AL Baraha Hospital
Scope of Services for Surgery Department
SW1, SW2 and surgical outpatient
Our mission:-
 To provide and implement a comprehensive system in treating surgical patients according to evidence based protocol, currently in place.
 To keep improving the quality of service and reducing the medical and surgical errors.
 To provide the technical support to get the JCIA.
Services:-
Our services include but not limited to:-
 Treating the patients who present to our general surgical and urology outpatient and accident and emergency departments.
 Doing elective and emergency operations and following up on the patients in the wards.
 Responding to consultations from all other departments.
 Our surgical oncall is the team leader in the disaster control and code red situation.
Physical layout:-
Set up
Number
Total Bed Capacity
24
High dipendency unit
2
Transit Lounge chairs
6
Beds for female
6
Beds for Male
16
Page 2 of 8
ABH/CQI/F004
Admission Criteria:-
1- Admission can be done only by a privileged physician.
2- Emergencies through accident/emergency department.
3- Elective cases for surgery through surgical clinic.
4- Referred in-patients from other departments of Albaraha Hospital.
5- Patients can be transferred from other hospitals.
The following conditions require emergency admission to surgical department:-
1. Acute abdomen ( appendicitis, cholecystitis, pancreatitis, diverticulitis, perforated viscus, peritonitis)
2. Internal or severe external bleeding.
3. Polytrauma patients, head trauma, more than two ribs fracture, pneumo or hemothorax.
4. Septic, hemorrhagic or hypovolemic shock.
5. External surgical infections ( abscess , cellulitis, diabetic septic foot).
6. Intestinal obstruction.
7. Obstructive jaundice.
8. Suspicious or proof of ischemia.
9. Urological emergencies ( urine retention, hematuria, urinary tract caculi , priapism, fracture penis , urinary infection and testicular pain).
Page 3 of 8
ABH/CQI/F004
The following conditions require elective admission to surgical department:-
1. Endocrine surgery: goiter, hyperthyroidism, thyroiditis, neoplasm of thyroid, hyperparathyroidism, adenoma of parathyroid, carcinoma of parathyroid glands, adrenal gland tumor, pheochromocytoma.
2. Oncological surgery: tumors of skin, soft tissue, thyroid, parathyroid, lymph nodes, parotid, salivary glands, esophagus, stomach, liver, gallbladder and bile ducts, pancreas, small bowel, colon, rectum, anus, adrenal gland, metastasis and recurrence of tumors after surgery.
3. Pelvic floor: anal diseases such as haemorrhoids, fissures, fistulae, prolapse, abscess, tumor, warts, Intussusceptions, pelvic hernias.
4. Hernia center: umbilical, Para umbilical, epigastric, inguinal, femoral, incisional, Spighelian hernia, pelvic hernias, recurrent hernias, diaphragmatic, internal, and lumbar hernias.
5. Laparoscopic surgery: cholelithiasis, exploratory laparoscopy, adhesions, hernias, appendicitis, spleenomegaly, hypersplenism, pancreas necrosis, perforated ulcer, feeding tube and bariatric surgery.
6. General and metabolic diseases: sinuses, abscesses, cellulitis, lymphangitis, necrotizing fasciitis, diabetic foot-leg, ischemic gangrene and amputations.
7. Malformations: intestinal malrotation, Meckel diverticulum.
8. Urology: urinary tract calculi, urological malignancies, urinary tract infections, prostatic enlargement and circumcision.
Discharge Criteria:-
1- To be instructed only by the most responsible physician.
2- When the physiologic status has been stabilized.
3- Complete assessment to be done prior to the discharge .
4- Proper documentation to be done in the patient’s medical record.
Page 4 of 8
ABH/CQI/F004
5- A copy of discharge summary which contains final diagnosis, procedure performed, brief note regarding treatment rendered, progression in the hospital specific instructions relating to medications, diet, wound care, sick leave and follow-up instructions should be given to the patient.
6- Insure patient education .
Page 5 of 8
ABH/CQI/F004
Organization Chart
Specialist A
Specialist B
Head Of Surgery Department
General Practitioner
Consultant A
Doctors
Nurses in urology, surgical outpatient and wards
Incharge nurse
Staff nurse
Assisstant A, B
Senior incharge nurse
Page 6 of 8
ABH/CQI/F004
Competencies :-
Refer to section 9 in the Total Quality Manual file (TQM).
Hours of Operation :-
 Doctors provide 24 hours surgical resident, covering emergency patients , inter departmental calls as well as the surgical inpatients, covered by a second on call surgeon.
 Doctors work five days a week from 07:30 to 14:30 day time.
 The Nurses in charges are working 5 days a week 8 hours a day, weekends and public holidays off .
 The remaining of nursing staffing categories are working 3 days a week 8hours a day.
 We have twice weekly elective operation lists.
 Working in the surgical out patient clinic 5 days a week.
 During weekends and public holidays staffing will be covered and compensation of the hours will be given at later time
Equipment specific for your service:-
1- Dressing and debridement sets.
2- Fine needle aspiration.
3- Truecut biopsy needle.
4- Harmonic device.
5- Laparoscopic tower.
6- Skin Staplers.
Page 7 of 8
ABH/CQI/F004
7- Transrectal endoscopic surgery.
8- Gastrointestinal staplers.
9- Skin grafting knife.
10- ECG machine.
11- Vital signs monitor.
12- Glucometer and oxygen
Documentation specific forms/templates/records used by your service :-
1- Consent procedure form.
2- Time out procedure form.
3- KPI card .
4- KPI Tracking form.
5- Operation request form.
6- Anti venousthromboembolic prophylactic form.
Internal & External Disaster plans: unit specific responsibilities :-
 Refer to the intranet Al Baraha in Ministry Of Health website .
Key Performance Indicators:-
Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 hours Prior to Surgery .
Page 8 of 8
ABH/CQI/F004
Prepared by :-
Dr .Haitham Omer Dr. Haitham Fouad
Date: 01/11/2014
Reviewed and Approved by Head of Department
Dr. Shuaib Kazim
Date:
Acknowledge by Head of Quality Section
Ms.Alanoud Salman
Date :
Reviewed and Approved by Director of service/ Department
Dr. Ahmed Alammadi
Date:
Approved by Hospital Director
Mr. Ahmed Alkhadiem
Date: