Deptt Manual Final

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QUALITY MANUAL

MANUAL OF OPERATION

FOR

PEDIATRIC SURGERY SERVICE

DATE OF

ISSUE:

17.7.09

1

MANUAL OF OPERATION

FOR


Date issued:

Approved By :

Chairman

Name :

Signature :

Reviewed By : Head of the department



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Name :

Signature :

Created and issued By :

Head of the department

Name :

Signature :



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Page contents:

A. Introduction

B. Department hierarchy

C. Scope

D. Job Description

E. Out patient consultation:

F. FLOW OF ACTIVITY

G. ANESTHESIA

H. PREOPERATIVE CHECKUP

I. Surgical technique

J. Immediate post operative monitoring

K. Records



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A. INTRODUCTION:

Department of Pediatric surgery is a super specialty department that caters to the

patient population ranging from neonatal and pediatric age groups upto 14 years of

age. In the neonatal age group the diseases commonly found are congenital

malformations like tracheoesophageal fistula, anorectal malformation, congenital

diagphragmatic hernia and intestinal atresias which are incompatible with life and

require urgent intervention to save the life of newborn. Common diseases of pediatric

age group include acute abdomen like appendicitis, Urinary tract infection, inguinal

hernias, and developmental problems only. Treatment of these routine problems

requires a keen observation of the symtoms and prompt actions to limit the damage

caused due the disease. Availability of the world class diagnostic and therapeutic

equipments plays a crushial role in the proper management of the congenital

malformation lowering the overall death rates and improving the survival of the

patients. new dimension at the department through the availability of the latest world-

class equipment, which gives a better outcome for overall patient healthcare



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management.

The department offers a wide range of pediatric surgery services while maintaining

high standards of care. The aim is to make the best pediatric surgery care accessible

and affordable to people. Service provided includes:

y All pediatric surgery Operations

y Emergency pediatric surgery operations

y Counseling of the expecting parents with congenital malformed fetus

y Counseling of the parents with previous baby with congenital malformations

y Working in close collaboration with gynecologists for prompt surgery of babies

born with congenital malformations in the institute

y Working in close collaboration with pediatricians for prompt surgical

interventions of the babies admitted in the neonatal intensive care units and

pediatric intensive care units for intravenous line maintenance for total



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parenteral nutrition, exchange transfusions and various other surgical

conditions

y All neonatal and pediatric Cancers amenable to surgery and care thereafter.

The pediatric surgery Operation Theatre is equipped with the latest operating

equipments. Also the advances in anesthetic instruments are available for safe

operative procedure and smooth post operative course.



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B. DEPARTMENT HIERARCHY:

Op assistant

C. SCOPE OF DEPARTMENT:

Chairman

President

Department of Pediatric

2 Pediatric Surgeons

1 medical officer



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1. Congenital malformations like Tracheoesophageal fistula, anorectal

malformation

2. Pediatric urological surgeries i.e. hypospadias, VUR,

3. Pediatric neurosurgical surgeries i.e. meningomyelocele, hydrocephalus

4. Pediatric hepatobiliary surgeries i.e. choledochal cyst, EHBA

5. Pediatric plastic surgeries i.e. cleft lip and palate, syndectyly, skin grafting

6. Pediatric oncosurgeries i.e. wilms¨ tumor, sacrococcygeal teratoma

7. Pediatric gastrointestinal surgeries i.e. atresias, hirschsprung¨s disease.

8. Antenatal check up and counseling for congenital malformations

9. Post natal investigations and prompt surgeries for congenital malformations

10. Parental counseling with babies of congenital malformations

D. JOB DESCRIPTION:

1. Pediatric surgery doctors:



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a. For outpatient procedure

Taking history (detail history regarding past treatment if any, family history,

complaints, symptoms, of present problems)

Examining the patient and carrying out basic evaluation of system concerned

Carrying out special test procedures like per rectal examinations, proctoscopy

Explaining the test results, presenting conditions and further treatment needed

for the patient.

Counseling the patient and attenders if any surgical procedure needed



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Giving appropriate prescription for problems and explaining the same to the

patient.

Giving appointments for further services.

b. .For In-patient procedure:

Receiving IP list from outpatient.

Carrying out IP rounds

Examine the patients and providing appropriate treatment

In case of post operative (surgery patient) dressing will be done periodically

Discharge advice will be given on time

Discharge summaries will be signed and issued when they get discharge



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Counsel and educate the patient regarding Do¨s and Don¨t¨s after surgery

Giving appointment for next review (date & time)

c. In- patient procedure:

Carry out IP rounds & counseling the patient and enter in IP register in brief.

Meeting doctors and getting referrals.

Assessment and diagnosing

Counseling the patient.

Discussing the results/ reports with the doctors who referred the case.

Carrying out IP rounds and dressing the wounds.

Removal of chest tubes and various drains during rounds

Appropriately timing the surgeries for previously admitted patients kept on

conservative treatments.



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Working in associations of anesthetist to get special test done required for safe

anesthesia practice.

Discharging the patients once satisfied with the results of the surgeries

Detailing the patients and attendants about the care to be taken at home.

Sending local purchase requisitions for material not available in the hospital

Timely informing the authorities about the patients not depositing bills on time

d. OP assistant:

Getting the OP key and opening the department on time.

