1. SCOPE

The purpose of this DT 01 is to make proper arrangements for the provision of necessary medical care to patients across all departments of the Polyclinic (reception, Family Medical Centre, Department for Secondary Level Services, Mental Health Centre as well as Dental and Diagnostics Departments). To ensure timely and quality provision of necessary medical care and proper formalisation of services provided to patients.

2. TERMS AND DEFINITIONS

2.1. Acronyms
HCI’ shall mean a health care institution
D’ shall mean the Director.
WI’ shall mean a work instruction
F’ shall mean a form
D’ shall mean a doctor
QMS’ shall mean the Quality Management System
Polyclinic’ shall mean Public Institution Naujoji Vilnia Polyclinic
MD’ shall mean health statistics (medical) documentation
P’ shall mean a procedure
DM’ shall mean a departmental manager (head of a centre, department or agency)
REG’ shall mean a medical registrar
N’ shall mean a general practice/community nurse
MH’ shall mean the Ministry of Health
SN’ shall mean a senior nurse at the department

2.2. Definitions (and Main Terms)
‘Necessary medical care’ shall include medical first aid and emergency medical care provided in health care institutions (outpatient or inpatient). The scope of necessary medical care shall be outlined in the list of conditions which are subject to necessary medical care to be provided (Annex 1) as approved by the MH.
‘Emergency medical care’ shall mean such medical assistance that is provided immediately (Category 1) or without delay (Categories 2, 3 and 4) where because of acute clinical conditions listed in Column 4 of the table for the Scope of Emergency Medical Care of this Instruction there is danger to the life of the patient and/or those around them, or where failure to provide such assistance in a timely manner causes a risk of serious complications to be inflicted on the patients.
‘Medical first aid’ shall mean the key targeted actions to provide assistance to the health and life of others or oneself using available medical and/or other tools and materials pending the emergency institutional medical care to be provided to the victim/patient or pending the patient’s condition becoming normal, or pending them being pronounced dead.
‘Severe injury’ shall mean an injury that meets at least one of the following characteristics:

  • An individual has suffered an injury due to exposure to high kinetic energy:
    - An individual has suffered an injury as a pedestrian, cyclist, motorcyclist or horse driver during a car accident;
    - The same vehicle in which an individual had suffered an injury has deceased people;
    - Rescuing an individual, who has suffered an injury, required assistance of rescuers;
    - An individual has suffered an injury in an explosion or crossfire;
    - An individual has suffered an injury during a fall or dive (for adults, from a height in excess of 5 m, for children, from a height in excess of their own height);
  • Visible injuries or conditions following the trauma are potentially life-threatening:
    - Penetrating neck, chest or waist injuries;
    - Fractures of at least two long bones;
    - Amputation of limbs above hands or feet;
    - More than 18% respiratory or body burns;
    - Unstable chest;
    - Manifest neurological symptomatology;
    - A pregnant woman has suffered an injury in a car accident.


3. RESPONSIBILITIES AND POWERS

The responsibility for making arrangements for the provision of necessary medical care in the Polyclinic shall be vested with the D.
The responsibility for the provision of necessary medical care shall be vested with the D/N.
The responsibility for referring the patient to the appropriate specialist shall be vested with the REG.

4. DESCRIPTION

Every individual health care institution must ensure (provide and arrange for), within the remit of its powers, the necessary medical care.
If the Polyclinic is contacted for necessary medical care, no doctor’s referral shall be required.
Necessary medical care (first aid and emergency care) shall be provided to all patients in the Polyclinic. Necessary medical care shall be provided in stages with medical first aid going first followed by emergency institutional care. In certain cases, they me offered simultaneously.

A. Providing Necessary Medical Care when a Patient Contacts the Reception

Tasks (measures)

Imple-menters

Action

Time

Comments and documentation

1. Screening of patients in need of necessary medical care (first aid and emergency care) at the reception

REG

Urgently notifies the D about the patient’s arrival based on the profile of care required, if necessary, calls the on-call D, and, where necessary, accompanies them to the doctor’s or treatment room.

