NCM 106 SY 2020-2021

Emergency Room Protocols in the Philippines

Gagarin, Jervin John I.
Union Christian College
 NCM 106 SY 2020-2021 2

Emergency Room Protocols in the Philippines

Emergency Room - An area in the hospital where patients with emergent health conditions can
go for consultations and management; it operates 24/7.
The ER is primarily intended for patients with acute life-threatening health problems needing
immediate resuscitation and stabilization. However, in real practice, only about 30% consulting
in the ER have real emergencies by medical standards. Thus, one of the basic issues that the
hospital administration has to resolve and set down as a policy is whether to limit the clients of
the ER to patients with life-threatening conditions by medical standards or to accept all clients
who are brought into it, regardless of whether they have real life-threatening conditions or not
based on medical standards, accepting whatever be and respecting the perception of the patients
and their relatives that they have life-threatening conditions.

General Functions

 TRIAGE – An Emergency Room Nurse helps staff prioritize care based on the critical
nature and severity of a patient’s condition.  A nurse’s medical knowledge, quick
thinking, and attentions to detailed and hand towards comprehensively assessing a
patient’s needs, obtaining thus medical history and personal information and seeking
doctor’s evaluation immediately for life-threatening issues.
 TAKING VITAL SIGNS – Logging vital statistics is a staple responsibility of an
Emergency Room Nurse.  Taking Vital signs includes recording a blood pressure reading
with a blood pressure pump, as well as measuring pulse rate, respiration and temperature
over the course of a patients stay in the E.R Vital sign provide a bird’s eye view of a
patient’s state and alert nurse to changes in condition which might require a doctor’s
attention.
 ADMINISTERING MEDICINE – Once presented by a doctor, a nurse will be the one
to legally administer medicine whether it is in setting up and priming an intravenous (IV)
infection or handling over pills for swallowing with water.  Sometimes E.R patients will
already be an existing medication which needs to be administered during their stay here. 
Nurse’s will confirm current medication lists with patient and family (or call on the
Hospital Pharmacist to) and acquire in hospital prescriptions from the E.R. doctor for
those medicines.
 PROVIDING TREATMENT – In addition to dosing meds, emergency room nurses
may help with medical treatment for everything from sore throats to kidney infection. 
Nurses may also assist with minor medical procedures as part of the treatment response,
helping to stabilize a patient and assist the doctor with everything from suturing wounds
to intubation critical – ill patients.
 MONITORING PATIENTS – Nurses are responsible for overseeing follow – through
on doctor’s orders, from making sure medications are given to checking on completion
and results of diagnostic tests which are ordered.  While nursing attendants typically
transport a patient in their bed to a diagnostic test.  i.e an x-ray or ct scan, when staff are
short handed, a nurse maybe asked to assist. It a patients’ condition or worsens while they
are in the E.R, nurses are in charge of notifying the doctor right away. Patients and their
family may make requests for simple things like another blanket or a gown, and nurses
bear the responsibility of fielding these requests and keeping the patient comfortable.
 CHARTING/ DOCUMENTATION – Emergency room nurses are required to chart all
patient medical history, contact information current condition and medications and
treatment as well as update their electronic medical record throughout their stay in the
E.R. accurate documentation in a patient’s chart gives other member of the medical team
correct information to act on throughout the patient evaluation and treatment journey.
Efficient and Vigilant charting also protects hospitals and staff team potential legal
liability down the like.
 NCM 106 SY 2020-2021 3

 DISCHARGE – When a patient does not require being admitted to the hospital and is
deemed ready to leave the emergency room after treatment their emergency room nurse
handles the discharge paperwork. Explaining it to the patient and their family/care givers
and answering any questions they may have. They also conform transportation from the
E.R. with the patient their destination and follow up recommendations for care and
doctor’s visit.
 Emergency room nurses will also help translate complicated medical jargon from a
doctor regarding diagnosis and treatment into under stable layman’s term for patients and
their families. Upon discharge, emergency room nurses maybe called onto educate a
patient and their family about further care and treatment example how to dress a patient
wound and how often they will clean.
 In addition to acute and attentive medical treatment, emergency room nurses act us
translators, advisors, educators, assistants, organizer and therapist, powerfully speaking.
 As the liaison between the doctor and the patient. Emergency room nurses require
compassion; empathy and good bedside manner in their care they may need to help calm
a patient dawn, listen and answer their questions or soothe them through reactions of
shock and pain.
DOH guidelines in the planning and design of a hospital and other health facilities

