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KARNATAKA HEALTH SYSTEMS
DEVELOPMENT PROJECT
UB i'*
!WLC S?3TE!M 9V£$4fX&15lL
TUMKUR DISTRICT
June 1999
Printed on Riso and Binded at Project Secretariat
am
PREFACE
Health service in Karnataka is being delivered at three'levels - Primary, Secondary and
Tertiary. But access to health facilities and effective quality care in these facilities has been a dire
need which has not been addressed for a long time.
An effective mechanism which affords
accessibility to the entire population as well as quality care at each level of health facility is
lacking. The result is that the bulk of the health facilities like PHCs / PHUs at primary level are
underutilized with the population depending on the more credible secondary and tertiary level
health facilities such as district hospitals for all their health needs. The levels of health care are
working independent of one another with no linkage between them.
One of the major objectives of the KHSDP Project is to build an effective referral
mechanism which removes these anamolies and establishes an appropriate and well-linked
multi-tier health care delivery system with improved service quality, access and effectiveness.
Such a referral mechanism needs adequately spaced, well equipped health facilities manned ably
by well-qualified and trained staff. All these needs are being addressed under the project.
This Referral System Manual has been developed to provide a strategy for implementation
of a credible referral and linkage mechanism involving all health facilities from PHCs to tertiary
hospitals. The Referral System envisaged in this manual emphasizes the quality service rendered
by PHCs and First Referral units so that the patients develop confidence in these lower level
1
health facilities.
The Referral guidelines and protocols discussed here should be clearly
understood by all doctors and nurses and followed meticulously at all times. Consistency is the
catch word for a successful referral system.
This is a relatively new concept and needs good publicity not only among health
professionals but also among the community members. Coordination and support between health
facilities of different levels is essential to ensure an effective implementation of the Referral
System.
Dr. G. V. Vijayalakshmi, MBBS., MD., FICS.,
Consultant, KHSDP, Bangalore
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REFERRAL SYSTEM
Dr. G.V. Vijayalakshmi, Consultant, KHSDP
Karnataka Health system and services has evolved over years from an amalgamation of
the different geographical areas and their services. The state has 70% population living in rural
areas. Only one-third of the rural areas are well connected by fair weather roads. About 40% of
the population is below poverty line. Although the average literacy rate of the state is 67%, some
districts of northern Karnataka have as low a literacy rate as 50%.
The state has four
administrative divisions and 27 districts.
The health care delivery system of the state consists of three tiers - Primary, Secondary
and Tertiary. The lowest tier of Primary Health Care comprising 1357 Primary Health Centres
(PHCs) and 621 Primary Health Units (PHUs), offers basic curative and preventive services in
health as well as some promotive services in Maternal & Child Health and Family Welfare areas
and implement all national and locally introduced health programmes.
Secondary level health delivery is implemented through hospitals, with bed strength
varying from 30 to 800, such as Community Health Centres (CHCs) with 30 beds, Taluka level
hospitals with 50 - 100 beds and Sub-district and District Hospitals with 250 - 800 beds. The
186 CHCs in the state are designed to be the First Referred Units (FRUs) offering curative
services including minor operations and implement national programmes in health and family
welfare. There are 45 taluka level hospitals with bed strength 50 - 100 where advanced curative
services in the four major specialities of medicine, surgery, obstetrics and gynaecology and
paediatrics along with dental services are offered. The sub-district and district hospitals which
have all the specialities and improved diagnostic laboratory facilities are expected to provide high
level inpatient and outpatient care.
PRESENT SITUATION :
In such a multi-tier health care system, health facilities at lower echelons are expected to
hold and manage all patients needing basic curative and preventive services and refer only those
with more complex problems to appropriate higher health facilities.. In Karnataka, this referral
system is not functioning effectively. Out-patients in secondary and tertiary level hospitals are
over burdened with patients suffering from simple ailments who could have been managed at a
2
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lower level health facility which remains under-utilised. Such patients make up one third of the
out-patient in these hospitals. The reasons for this are:-
1
Self referrals by patients to higher level hospitals
2. Lack of confidence in lower level facilities due to perceived low quality of care.
3. Lack of proper linkage between different levels of health care.
4. Absence of guidelines or procedures that govern health facilities at different levels in a
referral chain.
5. Non-availability of written conventions guiding what conditions should be treated
where and when.
6. No triage or prioritisation of referred patients in health institutions.
7.
Lack of basic space, equipment and staff facilities at lower level facilities, and
mismatch in the availability of different specialists in lower tier hospitals.
8. There is duplication of investigations and treatment due to absence of an ideal referral
system.
Need and Objectives of the Referral System :
There is, thus a need to develop a well functioning referral system through which patients
with complex health problems are identified in a timely and systematic manner and examined,
investigated and / or treated promptly at an appropriate health care facility.
Main Objectives :
1. Increasing community accessibility to the primary care level which provides bulk of
preventive care services as well as the first contact for treating common diseases.
2. Developing a linkage through a referral system between different tiers of the health
delivery system.
3. Ensuring that each successive level provide technically more complex services, and
the higher tier provides technical leadership and support to the lower levels.
Detailed Objectives :
Every health facility in the state will achieve the following objectives when a referral
system under this project is implemented:1
Timely identification and triage of different categories of patients for referral.
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2. Referring only needy patients to higher facilities of management through a credible
referral protocol.
3. Ensuring that the community develops confidence in. the facilities at all levels.
4. Creating awareness in health workers and the community about the service
availability.
5. Appraising the patients about the incentives for participating in the referral system.
Such a system ensures that the community develops confidence in the quality of care
provided and patients understand that they will be referred according to their health needs. A
The
credible referral system will minimise by-passing of lower level of health facilities.
requirements of such a referral system are as follows:1. Clearly defined services at primary, secondary and tertiary levels.
2. Quality service at each level which promotes confidence among patients.
3. Confidence in patients and community that they will be properly referred and
promptly transferred to higher facilities as needed.
4. Awareness in the community as to types of services available at each level of
care.
5. Procedures to be implemented to ensure that patients do not by-pass lower level
facilities.
Under the project, the referral system will be developed and strengthened through a
number of activities :
1. Renovating and upgrading hospital buildings to provide adequate space for services.
2. Provisioning equipment and support service at each level of health facility.
3. Upgrading and updating clinical skills of medical and paramedical staff through in
service training programmes.
4. Providing ambulances for transporting all referred patients and,
5. Installing communication network through phone, fax and/or radio.
Some of the activities are already being implemented in a number of secondary level
hospitals under the project. These hospitals will serve as focal referral points for the primary
health care level. The project would also ensure that proper linkage is established between the
primary and secondary level facilities so that most of the patients coming to first referral units
have been seen at PHCs.
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Strengthening Measures :
A number of measures would be implemented to strengthen the referral system :
1. Introducing the use of Referral and Feedback cards.
2. Implementing Referral Guidelines.
3. Establishing an incentive system.
4. Establishing linkages and communication between FRUs, PHCs through regular
training and out-reach visits.
5. Developing intensive Information, Education and Communication (EEC) strategies
for both health service providers and community.
6. Bringing referral system under the perview of District Level Health System
Committees.
PREPARATION FOR IMPLEMENTATION OF REFERRAL SYSTEM :
A good preparation to ensure that all pre-requisites for strengthening the referral system
are met, is necessary for a successful implementation. The preparation will include the following
aspects:-
1. Referral cum Feedback card (which will be referred to as Referral Card only in
the text further):
New Referral cum Feedback card will be introduced. Once a decision is made to refer a
patient to a higher facility, a referral card for the patient is initiated by the medical officer
referring the patient. The referral card provides the patient direct access to the Referral Hospital.
This pink referred card contains:
a. General information about the patient - name, age, sex, address etc..
b. Medical information such as clinical findings and diagnosis, investigations done,
treatment given and condition of the patient at the time of referral, and
c. Purpose of referral. The referred patient gains direct access to the department to
which he has been referred in the Referral Hospital without following the general
queue. Referral Hospitals may provide a special counter to receive referred patients
to avoid delays. Under ‘yellow card scheme’, an annual health check scheme for
SC/ST population in the state, these referral cards and special dispensations are
already available.
5
refeys
Once the patient has been managed at the Referral Hospital, he will be given the same
Referral card which includes general information about the patient, final diagnosis, procedures
and treatment given, investigations done and follow-up advice.. Specimens of the card are given
in annexure. All health facilities from PHCs / PHUs to district hospitals will make available the
Referral card.
2. Referral Guidelines :
In order to ensure that an effective and acceptable Referral System is implemented, this
manual of Referral Guidelines that will specify procedures will be issued to all health facilities. It
includes (a) Administrative guidelines and (b) Referral protocols. Every health unit in the state is
expected to strictly follow these guidelines and protocols all the time.
a) Administrative guidelines :
Under the project, directives providing guidelines will be issued for all health institutions
covered by the project. These guidelines may be grouped as follows :
i) Administrative guidelines for the Referring Health Facility :
• Patients will be referred to the nearest, higher, properly equipped referral unit as
provided in the Referral flow chart of this Manual.
• Patients will be referred from the lower health facility to the designated referral
hospital strictly following the Zonal system in the Referral flow chart.
I
I
• A critically ill patient will be referred to the appropriate higher health facility for
admission without any delay but only after s/he is stabilized with appropriate care
and treatment.
• Before referring any patient, the referring medical officer will ensure:
• That the Referral Card is duly filled arid signed with the Feedback portion /
component attached for Reverse Referral.
•
The patient’s details are filled in the IP/OP Referral Register maintained to
facilitate monitoring.
•
The patient is informed as to his destination and purpose of Referral.
• The referring medical officer and/or the staff nurse I/C will ensure that adequate
I
supply of needy drugs are available for the referred patient both before referral and
6
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enroute to the Referred Hospital. A trained nurse shall always accompany critically
ill patient who is being referred.
•
:
Transport
The Referring Hospital will provide suitable transport to the
referred patient to reach the higher hospital using the following guidelines :
•
The ambulance transferring the referred patient shall have necessary patient
care equipment such as oxygen cylinder, resuscitation kits, TV. fluids and
emergency life saving medicines.
•
In the event ambulance is not available the Referring hospital may hire a
suitable private transport to refer the patient.
•
Very poor critically ill and poor patients will always be provided with
transport free of cost. The discretion whether to charge or not rests with the
referring Medical Officer.
•
Other referred patients will pay a stipulated fee which is equivalent to the
actual cost of fuel used by the transport.
•
Payment will be collected by a designated person of the referring hospital
who will issue a receipt to the patient or attendant accompanying the patient.
The amount thus collected will be deposited into the hospital user charge
account.
•
If the ambulance transports the referred patient, beyond the Referral hospital
to the next higher hospital, on the advice of the medical officer receiving the
patient, the driver of the ambulance will be authorised to collect money and
issue receipt.
ii) Administrative guidelines for the Referral Hospital :
•
The Referral Hospital will promptly receive the referred patient without any delay
and guide him/her to appropriate consultation / investigation / treatment area.
•
The Referred patient need not follow the queue at the OPD nor does he need to
procure any outpatient ticket or slip. He will produce the referral card to the
receiving staff
•
The appropriate specialist/medical officer/technician/nurse will attend to the
referred patient promptly without any delay.
•
Critically ill referred patients will be given top priority and admitted and managed
diligently.
Women and children should be given immediate attention and
7
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managed, as their conditions often deteriorate following prolonged travel that the
referral entails.
•
Referred patients managed as an out-patient x>nly, will be. referred back to the
Referring Institution along with the duly filled feedback card for follow up
preferably on the same day.
•
A Referal Register may be kept at an accessible Referral Counter.
•
It is the responsibility of the Administrative medical officer of the Referral
Hospital to provide diet for the referred patient - when admitted. Dormitory
accommodation for Attendants to be made by Medical Officer, if feasible.
•
Where fax/telephone facilities are available, the Administrative medical officer of
the Referring Institution will communicate advance information about the patient
being referred, especially in emergencies to the Referral Hospital to alert them to
receive the patient.
The communication may be used both ways to convey
information.
•
Every health facility in the Referred chain shall fix operational hours during which
all patient care services are rendered, particularly hours for specialist
consultation, investigations like X-ray, laboratory tests and visiting hours for
attendants.
These hours should not only be prominently displayed at the
Reception
of the Hospital but also be communicated in writing to all the
Referring units in the Referral Zone
•
All Referral health facilities shall develop procedures for handling referred
emergency patients through 24 hours and fix rolls for staff.
•
All health facilities from CHCs to District Hospitals will have a Referral Task
Force with the Administrative head of the institution as Chairman. CHCs will
include the Administrative Medical Officers of all PHCs in their Referral Task
Force.
•
The Referral Health Facilities from CHCs to District Hospitals will receive
patients referred from non-governmental health institutions including private
clinics present in their Zonal areas of referral and manage them as per the same
guidelines given above.
8
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10
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b. Referral Protocols :
Referral protocols are written conventions as to what clinical entities should be treated
where and when. The whole referral exercise depends on how meticulously these protocols are
observed in all the three tier health facilities. These protocols will specify:
1.
Types of conditions that should be referred for investigation and/or treatment to higher
health facilities. A working group consisting of specialists in various specialities of
medical care has prepared a clinical management protocol which provides guidelines
and standards of management and procedures for stabilisation for common conditions
by doctors with basic medical qualification who work without supervision in Primary
Health Centres/Units and Community Health Centres. These protocols are given in
annexure 2.