Without delay* following the patient’s arrival

ID documents

(if any);

F 025/a

F 025/a-LK

2. Booking an appointment for the patient to see a doctor at the reception of the Polyclinic and starting MD

REG

If the patient is registered with the Polyclinic, verifies documents and records on a computer database.

If the patient is not registered with the Polyclinic, completes a temporary medical record.

Without delay* following the patient’s arrival

 

3. Seeing the patient in a room. Initial examination and preliminary diagnosis

On-call or family D

Examines the patient and assesses their condition:

If necessary because of the patient’s health condition, N calls consultant Ds or an ambulance to take the patient to the hospital.

Performs urgent tests to clarify the diagnosis, makes a preliminary diagnosis and, if necessary, makes arrangements for specialist consultations or hospitalisation, as well as gives instructions to the N.

15 mins from receiving information

 

4. Drawing up a test and treatment

plan

D with N

Prescribe treatment, additional necessary tests and consultations and book repeat appointments.

Without delay* following

initial examination and preliminary diagnosis

made

 

5. Implementing prescriptions

N

Implements D’s prescriptions, informs the D/DM about any issues

Records nursing procedures and nursing actions in the medical record

Without delay*,

based on the deadline provided by the D in the medical record.

 

 

 

N

Transports the patient to the specified unit along with their medical record. After performing the actions prescribed to the patient, returns them to the room.

Without delay*,

based on the D’s instruction

 

* The term ‘without delay’ used in the ‘Time’ column shall mean that the patient’s condition is assessed simultaneously with treatment actions being carried out. If it is necessary to perform several actions at the same time for the same patient or multiple patients, the order of actions shall be determined by the doctor providing care.

NOTES:
1. The patient shall be hospitalised as a matter of urgency after D’s examination, and, if necessary, after appropriate instrumental tests and laboratory sampling.
2. If the patient dies, the MD shall be handled following DT 02 ‘Handling Cases of Death’.

B. Provision of Necessary Medical Care Following an Emergency in the Polyclinic
When there is an emergency, first aid shall be launched by the medical member of staff that was the first to notice it, while calling colleagues to help them make arrangements for the provision of care. Necessary medical care shall be provided in accordance with the general rules for the provision of necessary medical care (ABCD). One of the members of staff shall urgently call the D that is on call in the Polyclinic based on a prescribed schedule and that is responsible for providing necessary medical care. The on-call D shall arrive without delay to provide care together with the N carrying a first aid bag with them.
Storage locations of medicines, defibrillators, stretchers and wheelchairs are set out in Annex 3.

C. Provision of Necessary Medical Care to Non-Citizens of the Republic of Lithuania
Necessary medical care for non-citizens of the Republic of Lithuania shall be provided in accordance with the general principles for the provision of necessary medical care.

5. DISTRIBUTION

The main document of this DT 01 shall be kept in conjunction with the Director’s order, while the second copy thereof, at the VA. An electronic version of controlled documents has been uploaded on the Polyclinic’s intranet at Doclogix/21 kokybė/21-4 bendri poliklinikos KVS dokumentai.

6. AMENDMENTS

Any amendments to this DT 01 shall be made by the originator in accordance with section 5.6. ‘Amendment of QMS Documents (Identification of Changes)’ of P 01.1 ‘Drafting and Management of QMS Documents’.

7. ANNEXES

Annex 1. Scope and List of Emergency Medical Care.
Annex 2. Conditions for the Reception of the Polyclinic to Refer Patients as a Matter of Urgency for Necessary Medical Care to be Provided.
Annex 3. Storage Locations for Measures of Necessary Medical Care.

REFERENCES (RELATED DOCUMENTS AND BIBLIOGRAPHY)

1. Order No V-598 of the MH of the Republic of Lithuania of 23/05/2018 Amending Order No V-208 of the Minister of Health of the Republic of Lithuania of 8 April 2004 Approving the Procedure and Scope for the Provision of Necessary Medical Care and Services of Necessary Medical Care.
2. Other applicable legislation of the Republic of Lithuania and documents of internal procedure of Public Institution Naujoji Vilnia Polyclinic.



