CBAHI -Assessment Tool …….
…………………… HOSPITAL
EMERGENCY CARE(ER) DATE OF VISIT:
STANDARD 15 - SUBSTANDARD 51 - ESR 0 …../……/20…..
Std EOC
Standard Measurable Element 0 1 2 NA Comment/Remark
No.
ER.1 Qualified physician is PF ER.1.1 The head of the emergency
responsible for department is a physician
managing the qualified by education, training,
emergency and experience in managing
department. emergency patients.
PF ER.1.2 The head of the
emergency department
supervises the development and
implementation of policies and
procedures related to managing
emergency patients
ER.2 Emergency D,PF ER.2.1 The emergency department
department staff is covered twenty four hours a
members have the day, seven days a week by
appropriate qualified emergency physicians.
qualifications. O ER.2.2 On call rosters for all
specialties are available and
posted in the emergency
department.
D, ER.2.3 There is an established
OMR policy on how to call consultants
for opinions.
PF ER.2.4 All staff members are
qualified and experienced in
emergency care.
PF ER.2.5 Clinical staff who participate
in caring for patients in the
emergency department are certified
in advanced life support as
appropriate to the ages of the patients
served (including Advanced Trauma
Life Support) and are present on site
or at least one certified individual is
assigned on every shift.
ER.3 Qualified nurse PF ER.3.1 The nurse manager in
manager supervises charge of the emergency
nursing services in department is a qualified registered
the emergency nurse with bachelor degree in
nursing and appropriate education,
department.
training, and experience in
emergency care.
ER.4 The emergency D,O ER.4.1 Nursing staffing plan is
department has based on patient volume and
adequate nursing patient acuity and ensures
coverage by qualified adequate coverage twenty four
staff. hours a day, seven days a week.
ER.5 Nursing staff in the PF ER.5.1 Nursing staff in the
emergency emergency department receive
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CBAHI -Assessment Tool …….…………………… HOSPITAL
EMERGENCY CARE(ER) DATE OF VISIT:
STANDARD 15 - SUBSTANDARD 51 - ESR 0 …../……/20…..
Std EOC
Standard Measurable Element 0 1 2 NA Comment/Remark
No.
department receive training and education as relevant
continuous training to the scope of services.
with competency PF ER.5.2 There is ongoing
assessment. competency assessment for the
nursing staff.
PF ER.5.3 The competency
assessment of the nursing staff is
documented.
ER.6 The emergency O ER.6.1 The emergency department
department has has the necessary equipment,
adequate resources supplies, and medications as
that support the appropriate to the scope of
provision of safe services.
care. O ER.6.2 There is a documented
process to check equipment and
stock refill on a regular basis or
when needed.
O ER.6.3 Resuscitation/trauma
rooms have adequate space to
perform resuscitation.
O ER.6.4 The medical bag contains
all essential resuscitation
medications.
D ,i ER.6.5 The medical bag is checked
daily and refilled after use.
O ER.6.6 Waiting areas are available
and are visually accessible to the
medical staff.
O ER.6.7 Registration clerk is available
to register emergency patients.
O ER.6.8 Security measures and
trained personnel are planned for
protection of emergency
department patients and staff.
ER.7 The clinical records o ER.7.1 There is an emergency
of the emergency department record form that is
department are completed for every patient
properly completed. presenting for care in the emergency
room
o ER.7.2 The emergency record is kept
in the patient’s medical record.
ER.8 There is an effective D ER.8.1 There is a process to
triage process to identify patients with urgent or
prioritize emergency emergent care needs.
patients. o ER.8.2 Patients with urgent or
emergent needs are given priority
for assessment and appropriate
and timely care.
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CBAHI -Assessment Tool …….…………………… HOSPITAL
EMERGENCY CARE(ER) DATE OF VISIT:
STANDARD 15 - SUBSTANDARD 51 - ESR 0 …../……/20…..
Std EOC
Standard Measurable Element 0 1 2 NA Comment/Remark
No.
i ER.8.3 Re-triage is performed
when appropriate (e.g., change of
medical condition, long waiting
time).
ER.9 Policies, procedures, D ER.9.1 There are policies and
pathways and procedures that are consistent
guidelines guide the with the hospital scope of services
care of patients in as well as the hospital wide
the emergency policies and procedures.
department. D ER.9.2 The policies and
procedures include, but are not
limited to, the following:
ER.9.2.1 Management of medico-legal
cases such as alcohol and narcotic
abuse and criminal acts..