When and how to refer : Procedures that should be followed before referring a patient
to a higher health facility are essential and sufficient information should accompany the
patient who is being referred. A referral card has been developed for this purpose.
3.
Advising the patient and his attendants before referral on :
a) Purpose and benefits of referral
b) Location and time and mode of reaching the Referral Hospital
c) Precautions / preparations prior to transfer and
d) Likely events at the Referral Hospital
4. Emergency protocol services. Guide lines for Immunisation, management and referral.
Organisation
State Level:
The Director of Health & Family Welfare Services will be the state nodal officer for
implementing, monitoring and supervising the Referral System in the state under KHSDP
He
will be assisted by a Additional Director (Medical) from the Project. The Project will provide
the pre-requisites for the referral system like infrastructure, equipment, transport and
communication facilities.
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District Level:
a) Referral Sub-Committee :
At district level, the District Health Committee will constitute a Referral Subcommittee
for the purpose of steering the implementation of Referral System in the district. The District
Surgeon who will be the Chairman of this Committee has the overall responsibility of ensuring an
effective Referral System in the district. The Committee consists of:
District Surgeon
- Chairman
Lay Secretary of the District Hospital
- Member Secretary
District Health & Family Welfare Officer
- Member
Nursing Superintendent of District Hospital
- Member
Medical Superintendents of Sub-district Hospitals
- Members
Administrative Taluka Medical Officers
- Members
Administrators of Tertiary Referral Hospitals (Both
government and non-govemment)
- Members
This subcommittee which meets once a month has the following responsibilities :
1.
Operationalisation of the Referral System in the district by identifying Referral
Zones and chains, introducing necessary guidelines and training the staff.
2.
Monitoring the implementation of the Referral System by assessing data from
referral registers, reviewing feed back from primary level institutions and
community.
3.
Mobilising transport for referral needs by ensuring availability of a functional
ambulance and/or by collaborating with NGOs or other Government agencies.
4.
Coordinating technical support for lower level health facilities.
5.
Making necessary budgetory provisions for necessary material support such as
fuel for transport, training, EEC, referral cards, communication channels etc...
6.
Training all health staff on Referral System as per guidelines issued.
7.
Developing suitable DSC program to disseminate information on Referral System.
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ref-sys
Taluka Level:
At the level of talukas, all health facilities which form the first level referral chain, viz., the
Taluka level hospitals, the CHCs and PHCs/PHUs will form a Referral Subcommittee which will
have the following constitution :
1. The Administrative Medical Officer of the Taluka Hospital: Chairman
2. Administrative Medical Officers of all CHCs
3. Administrative Medical Officers of all PHCs/PHUs
: Members
: Members
4. Medical Superintendent of all Private Health Facilities
5. One representative Private Practitioner
The Taluka Referral Subcommittee meets once a month and discusses implementation of
referral system at PHC/PHU, CHC and taluka hospital level. The subcommittee is responsible
for the following :
1. Implementation, monitoring and servicing of Referral System.
2. Technical support to primary and first referral units from Taluka Hospitals.
3. Training of health personnel at lower level institution.
4. EEC strategies at community level.
Incentives for Referred Patients :
Referral System is a new concept and needs a lot of motivational effort to operate
effectively and consistently. Besides creating awareness about the benefits of the system in the
patients, efforts are necessary to encourage them to follow proper referral procedures by
providing incentives which may be listed as under :
1. At the Referral Hospital, referred patients,
a) can report directly to the referred unit/department without going through the
out patient queue and other formalities.
b) don’t have to make separate outpatient slips.
The referral cards serve as
outpatient slips.
2. The Referral Hospital will provide food for the referred patient who may be managed
inpatients only.
3. The Referring Hospital will provide an ambulance or any other suitable transport to
the referred patient who will pay only the actual cost of fuel used in the transfer.
13
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Technical Support to Primary Level:
Success of the referral system much depends on the linkage established between primary
health care facilities, FRUs, CHCs and Taluka Hospitals on the one hand and the Sub-district /
District Hospitals on the other. In each Referral Zone, a sub-district / district hospital will be
assigned to provide technical support to all the lower level health facilities in the Zone by:
1. Their consultants/specialists accepting wider role
to strengthen Primary care
programmes like safe motherhood, child survival, FP, immunisation, nutrition, disease
surveillance etc,.
2. Coordinating by providing periodic consultant services, on-the-job training and
inservice training to staff at PHCs and CHCs.
3. Training of doctors and other paramedics through
i) Out reach visits to PHCs and CHCs by specialists from sub-district and district
hospitals to
a) provide on the spot consultation for selected cases and
b) to enhance skills in selected treatment techniques by demonstration.
ii) Providing clinical attachments for PHC and CHC and Taluka Hospital staff for
training in special clinical skills with emphasis on management of emergencies
including trauma care.
iii) Periodic clinical meetings at PHCs & CHCs and taluka hospitals to discuss
problems in clinical management.
iv) Provision of updates and other medical literature to staff at lower levels.
v) disseminating clinical protocol manuals to PHCs & CHCs and briefing the staff
on its use.
The District Surgeon who will coordinate all activities on technical support will make
necessary arrangements such as providing transport, stationary, teaching aids etc., to the
consultants after obtaining approval from the Referral Subcommittee.
The strategies for referral system including the details of the technical support plans, will
be included in the teaching syllabus in State Training Institutes by the Directorate of Health &
Family Welfare Services.
14
ref-sys
Information, Education and Communication (IEC)
Referral system is an EEC - intensive scheme. Wide Dissemination of information on
referral system to different target groups is the key to its success. The target groups are :
a) the health care providers at primary and first referral levels viz., the health workers of
PHCs, CHCs and Taluka level hospitals, who are actively concerned with referrals.
b) Government workers at grass root levels eg: anganwadis, M.S.S., school teachers,
who can disseminate information regarding availability of different health care types
and facilities at different levels and are considered as opinion leaders.
c) Patients who use the health facilites (priority target), as their first hand experience
carries weight.
d) Private Health facilities, practitioners and NGOs who also refer patients and therefore
should be aware of the available facilities in referral hospitals.
e) The SC/ST population in rural areas who are beneficiaries of referral under Yellow
Card scheme, should be aware of the improved primary health care services available
to them.
The strategy of EEC for Referral System focuses on dissemination of information
regarding service availability in all levels of health care in Karnataka. The various media that will
be adopted are : -
1.
Health workers in health institution who produce vast impact on patients by the way
they handle them, will be used as educators by providing training on communication
& education and visitor handling .
2.
Door to Door Campaign or interpersonal communication has been the EEC strategy in
yellow card Scheme. The same suits well for enhancing community awareness on
Referral System.
Junior and Senior Health Assistants, Block health educators &
grass root level workers will be trained to do these campaigns.
3.
Pamphlets and good sign posting within hospitals and maps showing referral chains
will provide information about services, hours of working etc..
The District Health Education Officer will be responsible for implementing an effective
EEC Campaign on Referral System.
15
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Training :
Training the hospital personnel is an essential prerequisite for the successful and sustained
implementation of Referral System in health care settings. Proper training alters mindset and
makes operationalisation a lot easier.
Creating referral awareness, motivating and educating
hospital workers is the first step.
Goals of Training Programme are :
1. Defining the problem in general and in particular reference to the hospital referral
system.
2. Bringing out effective referral chain.
3. Obtaining feed back and support by active participation.
4. Initiating co-ordination between various staff.
5. Establishing the organizational role of each health unit.
The medical officer is responsible for the training, dissemination of information &
education of all workers. The target group for training should be broad & should include both
the hospital and extra-hospital personnel who directly or indirectly use the health facility.
1. Hospital
- Doctors nurses & para medicals.
2. Non-Hospital staff
- General workers
3. Patients and visitors.
4. Socially active groups
- eg : women groups, NGOs.
5. Administrators of key institutions, Heads
of schools.
- eg : Zilla/Taluka parishat members
Trainer:
Trainer is the Medical Officer of health care who is already trained at district/state level
and will be equipped with information on referral system through a manual prepared for the
purpose.
Activities :
The training methodology may be divided into the following segments :
1. Teaching.
2. Discussion.
3. Feedback.
16
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Teaching and discussion will be parts of the initial training activity. Feedback from
personnel should be a continuous process, which helps monitoring and evaluation of the Referral
System in course of time.
TRAINWG PROGRAMME
Groups
Participants
Training
Institution
Duration
Trainer
1. Jr Health Assts. of subcentres
2. Nursing Personnel of PHCs & CHCs
3. BHE and other paramedics
CHC Level
One day
1
Senior
Staff
Nurse T H.
2
1. Medical Officers of PHCs & PHU
2. Medical Officers of CHCs
CHC Level
One day
Administrative
Medical
Officer TH
3
General workers of PHCs, PHUs &
CHCs
CHC Level
One day
Senior
Staff
Nurse TH
4
1. Nursing personnel of T.H., Sub
district Hospital & D.H. and medical
social workers.
2. Paramedical & Administrative Staff
1. Medical Officers of TH., S.D.H.,
D.H., DHO & District Medical
Officers._____________________
1. Patients in wards
2. Visitors
District
Hospital
One day
Nursing
Superintendent
DH
District
Hospital
One day
District
Surgeon
One day
Nurse I/C of
ward/PHC,
BHE________
Junior Health
Assistants
5
6
7
1. Anganawadi workers
2. Other NGOs
One day
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Training Activity for Group 1 & 4
Lesson
Outline Syllabus
Nos.
Existing Health System in
1
Karnataka - Primary,
Secondary, Tertiary Health
care - Facilities and utilisation
at Primary Level - Existing
Referral Pattern
Outcome of Training
1. Health care is delivered at
1. Organisational chart
three levels in the state
of three tier system
2. Under utilisation of primary
level services and
overburdening of hospital
outpatients
3. Realise need for an effective
Referral system__________
1. Understand objective of new Hand outs on
referral system
1. Referral guidelines
2. Know referral guidelines and
2. Referral procedures
procedures and organisation
3. Organisational chart
of referral system
of Referral System
2
New Referral System - Needs
and objectives - Referral
System under KHSDP Referral Guidelines - Referral
Protocol - Referral Procedures
- Outline of organisation
3
Role of Nursing in management 1. Clearly understand their role
of referred patients in managing referred
Prioritization of patients patients
Stabilising Emergency Patients 2. Be able to prioritise patients,
- Handling visitors stabilise emergency patients
Documentation of Referrals
3. Understanding filling up
referral registers and reports
4
5
Training tools
Role of Nurses in dissemination 1. Understand that community
of information - Confidence
should know where, what
building
facilities exist
2. Understand that patients
should know advantages of
referral system
Hand outs on
1. Referral Protocols
2. Emergency
management of
patients
Specimen of
1. Referral Cards
2. Referral Registers
1. List of facilities /
services available at
PHC/CHCetc..
Discussion
Each Lesson is for a duration of 1 hour.
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5. Information, Education & Communication :
Being an EEC - intensive scheme. Referral System requires good input for EEC activities.
Activities such as preparing audiovisual aids for health workers, pamphlets, signposts & maps in
health facilities, conducting street dramas etc., will need funds. Rupees 1.0 Million has been
estimated as the annual requirement.
The total budget requirements for implementing the Referral System in the state is
estimated to be Rs. 5.2 Million for the year 1998 - 99.
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5'E‘R^ICE OVtA'I’KIX
CONDITIONS AND PROCEDURES : MEDICAL
Condition / Procedure
PHC
Respiratory System
Upper Respiratory
Infection_________
Lower Respiratory
Infection_________
Asthma
Tuberculosis *
COPD
Pediatrics______
ARI___________
LRI
Febrile convulsion
Childhood Asthma &
Allergic Bronchitis
Tuberculosis *
Manage &
Treat________
Treat Bronchitis
& Pneumonia
Asses, initiate
treatment and
refer if necessary
Manage as per
protocol for
natural
programme
Supportive &
symptomatic
treatment then
refer
*
Treat
Manage if no
respiratory
distress_____
Manage as per
protocol
Community
Hospital 30Beds
______ Secondary Level Hospitals
Community
Sub-district Hospital
Hospital 50Beds
100 Beds
District Hospital
>250 Beds
Tertiary Hospital
Manage &
Manage &
Manage &
Manage & Treat
Treat__________ Treat__________ Treat____________
Treat Bronchitis & Treat Bronchitis & Treat referred severe Treat referred severe
Pneumonia______ Pneumonia______ cases____________ cases____________
Manage mild cases Manage mild cases Investigate & treat Investigate & treat
symptho-matically. symptho-matically. severe cases
severe cases
Refer severe cases Refer severe cases
Manage as per
Manage as per
Manage as per
Manage as per
protocol for natural protocol for natural protocol for natural protocol for natural
programme
programme
programme
programme
Supportive &
symptomatic
treatment then
refer
Supportive &
symptomatic
treatment then
refer
Investigate, manage Investigate, manage
& follow-up
& follow-up
Treat___________ Treat___________ Treat______
Mild: symptomatic Mild: symptomatic Investigate &
treatment refer if treatment refer if Manage
no improvement
no improvement
Without
Without
Without respiratory
respiratory distress: respiratory distress: distress: manage
manage_________ manage_________
Manage as per
Manage as per
Manage as per
protocol
protocol
protocol
Treat______
Investigate &
Manage
Without respiratory
distress: manage
Manage as per
protocol
* This comes under National TB Control Programme (NTCP).
