out.

5.15. The admission room shall be informed of inter ward transfer.

5.16. The next-of-kin of dangerously ill patients shall be informed immediately of the patients
condition.If the next of-kin is not around at the moment,he/she shall be informed via the
telephone operator/nearest police station.

5.17. Patients or next of-kin of patients wishing to leave the hospital against medical device
may also do so in writing in the appropriate form.

5.18. The next-of-kin shall be informed of patients death in the ward,or notified via the
telephone operator/nearest police station ,if necessary.The cadaver shall be sent to the
mortuary at the end of an hour for release to the next-of-kin or post mortem.
5.19. The ward shall maintain a record and notify the hospital director of any untoward
incidences occuring inthe ward.

5.20.No leave of absence shall be granted to patients.

5.21.All notifiable diseases shall be notified to the Health Officer through Medical Record
department.

5.22. Consent shall be obtained from the patients/next-of-kin prior to carrying out any
procedures.In case of an emergency and after efforts to trace relatives and next-of-kin have
failed,the hospital director and specialist shall authorize for the procedure to becarried out.

5.23. Cases requiring surgery in the theatre shall abide by the policies of the operating
theatre.

5.24. Patients Movement :

5.24.1 .Patients shall be transport on mobile beds or transport trolley.

5.24.2. The ward attendants shall be resposible for moving patients within the
department as well as to other department.

5.24.3. Any patients who dies in the hospital shall be transported on a cadaver trolley
to the mortuary attendants.

5.24.4 . All referrals shall be in accordance with existing guidelines as stated in the
Garis panduan Rujukan.

5.25. Visiting shall be limited to twice a day.Only two (2) visitors at a time is allowed for a
patient.

5.26. No visitor shall be allowed to stay and nurse the patient.

5.27. Relatives shall be allowed to see critically ill patient at any time with the consent of the
Medical Officer/Sister i/c,Medical assitant i/c,staff nurse i/c.

5.28. Staffs and visitors shall abide by the dress code of the ICU,CCU and HDW.

5.29. No food ,drinks,flowers etc from relatives for the patients are allowed inside the
ICU,CCU,HDW.

5.30. Patients able to eat shall be supplied with four meals a day and where nessary,dietry
guidelines of the Ministry of Health shall be followed.

5.31. Food shall be served in specific food plate at the ICU,CCU,HDW pantry.

5.32. Patients shall be charged according to the Fees Order(Medical)1982.

5.33. Special prayers for the critically ill patient shall be allowed,if requeated by relatives or
the patients themselves provided no disturbances guaranteed.

5.34. Transportation of the patients to their home shall be provided if requested(milage

payment to be settled in advance).
5.35. Rehabilitation and health education shall be given to patients according to their illness.

KEY ASPECTS OF WHOLE HOSPITAL POLICIES.

1. Domestic services.

1.1 General cleaning shall be carried out by Hospital Support Service

Staff.This service has been privatised.

2. Movement Management.

2.1 Medical supplies shall be indented fromthe medical store by the ward.The
supplies shall be checked at the issuing areas in the medical store by the
designated officer before being deliverd to the ward using the hospital
transport services.
3. Waste Management.

3.1 Clinical and domestic waste shall be bagged in yellow and black colour-
coded bags respectively.
3.2 Hospital Support Service staff transport all clinical and domestic waste to
the respective collection areas.

4. Laundry service.

4.1 This service has been privatised.Soiled linen shall be collected and clean
linen returned from the launderette by the Hospital Support Service linen
staff according to the schedule.
5. Infection Control

5.1 Cross infection precautions shall include frequent hand washing and use
of gown by anyone having direct contact with an infectious patients.
5.2 Soiled instrument shall be decontaminated and sent to CSSD.
5.3 All item uesd on infectious patients shall be bagged immediately in colour
code bags(without soaking) and sorted only after decontaminated.
5.4 Existing regulations shall be followed as indicated in the following
document:
5.4.1 Policies And Procedures On Infection Control2010 2nd
edition.
5.4.2 Disinfection and sterilization Policy and Practise,Ministry of
Health
6. Maintenance

6.1 This service has been privatised.All requests for repairs and maintenance
need to be notified via the helpdesk of the Hospital Support Service at Ext
214.The Assitant Medical Officer in charge shall maintain an updated
inventory of all equipment and assets in the department.He/She shall
ensure that these equipments are serviced regularly and maintained by the
privatized entity.
7. Security.

7.1 The patients shall be requsted to make arragements to send their valuable
home,if not,arrangement shall be made for safe keeping by the hospital.
7.2 Controlled drugs shall be store in the controlled drugs(DDA)cupboard.

8. Visiting Hours.

8.1 Visiting hours are scheduled between 12.30pm to 2.00 pm and 4.30pm to
7.00pm each day.
8.2 Visiting privileges for relatived of critically ill cases shall be at the discretion
of the Medical Officer in charge/Assitant Medical incharge/sister in
charge/staff nurse in charge.

9. Protocols And Procedures.

9.1 Protocol and procedures shall be developed by the department head of:

Clinical managemet of cases.

Clinical emergenies.
Work procedures.
Disaster management.
 DASAR OPERASI DAN POLISI
UNIT RAWATAN RAPI,UNIT
RAWATAN JANTUNG DAN HDW
HOSPITAL BANTING.
SELANGOR