Orientation on Referral System in RHSDP

(Under Aegis of Rajasthan Health System Development Project)

May 2005

State Institute of Health & Family Welfare

Rajasthan, Jaipur

PrefacePrefacePrefacePreface

SIHFW, Rajasthan is involved in selected in-service trainings in Rajasthan Health System Development Project. Trainings in context of strengthening referral system happens to be one of them. As per

project implementation plan selected professionals from each of the secondary facilities of the project would be given an in-service orientation on referral system.

SIHFW has proposed a strategy in which the trainees to be

identified by the RHSDP shall be oriented for two days covering the

diseases from various specialties. We speculate around 42 training program of two days each which will be conducted at two HFWTCs and at our own Institute. Further, we propose sensitization program for primary and tertiary level facilities may be convened to complete the

chain of referral.

I must bring on record the effective contribution from Dr. J.P. Jain our Consultant, Dr. B.N. Sharma, Nodal Officer from this Institute

and Dr. P.C. Ranka of the RHSDP in bringing out this module.

31.5.2005 Shiv Chandra Mathur SIHFW, Rajasthan, Jaipur Director

CO#TE#TS

Chapter. - Title - Page No.

1. Introduction 1

RHSDP goal & objective

Proposed Referral System

Manpower deployment

2. Structure of organization 7

& Medical care facilities

3. Linkage at various levels 10

Decision Making

Transport and communication

Management of Blood

4. Referral Norms in RSHDP 15

a) Disease-wise services at

various facilities

b) Directives for Referral Norms

5. Feed back and Follow-up 41

6. Rajasthan State Essential 44

Medicines List

Appendices 1 Manpower Norms

2. Referral Cards

3 Referral Register

4 Program for Training of Referral System

Chapter – 1

I#TRODUCTIO#

Rajasthan Health System Development Project (RHSDP) was conceived with

the support of World Bank. The ultimate goal of the project is improvement in

the Health of people of the State, with the following aims and objectives.

1. To enhance the effectiveness and quality of health services at the

primary and secondary levels through policy and institutional

development.

2. To increase access to and equity in health care service delivery with

particular focus to the underserved sections. {

To achieve these objectives the whole project has following components.

1. Policy Development and Project Management

2. Improving Quality and Efficiency of Public Health Care services at

Primary/secondary level.

3. Improving access to Health care services for poor.

In consonance with the components it is proposed to strengthen the referral

system. In this context quality norms have been decided for various levels of

Medical Care facilities.

Referral services are non-existent in the state and do not have definite norms.

Patient is at liberty to seek care at any level of his/her choice and convenience.

In other words a patient does not require referral slip or prior appointment to

seek care at higher level facilities. Most of the in- patients at the secondary level

institutions, such as CHCs or district hospitals, by pass the primary health

facilities, whenever they wish. Self referrals even for common ailments create

overcrowding at higher-level institutions. CHCs are also bypassed for even

minor ailments resulting in extremely poor bed occupancy. The main reasons

for bypassing lower level institutions seem to be lack of diagnostic and

treatment facilities at these centers, absence of qualified medical

1

and nursing staff, non-availability of drugs, poor equipment, and people’s lack

of knowledge about the available services. On the other hand, people often

refuse to be referred to higher-level institutions, especially in backward areas,

due to high transportation and other costs, and apprehension of mistreatment or

poor attention there. In improving quality of health services, a key instrument is

referral system, which has to be reviewed to make it stream lined.

The project strongly emphasizes that strengthening of secondary level hospitals

would raise credibility of the primary health care system as the referred cases

from the primary level will get better quality care on the one hand while

reducing the work load of tertiary care hospitals on the other. It is thus

imperative to have a good referral system with adequate support so that services

are available in a comprehensive manner nearer their doorsteps. An efficient

and effective referral system depends upon

• Linkages between different levels of health care

• Availability of specialists and support services

• Resources

• Timely decision

• Transport and communication

• Referral criteria and protocols

• Feedback and follow-up

Proposed Referral System

With the up gradation of health facilities provision of additional inputs, and

enhancement of skills of service providers it is expected that the health facilities

would comply with the requirements of the clients. The utilization of these

institutions depends upon the flow of the patients from the outreach area.

Referral at appropriate institutions will reduce the gap between illness and

seeking treatment and out-of-pocket expenditure. The institutions below district

level would be able to screen the patients, limiting the load on district hospitals.