ORDER OF THE MINISTER OF HEALTH OF THE REPUBLIC OF LITHUANIA AMENDING ORDER No V-208 OF THE MINISTER OF HEALTH OF THE REPUBLIC OF LITHUANIA OF 8 APRIL 2004 APPROVING THE PROCEDURE AND SCOPE FOR THE PROVISION OF NECESSARY MEDICAL CARE AND SERVICES OF NECESSARY MEDICAL CARE

23 May 2018 No V-598 Vilnius
COPE OF PAEDIATRIC EMERGENCY MEDICAL CARE

Emergency medical care category

Time to start the provision of care

Acute clinical conditions or indications for emergency medical care to be provided

1

2

3

Category 1

(immediate)

Immediately, with the patient’s condition being assessed and treatment actions performed simultaneously.

1. Obstructed airways (complete airway obstruction).

2. Respiratory arrest or gasping for breathing (agonal breathing).

3. Ongoing very heavy bleeding.

4. Cardiopulmonary insufficiency.

5. Shock.

6. Ongoing convulsive seizure.

7. Impaired consciousness with complete unresponsiveness to voice and pain.

8. Acute chemical eye injury.

Category 2

(very urgent)

Emergency medical care must be started for the patient no later than within 10 minutes from their arrival at a health care institution.

1. Very severe / unbearable (9-10 points) pain.

2. Heavy bleeding that has not been stopped.

3. Impaired consciousness (responds only either to voice or pain, or responds abnormally).

4. During clinical evaluation, the skin is felt very hot and/or the measured body surface temperature for a child up to 6 months of age is 38.5oC or above, for a child aged 6 months to 18 years, 40oC or above.

5. During clinical evaluation, the skin is felt cold and/or the core body temperature (measured in the oesophagus or rectum) is below 35oC.

6. Very low SpO2 (< 92% breathing ambient air or < 95% with oxygen therapy prescribed).

7. Allergy or bite (sting) with Quincke-type oedema and/or a history of anaphylactic reaction, and/or tongue/facial oedema.

8. Acute shortness of breath (increased work of respiratory muscles, unable to speak in sentences, stridor, salivation).

9. Inhalation injury to the respiratory tract.

10. Bite of a venomous animal.

11. Acute sensory and motor disorders.

12. Meningeal symptoms or meningism.

13. Acute haemorrhagic rash.

14. Local infection of tissues with emphysema or vascular damage.

15. Vomiting blood or bowel movements with fresh or altered blood.

16. Diabetes mellitus with hyperglycaemia and ketoacidosis.

17. Severe injury.

18. Pathology of the limbs with a circulatory disorder.

19. Penetrating eye injury or acute complete loss of vision.

20. Vaginal bleeding (of any intensity) with the pregnancy of over 20 weeks.

21. Poisoning (or suspected poisoning) with hazardous or very hazardous substances, overdose of medicines.

22. Mental illness or behavioural disorder with a high risk of self-harm and/or harm to others, history of self-harm, characteristic active actions to harm oneself or a desire to escape in order to self-harm.

23. A known congenital or acquired immunosuppressive condition coupled with a suspected infectious disease.

24. Acute chemical burn.

25. If a patient is suspected of being infected with a particularly dangerous infection, the patient must be isolated.

Category 3

(urgent)

Emergency medical care must be started for the patient no later than within 30 minutes from their arrival at a health care institution.

 

1.     1. Severe pain (6-8 points).

2.     2. Minor bleeding that has not been stopped.

3.     3. A history of loss of consciousness and/or seizures over the past 24 hours.

4. During the clinical evaluation, the skin of a child aged 6 months to 18 years is felt is very hot and/or the measured body surface temperature is 38.5oC or above.

4.     5. Unclear medical history: the findings do not match the details in the medical history or there is suspected violence against or mistreatment of the child.

5.     6. Low SpO2 (< 95% breathing ambient air).

6.     7. Sudden vision impairment.

7.     8. Allergy or bite (sting) with a spread rash or blisters that have appeared over the past 24 hours.

9. Poisoning with an average risk of self-harm (the desire to self-harm is declarative).

8.     10. Mental illness or behavioural disorder with a clear medical mental history and/or a moderate risk of self-harm (the desire to self-harm is declarative) and/or the risk of inflicting harm on others.