ER.9.2.2 Management of suspected
victims of abuse, neglect, and
domestic violence
ER.9.2.3 Management of suicidal
patients.
ER.9.2.4 Care of trauma patients.
ER.9.2.5 Care of patients not
competent to care for themselves.
ER.9.2.6 Care of minors.
ER.9.2.7 Patient transfer from
emergency department to inpatient
areas or to another organization..
ER.9.2.8 Patients who leave against
medical advice
ER.9.2.9 Patients who leave without
being seen.
D ER.9.3 There are clinical practice
guidelines developed as guided by
the most common emergencies
and the top emergency diagnoses.
D ER.9.4 The policies, procedures,
and guidelines are developed by
the emergency department head,
the nurse manager, and staff in
collaboration with other relevant
department heads.
ER.10 The hospital D ER.10.1 The policy defines the
implements a policy physician responsible for the care
that defines the of patients in the emergency
responsibility for department including patients
patients in the under observation, patients
emergency waiting for admission, patients
department. waiting for admission with no bed
available (boarding patients) and
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CBAHI -Assessment Tool …….…………………… HOSPITAL
EMERGENCY CARE(ER) DATE OF VISIT:
STANDARD 15 - SUBSTANDARD 51 - ESR 0 …../……/20…..
Std EOC
Standard Measurable Element 0 1 2 NA Comment/Remark
No.
patients waiting for transfer to
another organization
i ER.10.2 Boarding patients receive
the same care as inpatients.
CMR ER.10.3 The transfer of
responsibility is documented at
times of shifts, handovers,
referral and admission
ER.11 Emergency I ER.11.1 Laboratory and radiological
diagnostic tests are diagnostic investigations required
performed and for a safe patient care are available
results twenty four hours a day, seven days
a week.
communicated on a
D ER.11.2 The hospital has a
timely manner.
process to provide all
investigations that are essential
but not available.
CMR ER.11.3 Results of investigations
are available to the emergency
staff within a defined time frame.
ER.12 The emergency O ER.12.1 The contact details of the
department has a regional drug and poison
channel of information center are available
communication with and accessible to the staff in the
the designated emergency department.
regional drug and I ER.12.2 The hospital
poison information communicates with regional
center when needed. poison center when a need arises.
O ER.12.3 The emergency
department is equipped to deal
with the most common and/or
risky poisonous injuries in the
community it serves.
ER.13 There is an efficient D ER.13.1 The hospital implements a
process for clear policy and procedure that
emergency regulates consultation requests
consultations. coming from the emergency
department.
CMR ER.13.2 Levels of consultations are
identified including Immediate
(life, limb, or function
threatening) and emergent
consultations.
CMR ER.13.3 Level of consulted
physicians and the ways of
communications are included.
CMR ER.13.4 Timelines of phone
response and physical presence to
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CBAHI -Assessment Tool …….…………………… HOSPITAL
EMERGENCY CARE(ER) DATE OF VISIT:
STANDARD 15 - SUBSTANDARD 51 - ESR 0 …../……/20…..
Std EOC
Standard Measurable Element 0 1 2 NA Comment/Remark
No.
different types of consultations
are included.
D ER.13.5 If a consultation from
outside the hospital is needed, the
process is included in the policy
(e.g., admit and consult, patient
transfer, city wide on call
specialty).
ER.14 Emergency D ER.14.1 The Emergency
department quality department selects and monitors
indicators are key quality indicators that are
monitored and monitored and reported on a
reported. regular basis.
I ER.14.2 The selected emergency
department indicators may include,
but are not limited to, the following:
ER.14.2.1 Time to ECG in chest
pain patients.
ER.14.2.2 Time to antibiotics in
sepsis patients.
ER.14.2.3 Triage to physician
time.
ER.15 The hospital D,I ER.15.1 Emergency department has
maintains effective appropriate channels of
ambulance services. communication with Red Crescent
services upon receiving or
transferring patients.
PF ER.15.2 The ambulance services are
supervised by emergency department
director or emergency department
nursing manager.
O ER.15.3 The ambulances have
adequate equipment and supplies to
be ready for transfer of patients
twenty four hours a day, seven days a
week.
O ER.15.4 Equipment and supplies are
based on Trauma/resuscitation area
preparation to transfer critically ill
patients.
D ER.15.5 A documented daily check is
conducted on both medical and
mechanical functions of ambulances.
D ER.15.6 Maintenance of ambulance
equipment is regularly conducted and
documented.
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