However,

2

the above investments could really bring forth the desired results if only they

are backstopped by an effective referral system. An effective referral system

would derive its substance from the following elements.

▪ Procedural directives;

▪ Dissemination of information to the community about the available

services

▪ Referral protocols with explicitly laid methodology of the working

of referral system;

▪ Improved support to enhance the referral of cases from remote

areas;

▪ Sensitization and training of those who refer and those who receive

the referred; and

▪ Timeliness

For developing referral protocols, the service norms at each level of institutions

have been considered. Based on these norms and the capacity of an institution,

referral norms for common conditions have been developed. They will be

further extended and refined as part of the routine service delivery during the

project. A system of coloured referral cards will be introduced as follows:

PHC

CHC

SDH

DH

[[[

3

Green

Green

Green

Red

Yellow

Yellow

Yellow

Teaching Hospital

Green

The Referral Card (given in appendix) would have basic patient identification

and clinical information like:

a) Patient identification (Name, age, sex, address)

b) A brief history of sickness (major complaints, findings and

treatment taken)

c) Clinical diagnosis

d) Treatment given (including date and admission and length of

stay)

e) Diagnostic tests and their results (reports to be attached)

f) Condition at the time of referral

g) Centre to which referred

h) Reasons for referral

This card along with the available diagnostic test reports shall be taken to

higher levels where the patients are referred. The down-referral/feed back

would be made to the referring institution and will include final diagnosis,

treatment to be continued and other follow-up instruction. The Feedback Card

is given in appendix.

For people to know the health facility and the services it offers, all district

hospitals are in the process of developing Citizen Charter, in a participatory

manner keeping in view the beneficiary needs and services available at the

facility, which would make people aware of services, staff, structure, fee,

facilities and free services. To start with, CHC/SDH will be covered through

effective IEC and gradually it is intended to have a Citizen Charter for every

CHC/SDH/DH. Referral Norms have been developed keeping in view the

assignment of Health Care providers and their expertise/skills in diagnosis and

treatment of respective illness of their discipline. For Health care provider at

different facilities referring the case to higher level institution, it is imperative

to know the availability of expertise of the specialty and supportive staff.

Looking to the necessity and capacity of beds at different levels the specialist,

SMO, MO and supportive staff are deployed (man power is given in the

appendix.1)

4

The department will issue the procedural directive to avoid delays and

confusions. Some of them relate to the following.

▪ All patients will be entitled for use of ambulance/vehicle on

payment.

▪ At receiving institutions a referred patient would be an out of

queue priority.

▪ A record of referrals received and referrals made will be

maintained to facilitate follow up.

▪ If necessary, to be justified by the treating physician, a member of

the medical staff would escort referred cases.

▪ A minimum set of clinical documents to be sent with the patient in

order to avoid duplication, cut costs and reduces treatment

initiation time.

The proposed Project Coordination and Monitoring Committee at the district

level will ensure creation of a District Referral, Committee at each hospital. The

committee will consist of the following members: PMO, CMHO, DY. CMHO

at sub-divisional level, Medical Officer In-charge of hospitals/CHCs located at

sub-divisional, Medical Officer In-charge of all CHCs and Superintendents of

teaching hospital (wherever applicable). This committee will meet once in a

month and ensure the following activities.

▪ Monitoring upward as well as down ward referrals.

▪ Mobilizing NGO/community support for transporting patients.

▪ Disseminating information to health staff and public on guidelines

of referral and services available at each level.

▪ Using referral data for decision-making.

The follow-up will be done through the feedback received from the district

referral Committees. Initially, on the basis of two or three major disease will be

considered for follow-up of referral interventions.

5

Incentive for good referral practices will encourage and be considered at the

time of ranking of hospital on quality indicators.

The mobile camps to be organized to extend the out-reach services in the tribal

and desert areas will also follow the same referral system.

With above background, the Referral System Training aims at:

(a) Orienting the medical care professionals posted at secondary

facilities on the process of referral.

(b) Enhancing the capacity of trainees to disseminate the referral

related information to primary and tertiary level facilities.

6

Knowing is not enough,

We must apply,

Willing is not enough,

We must act,

Johann Wolfgang Von Goethe

Chapter -2

STRUCTURE OF ORGANIZATION

To implement the proposed project strategy, a project management structure is

required. The proposed Project Management structure would have identified

roles and responsibilities of individuals in implementing the project. Among

these roles would be those that seek to strengthen management and institutional

capacity through improved management and development of human resources.

It is expected the HR management will go beyond and include personnel

policies and decisions affecting recruitment, posting, performance, appraisal,

and rewards. Support by way of improved management of information through

a comprehensive and integrated information system would be provided such

that it would enable managers at all levels to access performance. Importantly,

this would be done through decentralized structures and systems that facilitate

implementation.

Organization of medical care facilities

The districts are divided into a number of administrative blocks (conforming to

the area of Panchayat Samiti). At the Block HQ, the Medical Officer In-charge

of the Block PHC is responsible for implementing all national health

programmes, family welfare and reproductive health and curative services in

the block area through the network of PHCs and Sub-centres. From the

administrative point of view the block PHC compiles all the performance

reports sent by CHCs and PHCs.

At the PHC level the Medical Officer in charge is responsible for implementing

all the programmes in his PHC area. Sector supervisors assist him in monitoring

the progress of various activities. At the village level, an Auxiliary Nurse

Midwife (ANM) manages Sub-centre. She is responsible for implementing all

the programmes in the Sub-centre area, which usually covers 4-6 villages. At

the village level, Village Health Committees have been already constituted

which include ANM, teacher, Anganwadi worker,

7

and Patwari, for implementing various health and family welfare activities at

the village level and enhance community participation in health planning and

monitoring at the grass roots level.

Tertiary Level Medical College

District Hospital

Secondary Level

Sub Division Hospital/ CHC

Block PHC

Primary Level PHC

Sub Centers

Health Care Services Constitute a critical core in the organizational set up of

Medical, Health, and Family welfare services provided through a public system.

In this background Medical, Health and Family welfare Department bears an

onerous responsibility to manage more than 12000 rural health facilities ranging

from sub divisional Hospital/CHC through PHC to sub centre. These facilities

cater to the medical care, health and family welfare needs of three- fourth of the

communities of the State whose total population has already gone beyond 55

million.

8

Administratively:- The State has been divided in to 7 Divisions, 32 Districts,

which are further sub divided in to various peripheral urban/rural health

facilities Viz, DH/CHC/FRU/ PHC and Sub centers etc.

The services at District to village level are provided by the network of health

facilities of different levels determined by their bed strengths as follows:

No. of beds 300 bed 150 bed 100 beds 50 beds 30beds PHC Sub center

No of Hospitals 8 20 12 81 226 1706 10387

9

All beings are born free and equal in dignity and rights

Article 1, UDHR

Chapter -3

LI#KAGE

Community PHC CHC DH

Since most of the referrals originate from the field, the information on

availability of emergency services at FRU/CHC/SDH/DH will have to be

effectively disseminated to all villages in the area so that population know

where they should reach for getting appropriate emergency care.

One of the main constraints experienced in operationalizing the referral system

is linkage. Adequate linkage at different levels of the health system is an

essential requirement of sound referral system. This frame work serves as a

planning tool as to what action is required at different levels of the health

system. At the same time it emphasizes the need of proper linkage between

these levels through transport and communication system on one hand, and

supervision, outreach and community based activities on the other. Community

awareness, improved options for emergency transport and quality of care in

health facilities, are thus expected to reinforce each other: Access and quality

enhance community trust. There should be clear guidelines to manpower or

health workers working at different facilities like at PHC/CHC/SDH/DH about

what management can be done at the respective facilities.

10

They should also guide the patient where he needs to go for further diagnosis/

treatment pertaining to the ailment.

Many times, to facilitate appropriate level of reference in cases of emergency

where high risk cases present with threat of life and hierarchy of referral is not

feasible to follow, the cases may be referred directly and immediately to the

higher level facilities as per need. For example in Obstetrics cases of severe

APH/PPH, obstructed/ Complicated labour, Eclampsia, Ectopic Pregrency,

Vesicular Mole and Severe Anemia needs immediate referral. In Paediatrics

viz. cases of Birth Asphyxia, Low Birth rate babies, Meconium Aspiration

Jaundice, Convulsions, Tetanus Neo-natorum, septicemia and congenital

Anomalies may need immediate referral from community /PHC to DH or

Tertiary Level facilities by bypassing the PHC/CHC/SDH/DH.

The referring centre should also communicate relevant information like

investigation carried out with reports there of etc., probable diagnosis and

treatment given. This can be ensured by filling referral cards properly after

careful examination of the patient. To differentiate the cards to be used at

different levels (upwards and down wards), separate colors have been used.

Proper receipt and monitoring of these cards will be verified through referral

register (enclosed). District level officers such as PMO, CMHO and district

project officer will be required to monitor the referral system regularly so that,

the prescribed linkage chain is not disrupted.

Referral system is a system of team work and to manage the referral system

meticulously, the formation of referral committee at district level are suggested.

The proposed project coordination and monitoring committee at district level

will ensure creation of a District Referral Committee at each district hospital.

The committee will consist of PMO, CM&HO, DY. CM&HO, at sub divisional

level, Medical Officer in charge of Hospital/CHCs located at subdivision,

Medical Officer in charge of all CHCs and superintendents of teaching hospitals

(wherever applicable) . The committee will meet once in a month to monitor

and review entire referral, the follow-ups of referral data will be used for

decision making pertaining to improvement in existing scenario.

11

Decision-Making

Decision Making is really a complex mental exercise in turbulent situations.

Vital decisions are taken in crises, at speed with little time for thought or

consultation. There are four `Cs’ of decision making – checking, consulting,

considering and communicating.

Appropriate timely decision requires better interpersonal relationship between

clients and service providers informing them about causes and seriousness of

their health problems and types of services currently available and their sources.

You have to also provide counseling services wherever needed so that the

clients are enabled to take correct decision for accepting services. This, in turn,

is expected to increase satisfaction with the services received among clients and

thereby further increase the acceptance of services.

Adoption of wrong referral may lead to heighten the cost of treatment and

involving risk of life. Delay in decision making may be defined in phase

manner as below:-

○ Phase 1 delay : Decision-making at community level.

○ Phase 2 delay : Accessibility, transport and communication.

○ Phase 3 delay : Accessibility of appropriate care, quality of care.

Examining the decision-making process regarding primary health care,

especially in pregnancy/childbirth in communities, will highlight both the

‘birth- preparedness’ at community level (delay1), the options for

communication and transport from community to health facility (delay 2) and

the (perceived) quality of care (delay 3).

The risk assessment should be done with out delay at primary level itself and

decision should be communicated to companions of the patient without creating

panicky. Health provider should motivate and be able to help the attendants to

arrive at some decision by way of counseling for referral. He should also

address the relevant information like general condition of patient, prognosis,

probable need of blood transfusion and need of vehicle for shifting the patient

to higher level facilities. In other words helping people to make decisions about

the type of specific health care they need with a minimum inconvenience and

delay.

12

It is no longer our resources that limit our decisions; It’s

our decisions that limit our resources. U Thant

Transport and Communication.

For emergency cases ambulance will be provided to the patient by the MO in

charge of the hospital referring the case. He may also communicate to the

referred specialist simultaneously on telephone (land line/mobile) regarding

status of patient, purpose of referring and services urgently required. Providing

Government procured vehicles should not be seen as the only option for referral

transport. To make local arrangement for referral PRIs, Community members

and NGOs should also be motivated to take part in this process. A social

response for effective communication and transport arrangement for women

experiencing complication can tremendously cut-down delays and save lives.

With the consensus of community leaders a list of vehicles along with owners

available in the village/town should be recorded with the health facilities so that

at the time of crisis these vehicles can be utilized.

In emergency, before transporting the case to higher level facility, treating

physician/medical officer should ensure.

1. The patency of fluid infusion

2. Sufficient quantity and regular supply of oxygen, if required

3. Availability of possible need of drugs during transportation.

The attendant/ companions from family and friends of the same blood group

must accompany the patient so that they might be used as blood donor if need

arises. They should also carry some money in cash for forthcoming

expenditures during treatment.

If necessary and justified by the treating physician a member of

Medical/Trained paramedical staff would escort the referred case. During the

way to higher level facility he will make possible sincere efforts to maintain the

vital signs of the patient with his own knowledge and judgment. At last the

patient will be handed over to receiving institute/ specialist providing out of

queue priority along with referral cards and reports with briefing.

13

Management of Blood

Availability of blood is critical to reducing mortality, as hemorrhage is the

leading cause of accidental and maternal death. Availability of blood is

dependent upon blood donors as it cannot be synthesized artificially even today.

Lack of donors is frequently cited as the cause of unavailability of blood. Blood

banking services by Government should not be seen as the only place of

availability of blood. Strong advocacy in the form of information, education

and counseling (IEC) for blood donation must be undertaken to overcome this

barrier to save the human lives. This advocacy also stems from religious and

cultural values that support the act of giving blood to ensure the health and

survival of others. Alternatively we must also give a thought to involve

voluntary organizations, NGOs and other individuals who come forward of

their own for blood donation.

In context to referrals, medical officer, is a key person who should have good

reputation in the community and among government officials. He should keep

close liaison with the community leaders, persons from ICDS, Revenue,

Auyurved, Police, Education and various social welfare agencies. He must use

his goodwill and do counseling in motivating the volunteers for blood donation.

The attendant of patient should also be made clear regarding the need of blood

at the place where patient is being referred. Following thorough counseling, the

companions should be advised to get ready for blood donation when need

arises.

14

Compassion is a sense of caring or sympathy for the suffering of others that

brings clarity regarding their needs and pain. It is also practical

determination to do whatever is possible to help alleviate their suffering.

Compassion is not true compassion unless it is active. Sogyal Rinpoche

Chapter -4

REFERRAL NORMS IN RHSDP

a) Disease-wise services at various facilities

Referral norms have been developed keeping in view the deployment of health

care providers and their expertise/skills in diagnosis and treatment of respective

illnesses of their discipline. Hence it is imperative to look at the services norms

at this juncture which are given below, ‘vis a vis’ referral norms:

Recommended Service Mix at Various Levels (30 Beds and above)

No

.

Conditions Primary Level Secondary Level

30 beded 50 beded 100 beded 150 beded

GROUP 1 : Infectious, Parasitic diseases and prenatal conditions

1 Diarrhea

Diseases

Treatment, Refer

cases not

responding to

routine line of

treatment to nearby

institution.

All direct and

referred cases,

Support to PHC

for Epidemic

control.

All cases, Cases

referred by

PHC/CHC.

Support to PHC

for Epidemic

control.

All cases, Cases

referred by

PHC/CHC/SDH

Manage the

referred cases.

All cases,

Bacteriological,

Electrolyte Test.

Manage the

referred cases.

2. Typhoid /

Paratyphoid

Preliminary

treatment as PUO.

Refer non-

responding cases

(5days) to nearest

institution.

Treatment of

uncomplicated

enteric fever.

Basic relevant

investigations,

support to PHC

for epidemic

investigations

Treatment of

uncomplicated

enteric fever.

Basic relevant

investigations,

support to PHC

for epidemic

investigations,

management of

the referred

cases.

Widal test/

culture, treatment

of complications

drugs sensitivity,

management of

complications

such as intestinal

perforation etc.

Widal test/ culture,

treatment of

complications drugs

sensitivity,

management of

complications.

15

3. Tuberculosis Sputum exam of

suspect cases,

treatment and

follow-up of

confirmed cases,

refer sputum

negative cases, (for

x-ray) and cases

with

complications.

Sputum exam and

x-ray, treatment

of cases, refer

cases with

complications

and extra

pulmonary cases

to DH (lymph

node biopsy) &

further

management.

Sputum exam

and x –ray,

biopsies,

treatment of

cases, refer

cases with

complications

and extra

pulmonary

cases to District

Hospital.

Sputum exam

and x –ray,

biopsies,

treatment of

cases, refer

cases with

complications

and extra

pulmonary

cases to District

Hospital.