23
Ref_sys-b
Condition / Procedure
Secondary Level Hospitals
Procedures
PHC
Community Hospital
SOBeds
Community Hospital
50Beds
Do
No
Do
No
Do
Do
Do
Do
Do simple cases
Do____________
Symptomatic
treatment & refer
Treat__________
Treat
Do simple cases
Do____________
Symptomatic
treatment & refer
Treat__________
Treat
Do simple cases
Do________________
Symptomatic treatment
& refer_____________
Treat______________
Treat
Do
Do____________
Symptomatic
treatment & refer
Treat__________
Treat
Refer
Manage & refer if
necessary_______
Manage, refer if
necessary
a) Pleural Aspiration
b) Pericardial Tap
c) Foreign Body
removal
d) Lumbar puncture
Refer
Malignancy
Refer
Rheumatic Fever*
Essential Hypertension
Treat____________
Initiate treatment &
refer_____________
Initiate treatment & Investigate & manage Manage
refer
__________
Diagnose, initiate
Stabilise and refer
treatment stabilise &
refer________
Diagnose & refer
* Manage, refer if
further investigations
necessary_________
Diagnose & refer
* Manage, refer if
necessary
Diagnose & refer
Malignant Hypertension
Stable/Unstable/Post MI
Angina
Acute MI
Rheumatic Heart Disease
with Pregnancy________
Congenital Heart Disease
CCF
Pericordial Tapping
Diagnose initiate
treatment, stabilise
& refer_________
No
Sub-district Hospital
100 Beds
District Hospital
>250 Beds
Tertiary hospital
Refer
-►
No
Manage
Manage
Manage
Investigate & manage, Manage
refer if specialised
treatment necessary
Manage
>
No
2#
Treat
Manage, refer if
* necessary
Manage, refer if
necessary
No
Investigate and manage
Do
Rcfsys-b
Convulsion including
Epilepsy
Coma
Encephalitis #
Meningitis
Initiate treatment & Treat &manage
refer for
investigations______
Supportive treatment
& refer
Treat &manage
Diagnose treat and
refer to PH______
Diagnose, initiate
treat refer to SDH
Diagnose treat and
refer to DH
Diagnose treat and
refer to DH
Treat &manage
Treat &manage
Investigate & manage Manage
treatment and manage.
If no improvement
refer to tertiary level
Diagnose treat and refer Manage
to DH______________
Treat & Manage
* Refer Rheumatic Heart Diseases to Tertiary level
+ If not treatable refer to Tertiary level
# Notifiable disease
Condition/Procedure
Secondary Level Hospitals
PHC
Head Injuries
C.V. Accidents
Psychosis @
Neurosis^
Mental Retardation
Drug Abuse &
Alcoholism
Organic Brain
Syndrome
Community Hospital
Community Hospital
3QBeds
______ 50Beds_____
Manage as per
Manage as per
Manage as per
emergency conditions emergency conditions emergency conditions
protocol_____ 2_____ protocol___________ protocol___________
Symptomatic
Symptomatic
Symptomatic
treatment, stabilise
treatment, stabilise
treatment, stabilise
and refer__________ and Refer__________ and Refer__________
Diagnose & Refer
Manage & Refer if
Manage & Refer if
necessary__________ necessary__________
Diagnose & Refer
Manage & Refer if
Manage & Refer if
necessary__________ necessary__________
Diagnose & Refer
Manage & Refer if
Manage & Refer if
necessary
necessary__________
Diagnose & Refer
Treat & Refer for deaddiction if necessary
Treat
Treat
25-
Sub-district Hospital
District Hospital
_____ 100 Beds
______ >250 Beds______
Manage as per
Manage as per emergency
emergency
conditions protocol
conditions protocol
Symptomatic
Investigate & manage
treatment, stabilise
and Refer________
Manage & Refer if
Manage & Refer
necessary_________
Manage & Refer if
Manage & Refer
necessary_________
Manage & Refer if
Manage & Refer
necessary
Tertiary Hospital
►{Manage
Treat
Treat
Rcfsys-b
Skin Diseases
Leprosy #
Pemphigus
Skin Allergy
Sarcoidosis
Psoriasis
Diagnose &Follow
National Programme
Protocol_______ _
Diagnose / Suspect
Refer
Diagnose &Follow
National Programme
Protocol__________
Diagnose / Suspect
Refer
1
Diagnose &Follow
National Programme
Protocol__________
Diagnose / Suspect
Refer
t
Diagnose &Follow
National Programme
Protocol__________
Diagnose / Suspect
Refer
t
Diagnose &Follow
National Programme
Protocol__________
Manage
Diagnose / Suspect
Refer
Treat___________
Diagnose / Suspect
Refer
1
Treat___________
Diagnose / Suspect
Refer
<
Treat___________
Diagnose / Suspect
Refer
1
Treat
Manage
Diagnose & Refer
Diagnose & Refer
Treat,if Complicated
Refer to Dermatologist
Diagnose &Follow
National Programme
Protocol
Treat
*
Neoplasm
STD
Refer
Refer
Refer
Investigate & treat
Pri.Syphilis:Diagnose Pri. Syphili s: Diagnose Pri. Syphilis: Diagnose Investigate & Treat
& Treat.
& Treat.
& Treat.
Secondary' & Tertiary: Secondary & Tertiary: Secondary & Tertiary :
Refer
Refer
N
Refer
k
------------------------- 2^--------------- >
Gastrointestinal
Bleeding
Diagnosis, Manage
Stabilise. Referito DH
for Investigation
Diagnosis, Manage
Stabilise. Refer to DH
for Investigation I
Diagnosis, Manage
Stabilise. Refer to DH
for Investigation!
26
Diagnostic
investigation &
treatment Refer if
necessary
Manage
Ref_sy5-b
G.E & Dysentery
Hepatitis
Manage & Refer if
Treat & manage
necessary__________
Uncomplicated :
Uncomplicated :
Uncomplicated :
Manage
Manage
Manage
Complicated (Deep
Complicated (Deep
Complicated (Deep
Jaundice,
Jaundice,
Jaundice,
Haemorrhages,
Haemorrhages, Altered Haemorrhages,
Altered Sensorium)
Sensorium): Refer
Altered Sensorium):
Refer
Refer i
Treat & manage
Treat & manage
Manage
------------ ------------- »
Hepatic Coma
Diagnose, Supportive Diagnose, Supportive Diagnose, Supportive Investigate & Treat
treatment & Refer
treatment & Refer
treatment & Refer
-
Amoebiasis
Intestinal & Hepatic:
Manage
Complicated( Abscess,
Ulcer) Refer
Intestinal & Hepatic:
Manage
Complicated( Abscess,
Ulcer) Refer
Cholysysticis
Symptomatic
treatment & Refer
Pancreatitis
Diagnose & Refer
Abdominal Tapping
Liver Biopsy
Yes
No
■
>
Intestinal & Hepatic:
Manage
Complicated(Abscess,
Ulcer) Refer
Intestinal & Hepatic:
Manage
Complicated( Abscess,
Ulcer) Refer .
Manage
Symptomatic treatment Symptomatic
& refer
treatment & refe^
Manage. If needs
Surgery, Refer
Manage
Symptomatic treatment Symptomatic
& refer
treatment & Refei
Symptomatic
treatment & Refer
Investigate & Manage
________ Yes
Yes
Yes
Yes
No
No
Yes
@ If not under control with conventional psychiatric drugs refer for EEG.
# Refer to Tertiary level for reconstructive surgery. National Leprosy Control Programme (NLCP)
I No"
2.T
Ref_sys-b
Condition/Procedure
Secondary Level Hospitals
PHC
Fiberoptic Endoscopy
UTI
No_______________
Diagnose & Treat. If
Refractory/Recurrent,
Refer
Acute Nephritis
Diagnose & Refer
Community Hospital Community Hospital
30Beds
50Beds
No_______________ No_______________
Diagnose & Treat.
Diagnose & Treat. If
If
Refractory/Recurrent,
Refractory/Recurrent Refer t
, Refer 'C
Sub-district Hospital
District Hospital
100 Beds
____ >250 Beds
Yes_______________ Must
Investigate & Manage
Diagnose & Refer
Uncomplicated: Treat Manage
Complicated
(Nephrotic Syndrome,
Fulminant Type,
Renal Failure): Refer
Uncomplicated: Treat
Complicated
(Nephrotic Syndrome,
Fulminant Type, Renal
Failure): Refer ■
Tertiary Hospital
>
Nephrotic Syndrome
Diagnose & Refer
Renal Failure
Diagnose & Refer
Diagnose & Refer
V
Initiate Treatment,
Stabilise & Refer
Manage
Initiate Treatment,
Stabilise & Refer
Initiate Treatment,
Stabilise & Refer
Manage
>
Anaemia
Moderate(>6gms)
Uncomplicated:
Manage
Severe(<6 gms)&Complicated(Cardiac
Failure): Refer
Moderate(>6gms)
Uncomplicated:
Manage
Severe(<6gms)&Com
-plicated(Cardiac
Failure): Refer
Moderate(>6 gms)
Manage
Uncomplicated:
Manage
Severe(<6gms)&Com
-plicated(Cardiac
Failure): Refer
>
Leukaemia
Suspect, Refer
Suspect, Refer,
Suspect, Refer
Investigate, Diagnose
Refer
Investigate, Diagnose
& Refer
Manage
>
25
Rcfsys-b
Thalassemia
Suspect, Refer
Suspect, Refer
Suspect, Refer
Procedures__________
Bone marrow Aspiration
Diabetes
No___________
Suspect & Refer
No___________
Manage
Complicated
(Nephropathy,
Retinopathy,
Arteriosclerosis):
Refer
No________________ No___________
Manage
Manage
Complicated
Complicated
(Nephropathy,
(Nephropathy,
Retinopathy,
Retinopathy,
Arteriosclerosis): Refer Arteriosclerosis):
Refer i
Neonatal___________
Premature Baby (>2Kgs)
Refer
Manage.
Complicated (ABO
incompatibility,
ARI, etc..): Refer
Manage. Complicated Manage. Complicated Manage
(ABO incompatibility, (ABO incompatibility,
ARI, etc..): Refer
ARI, etc..): Refer
Refer____________
Physiological: Treat
Complicated
(Kemicturus): Refer
Refer____________ Refer____________
Physiological: Treat Physiological: Treat
Complicated
Complicated
(Kernicturus): Refer (Kemicturus): Refer
< 2 Kg
Jaundice within 24 Hrs.
Investigate, Diagnose
& Refer
Manage__________
Physiological: Treat
Complicated
(Kemicturus): Refer
Investigate, Diagnose Manage
& Refer i
Yes
Manage
Manage
Manage
-►
Convulsion
Initiate treatment and refer if not controlled
Poisoning___________
Physiotherapy treatment
Treat
No
Diagnose & treat
Treat
Treat
No
29
Treat
Treat
Ref_sys-b
CONDITIONS AND PROCEDURES ; SURQICAL
Abscess including breast &
perianal_______________
Wound Debridement
Trauma Needing Life
Support______________
Musculo Skeletal Injuries
Manage
Manage
Manage
Manage
Manage
Simple wounds :
Manage
Major / Compound
wounds : Refer
Simple wounds :
Manage
Major / Compound
wounds : Refer
Simple wounds :
Manage
Major / Compound
wounds : Refer .
Manage
Manage
Resuscitate, Stabilise Resuciate, Stabilise
& Refer____________ & Refer__________
Simple sprains, strains Simple sprains,
& contusions :
strains & contusions
Manage
: Manage
Complicated
Complicated
(Haematomos, Muscle (Haematomos,
tears, fractures):
Muscle tears,
Refer
fractures): Refer
Resuciate, Stabilise &
Refer
—>
Investigate & manage, Investigate & Manage
if needed Refer
Manage
If necessary refer
Manage
If necessary refer
Manage
If necessary refer
Manage
>
Abdominal Injuries :
Penetrating, Internal
bleeding, with shock
(Emergencies)_____
Abdominal Surgeries
(Planned) ______
Appendectomy_____
Haemorrhoids
Anal Fissure
Stabilize & Refer
Stabilize & Refer
Stabilize & Refer
Stabilise & Refer
Manage
No
No
No
Yes
Yes
No________________ No__________ ___
Uncomplicated:
Uncomplicated:
Manage
Manage
Complicated
Complicated
(Refractory, needs
(Refractory, needs
surgical intervention): surgical
Refer______________ intervention) : Refer
Uncomplicated :
Uncomplicated ;
Manage
Manage
Complicated (needing Complicated
surgery) : Refer
(needing surgery) :
Refer
No________________ Yes
Uncomplicated :
Manage
Manage
Complicated
(Refractory, needs
surgical intervention):
Refer______________
Uncomplicated:
Manage
Manage
Complicated (needing
surgery): Refer
38
Yes
Manage
Manage
Rcfsys-b
Condition/Procedure
Secondary Level Hospitals
PHC
Community Hospital
30Beds
Community Hospital
SOBeds
Sub-district Hospital
100 Beds
District Hospital
>250 Beds
Surgery_____________
Acute Retention of Urine
Catheterise & refer
Catheterise & refer
Catheterise & refer
Manage
Manage
Circumcision
Hydrocele
Yes
Refer
Yes
Refer
Yes
Yes
Yes
Yes
Yes
Yes
Hemeorrhaphy_____
Urethral Dilatation
Rupture of Bladder &
Urethra___________
Major Urological
Procedures________
Fracture Spine_____
Optholomology
Eye * @
Refer
Refer
Refer
Refer
Yes
Yes
Refer
Yes
Yes
Refer
Yes
Yes
Manage
Refer
Refer
Refer
Refer
Stabilize & refer
Stabilize & refer
Manage
Manage
Removal of foreign
bodies
Removal of foreign
bodies
Management of
corneal aberration,
ulcer & cataract +
Glaucoma surgery
Conservative
All types of
dentistry, tooth
extractions,
extraction, alltypes of impactions & Jaw
fillings________ __
fractures________
Sigmoidoscopy
Oesophagogastroscopy,
colonoscopy
Dental
Gastro Enterology:
Endoscopy
Removal of foreign
bodies
Conservative dentistry, Conservative dentistry, Conservative dentistry,
extraction, others refer tooth extraction, alltypes tooth extraction,
of fillings
alltypes of fillings
Refer
Refer
31
Tertiary Hospital
Manage
Management of
corneal aberration,
ulcer & cataract
Ref_sys-b
Condition/Procedure
Secondary Level Hospitals
PHC
Thoracic________
Acute Empyaema
Chronic Empyaema
Community Hospital
30Beds
Community Hospital
SOBeds
Sub-district Hospital
100 Beds
Manage by ICD
Refer
Manage by ICD
Refer
Manage by ICD
Refer
Refer
Refer
Refer
District Hospital
>250 Beds
Tertiary Hospital
Manage by ICD
Rib resection &
drainage. Refer for
decartication &
resection________
Manage, refer if
necessary
Foreign Bodies in the
Oesophasgus and Tracho
Bronchial Tree $______
Thoracic____________
Simple fracture ribs
Intercostal under-water
seal drainage__________
Flail chest
Manage
Manage
Yes*
Manage
Yes*
Manage
Yes *
Manage
Yes*
Refer
Resuciate & refer
Resuciate & refer
Resuciate & refer
Mediastinal injury
Refer
Resuciate & refer
Resuciate & refer
Resuciate & refer
Manage with
ventilatory support
Manage, refer if needs
ThoractOmy
* Covered under NPCB
@ ^Corneal grafting, retinal diseases, vitreous surgery, intraocular foreign bodies: refer to Tertiary
ENT________________
Foreign bodies in nose &
ears_________________
Epistaxis_____________
Tracheostomy_________
Peritonsilar abscess
Tonsillectomy_________
Mastoid Abscess
OBG______________
High Risk Pregnancies
including APH, PET,
Eclempsia
Nose: remove Ear:refer
Nose &Ear: remove
Yes
Yes
Manage
Yes
Refer
Refer
Refer
Manage
Yes
Manage
Refer
Refer
Refer
Early diagnosis & refer
Refer if necessary'
30.
Manage if ENT
specialist available
Manage_________
Yes____________
Manage_________
Manage_________
Manage if ENT
specialist available
Manage
Manage
Yes
Manage
Manage
Manage
Investigate & manage Manage
if possible
Ref_sys-b
General Obstetric
Procedures___________
Tear & Episiotomies
Repair
Repair
Repair
Repair
Repair
Craniatomy (Dead foetus, Yes
Yes
Yes
Yes
Yes
Hydrocephalus)________
Low Forceps Delivery
Tes
Yes
Yes________________ Yes
Yes
Vaccum Extraction
Refer
Yes
Yes______________ Yes
Yes
Breach Deliveries______ Refer
Refer
Refer if complicated
Manage
Manage
Manual Removal of
Refer
Refer
Manage if Anaesthetist Manage
Manage
Placenta______________
available___________
Inversion of the Uterus
Refer
Refer
Refer
Refer if complicated Manage
• If trained in thoraci surgery for one or two months # Refer all major Thoracic procedures to tertiary level $ refer to tertiary' level
Scan & advanced management.
Condition/Procedure
@ Refer to tertiary level for CT
Secondary Level Hospitals
PHC
Community Hospital
30Beds
Community Hospital
50Beds
Refer__________
Conservative
D&C_________
Stabilize & Refer
Manage
Conservative
D&C
Laparotomy
Manage
Conservative
D&C
Laparotomy
Yes. Arrange special
programmes_______
Yes. Arrange special
programmes_______
Diagnosis &
Management______
Diagnosis &
Management______
Manage
PAP Smear Biopsy
&manage
Sub-district Hospital
100 Beds
OBG________________
Rupture of Uterus______
Threatened/or Incomplete
Abortion_____________
Ruptured Ectopic
Pregnancy____________
Female Sterilization,
IUD *________________
Vasectomy, Laproscopic
Sterilization *_________
Manstrual Irregularities
Refer
Refer_________
Conservative
D&C_________
Stabilize & Refer
Yes. Arrange special
programmes_______
Yes. Arrange special
programmes_______
Refer
Yes. Arrange special
programmes_______
Yes. Arrange special
programmes_______
Refer
Infertility
Refer
Refer
Yes. Arrange special
programmes_______
Yes. Arrange special
programmes_______
Diagnosis &
Management______
Refer
Planned Surgery for
Prolapsed UT, DUB etc.
Cervical Erosion
Refer
Refer
Refer
Yes. Arrange special
programmes_______
Yes. Arrange special
programmes_______
Diagnosis &
Management______
Diagnosis &
Management______
Manage
Refer
Refer
PAP Smear Biopsy
PAP Smear Biopsy
Refer
Refer
33
District Hospital
>250 Beds
Tertiary Hospital
Ref_sys-b
PHC
Malignancies
Refer
Refer to Tertiary level for
Surgery & Radio Therapy
Colposcopy & Hystoscopy Refer
Reconstructive Surgery Refer
Community Hospital
Community Hospital
Sub-district Hospital
______ 30Beds_____ ______ 50Beds_____ ______ 100 Beds____
Refer
Refer
Diagnosis & refer
District Hospital
>250 Beds
Diagnosis, manage &
refer
Refer
Refer
Refer
Manage, if possible
Refer
Refer
Refer
Manage, if possible
* Covered under IPP, CSSN Programme and also MCH & FW Programmes
ANAESTHESIOLOGY
LA
LA
Care of airway
equipment
Management of
general & G A
regional or S A if
anaesthesia possible
Management of
general & regional
anaesthesia
Management of
general & regional
anaesthesia
Ref_sys-b
‘E?M:‘E!Kg,E9<Cy
JfESWTH
CONTENTS
OBSTETRICS EMERGENCIES
1. IDENTIFICATION, MANAGEMENT AND REFERRAL
• Introduction
2. PARTOGRAM
3. ECTOPIC PREGNANCY
• Protocol for Management of Ectopic Pregnancy
4. ANTEPARTUM HAEMORRHAGE
• Placental abruption (accidental haemorrhage)
• Placenta Praevia
5. ECLAMPSIA
• Magnesium Sulphate Protocol
• Lytic Cocktail Regime or Diazepam
6. SCHEME OF MANAGEMENT OF RH -VE MOTHER
7. POST-PARTUM HAEMORRHAGE
• Other causes of Postpartum Collapse
8. RETAINED AND ADHERENT PLACENTA
9. INVERSION OF UTERUS
10. OBSTETRIC SEPTIC SHOCK
11. OBSTRUCTED LABOUR
• Shoulder Dystocia (Obstetricians Night-mare !)
• Shoulder Dystocia Management
12. RUPTURE UTERUS
• Causes
• Clinical features
• Management
• Prophylaxis
13. AMNIOTIC AND THROMBOEBOLISM
14. DEEP VEIN THROMBOSIS (DVT)
15. CONCLUSION
35
ref-obs-emrgn
OBSTETRIC EMERGENCIES
IDENTIFICATION, MANAGEMENT AND REFERRAL
INTRODUCTION :
In Obstetrics there is an extensive list of potential sudden and unexpected situations
which demand prompt action. Non Obstetricians callously characterise obstetrics as ‘hours of
boredom punctuated by moments of terror’. However, jokingly this has been stated, as
Obstetricians we always dread there moments of terror.
In modem Obstetrics, except for a few situations viz., amniotic fluid embolism, we can
forearm ourselves by anticipating there complications by early identification of certain warning
signals in each and every catastrophe.
Most of the emergencies can be prevented in a PHC set up by early reference of
patients with the high risk factors during the antenatal period to a major institution.
However, certain emergencies arise even in a low risk pregnancy. The PHC
obstetricians should be competent enough to identify and manage these emergencies to
prevent fatal sequelae.
A Partogram has been inserted under this topic for the use of all categories of hospitals
to record the details of Management of Labour of every delivery conducted. This helps to
review the outcome and assess the quality and reasons for any mishaps in the procedures
besides helping post-graduate and research studies.
36
ref-obs-emrgn
PARTOGRAM
o
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Date
Time
(In hrs.)
190
180
170
160
150
140
130
120
110
100
Fetai
Heart
Rate
(1/2 Hly)
90
80
70
X
c
■3
-2
E
7
6
-1
c
z
0
+1
2
1
+2
C
+3
Position
R z'
Effacement
x L R ,z
L R /
"L R
Contractions
One in
Strength
Duration
Syntocinon Drip - Drops / Min
Pulse
Bp
Other
Drugs:
•37
KHSDP-RLso 1998
ECTOPIC PREGNANCY
CLINICAL SUSPICION
OF ECTOPIC
GESTATION
Measure
HCG
r
- ve
+ ve
> Ultrasound
not available
>
LAPAROSCOPY
or LAPAROTOMY
ULTRASOUND
Gestational
sac in
UTERUS
Ectopic
Gestation <
Ruled Out
Gestational
sac in
TUBE
LAPAROTOMY or
LAPAROSCOPY
and Treatment
Doubtful
LAPAROSCOPY
38
ref-obs-CTnrgn
PROTOCOL FOR MANAGEMENT OF ECTOPIC PREGNANCY
Unruptured Ectopic
Ruptured Ectopic
Short period of Amenonhoea (+/-)
Attacks of Lowr Abdominal Colicks
+ Spotting of Blood P. V.
Black outs
Sub Acute or Chronic
Symptoms become Chronic
Dull aching plin
Difficult in defecation
Gentle Pelvic examination
Tender mass in adnexal
region
Tender Cervical movement
Hypochromic Anaemia
Pain & Bleeding reduces
by rest
Ultrasound (U/S)
Laparoscopy
Urme - b HCG
Start I.V. (Saline or Blood
Substitute)
<
Arrange for blood
B.T., C.T., + B%
Laparoscopic
management
LAPAROTOMY
Conservative Surgery
Salpingectomy
<■
Acute Rupture
Patient in shock
Pollar Disproportionate
to external bleeding
Tenderness, Rigidity &
Fullness in Labd.
Auto Transfusion
(5 part blood + 1 part
citrate solution = 3.8%)
Milcking out products
Linear Salpingostomy
Resection of Tube & end
to end Anastamosis
39
ref-obs-emrgn
ANTEPARTUM HAEMORRHAGE
PLACENTAL ABRUPTION (ACCIDENTAL HAEMORRHAGE)
Identification :
Painful bleeding per vaginum, sudden pain with sensation of fetal movements clinical
picture may be out of proportion to the amount of blood lost and patient may be in a state of
shock. If early treatment is not instituted the patient may succumb to shock, coagulation
failure and renal failure.
Placenta Praevia :
Painless bleeding per vaginum after 24 weeks and before delivery of the foetus.
Identification :
By ultrasound depending on condition of mother and foetus, expectant time of
management. No vaginal examination in outpatient or labour room.
Preferable to terminate at 38 weeks by LSCS in II, HI & IV degrees.
40
ref-obs-etnrgn
ANTEPARTUM HAEMORRHAGE
All A.P.H patient to be admitted
Gen. and abdominal examination
Hb, Blood group and Rh typing
Resuscitation
▼
Active interference
• Preg. 38 weeks +
• In labour
• Ex sanguinated
• Bleeding continues
• FHS absent
• Gross foetal malformation
Expectant Treatment
• Preg. <38 weeks
• G.C. - good
• No active bleeding
• FHS - good
38 weeks
t___
T
Interference in O.T
P.V. examination under G.A
r
Type I without complication
Type II anterior and posterior, III
&IV
A.R.M
Type I with complication.
Bleeding Continues
Caesarean section
r
Foetal condition good
Caesarean section
3
Premature or dead
Bring down a foot, scalp traction.
Destructive operation
41
ref-obs-enirgn
ECLAMPSIA
Identification by first occurrence of convulsions with hypertension and proteinum in a
pregnant patient.
It has been proved beyond doubt that the Magnesium sulphate regime is superior to
other modalities of treatment. Initial 4G loading dose (diluted and later drip at rate of IG/hr
would be ideal.
Prompt delivery should be done. Strict monitoring of fluid balance, urine output
(30ml/hr) patella reflex and respiratory rate are mandatory.
