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Definition of Emergency Health Services

Emergency Health Service is well-defined to encompass, in addition to emergency medical service, the service provided in response to emergency events of public health importance. Emergency Medical Services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care.

The purpose of emergency medical service is to stabilize patients who have a life-threatening or limb-threatening injury or illness. These services are established to essentially address the basic principles of first aid,
i.e. preserve life, prevent further injury and damage, and promote recovery.

Features of the Emergency Health Services

The Public Health Service Regulation 2020 states the following important features regarding the Emergency Health Services.
(1) Emergency health services shall be as mentioned in Schedule 2 (listed in the Annex I of this document).
(2) General hospitals, specialist hospitals, specialised hospitals, teaching hospitals under the Institute of Health Sciences and other teaching hospitals shall provide emergency health services as mentioned in Schedule 2.
(3) Ayurveda service centres, specialist Ayurveda hospitals and homeopathy hospitals shall provide emergency health services as per their related medical practices.
(4) At least Primary Hospitals shall provide 24-hour emergency health services in accordance with this Regulation.
(5) While providing emergency health services, priority shall be given on the basis of the severity of the patient’s condition.
(6) If the emergency health services required to treat the patient are not available in a given health institution, the health institution shall immediately provide whatever emergency health services are available, and the patient shall be immediately referred to the most convenient health institution that provides the required services, with proper counselling to the patient or his/her visitor/patient party.
(7) Every health institution shall immediately provide emergency services to patients that have come for treatment in such institution and, if necessary, the patient shall be admitted to the hospital.
(8) Notwithstanding anything mentioned elsewhere in this Regulation, if the patient seeking emergency health services cannot immediately pay the expenses of the treatment, such patient too shall not be deprived of emergency health services.
(9) The expenses required in delivering emergency health services as per this Regulation shall be paid pursuant to Section 4 of the Act.5

Rationale of the STP

Standard Treatment Protocol (STP) lists the preferred pharmaceutical and nonpharmaceutical treatments for common health problems experienced by people in a specific health system. As such, they represent approach of therapeutically effective and economically efficient prescribing. When implemented effectively, an STP offers advantages to patients (e.g., it provides more consistency and treatment efficacy), providers (e.g., it gives an expert consensus, quality of care standard, and basis for monitoring), supply managers (e.g., it makes demand more predictable and allows for pre-packaging), and health policy makers (e.g., it provides focus for therapeutic integration of special programs and promotes efficient use of funds).

Utilization of the STP

The guidelines provided in this Standard Treatment Protocol of Emergency Health Service Package is expected to be useful for all health workers including nurses and doctors and other health-care providers, and health promoters. This can be used to:
-Support the emergency health services by developing a national standard treatment protocol in all health institutions.
-Ensure that all the necessary equipments and resources are available.

The STP is proposed to be used at the following levels of health service as endorsed recently by the Government of Nepal, depending on the resources available:

  1. Basic Health Service Centers (BHSC)
  2. Primary hospitals (up to 5-15 bedded hospitals)
  3. General hospitals (up to 50 bedded hospitals)

How to use the STP

The STP has been developed to fulfill the need of having a comprehensive guidance to health care providers while treating patients in the Emergency room. The ABCDE approach in the emergency room has been described.
The management of Airway, Breathing and Circulation has been elaborated with tables, figures and flowcharts along with the services that are needed to be provided as per the levels of health facilities. Common emergency diseases/conditions, as outlined in the Public Health Service
Regulations 2020 Schedule 2 is presented, and are grouped as the following:

  1. Respiratory emergencies: Shortness of breath, Acute exacerbation of chronic obstructive pulmonary disease (COPD), Bronchial Asthma, Pneumonia, Aspiration Pneumonia, Pneumothorax, Hemoptysis, Acute Pulmonary Embolism, Acute
    Mountain Sickness, High Altitude Pulmonary Edema (HAPE), High Altitude Cerebral Edema (HACE), Acute Respiratory Failure, Acute Respiratory Distress Syndrome (ARDS)
  2. Cardiac Emergencies: Chest pain, Acute Coronary Syndrome, Acute Myocardial Infarction, Arrhythmias- tachyarrhythmias and brady arrhythmias, Acute Pulmonary Edema, Cardiac Tamponade, Cardiogenic Shock, Hypertensive Emergencies
  1. Neurological Emergencies: Coma, Seizures, Acute CNS Infections, Cerebrovascular Accidents, Guillain-Barre Syndrome (GBS), Raised Intracranial Pressure
  2. Gastrointestinal Emergencies: Abdominal pain, Acute Gastritis, Acute Gastroenteritis, Acute Appendicitis, Acute Cholecystitis, Gastrointestinal Bleeding (GIB), Fulminant Hepatic Failure, Acute Pancreatitis, Strangulated/ Obstructed
    Hernia, Intestinal Obstruction, Hollow Viscous Perforation, Peritonitis
  3. Genitourinary Emergencies: Renal Colic, Hematuria, Acute Retention of Urine, Testicular Torsion, Para phimosis
  4. Gynaecology and Obstetrical Emergencies: Ectopic pregnancy, Antepartum Haemorrhage, Ruptured uterus, Pregnancy Induced Hypertension (PIH), Obstructed labour, Postpartum Haemorrhage, Puerperal pyrexia, Hyperemesis gravidarum
  5. Orthopedics and Trauma: Head Injury, Abdominal and Pelvic Injuries, Chest injuries, Musculoskeletal Injuries, Compartment Syndrome, Traumatic Amputation,
  6. Dental Emergencies- Toothache/Odontalgia, Dental fractures, Temporomandibular joint (TMJ) Dislocation, Gum Bleeding
  7. Metabolic Emergencies: Hypo/hyperkalemia, Hypo/hypernatremia, Hypoglycemia, Diabetic Ketoacidosis (DKA), Acute Adrenal Crisis
  8. Ocular Emergencies: Foreign Body Eye, Sudden Loss of Vision, Chemical Injuries
  9. ENT Emergencies: Epistaxis, Foreign body ENT
  10. Burns: Thermal burns, Electrical and Lightening Injuries
  11. Mental Health Emergencies: Alcohol Intoxication, Alcohol Use Disorders, Anxiety Disorder, Conversion Disorder, Depression, Acute Psychosis
  12. Toxicological Emergencies: Outline of Poisoning, Organophosphorus Poisoning, Zinc Phosphide (Rodenticides), Aluminium Phosphide, Mushroom Poisoning, Wild Honey Poisoning, Dhatura Poisoning, Paracetamol Poisoning, Antidotes
  13. Snake Bite, Animal Bite-Rabies, Insect Bite.
  14. Paediatric Emergencies: Diarrhoea, Acute Respiratory Tract Infection-Acute epiglottitis, laryngitis and laryngotracheobronchitis, Pneumonia, Febrile Convulsions
  15. Miscellaneous: Anaphylaxis, Needle stick injuries, Pain management in the Emergency
    i. Each system starts with the commonest symptom encountered in the
    emergency room and includes:
    a. Introduction
    b. Causes
    c. Clinical features (common symptoms and signs of presentation)
    d. Differential diagnosis of the related symptoms and signs
    e. Investigations
    f. Management

ii. Each disease/emergency condition includes:
a. Introduction
b. Causes
c. Clinical features (common symptoms and signs of presentation)
d. Investigations
e. Management and disposition (shown in flowcharts)
iii. Management of each disease/emergency condition starts with the resuscitation and initial management in case the patient presents in an unstable condition followed by the recommended pharmacological and definitive management.
This includes doses, routes and duration of the pharmacological agent and the active interventions and emergency procedures. It is based on the latest national and international evidence-based guidelines and medical literature,
which can be adopted by the health care provider, and bring into practice in the emergency room.
iv. Competence of the health care provider, availability of resources including human resources, lab facilities, diagnostics, medications, infrastructure and equipment present in the level of health facility where s/he is working are
important factors that affect compliance to this STP.
v. Care should be taken for arrangement of referral services when the health care provider is unable to manage the patient either due to lack of experience or the unavailability of necessary resources. Patients should be referred to facilities.
where the necessary competence, diagnosis and support facilities exist after providing the necessary emergency services and stabilizing the patient. A patient referral form has been provided in the annex.
vi. The emergency drug list, referral form, bibliography and list of participants of the various consultative meetings are provided in the annexes.

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