11. Any injury coupled with congenital or acquired disorders of the coagulation system.

Category 4

(standard)

Emergency medical care must be started for the patient no later than within 60 minutes from their arrival at a health care institution.

 

1. Moderate pain (4-5 points).

2. Children under 8 years of age with a potential risk of serious complications because of their medical history (a chronic illness or previous life-threatening events or illnesses) and clinical signs (changed behaviour or state of consciousness, respiratory or circulatory disorders, impaired fluid intake or diuresis, raised body temperature and rash).

3. Fever of >38oC in children persisting with antipyretic medicines taken for more than 24 hours.

4. Acute dehydration.

5. Inhalation of toxic fumes.

6. Other injuries (not listed in categories 2 and 3) and accidents over the past 48 hours with increasing swelling/increasing dysfunction.

7. Bites of rabid or potentially rabid animals/scratches with saliva spread.

8. Tick bite.

9. Suppuration of maxillofacial area.

10. Disorders of artificial stomas (where bags need to be changed or flushed out).

11. Complications after medical intervention (torn suture, purulent discharge, increasing swelling, insufficient immobilisation) that have occurred up to 48 hours after the treatment or discharge from an inpatient health care institution.

12. Foreign bodies (existing or suspected) in tissues or natural body openings/body cavities that have occurred over the past 48 hours.


SCOPE OF ADULT EMERGENCY MEDICAL CARE

Emergency medical care category

Time to start the provision of care

Acute clinical conditions or indications for emergency medical care to be provided

1

2

3

Category 1

Immediately, with the patient’s condition being assessed and treatment actions performed simultaneously.

1. Existing or imminent cardiac and/or respiratory arrest. Patient after resuscitation.

2. Respiratory rate (RR) is < 10 times a minute

RR is >29 times a minute.

3. Systolic arterial blood pressure (hereinafter the SABP) is < 80 mmHg.

4. Loss of consciousness and unresponsiveness to pain or reaction of < 9 points on the Glasgow Coma Scale (hereinafter the GCS).

5. Convulsions of the whole body.

6. Intravenous medicine or drug overdose that caused hypoventilation and hemodynamic impairment.

7. Acute chemical eye injury.

Category 2

Emergency medical care must be started for the patient no later than within 10 minutes from their arrival at a health care institution.

1. Acute, life-threatening respiratory and/or circulatory disorder.

2. Acute loss of large amount of blood (25% or more of circulating blood).

3. Very severe/unbearable pain for various reasons, where the intensity of pain is rated 9-10 points on a ten-point scale.

4. Hypoglycaemia or hyperglycaemia with a risk of developing a hypoglycaemic coma, diabetic ketoacidosis or hyperosmolar hyperglycaemia.

5. Fever with clinical signs of sepsis (at least two of the following signs: RR is > 22 times per minute, SABP is < 100mmhg, impaired consciousness of any level). Total body cooling with the temperature of < 36oC.

6. Severe injury.

7. High risk medical history:

7.1. consumption of large amounts of sedatives or consumption of toxic substances of other origin;

7.2. other life-threatening poisoning;

7.3. life-threatening exposure to environmental factors (generalised allergic reaction).

8. Mental and behavioural disorders:

8.1. aggression or violence that threaten the patient and others;

8.2. intense psychomotor agitation, where a physical restraint of an individual’s freedom is required due to a threat to themselves or others.

Category 3

Emergency medical care must be started for the patient no later than within 30 minutes from their arrival at a health care institution.

1. Hypertensive crisis with rapidly progressing signs of cardiovascular and/or central nervous system damage.

2. Moderate bleeding with clinical signs present for any reason.

3. Somnolence/slow response for any reason (< 13 points on the GCS).

4. Oxygenation < 90 percent.

5. Recurrent seizures recorded over the past 12 hours.

6. Recurrent vomiting and/or diarrhoea with systemic intoxication.

7. Acute dehydration.

8. Head injury and short-term loss of consciousness.

9. Severe pain rated 6-8 points on a ten-point scale where urgent pain relief is required.

10. Acute focal neurological symptomatology.

11. Limb injury that led to impaired blood circulation.

12. Mental and behavioural disorders:

12.1. attempted suicide or threat of such an act;

12.2. acute psychosis;

12.3. severe psychological trauma that causes behavioural disorders;

12.4. severe depression;

12.5. pronounced psychomotor agitation.