1. Admit & Resuscitate
2. Confirm diagnosis
•
Pregnancy
•
Convulsions
•
No h/o epilepsy
•
Blood pressure (>140 / 90)
3. Position - head end - Low and to one side.
4. Airway (Keep pharyngeal)
5. Oxygen, suction
6. CPR if necessary
7. Start IV line - (21 G) - Draw blood for investigation and start 10% dextrose drip.
8. Loading Dose IV Magnesium sulphate (4G +)
9. When Patient has been stabilised - clinical Obst. exam and ultrasound examinations to
assess foetal condition and maturity.
10. Monitor urine output
Indwelling foley’s catheter.
Respiration
Urine for proteins
Patellar jerk
11. Refer to district Hospital when stable.
MAGNESIUM SULPHATE PROTOCOL
1. Intravenous
Loading Dose - 4G I V in 15 mins. (25% or 50%) - Vol. 20 ML
2. Intra-muscular
•
•
•
•
5 G deep I M gluteal (Large bore needle)
Alternatively : I V as above and
I V 5 G Mg SO4 is 500 ml Ringer
Lactate at the rate of 1 G per hour.
42
ref-obs-emrgn
3. Maintenance dose
5G/4 hrs. I.M. or infusion
4. IV fluids 1.5 litre / 24 hrs.
R-Lactate
5. Monitor
•
•
•
•
Urine Output
Respirate
Patellar
P-Jerk strict
- 30ml per hour
- 18/mt
- Brisk jerk
- I/O Cart
6. Terminate pregnancy -
•
•
•
Vaginal delivery
(CIF criteria satisfied - Bishop’s score >6)
Caesarean section for all other conditions.
LYTIC COCKTAIL REGIME OR DIAZEPAM
If magnesium sulphate is not available.
•
Dilute pethidine lOOmg in 20 ml 5% Dextrose and administer slow TV. followed
by intra muscular chlorpromazine phenergan 4th hourly or
•
Diazepam
Dextrose.
lOmg slow IV followed by diazepam 40 mgm in 500 ml in 10%
43
ref-obs-einrgn
Scheme of Management of Rh -ve Mother
r
Rh -ve Mother
a) To detect Rh of father
b) Indirect Coomb’s test
1
No Antibody
Antibody present
(i) Genotype of father
(ii) Antibody titration at
weekly intervals
I
Primi gravid
Repeat at 36 wks.
Parous
Repeat at monthly
intervals from 24 wks
♦ Titre >1:8
♦ Father Heterozygous
♦ H/o Previous affection
AMNIOCENTESIS : Done at 28
wks. of no H/o previous affection
(or) 10 weeks prior to previous
still birth
Optical density of bilirubin by spectro photometry and plotted in liley’s chart.
a) Low zone
b) Mid zone
Pregnancy continued to
term.
Premature termination
beyond 34 wks.
c) High Zone ----
"► (i) Pregnancy >34 wks. - Termination
> (ii) <34 weeks - Intrauterine foetal transfusion. Terminate at
34 weeks.
44
ref-obs-emrgn
POST PARTUM HAEMORRHAGE
Distinguish between atonic and traumatic varieties. In atonic PPH, bimanuel
compression, Oxytocin IV IM and I V infusion mandatory.
General Management
I
I
Placenta Expelled
Placenta in Situ
I
I
Uterus Lax
Uterus Firm
•
•
Fundal
Massage
Explore Cervix &
Vagina
•
•
Fundal Massage
Normal Saline 500
with oxytocin 20 / 40 units
Inj. Methergine 1 amp I.V.
Placental seperation
I
• Bimanual Compression
• Draw blood for
investigation
• I.V. line normal saline
with oxytocin 20 units
• Inj. Methyl Ergometrine
(Methergine) lamp
(0.2 mg)
• Inj. Prostodin
(Prostaglandins) 1 amp
(25 mg) IM
• Still lax (10 minutes)
• Inj. Prostodin 1 amp +
• Inj. Oxytocin Myometrial
Yes
• Cervical Tears
• Vaginal Tears
• Calporrhexis - Refer
• Perineal Tears
I
r
No
I
I
Remove by
Brandt-Andrews
method
Manual removal
of placenta
I
Yes
No
I.V. Suture
Scan for retained
placental fragments
I
I
Yes
No
Curetage
Uterine Rupture
(Rule out &
Uterine rupture
partial Uterine
inversion)
Refer to District
Hospital
Arrangements
for surgical
management
Hysterectomy /
Internal iliac
artery ligation
45
ref-obs-emrgn
~
Other Causes of Postpartum Collapse
Haemorrhage
Amniotic
Pulmonary embolism
Acute cardiac failure
Pneumonitis
Pneumothorax
Cerebrovascular accident
Eclampsia
Hypoglycemia
Septicemia
RETAINED AND ADHERENT PLACENTA
Manual removal of placenta should be done if placenta is not expelled within 30
minutes. Adherent placenta can be treated conservatively, or surgically by hysterectomy
depending on clinical findings.
INVERSION OF UTERUS
Occur when there is uterine atony or mismanagement of third stage of labour.
Immediate reposition should be done. In case of failure, surgery at District Major Institute.
OBSTETRIC SEPTIC SHOCK
Definition :
Infection resulting in peripheral circulatory failure with inadequate tissue perfussion
leading to cell disfunction or death. A variety of gram negative anaerobes and gram positive
aerobes and anaerobes are implicated. As multiorgan involvement is common, Broad
Spectrum antibiotics are mandatory. Gentamycin, ampicillin and metrogyl could be a safe
regime. In a few cases mechanical ventilation may be needed. In uncontrolled cases surgical
modality of treatment may be necessary. Prompt delivery is a must.
46
ref-obs-cmrgn
OBSTRUCTED LABOUR
Shoulder Dystocia (Obstetricians Night Mare!):
Anticipate shoulder dystocia in a DOPE patient.
large baby and excessive weight gain.
Diabetes, obesity post-term/prior
Suspect and anticipate when there is prolonged second stage of labour. Oxytocin use
and midpelvic delivery.
Management:
Assess whesther bilateral, if unilateral perform Me Robert’s maneuver. If it fails
perform woods maneuver. If this also fails deliver the posterior arm final resort is Zavaelli
restitution Alert personel and deliver within 5 minutes.
When shoulder dystocia in anticipated, the obstetrician should mentally rehearse the
sequence of steps necessary to treat this problem and be ready to act in a logical step by step
fashion. Identify dope i.e,f (Diabetes, OBESE, Post-term, Excessive weight gain).
Step I: Note the time and have the minutes counted off.
1. Call anaesthesia and alert the operating room and call for help.
2. Do not pull the baby’s head.
3. Do not apply fundal pressure.
Step II:
1. Enlarge the episiotomy
2. Feel for posterior shoulder in the hollow of the sacrum.
3. If posterior shoulder is not found, it is bilateral shoulder dystocia and replace the head into
the vagina and perform caesarean section . Restitute the head to original position, flex and
apply upward pressure. (Zavanelli restitution)
Step III: Me Robert’s maneuver
1.
2.
3.
4.
Remove the mother’s legs from stirrups.
Abduct her legs and sharply flex them against her abdomen.
Ask your assistant to apply suprapubic pressure directed laterally and inferiorly.
Apply moderate traction on the fetal head to a count of 30.
Step IV: Oblique diameter :
1. Move shoulder from anter
posterior to oblique diameter of the inlet.
2. If there is no descent rotate posterior shoulder to anterior under the symphysis pubis and
simultaneously apply suprapubic pressure in the opposite direction.
47
ref-obs-emrgn
Step V:
If no progress extract the posterior arm. Sweep the posterior arm of the fetus across
the chest keeping the arm flexed at the elbow. Grasp the fetal hand and pull the hand of the
arm along the fetal head delivering the posterior arm. If unsuccessful proceed to step 6.
Step VI:
Zavanelli restitution and Caesarean section.
Meconium aspiration syndrome:
1. Amnio infusion before delivery (500ml of warm normal saline).
2. Nasopharyngeal aspiration before the first breath.
3. Endotracheal aspiration immediately after birth.
RUPTURE UTERUS
Identification : Scan rupture
Foetal distress, pain and tenderness over
uterine scan. Bleeding per vagina.
Rupture due to Obstructed labour
Identification of Bandl’s ring stretched lower
segment recersion of presenting part after
uterine rupture.
In complete rupture foetal parts will be felt superficial, uterus conton will be lost and
patient would be in a state of shock.
Definition :
Dissolution of continuity of uterine wall any time beyond 28 wks. Of pregnancy.
1) Complete - Laceration extends into peritoneal cavity common in upper segment.
2) Incomplete- Peritoneum is intact common in lower segment.
Causes:
1. During Pregnancy :
•
•
•
•
•
•
•
•
•
Multipara (because of increased fibrosis)
Previous C/S sear, Hysterotomy
Pregnancy in rudimentary bom
Previous H/o curettage of puerperial ut.
Manual removal of placenta (MRP)
Myomectomy
Fall / Blow
Adenomyosis
Perforating mole
48
ref-obs-emrgn
2. During Ordinary labour :
•
•
•
In addition to above causes
Acquired cervical stenosis
Misuse of oxytocic drugs
3. During Protracted Labour :
•
•
•
•
•
•
•
Bandl’s ring
Pelvic deformity
Malpresentations: Brow
Shoulder
Hydrocephalus
Iatrogenic trauma in delivering foetus
Internal version / failed forces/ destructive operation
MRP
4. Rupture uterus:
•
During Pregnancy
- Spontaneous
- Scar rupture
•
During Labour
- Scar rupture
- Obstructed labour
Clinicalfeatures:
•
•
•
•
•
H/o giving way of uterus
Severe abdominal pain, supra pubic pain.
Shock / collapse
H/o Blood stained urine.
Bladder tenesumus - in silent rupture.
On Examination :
•
•
•
•
Foetal parts palpable superficially, uterine contour absent.
Localised fullness + Tenderness over uterine scar, broad ligament
Vaginal Hemorrhage
Features of shock
Silent rupture can also occur without any symptoms, especially in previous caesareans.
Management:
•
•
Resuscitation and Laparotomy should be done simultaneously
On Laparotomy
1) Closure of the rent with deep sutures + Tubectomy
2) Hysterectomy - to stop hemorrhage if uncontrolled by other
means.
49
ref-obs-emrgn
Prophylaxis :
•
•
Rupture during protracted labour can be avoided by early recognition of problem
and use of proper method of delivery.
In case of anticipated rupture - C/S done at 38 weeks.
AMNIOTIC AND THROMBOEBOLISM
Sudden and mostly fatal (80%) catastrophe in Obstetrics.
Treat respiratory distress and DIG which accompany this condition.
DVT (DEEP VEIN THROMBOSIS)
Can be diagnosed clinically and confirmed by Doppler ultrasound and venography.
Pulmonary embolus can be suspected by a VQ scan mismatch ad confirmed by
arteriography.
Treatment: • Heparin
• Oxygen
• Maintenance of cardiac output
• Blood pressure
• Correction of coagulopathy.
CONCLUSION
Thus, most of the Obstetric emergencies are concerned with massive haemorrhage, be
it during pregnancy or Labour, Professional Knowledge and Skill with prompt action can save
almost all the lives.
Occasionally encountered emergencies like shoulder dystocia is an Obstetrician’s
nightmare. Rehearse ad practice the steps again and again. Display the protocol in the Labour
room. Identify the patients at risk and refer for early Caesarean section.
Emergencies like eclampsia and medical complications should be thoroughly mastered
by every PHC medical officer.
50
ref-obs-emrgn
HYPERTENSION
Simple, uncomplicated
Diastole
120
Hypertensive urgencies
• Asymptomatic /
symptomatic
Hypertension
(BP >240 mmHg)
> 130
Manage at all levels
Manage at all levels
Hypertensive emergencies
Diastole >130
• Hypertensive / encephalopathy
• Hypertensive / nephropathy
• Cerebral haemorrhage
• Eclampsia
• Pulmonary infarction
Aim : Reduce BP within 1 hour.
Reduce BP to safe limits at PHC
Malignant Hypertension
High BP with encephalopathy /
nephropathy and papillaedema
Manage at 50 bed hospitals with
parenteral infusion of antihyper
tensive which requires continuous
monitoring.
Refer
52
Ref-erngpcs
ANGINA PECTORIS
Angina Pectoris
Stabilize at primary level by
• Assurance
• Rest
• Sublingual nitroglycerin
Myocardial Infarchi
• Assure patient
• Keep patient strictly in bed
• Administrator oxygen
• Sublingual nitroglycerin, if no response, I V,
Morphine sulphate
Manage at District Hospital in ICU
Refer
Manage at District Hospital
•
•
•
53
With Throbolytic agents (Streptikinese, Urinkinese)
Antiarrhythmic prophylaxis
Anticoagulents.
Ref-emgncs
EPILEPSY
Epilepsy
Recurrent seizures
•
Abnormal mental status or focal neurologic symptoms postictally.
PHC Level
•
Control generalised seizures by giving phenytoin / carbamazepine / phenobarbitane
Refer to District Hospital
Investigate (FBC, Blood glucose, LET, STS etc.,)
Refer to Neurophysician for detailed investigation (ECG, imaging) and management.
54
Ref-emgncs
HEAD INJURIES
1. Maintain airway patency by keeping the patient in the lateral position to prevent the
tongue from falling back. Clear the mouth and oropharynx., of secretions by means of suction.