Cleaning and hygiene to be ensured.

Changing the sheets/ mattress/pillows cover

Getting the instruments from CSSD (after autoclave)

Getting the OP register from cash counter

Entering the patients (new/review) OP card in respective doctors OP register.



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Making the patient set comfortably and explaining the order for doctors

consultation

Issue hospital pamphlets to the patient.

Calling the patients one by one and helping the patient to see the doctors

Assist the doctors when they examine the patient.

Assist when they carry out any special test/ procedure

Examine the patient regarding the procedure to be done.

Payment terms

Write and give requisition form if the doctors ask for further test.

Guide the patient to other department if any further referral made.

Giving payment slip to the patient and check if payment is made.

Note down the appointment dates further review.

Issue the OP card to patients after explaining the prescription to be taken.

e. OUT PATIENT CONSULTATION:



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Specialist consultation is available between 10 a.m. and 1 p.m., and 4 p.m. and 6

p.m. On all days except Sunday emergency care is available round the clock. Utmost

care is taken to reduce patient waiting times. The department possesses latest

modern diagnostic instruments to assess the patient problems accurately without

much discomfort to the patient. Kindly refer to hospital registration policy.

(KGH/OPD/01)

F. FLOW OF ACTIVITY:

When the patient enters the OP for consultation, they will be made to sit

comfortably and seen one after the other

OP registration done and entered in the respective doctors OP register.

Doctor examine the patients and do basic evaluations and advice the patient if

any special tests needed.

Payments terms for special tests will be explained to the patient.



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If needed the patient will be referred for further evaluation like x-ray/blood

test/CT scan/ MRI.

If any associated problem present or if the presenting complaint or secondary

to other problems, then appropriate referral made.

Patient will be given detailed for reports along with the prescription slip and

same will be explained to the patient.

Counseling will be given for next review

Patient phone number and contact number address will be taken for if any

further communication required.

G. ANAESTHESIA:

Premeditation was a standard regime given below:

y Tablet Diazepam 5 mg at bedtime on the preoperative night.

y Injection Atropine (10 g/kg to a max of 0.6 mg I/M) 45 min before surgery.

y Injection Pethidine (1 mg/kg to a max of 50 mg I/M) 45 min before surgery.

y Injection Phenergan 25 mg I/M 45 min before surgery.



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y A combination of standard regional, infiltrative and topical

y Local anaesthesia is used.

H. PREOPERATIVE CHECKUP:

Routine preanaesthetic (PA) check up was done, with demand of special tests if

further confirmation of the condition and suitability for operation is to be assessed for

operations by subjecting the patients to ECG, Blood Sugar (Fasting and PP), X-ray

chest.

I. SURGICAL TECHNIQUE: Standard surgical techniques described in the standard

pediatric surgical textbooks are used.

J. IMMEDIATE POST OPERATIVE MONITORING:



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Post operatively patients are detained and monitored in the pediatric intensive care

unit for minimum 4 hours. Patients are shifted to non intensive areas only when fully

satisfied about the condition of the patients regarding the safety in post operative

period.

Discharge criteria: The criteria followed for discharge from the detention room are.

y Correct orientation as to time, place and relevant people.

y Stable vitals signs for at least one hour.

y Adequate pain control with oral analgesics.

y Oral diet/fluids commenced without vomiting.

y Minimal bleeding or wound drainage.

y Follow up protocol

y Lesion and pack checked 48 hours post operatively.

y Pack removed after 48 hours where applicable.

y Sutures and dressing removed on fifth day post operatively.

y Rest for 72 hours given post operatively.



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y Review fortnightly and thereafter if required.

All the relevant data is maintained in a computer database. Informed consent is

obtained from all patients. Prophylactic antibiotics are used in all cases in the form of

oral first generation cephalosporin for 5 days. Prophylactic analgesia in the form of

oral NSAIDS is used in all cases for 5 days post operatively. Patient satisfaction is

asked about at the first fortnightly review in the form of questionnaire. The points

covered were:

(i) Intra-operative and post-operative pain experienced

(ii) Suitability of the surgery as per the operation performed

(iii) Post-operative experience in the clinic and at home

We suggest that certain selection and exclusion criteria be maintained for patient

selection for day care surgery. These are listed briefly below as guidelines.



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a. Simplicity of the procedure: The operative procedure should be of relatively

short duration.

b. Incidence of postoperative complications: The potential incidence of

postoperative complications should be low and recovery period minimal.

c. General good health of the patient: The patient should be in good health or

have a systemic disease, which is under good control.

d. Patient reliability: Patient should understand and be willing to follow post-

operative instructions.

e. Home situation of the patient: Patients should have some one to take care of

them at home postoperatively.

Patients who should be excluded include those with serious infections, patients

staying alone and those requiring emergency surgery, except those suffering from

uncomplicated fractures, or from other minor trauma routinely treated on an

ambulatory basis.

K. RECORDS MAINTAINED:



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OP and IP register of pediatric surgery doctors.

Daily statistics and monthly statistics notes register.

Indent list and issued file.

Referral list and issued file.

Consent file.

CSSD register

Stock register

Pediatric surgery Performa invoice file

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