 The ER shall be located in the outer zone of the hospital, in the area that is immediately
accessible to the public. It is located near the entrance of the hospital.
 It shall be located in the ground floor to ensure immediate access. A separate entrance to
the ER shall be provided.
 There must be adequate road signs and signboards indicating the location of the ER.
 It must be in an area where hospital routines will NOT be disrupted when there is a
sudden and great flow of patients to the ER.
 Supportive departments such as laboratory, radiology, and operating room must NOT be
far from the ER.
DOH requirements:
Zoning: The different areas of a hospital shall be grouped according to zones as follows:
 Outer Zone – areas that are immediately accessible to the public: emergency service,
outpatient service, and administrative service. They shall be located near the entrance of
the hospital.
 Second Zone – areas that receive workload from the outer zone: laboratory, pharmacy,
and radiology. They shall be located near the outer zone.
 Inner Zone – areas that provide nursing care and management of patients: nursing
service. They shall be located in private areas but accessible to guests.
 Deep Zone – areas that require asepsis to perform the prescribed services: surgical
service, delivery service, nursery, and intensive care. They shall be segregated from the
public areas but accessible to the outer, second and inner zones.
 Service Zone – areas that provide support to hospital activities: dietary service,
housekeeping service, maintenance and motorpool service, and mortuary. They shall be
located in areas away from normal traffic.
Equipment/Instruments: DOH requirements

 All equipment and instruments necessary for the safe and effective provision of services
are available and are properly maintained.
 Records of equipment are maintained and updated regularly.
 A preventive maintenance program ensures that all equipment are maintained and/or
calibrated to an appropriate standard or specification.
 There is a plan in place for essential equipment replacement.
 NCM 106 SY 2020-2021 4

 Personnel are competent when using equipment in line with manufacturer’s

instruction/operational manual.
 Operational manuals of all equipment and instruments are available for reference and
guidance.

Staff Requirements of an ER
 Physicians
 Nurses / nursing aides / utility workers
 Security guard
 Driver of ambulance
Policies and procedures in an ER
Operations Manual
 To provide order, to promote standardization, to facilitate communication, to promote
effectiveness and efficiency, and to provide a guide to present and future staff, among
other things, policies and procedures must be in place.
 These must be collaborated by the ER physicians, nurses and other physician-users
through the ER committee and authorized by it and a higher office.
 These must be aligned with those of the hospital.
 These should be reviewed and revised periodically.
 Presence of policies and procedures is a requirement for licensing by DOH, accreditation
by PhilHealth and other accrediting bodies like ISO and JCI.
 There must be policies and procedures on:
 Governance
 Service (Patient Management)
o Clinical practice guidelines in the ER
o Clinical pathways in the ER
o ER nursing care
o General nursing care
 Training
 Research
In patient management, clinical practice guidelines and clinical pathways are useful in
standardization of procedures as well as in the promotion of efficiency.

 Clinical practice guidelines – systematically developed statements, built on synthesis of

evidence, which provide formal recommendations about appropriate and necessary care,
intended to assist practitioner and patient to make decisions about appropriate health care
for specific clinical circumstances.
 Clinical pathway – an interdisciplinary plan of care that outlines the optimal sequencing
and timing of interventions and expected outcomes for patients with a particular
diagnosis, procedure or symptom.
Hospital Code Alert Level

Code Alert Level Conditions for adopting color code alert

a. Code White  Strong possibility of a military operation within the area, example:
coup attempt.
 Any planned mass action or demonstration within the catchment area.
 Forecast typhoons (Signal No. 2 up) the path of which will affect the
area.
 National or local elections and other political exercises.
 National events, holidays, or celebrations in the area with potential for
MCI (Mass Casualty Incident).
 Any emergency with potentially 10-50 casualties (deaths, injuries).
 NCM 106 SY 2020-2021 5

 Any other hazards that may result in emergency.