Introduce an oro-pharyngeal or naso-pharyngeal airway. Perform endotracheal intubation if
necessary.
2. Ensure adequate gaseous exchange by providing oxygen,
ventilation using the Ambu bag if necessary.
Give positive pressure
3. Check the vital signs. The presence of hypo-tension is more likely to be due to injuries
other than head injury. These may be external or internal injuries. Therefore it is essential to do full
physical examination.
4. Evaluate the severity of the head injury using the Glasgow Coma Scale.
Eye Opening
Verbal Response
Motor Response
El No eye opening________
E2 Eye opening to pain
E3 Eye opening to call_____
E4 Spontaneous eye opening
VI No verbal response
V2 Incomprehensible
V3 Inappropriate words
V4 Confused________
V5 Oriented
Ml No motor response
M2 Abnormal extensor
M3 Abnormal flexion
M4 Withdraws______
M5 Localises________
M6 Obeys commands
A GCS RATING OF LESS THAN 7 OR 8 DENOTES COMA
5. The presence of pupillary asymmetry denotes incipient herniation. This requires urgent
management with anti edema measures. In such a case rule out direct optic nerve or III cranial
nerve injury.
6. Start an IV line. Anti edema measures and anticonvulsants may be given in consultation with the
neurosurgeon.
7. Raise the head end of the cot by 30 degrees.
8. In case of local scalp injury - shave the area liberally, wash thoroughly with saline and probe the
area gently with a gloved finger. Do not use any sharp instruments or probes for this purpose.
Do not try to dislodge fractured fragments of skull. Suture the wound after lavaging with
hydrogen peroxide and povidone iodine (Betadine / Wokadine).
9. In paraplegic / quadriplegic patients - do not try to extend or move the neck eg., during
intubation. Put the patient on a flat board with sand bags on either side of the head to prevent
movement. Put a cervical collar before shifting the patient anywhere.
10. Before doing any investigations - Eg. X-ray, CT Scan, consult the Resident on duty in
Neurosurgery or the Neurosurgeon, if available or refer the patient to neurosurgeon unit.
55
ref-emgncs-l
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TWtf^WCDISTRJCT
1st Level
Referral - Zoning of PHC and CHC Hospitals within District
1. District Hospital, Tumkur
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
2. Taluk Hospital, Gubbi
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
3. Taluk Hospital, Kunigal
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
4. Taluk Hospital, Tiptur
1.
2.
3.
4.
5.
6.
7.
8.
64
Kyatasandra
Urdigere
Mallasandra
Bellavi
Sirivara
Guluru
Honnadike
Nagavalli
Hebbur
Tumkur
Hosakere
Cheluru
Tyagaturu
Nittur
Kadaba
Kallur
Doddachangavi
Chikkakunnula
Chandrashekarapura
Gubbi
PHC - Bidare
PHC - M M Kote
Baktarahalli
Yadayuru
Amruttur
Hurkidurga
Chowdanakuppe
Yedavani
Huttaridurga
Kunigal
K.Honnaniachanayya
Halapanagudda
Teredakupse
Halkurike
Halepalya
Aralaguppe
Honnavalli
Suguru
Nonavinakere
Hongelakshmikshetra
Biligere
refcys-tumkl
5. Taluk Hospital, Turuveker
1.
2.
3.
4.
5.
6.
7.
8.
9.
Banasandra
Turuvekere
Dandinashivara
Maya^andra
Mavinakere
Dabbegatta
Kanattur
Shettigondanahalli
Talakere
6. Taluk Hospital, Chikkanayakanahalli
1.
2.
3.
4.
5.
6.
7.
8.
9.
Chikkanayakanahalli
Dasudi
Huliyaru
Timmanahalli
Handanakere
Kanaikere
Matigatta
Shettikere
PHC - J C Pura
7. Taluk Hospital, Pavagada
1.
2.
3.
4.
5.
6.
7.
8.
Pavagada
Tirumani
Y N Hosakote
Lingadahalli
Kotegudda
Mangalavada
Venkatapura
KTHalli
8. Taluk Hospital, Madhugiri
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Madhugiri
Hosakere
Midigeshi
IDHalli
Muddenahalli
Kodigenahalli
Kodlupura
Maruvekere
Neralakere
Byalya
Dodderi
Badavanahalli
Kavandala
65
refsys-tumkl
FLOW CHART SHOWING REFERRAL ZONES AND CHAIN FOR TALUK HOSPITAL, TIPTUR
LEVEL
I
PHC
Halkurike
Aralaguppe
Nonavinakere
20
ii
CHC
ni
TALUK
HOSPITAL
13
Biligere
Suguru
20
6
Hongelakshmikshetra
Honnavalli
Halepalya
zo
5
13
13
TIPTUR
i
IV
DISTRICT
HOSPITAL
TUMKUR
NOTE : Numbers on the lines represent distance in kms
TO
I
I
I
I
1
I
u
I
1
I
I
I
I
I
1
I
FLOW CHART SHOWING REFERRAL ZONES AND CHAIN FOR TALUK HOSPITAL, CHIKKANAYAKANAHALLI
LEVEL
I
PHC
Dasudi
Kanaikere
Mattigatta
Timmanahalli
35
Huliyaru
Shettikere
J C Pura
za
32,
io
n
CHC
in
TALUK
HOSPITAL
IV
DISTRICT
HOSPITAL
Handanakere
zo
6
CHIKKANAYAKANAHALLI
/
TUMKUR
NOTE : Numbers on the lines represent distance in kms
71
II
FLOW CHART SHOWING REFERRAL ZONES AND CHAIN FOR TALUK HOSPITAL, TURUVEKERE
LEVEL
I
PHC
Shettygondanahalli
Kanattur
Mayasandra
U
II
CHC
HI
TALUK
HOSPITAL
IV
DISTRICT
HOSPITAL
Mavinakere
Talakere
25
15
Dabbegatta
Dandinashivara
Banasandra
20
TURUVEKERE
TUMKUR
NOTE : Numbers on the lines represent distance in kms
72
2^
19
16
FLOW CHART SHOWING REFERRAL ZONES AND CHAIN FOR TALUK HOSPITAL, MADHUGIRI
LEVEL
I
PHC
ID Halli
Muddenahalli
Byalya
30
n
CHC
in
TALUK
HOSPITAL
IV
15
Kavanadala
Hosakere
^8
DISTRICT
Kodigenahalli
Kodlupura
u
Midigeshi
lo
Badavanahalli
Dodderi
Maruvekere
23
Neralekere
2^
£
20
16
MADHUGIRI
!
TUMKUR
HOSPITAL
NOTE : Numbers on the lines represent distance in kms
73
FLOW CHART SHOWING REFERRAL ZONES AND CHAIN FOR TALUK HOSPITAL, PAVAGADA
LEVEL
I
PHC
Tirumani
35
II
CHC
HI
TALUK
HOSPITAL
Y.N. Hosakote
Lingadahalli
Kotegudda
Mangalavada
22,
16
K T Halli
Venkatapura
50
25
PAVAGADA
!
IV
DISTRICT
TUMKUR
HOSPITAL
NOTE : Numbers on the lines represent distance in kms
V4
FLOW CHART SHOWING REFERRAL ZONES AND CHAIN FOR TALUK HOSPITAL, SIRA
LEVEL
I
PHC
Chiratehalli
Doddahulikunte
Taruru
Bukkapattana
Pattanayakanahalli
30
CHC
in
TALUK
HOSPITAL
Kallambella
2z
18
II
Baraguru
18
Dodda Agrahara
Tavarekere
20
12
20
8
SIRA
i
IV
DISTRICT
HOSPITAL
TUMKUR
NOTE : Numbers on the lines represent distance in kins
75
t
FLOW CHART SHOWING REFERRAL ZONES AND CHAIN FOR TALUK HOSPITAL, KORATEGERE
LEVEL
I
PHC
Yelachagere
Kolala
Thovinakere
Elerampura
Holavanahalli
26
12.
n
CHC
in
TALUK
HOSPITAL
rv
DISTRICT
HOSPITAL
Tita
Bukkapattana
2.0
22.
9
S
KORATAGERE
i
TUMKUR
NOTE : Numbers on the lines represent distance in kms
76
I
I
I
I
I
I
I
I
TO5Tl9<g5
I
I
Staffing Norms for Districts and Sub-District Hospitals
Category
30
1. Surgeon____________________
2, Deputy Civil Surgeon (R.M.O.)
3. Assistant Surgeon_____________
4, Dental Assistant Surgeon_______
5. Nursing Superintendent Grade -1
6. Nursing Superintendent Grade - II
7. Nursing Tutor________________
8, Staff Nurse__________________
9. Physiotherapist_______________
10. Pharmacist Grade I____________
11, Pharmacist Grade II___________
12. Senior Lab Technician_________
13, Junior Lab Technician__________
14. Lab attendants_______________
15, Refractionist_________________
16, Radiographer________________
17. X-ray Technician_____________
18, Dark Room Assistant__________
19. Lay Secretary________________
20. Office Superintendent__________
21. Senior Assistant / FDA_________
22, Junior Assistant / SPA_________
23. Typist-Cum-Clerk_____________
24, Medical Record Technician_____
25, Electrician___________________
26. Carpenter___________________
27, Plumber_____________________
28, Cook_______________________
29. Helper to cook_______________
30, Group D____________________
31, Driver____________________ _
32. Psychiatrist__________________
33, Clinical Psychologist___________
34, Psychiatric Social worker_______
35, ECG Technician______________
36. Social Worker (Skin VD)
£
1
Bed Strength
50
100
1
1
1
5
8
1
1
1
1
6
10
2
2
1
1
1
5
5
60
2
6
3
2
1
20
1
1
2
1
1
1
1
1
1
1
2
3
1
1
1
1
1
1
1
1
1
2
10
1
1
x
2
1
1
2
15
2
j_
2_
2_
1
1
2
25
2
1
77
>250
1
1
21
4
2
1
2
1
1
2
2
3
2
2
1
1
1
2
4
50
4
1
1
1
1__
2
refsys-tumkl
Staff position of District Hospital, Tumkur District as on 01-03-1999
Doctors :
No. of Sanctioned Posts : 32
SI. No.
Name
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Dr. ¥ N Raghavendra Rao
Dr. S Venkatachalaiah Shetty
Dr. M R Srinivas Yogan
Dr, M C Yogimat_________
Dr. M G Doddegoudar_____
Dr. K V Suryaprabha______
Dr, P S Komala___________
Dr. K T Doddathimmaiah
Dr. H D Indrakumar_______
Dr. H C Mruthyunjaya_____
Dr. Nadaf_______________
Dr. Shashikala____________
Dr. Ashok Sharaf_________
Dr. M H Govindraju_______
Dr. K U Tiwari________ i
Dr. S V Srinivas__________
Dr. Syed Ali Akbar________
Dr. G Raj anna____________
Dr. Kalleshaiah C K________
Dr. Shivaram_____________
Dr. V Govindarajalu_______
Dr. K P Kalleshaiah________
Dr. V G Ramesh__________
Dr. H Siddaiah____________
Dr. Sangitha Sharaf________
Dr. M R Krishnaiah
No. of Working : 23
No. of Vacant
: 09
Qualification
Speciality
Designation
Working since
OOD / contract
MBBS, MD_____
MBBS, MD_____
MBBS, MD_____
MBBS, MS_____
MBBS, MS_____
MBBS, DGO
MBBS, DGO
MBBS, D.Ortho
MBBS, D. Ortho
MBBS, DCH
MBBS, DCH
MBBS, DA_____
MBBS, MD (Anaes.)
MBBS, DVD
MBBS, DMRD
MBBS, MD (Anaes.)
MBBS, POMS
MBBS, MS (Ortho.)
MBBS, DCH
MBBS, MS_____
MBBS, ENT_____
MBBS, POMS
MBBS, DCH
MBBS, POMS
MBBS, DCP
MBBS, ENT
Physician
Physician____
Physician____
Surgeon_____
Surgeon_____
OBG________
OBG________
Orthopaedician
Orthopaedician
Paediatrician
Paediatrician
Anaesthetist
Anaesthetist
Skin Specialist
Radiology
Anaesthetist
Eye Specialist
Orthopaedician
Paediatrician
Surgeon_____
ENT Specialist
Eye Specialist
Paediatrician
Eye Specialist
Pathologist
ENT Specialist
Dist. Surgeon
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr, Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
24-06-98
30-05-90
02-12-98
27-07-95
10- 06-93
23-10-98
11-12-97
08-06-95
08-07-91
11-12-97
14- 08-97
11- 12-97
01-08-97
17-09-92
08-12-97
08-06-90
26-07-97
10-12-97
10-12-97
01-07-98
03-02-99
13-08-98
15- 12-97
12- 12-97
01-08-97
01-04-98
OOD
7^
Stfposn-tumk
Paramedical Staff:
Staff
Pharmacist
X-ray Technician
Lab Technician
Nursing Superintendent
Nursing Superintendent
Sr. Staff nurses______
Staff nurses_________
Refractionist________
Lab. Assistant_______
Dark room assistant
Sweeper____________
Cook______________
Dhobi______________
ANM______________
LHV
__________
Group D____________
Health Assistant (Male)
Health Assistant (Female)
Sanctioned
TLGH
KHSDP
Senior
Junior
Senior
Junior
Senior
Junior
Grade I
Grade II
Senior
Junior
Senior
4
2
1
_1_
2
4
Working
TLGH
KHSDP
Vacant
TLGH KHSDP
Working since
Remarks
4
2
1
j_
1
1
1
3
1
1
1
1
9
1
41
3
25
1
17
5
4
11
4
74
1
1
2
1
6
40
3
25
1
13
5
1
11
3
56
3
1
4
3
1
18
1
2
1
79
Stfposn-tumk
Staff position of Community Health Centre, Kunigal, Tumkur District as on 15-03-1999
Doctors :
No. of Sanctioned Posts
No. of Working
No. of Vacant
SI. No.
1.
2.
3_
4,
5_
6.
7.
8.
8
6
2
Name
Dr. K.R, Shivaprasad
Dr. D. Shivananda
Dr. K. Siddaiah
Dr. A.E. Govindaraju
Dr. B, Venkatesh
Dr. M.R. Krishnaiah
Qualification
Speciality
Designation
Working since
MBBS, MD
MBBS, DGO
MBBS, D.Ortho.
MBBS, MS (Oph )
MBBS, MS (GS)
MBBS (DLO)
Physician______
Gynaecologist
Orthopaedics
Ophthalmologist
General Surgeon
E.N.T.
TMO
MO_______
MO_______
MO_______
MO_______
Sr. Specialist
LMO
13-07-98
28-10-98
03-07-98
02-08-95
20-07-95
OOD / contract
OOP to GH, Tumkur
vacant
vacant
Dentist
Paramedical Staff:
Staff
Pharmacist
X-ray Technician
Lab Technician
Staff Nurses
Sanctioned
KHSDP
Senior
Junior
Senior
Junior
Senior
Junior
Working
KHSDP
1
1
1
1
1
Vacant____
KHSDP
Remarks
1
1
2
Working since
5
1
1
1
5
3Q
1
Stfposn-tumk
Staff position of General Hospital, Tiptur, Tumkur District as on 12-03-1999
Doctors:
No. of Sanctioned Posts
No. of Working
No. of Vacant
SI. No.
10
08
02
Name
Qualification
1.
Dr. T H Rangappa
2.
Dr. V N Ravindranath Singh
3_
4.
5_
6.
Dr. B N Tejpal_____
Dr. C L Prahalad
Dr. H A Ramegowda
Dr. B N Vishwanath
7.
Dr. B S Ramachandra
Dr. M N Ramakrishna
Dr. Rajashekhar
MBBS, DCH,
MD___________
MBBS, MS (Gen.
Surg)
MBBS, DCH
MBBS, D.Ortho
MBBS, D. Ortho
MBBS, DOMS,
MS___________
MBBS, MD
BPS, MPS
MBBS, DA
£
9.
Speciality
Designation
Working since
12-12-97
General Surgery
Administrative
Medical Officer
Sr. Specialist
19-06-95
Paediatrician
Orthopaedician
Orthopaedician
Eye Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
Sr. Specialist
03-09-90
22-11-97
12-08-98
07-01-99
General Medicine
Dental Surgeon
Anaesthetist
Sr. Specialist
Sr. Specialist
Specialist
01-01-99
22-08-96
07-05-99
Paediatrician
81
OOD / contract
Stfposn-tumk
Paramedical Staff:
Staff
Pharmacist
X-ray Technician
Lab Technician
Nursing Superintendent
Nursing Superintendent
Sr. Staff nurses______
Staff nurses_________
Refractionist________
Lab. Assistant_______
Dark room assistant
Sweeper____________
Cook______________
Dhobi______________
ANM______________
LHV
Group D____________
Health Assistant (Male)
Health Assistant (Female)
Sanctioned
TLGH
KHSDP
Senior
Junior
Senior
Junior
Senior
Junior
Grade I
Grade II
1
1
1
1
1
1
2
1
1
6
9
1
1
1
2
4
2
1
18
1
4
1
Vacant
TLGH KHSDP
Working since
Remarks
1
8
2
1
2.
2
3
2
3
Senior
Junior
Senior
Working
TLGH
KHSDP
3
9
1
15
3
9
1
Stfpocii-tumk
Staff position of Primary Health Centre, Turuvekere as on 17-02-1999
Doctors :
No. of Sanctioned
No. of Working
No. of Vacant
SI. No.
1.
2,
3.
2 + 2 (KHSDP) = 4
2 + 1 (KHSDP) = 3
0 + 1 (KHSDP) = 1
Name
Qualification
Speciality
Designation
MBBS
MBBS
MBBS, DCH
Paediatrics
THO_______
LMO_______
Asst. Surgeon
Sanctioned
KHSDP
Working
KHSDP
Dr. G. Shivaram
Dr. Sreelatha C.H
Dr. B. Nanjappa
Working since
OOD / contract
28-05-90
June-93
Aug -98
Paramedical Staff:
Staff
Pharmacist
X-ray Technician
Lab Technician
Staff nurses
Senior
Junior
Senior
Junior
Senior
Junior
1
1
1
1
1
1
1
4
3
83
Vacant____
KHSDP
1
Working since
Remarks
1
Stfposn-tumk
Staff position of General Hospital, Gubbi, Tumkur District as on 12-04-1999
Doctors :
Sanctioned Posts
Working
Vacant
SL. No.
: 4
: 4
: 0
Name
Qualification
Speciality
1
Dr. Chandrappa
MDBS, DCH
Children Specialist
2
Dr. S. Veerasangaiah
MBBS, DTCH
Chest & T B
Specialist
3
Dr. Nagapushpa
MBBS
4
Dr. Rangaswamy
MBBS, DCH
Children Specialist
Designation
Taluk Health
Officer_____
Sr. Specialist
Working since
OOD/ contract
10-11-98
20-02-98
Lady Medical
Officer_____
MOH
20-02-98
10-09-98
Paramedical Staff:
Staff
Pharmacist
X-ray Technician
Lab Technician
Staff nurses
Sanctioned
KHSDP
Senior
Junior
Working
KHSDP
Vacant____
KHSDP
Working since
Remarks
1
2
2
2
2
2
6
6
84
1
Stfposn-tumk
Staff position of General Hospital, Chikkanayakanahalli, Tumkur District as on 12-04-1999
Doctors:
Sanctioned Posts
Working
Vacant
SL. No.
2
2
0
Name
Qualification
1
Dr. D.C. Mahadeva
MDBS, DCH
2
Dr. T.D. Sateesh
MBBS
Speciality
Children Specialist
Designation
Administrative
Medical Officer
MOH
Working since
OOD/ contract
26-03-98
20-01-98
Paramedical Staff:
Staff
Pharmacist
X-ray Technician
Lab Technician
Staff nurses
Sanctioned
KHSDP
Senior
Junior
Working
KHSDP
1
i
2
2
2
2
2
4
4
8'5
Vacant
KHSDP
Working since
Remarks
Stfposn-tumk
Staff position of General Hospital, Madhugiri, Tumkur District as on 12-04-1999
Doctors:
Sanctioned Posts
Working
Vacant
SL. No.
2
3
Name
Dr. Choudhary
Dr. Lakshmi Raja
5
1
4
Qualification
Speciality
Designation
MS
DGO
General Surgery
Gynaecologist
Ophthalmologist
Sanctioned
Working
Vacant
4
2
1
o
1
2
3
2
Working since
OOD/ contract
Paramedical Staff:
Staff
Staff Nurses
X-ray Technician
Lab Technician
Pharmacist
Senior
Junior
Senior
Junior
1
0
86
Stfposn-tumk
Staff position of Community Health Centre, Pavagada, Tumkur District as on 06-03-99
Doctors:
No. of Sanctioned Posts
No. of Working
No. of Vacant
SI. No.
_L
2.
3.
: 5
: 3
: 2
Name
Qualification
Dr. T.G. Dayananda_______
Dr. G.R.. Manjunatha Gowda
Dr. N.S. Mamatha Devi
Speciality
MDBS, MD
MBBS, MD
MBBS, MD
Designation
Working since
Medical Officer
Medical Officer
LMO
24-06-93
____ Vacant
CHC
KHSDP
Working since
OOD / contract
12-01-98
12-01-98
Paramedical Staff:
Staff
Pharmacist
X-ray Technician
Lab Technician
Staff nurses
Sanctioned
KHSDP
CHC
Senior
Junior
Senior1
Junior
Senior
Junior
Working
KHSDP
CHC
Remarks
1
1
1
1
1
1
1
1
3
3
2
3
87
1
Stfposn-tumk
Staff position of Primary Health Centre, Sira, Tumkur District as on 16-01-1999
Doctors:
No. of Sanctioned Posts
No. of Working
No. of Vacant
8
4
4
SI. No.
Name
Qualification
Speciality
Designation
Working since
OOD/Contract
1.
2.
3.
Pr. B. Radhakrishna______
Pr. K V, Ramesh
Pr. R.T, Chandrashekarappa
Pr. N. Gurudutt__________
Pr. G.R. Ramesh_________
Pr. Manjuladevi
B.Sc., MBBS, MS (GM)
MBBS, P. Ortho______
MBBS, MS (Ortho)
MBBS, MP (Anae.)
MBBS______________
MBBS
Surgeon_____
Orthopaedician
Orthopaedician
Anaesthetist
Sr. MO / Specialist
Specialist_______
Specialist________
Anaesthetist
08-08-97
27-11-97
16-11-98
26-12-98
2 years
2 years
KHSDP
Contract OOP
Contract OOP
Working since
Remarks
4.
5.
6.
KHSDP
Paramedical Staff:
Staff
Pharmacist
X-ray Technician
Lab Technician
Staff Nurses
Sanctioned
KHSPP
Senior
Junior
Senior
Junior
Senior
Junior
Working____
KHSPP
1
1
1
1
1
1
1
3
Vacant_____
KHSPP
1
3
Sttposn-tumk
Staff position of General Hospital, Koratagere, Tumkur District as on 08-03-1999
Doctors:
No. of Sanctioned Posts
No. of Working
No. of Vacant
SI. No.
1.
2_
3.
4.
7
4
3
Name
Qualification
MBBS, (MD)
MBBS
MBBS, MS
MBBS, DCH
Dr. Muddukrishna
Dr. Gadag Nagappa
Dr. G.G. Batageri
Dr. K G. Ramappa
Speciality
Designation
Working since
General Medicine
Surgery
Paediatrics
Medical Officer
Sr. MO
Surgeon______
Paediatrician
07-91
08-97
09-98
10-97
Working
TLGH
KHSDP
____ Vacant
TLGH
KHSDP
Working since
OOD / contract
Paramedical Staff:
Staff
Pharmacist
X-ray Technician
Lab Technician
Staff nurses
Sanctioned
TLGH KHSDP
Senior
Junior
Senior
Junior
Senior
Junior
Remarks
1
1
1
2
3
3
1
2
3
89
1
Stfposn-tumk
Annexure
Communication Facilities in Health Institution of Tumkur District
Health Facility
Taluka
Telephone
District Hospital, Tumkur
Tumkur
DHO : 0816-78387
Fax
DS : 0816-78377
® : 0816-78437
CHC - Chikkanayakanahalli
Tumkur
08133-27211
CHC - Gubbi
Tumkur
08131-22271
CHC - Koratagere
Tumkur
08138-2146
CHC - Kunigal
Tumkur
08132-20450
CHC - Madhugiri
Tumkur
08137-32419
CHC - Pavagada
Tumkur
08136-20301
CHC - Sira
Tumkur
08135-25212
CHC - Tiptur
Tumkur
08134-51004
CHC - Turuvekere
Tumkur
08139-47317
90
refeys-tumkl
‘£Q‘U I'J’M'EM'.r 9<P!RMS
Name of the Hospital: District Hospital, Tumkur
SI No.
Name of the equipment
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
ECG
Cardiac Monitors____________
Defibrilators
_____________
Phototherapy Unit_____________
Foetal Monitor
____________
Ventilators
______________
Boyles Apparatus with flou tech
Slit Lamp
______________
Emergency Resuscitation Kit
Baby Emergency Resuscitation Kit
5 AMC ___________________
Dialysis Machine_____________
Automist
_______________
Microscope
_________
Photo Electric Calorimeter______
Spectro Photometer___________
Water Bath _________________
Hot air oven_______________
Distilled Water Stills___________
Glucometer
____________
Microtom
AC
___________________
Water coolers ______________
Two body mortuary____________
Generator 62.5 ______________
Intensifying screens 17 x 14______
Intensifying screens 15 x 12______
Intensifying screens 12x10______
Intensifying screens 10x8_______
DD&C____________________
MTP _________
Cervical Biopsy _____________
Evacuation___________________
Epiosotomy
____________
Delivery pack ______________
Venesection_____ ____________
Caesarean section_____________
P N Sterilization______________
Incision & Drainage____________
Abdominal Hysterectomy________
Vaginal Hysterectomy__________
Vagotomy___________________
Hemorrhoidectomy
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
Qty Supplied
91
____
___ 3
___ 2
___ 1_
___ 1_
Whether Installed
Yes
Yes
Yes
Yes
Yes
2
Yes
____
____ ]_
1
___
__ 4
___ 1_
__ 2
__ 2
___ 1_
___ 1_
___ 1_
___ 1_
__ 1_
___1_
__ 1_
__ 1_
___1_
__ 2_
__ 1_
__ 2_
2
__ 3_
__ 3_
_ £
_ £
- 4
__ 2_
4
_ £
_ £
_ £
_ £
__ 2_
_ £
_ £
__ 2_
2
refsys-tumkl
44.