13. Penetrating eye injury or acute complete loss of vision.

Category 4

Emergency medical care must be started for the patient no later than within 60 minutes from their arrival at a health care institution.

1. Fever of > 39oC, persisting with oral medicines taken for more than 24 hours.

2. Acute cardiac arrhythmias (supraventricular tachycardia, atrial fibrillation, atrial flutter, broad complex tachycardia) or conduction disorders (2nd-3rd degree AV block, atrioventricular rhythm) occurring over the past 48 hours.

3. Urinary retention, anuria, complications in a patient on dialysis: A-V shunt thrombosis, fall/thrombosis/dysfunction of a dialysis catheter.

4. Severe withdrawal condition that is likely to result in complications due to risk factors (history of psychosis, seizures; may result in complications due to intercurrent acute and chronic diseases; compulsive craving for psychoactive substances).

5. Bites, scratches and saliva spread by rabid or potentially rabid animals.

6. Other injuries (not listed in categories 2 and 3) and occurring accidents over the past 48 hours with increasing swelling/increasing dysfunction.

7. Tick bite.

8. Suppuration of maxillofacial area.

9. Disorders of artificial stomas (where bags need to be changed or flushed out).

10. Light vaginal bleeding or abdominal pain during pregnancy.

11. Complications after medical intervention (torn suture, purulent discharge, increasing swelling, insufficient immobilisation) that have occurred within up to 48 hours after the treatment or discharge from an inpatient health care institution.

12. Foreign bodies in tissues or natural body openings/body cavities that have occurred over the past 48 hours.


Annex 2
CONDITIONS FOR THE RECEPTION OF THE POLYCLINIC TO REFER PATIENTS AS A MATTER OF URGENCY FOR NECESSARY MEDICAL CARE TO BE PROVIDED

1. To be referred to family and paediatric doctors:
(a) severe pain (e.g. in heart area, epigastrium, abdomen, waist, etc.)
(b) sudden shortness of breath
(c) high blood pressure (above 180/100 mm Hg)
(d) fever (≥38°C)
(e) multiple episodes of vomiting, frequent diarrhoea (> 5 times a day)
(f) bleeding from the lungs and digestive tract
(g) acute allergic reactions

2. To be referred to dentists:
(a) acute tooth/facial/jaw pain
(b) facial wounds
(c) injuries to the facial area
3. To be referred to obstetrician-gynaecologists:
(a) bleeding from the genitals
(b) acute pain in lower abdomen
(c) genital injuries

4. To be referred to surgeons:
(a) acute abdominal pain
(b) wounds
(c) abscesses
(d) tick bite (up to 72 hours after the bite (letter No V-637 of the MH of 01/08/2007)
(e) acute rectal bleeding
(f) injury
(g) animal bites (up to 72 hours after the bite)

6. To be referred to otolaryngologists (ENT):
(a) bleeding from nose/mouth/ears
(b) nose/ear injuries
(c) foreign body in throat/nose or ear
(d) acute deafness or other acute hearing impairment

7. To be referred to ophthalmologists:
(a) eye injuries
(b) foreign body in the eye
(c) acute blindness

8. To be referred to neurologists:
(a) head injury in the presence of accompanying symptoms such as a headache/nausea/ vomiting

Annex 3
Storage Locations for Measures of Necessary Medical Care

1. Medical supplies: 118, 215, 111, 227, 321, 414.
2. Portable defibrillators: reception, treatment room No (111).
3. Wheelchairs/chairs: room No 506, reception.

WORKING HOURS

I-V – 7.00–20.00
VI  – 8.00–12.00

Family doctor and a dentist are available on Saturdays at
the Naujininkai clinic, (Dariaus ir Gireno st. 18, Vilnius).
Working hours:
8:00 a.m. to 12:00 p.m.

On Saturdays, family doctor and dentist at VšĮ Naujosios Vilnios Polyclinic (V. Sirokomlės st. 8) and Salininkai Clinic (P. Žvirkos st. 2)
DO NOT WORK.







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