 Unconfirmed report of re-emerging diseases, example: Avian
Influenza, SARS, Pandemic H1NI
Human Resource  First response team ready for dispatch to include the following:
requirement for  2 doctors preferably Surgeon, Internist and Anesthesiologist.
responding to the  2 Nurses First Aider/EMR Driver
Code White  Second response team should be on call
 The following should be available for immediate treatment of
incoming patients:
 General Surgeons
 Orthopedic Surgeons
 Anesthesiologist
 Internist
 O.R. Nurses
 Ophthalmologists
 Otorhinolaryngologists
 Infectious Specialists
 Emergency service personnel, nursing personnel and administrative
personnel residing at the hospital dormitory shall be placed on call
status for immediate mobilization.
Other requirements  The Hospital Operations Center should be activated. It should
for responding to continuously report and coordinate with the DOH Central Operation
Code White Center.
 Medicines and Supplies
 Ensures that emergency medicines (especially for trauma needs)
be made available at the emergency room.
 Medicines and supplies in the operating rooms should likewise be
reviewed and increased to meet sudden requirements.
 Other needs such as X-ray plates, laboratory requirements, etc.
should be made available and not required to be purchased by
victims.
 Personnel department to prepare for mobilization of additional
staff.
 Finance department to ensure availability of funds in cases of
emergency purchases and the like.
 Logistics department to coordinate with possible suppliers for
additional requirements.
 Dietary department to open and meet the need of the victims as
well as the health personnel on duty.
 Security force to institute measures and stricter rules in the
hospital.
 Activate Bird Flu Plan (Avian Influenza), SARS Plan, Pandemic
H1N1 Plan, etc.
 Enforce and monitor use of personnel (PPE) for all health
personnel.
 Triage system should be activated.
b. Code Blue Any of the following conditions
 When 20-50 casualties (red tags) are suddenly brought to the
hospital.
 Any internal emergency/disaster in the hospital which brings
down their operating capacity (ex. Vital areas) to 50% or which
would require evacuation of patients and setting up of a Field
Hospital.
 NCM 106 SY 2020-2021 6

 For conditions other than MCI, the influx of patients is beyond the
capacity of the hospital to handle.
 Confirmed/documented report of re-emerging diseases (SARS,
Human to Human Avian Influenza, Pandemic H1N1) within the
catchment area.
Human Resource  HEMS Coordinator to be physically present at the hospital.
requirement for  On-scene Response Team
responding to the  Medical Officer in charge of the Emergency Room
Code Blue  All Medical Fellows should be present
 Medical Officer in charge of the Operating Room
 Surgical Team on duty for the day
 Surgical Team on duty the previous day
 Mental Health Personnel (if available)
 All Anesthesia Fellow should be present
 Toxicologist/Chemical Experts (if available)
 Administrative Officer or designate
 Nursing supervisor on duty
 All OR nurses
 Social workers
 Dietary personnel
 Officer in charge of supplies at the CSSR
 The entire security force
 Housekeeping personnel
Other requirements All those mentioned in Code White plus:
for responding to  Activate Hospital Emergency Incident Command System
Code Blue (HEICS).
 Other needs of victims apart from medicines and supplies
depending on the disasters should as much as possible be made
available
 The Executive Director of his designate should make proper
coordination with other hospitals for networking and/or possible
transfer of patients.
 Incident Commander should assign a Safety Officer, Liaison
Officer to coordinate with other agencies, and Public Information
Officer to serve as the authorize spokesperson of the hospital.
 Social Service section should prepare assistance to victims in
coordination with mental health professionals of the hospital, if
available, and they should lead in providing information to
relatives of victims.
 Mortuary section should anticipate dead victims brought to the
hospital for proper care and identification.
 The security team, in anticipation of possible influx or patients,
relatives, responders, police, press, etc. should ensure smooth flow
of traffic inside the compound especially for the ambulances. -
Should report regularly to HEMS Operation Center and as much
as possible have regular press releases or briefings.
c. Code Red Any of the following conditions:
 When more than 50 (red tags) casualties are suddenly brought to
the hospital.
 An emergency wherein the services of the hospital is paralyzed
since 50% of the manpower are themselves victims of the disaster.
 Hospital is structurally damaged requiring evacuation and/or
transfer of patients.
 NCM 106 SY 2020-2021 7