45.
46.
47.
48.
49.
50.
.51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
Appendectomy____________
Hydrocele
___________
GJ______________________
Suturing tray
_________
Suture removal_____________
L P tray_____
Cholecystectomy
________
Thyrodectomy__________ _
Catherization tray__________
Needling & Cataract (13 items)
Cataract Operation_________
Enucleation ______________
Probing of Lacrymal Passages
Foreign Body in A C________
IM Nailing_____________
S P Nailing
____________
D C Plating _____________
Dynamic Hip Screw Fixation
Fixation of Radius & Ulna
A M Prosthesis_____________
Endo Laryngea Microsurgery
Tracheostomy______________
ENT Kit__________________
E E Set (7 items)___________
General Anaesthesia Kit______
General Orthopaedic Kit______
Dental Kit ______________
Adult laryngoscope__________
Baby laryngoscope__________
P Hammer ______________
TD______________________
Nebulizer_________________
Fire extinguisher___________
500 mA X-ray ____________
300 mA X-ray______________
100 mA X-ray
__________
60 mA X-ray______________
Tata Sumo___________ __
O T focussing______________
O T Mobile____________ _
O T Lights (shadowless)______
Pulse oxymeter_____________
Centrifuge_________________
Auto analyser______________
Oxygen Cylinder A__________
Oxygen Cylinder R with T
Nitrous Oxide A
2
2
2
4
4
8
2
2
8
4
4
4
4
4
2
2
1
1
1
2
2
4
4
4
4
4
3
6
4
10
26
4
7
1
1
1
1
1
1
2
2
1
2
1
2
1
2
reftyB-tumk 1
91.
92.
93.
94.
95.
Nitrous oxide B____________
Nitrous oxide R with T______
Autoclave horizontal________
Autoclave vertical__________
Workshop maintenance vehicle
j_
2
2
1
Name of the Hospital: Korategere, Tumkur
SI No.
Name of the equipment
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
ECG
Emergency Resuscitation Kit
Baby Emergency Resuscitation Kit
5 AMC_____________________
Foot Suction Apparatus________
Suction Apparatus (Electrical)
Instrument Sterilizer___________
Automist____________________
Microscope__________________
Water Bath__________________
Hot air Oven_________________
Glucometer__________________
Water coolers________________
DD&C____________________
MTP_______________________
Cervical Biopsy_______________
Evacuation ________________
Epiosotomy__________________
Delivery pack_________________
Venesection__________________
Caesarean section_____________
P N Sterilization______________
Incision & Drainage____________
Suturing Tray_________________
Suture remover_______________
L P Tray____________________
Catherization Tray_____________
Cataract Operation____________
Enucleation__________________
Probing of Lacrymal Passages
Foreign body in AC____________
Tracheostomy set______________
ENT Kit_____________________
General Anaesthesia Kit________
General Orthopaedic Kit________
Dental Kit____________________
Baby laryngoscope
Qty Supplied
93
___ 1^
1
Whether Installed
Yes
____
___ 1_
___ 2
___ 2
4
___
___ 1_
___ 1_
___ 1_
___ 1_
___ 1_
___ 2
___2
___ 1_
___ 1_
___2
___2
__ 2
___ 1_
__ 2
__ 2
___ 1_
___ 1_
. 2
__ 2
___ 1_
___ 1_
___ 1_
___ 1_
___ 1_
___ 1_
___ 1_
___1_
___1_
1
refsys-tumkl
38
39
40
41
42
43
44
45
46
Adult laryngoscope____
TD_________________
Nebulizer____________
Fire extinguisher_______
300 mA X-ray_________
Tata Sumo___________
O T focussing_________
Oxygen cylinder B_____
Oxygen cylinder R with F
1
10
1
4
1
1
1
10
5
Name of the Hospital: C N Halli, Tumkur
SI No.
Name of the equipment
Qty. Supplied
Whether Installed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
ECG
Emergency Resuscitation Kit
Baby Emergency Resuscitation Kit
Dental Kit___________________
Dental Chair_________________
5 AMC_____________________
Foot Suction Apparatus________
Suction Apparatus (Electrical)
Instrument Sterilizer___________
Automist____________________
Water Bath__________________
Hot Air Oven_________________
Glucometer__________________
AC________ _______________
Water coolers________________
DD&C____________________
MTP________________________
Cervical Biopsy_______________
Evacuation___________________
Epiosotomy__________________
Delivery pack_________________
Venesection__________________
Caesarean section_____________
P N Sterilization______________
Incision & Drainage____________
Suturing Tray________________
Suture remover_______________
L P Tray_____________________
Catherisation Tray_____________
Cataract Operation____________
Enucleation _________________
Probing of Lacrymal Passages
Foreign body in AC
1
1
1
1
1
1
2
2
5
1
1
1
1
1
1
2
2
1
1
2
2
2
1
2
2
1
1
2
2
1
1
1
1
Yes
94
Yes
refsys-tumkl
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
r 49
Tracheostomy set
ENT Kit_____________
General Anaesthesia Kit
General Orhtopaedic Kit
Dental Kit____________
Adult laryngoscope_____
Baby laryngoscope_____
P Hammer ________
TD_________________
Nebulizer_____________
Fire extinguisher_______
Tata Sumo____________
O T focussing_________
Oxygen cylinder B______
Oxygen cylinder RwithF
Autoclave 2 Bin
1
1
1
f
1
1
1
2
9
1
4
1
1
10
5
1
Name of the Hospital: Kunigal, Tumkur
SI No.
Name of the equipment
Qty. Supplied
Whether Installed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
~ ECG
Emergency Resuscitation Kit
Baby Emergency Resuscitation Kit
Dental Kit_____
Dental Chair_________________
Foot Suction Apparatus________
Suction Apparatus (Electrical)
Instrument Sterilizer______ Automist__________________
Water Bath________ __________
Hot Air Oven ______________
Glucometer__________
Water coolers_________________
' MTP________________________
~ DD&C
_______________
Cervical Biopsy _____________
Evacuation___________________
Epiosotomy__________________
Vaginal tray__________________
Delivery pack
____________
Caesarean section ____________
P N Sterilization ____________
Incision & Drainage____________
Suturing Tray______
Suture remover_______________
L P Tray
J.
J_
J_
J
J
2
2
Yes
95
Yes
Yes
_4
2
2
2
2
2
2
2
2
2
2
2
2
i
2
2
2
2
2
refsys-tumkl
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Catherisation Tray_________
Cataract Operation________
Enucleation______________
Probing of Lacrymal Passages
Foreign body in AC________
Tracheostomy set_________
ENT Kit_________________
General Anaesthesia Kit
General Orhtopaedic Kit
Adult laryngoscope________
Baby laryngoscope_________
P Hammer_______________
TD____________________
Nebulizer________________
Fire extinguisher__________
300 mA X-ray____________
100 mA X-ray____________
Tata Sumo_______________
O T focussing_____________
Oxygen cylinder B_________
Oxygen cylinder R with F
Autoclave horizontal_______
Autoclave vertical_________
Autoclave 2 bin
2
1
1
1
1
1
1
1
1
1
1
2
8
1
4
1
1
1
1
10
5
1
1
1
Name of the Hospital: Madhugiri, Tumkur
SI No.
2
2
2
2
5
Name of the equipment
Qty. Supplied
100 mA X-ray____________
O T Lights (shadowless)
Centrifuges_______________
Autoclave horizontal_______
Autoclave vertical
Whether Installed
i
i
i
i
i
Name of the Hospital: Sira, Tumkur
SI No.
2
2
±
5_
6
Name of the equipment
Qty. Supplied
300 mA X-ray____________
Tata Sumo
__________
O T Lights (shadowless)
Centrifuges_________ '
Generator 15 KVA________
Autoclave vertical
Whether Installed
1
2
2
i
j_
i
96
refsys-tumkl
Name of the Hospital: Pavagada, Tumkur
SI No.
2
3_
£
£
6_
7
Name of the equipment
Qty. Supplied
Whether Installed
2
Tata Sumo ____________
O T Lights (Mobile)________
O T Lights (Shadowless)
Centrifuges
_________
Generator 15 KVA________
Autoclave horizontal_______
Autoclave vertical
X
j_
j.
i
Name of the Hospital: Tiptur, Tumkur
SI No.
Name of the equipment
Qty Supplied
1.
2.
ECG
Phototherapy Unit_____________
Boyles Apparatus without flou tech
Optholmoscope ______________
Emergency Resuscitation Kit_____
Baby Emergency Resuscitation Kit
Air rotor ___________________
5 AMC______________________
Foot suction apparatus__________
Suction apparatus (electrical)_____
Instrument sterilizer____________
Dialysis Machine______________
Automist
_________________
Photo Electric Calorimeter_______
Water Bath _________________
Hot air oven__________________
Distilled Water Stills____________
Glucometer___________________
AC_________________________
Water coolers_________________
Generator 50 KVA_____________
DD&C_____________________
MTP___________
Cervical Biopsy________________
Evacuation___________________
Epiosotomy__________________
Delivery pack_________________
Vaginal tray ________________
Caesarean section______________
P N Sterilization_______________
Incision & Drainage
£
2
2
2
2
2
2
2
3.
4.
5.
6.
7.
8.
9.
10.
IL
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
97
Whether Installed
2
2
£
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2_
2
4
refeys-tumk 1
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
Abdominal Hysterectomy____
Vaginal Hysterectomy ______
Vagotomy________________
Hemorrhoidectomy_________
Appendectomy_____________
Hydrocele________________
GJ______________________
Suturing tray______________
Suture removal_____________
L P tray_______________ ■
Catherization tray__________
Needling & Cataract (13 items)
Cataract Operation_________
Enucleation_______________
Probing of Lacrymal Passages
Foreign Body in A C________
IM Nailing________________
S P Nailing________________
D C Plating_______________
Dynamic Hip Screw Fixation
Fixation of Radius & Ulna
Tracheostomy set___________
ENT Kit__________________
E E Set (7 items)___________
General Anaesthesia Kit______
General Orthopaedic Kit_____
Dental Kit_________________
Adult laryngoscope_________
Baby laryngoscope__________
P Hammer________________
TD______________________
Nebulizer_________________
Fire extinguisher____________
300 mA X-ray_____________
100 mA X-ray_____________
60 mA X-ray______________
Ultrasound scanner_________
O T focussing______________
O T Lights (shadowless)_____
Centrifuge_________________
Oxygen cylinder A__________
Oxygen cylinder R with T____
Oxygen cylinder B__________
Oxygen cylinder R with F____
Nitrous Oxide A____________
Nitrous oxide B ___________
Nitrous oxide R with T
2
2
1
r
i
i
i
2
3
3
4
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
4
2
2
3
15
2
6
1
1
I
1
1
1
2
1
2
1
17
8
2
1
1
98
rcfsys-tumkl
Name of the Hospital: Turuvekere, Tumkur
SI No.
i
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
Name of the equipment
ECG
Emergency Resuscitation Kit
Dental Kit________________
Dental Chair______________
5 AMC__________________
Foot Suction Apparatus_____
Suction Apparatus (Electrical)
Instrument Sterilizer________
Automist
______________
Microscope_______________
Water Bath_______________
Hot Air Oven______________
Glucometer_______________
Water coolers_____________
DD&C_________________
MTP_____________________
Cervical Biopsy____________
Evacuation________________
Epiosotomy_______________
Vaginal tray_______________
Delivery pack_____________
Incision & Drainage________
Suturing Tray______________
Suture remover____________
L P Tray ________________
Catherisation Tray__________
Tracheostomy set__________
ENT Kit__________________
Adult laryngoscope_________
P Hammer________________
TD______________________
Fire extinguisher___________
100 mA X-ray_____________
Tata Sumo________________
O T focussing_____________
Oxygen cylinder B__________
Oxygen cylinder R with F
Autoclave with 2 bin
99
Qty. Supplied
Whether Installed
1
Yes
J
J
Yes
Yes
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
i
refeys-tumkl
Name of the Hospital: Gubbi, Tumkur
SI No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Name of the equipment
ECG
Emergency Resuscitation Kit
Dental Kit_____ ___________
Dental Chair
5 AMC
____________
Foot Suction Apparatus_____
Suction Apparatus (Electrical)
Instrument Sterilizer________
Automist_______
Water Bath_____
Hot Air Oven _____
Glucometer
_____
Water coolers
DD& C
MTP
Cervical Biopsy____________
Evacuation________________
Epiosotomy_______________
Vaginal tray_______________
Delivery pack______________
Suturing Tray
__________
Suture remover ___________
L P Tray__________________
Catherisation Tray__________
Dental Kit______r__________
Adult laryngoscope_________
P Hammer___________
TD__________
Fire extinguisher___________
100 mA X-ray_____________
Tata Sumo_____ ___ ______
O T Lights focussing________
Oxygen cylinder B _________
Oxygen cylinder R with F
Autoclave with 2 bin
loo
Qty. Supplied
Whether Installed
1
1
1
1
1
1
1
3
1
1
1
1
1
2
2
1
1
2
2
2
1
1
1
1
1
1
1
5
2
1
1
1
5
3
1
Yes
Yes
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