 Conditions requiring mandatory quarantine of hospital and its

personnel (ex., SARS, Avian Infuenza, Pandemic H1N1);
uncontrolled human to human transmission of SARS/Avian Flu,
Pandemic H1N1 within the catchment area.
Human Resource  All personnel enumerated under Code Blue
requirement for  All medical personnel
responding to the  All nurses
Code Red  All nursing attendants
 All administrative staff
 All housekeeping personnel
Other requirements  All those mentioned in Code Blue plus:
for responding to  The Executive Director can cancel all types of leave and can order
Code Red all personnel to report to the hospital
 The Executive Director can temporarily stop all elective
admissions and surgeries and network with other hospitals.
 The Executive Director should anticipate request for additional
manpower and specialists not available in his hospital. He is
further authorize to accept medical volunteers and other
professional to augment the hospital’s manpower resources rather
than transferring patients based on some agreements.
 Networking with other hospitals for augmentation of resources
and transfer of patients in special cases.
 Answer all queries of the media pertaining to patients in the
hospital.
 Anticipate evacuation and/or use of field hospital; closure and/or
quarantine of the hospital.
 The Executive Director specifically be concerned with safety and
security, not only of the patients but of the personnel as well.
Determining Priority for Case Management
1. Use of Color Tag for Prioritization of care
i. Categories
a. RED – Immediate: Priority One (Lifethreatening Conditions). The
condition is life-threatening and the patient requires immediate attention and transport.
The following conditions should be present for a Mass Casualty Incident (MCI) victim to
be classified Priority One.
1. Obstruction or damage to airway.
2. Disturbance of breathing – respiration above 30/min.
3. Disturbance in circulation – capillary refill greater than 2 seconds or carotid
pulse weak, irregular or absent, radial pulse absent.
4. Does not follow commands or altered level of consciousness.
5. Need for life-saving measures (BLS and ATLS) and urgent hospital
admission.
6. Victims whose injuries demand definitive treatment in the hospital but which
treatment may be delayed without prejudice to ultimate recovery

b. YELLOW – Urgent: Priority Two. Patient has passed primary survey, but
with major system injury, may delay transport to one hour. Any one of the following
conditions could place a victim into a Priority Two Category:
1. Needs to be treated within one hour; otherwise they will become unstable.
2. Severe burns; burns involving hands, feet or face (not including the
respiratory tract); burns complicated by major soft tissues trauma
3. Hospital admission is required
4. Moderate blood loss; back injuries; head injuries with a normal level of
consciousness
 NCM 106 SY 2020-2021 8

c. GREEN – Delayed: Priority Three. An injury exists but treatment can be

delayed for four to six hours. Generally, anyone who can walk (walking wounded) to a
designated area for treatment will be a Priority Three. The following injuries are
examples:
1. Minor injuries not threatened by airway, breathing and circulatory
instability
2. Minor fractures, minor soft tissue injuries, minor burns.
3. May or may not be admitted.

d. BLACK or WHITE – Dead: Last Priority. Conditions are the following:

1. Patient is dead.
2. Those who die awaiting treatment, and those in cardiac arrest following
trauma.

Special Note: For Moslem communities, white tag will be used for dead Moslems.
 NCM 106 SY 2020-2021 9

References
Emergency Department, Regional II Trauma and Medical Center, retrieved on August 19, 2020

from https://riitmc.doh.gov.ph/nursing/emergency-department/

Health Emergency Preparedness, Response and Recovery Plan, Lung Center of the Philippines,

retrieved from https://lcp.gov.ph/images/Brochures/LCP-Health%20Emergency

%20Plan_Revised_May2014.pdf on August 18, 2020

Joson, R., (2008). Short Course on Hospital Organization and Management of Selected Clinical,

Ancillary, and Support Departments. Emergency Room (ER), Department of Emergency,

Medicine (DEMS), Emergency Medicine Department (EMD). Retrieved from

http://hospmgt.tripod.com/hosp_org_mgt_short_course_er_rj_08nov18.htm?

fbclid=IwAR1R84q4WrvR26uxdTYTASc6lGzDHnKeHCdPvtefLvK2kq_qL-CPPROidVs