Sputum e

x-ray biopsies,

Diagnosis of extra

pulmonary cases,

treatment of

resistant cases,

treatment of TBM,

AFB culture

4. Leprosy Diagnosis of

suspect, MDT

Diagnosis of

suspect, MDT,

Treatment of

reactions

Diagnosis of

suspect, MDT,

Treatment of

reactions

Physiotherapy,

treatment of

ulcers &

reactions

Physiotherapy,

treatment of ulcers

& reactions,

reconstructive

surgery

5. Vaccine

preventable

diseases

Immunization

services in

institution and in

outreach,

Diagnosis of VPD,

treatment of

measles and

whooping cough,

Referral for polio,

diphtheria, NNT

and adult tetanus

Immunization

services in

institution,

diagnosis of

cases, treatment

of measles and

pertussis

complication,

treatment of

referred cases

of diphtheria,

polio, NNT and

adult tetanus

Immunization

services in

institution,

diagnosis of

cases, treatment

of measles and

pertussis

complication,

treatment of

diphtheria,

polio, NNT and

adult tetanus

Immunization

services in

institution

diagnosis and

treatment of

referred cases of

measles and

pertussis

complication,

treatment of

referred and

complicated

cases of

diphtheria, polio,

NNT and adult

tetanus

Immunization

services in

institution,

treatment of

referred cases,

treatment for

complication of

immunization,

rehabilitative

surgery

16

6. Malaria Blood smear

for all fever

cases,

presumptive,

radical

treatment,

suspect

cerebral

malaria and

hepatitis

refer to sub

divisional

hospital or

DH

Blood

smear

examination

presumptive

treatment,

malaria

clinic,

radical

treatment

Blood

smear

exam.

Presumptive

treatment

malaria

clinic,

radical

treatment,

screening of

Hepatitis

cases,

treatment of

cerebral

malaria

Blood

smear

exam.

Presumptive

treatment,

malaria

clinic,

radical

treatment,

Screening

of Hepatitis

cases,

treatment of

cerebral

malaria

Treatment of

cerebral

malaria,

Complicated

malaria with

pregnancy,

malaria clinic

Treatment of

cerebral

malaria,

Complicated

malaria with

pregnancy,

malaria clinic.

7. STDs

excluding

HIV

Syndromic

approach for

RTI/STD and

counseling,

Refer to

nearest

institution for

confirmation

and

treatment.

Syndromic

approach for

RTI/ STD

and

counseling,

Refer to

nearest

institution

for

confirmation

and

treatment.

ANC

screening

Treatment

of all STDs,

Standard

tests for

STD, ANC

screening

Treatment

of all STDs,

Standard

tests for

STD, ANC

screening

Complete

diagnosis

(Clinical and

Bacteriological),

Treatment of

STDs,

Treatment of

Neurosyphilis,

ANC Screening

Complete

diagnosis

(Clinical and

Bacteriological),

Treatment of

STDs,

Treatment of

Neurosyphilis,

ANC Screening

8. HIV Suspect HIV

infection in

bleeding

STDs, bio-

safety

measures

Suspect HIV

infection in

bleeding

STDs, bio-

safety

measures

Suspect

HIV

infection in

bleeding

STDs, bio-

safety

measures

Suspect HIV

infection in

bleeding

STDs, bio-

safety

measures

ELISA

Testing

ELISA test, sero

surveillance

Blood and bio-

safety

,Treatment for

ARC and full

blown AIDS

ELISA test, sero

surveillance

Blood and bio

safety,

Treatment for

ARC and full

blown AIDS

9. Hepatitis Diagnosis,

Treatment,

Refer

complicated

cases such

as

pregnancy

with

Hepatitis,

suspect

seum

hepatitis

Diagnosis,

treatment,

Liver

function

tests,

support to

PHC for

epidemic

control

Diagnosis,

treatment,

Liver

function

tests, support

to PHC for

epidemic

control,

treatment of

hepatic pre

coma and

coma

Liver function

tests,

treatment of

complications

such as

Hepatic

Coma,

support for

epidemic

control.,

pregnancy

with Hepatitis

Liver function

tests, treatment

of complications

such as Hepatic

Coma, support

for epidemic

control,

pregnancy with

Hepatitis

Liver function

tests, treatment

of complications

such as Hepatic

Coma, support

for epidemic

control,

pregnancy with

Hepatitis

17

10. Helminthiasis Clinical

diagnosis

treatment,

Anti

helminthic

treatment to

pregnant

mothers,

treatment

of anemia

Microscopic

examination

and appropriate

treatment

Microscopic

examination

and appropriate

treatment

Treatment of

round worm

perforation,

obstruction and

other

complications

Treatment of

round worm

perforation,

obstruction and

other

complications

Treatment of

round worm

perforation,

obstruction and

other

complications

11. Dengue

Hemorrhagic

fever

Diagnosis,

treatment of

non

hemorrhagic

dengue,

refer for

DHF

Diagnosis,

treatment of

non

hemorrhagic

dengue, refer

for DHF,

support for

epidemiological

investigations

Treatment for

Dengue

Hemorrhagic

fever, support

for

epidemiological

investigations

Treatment for

Dengue

Hemorrhagic

fever, support

for

epidemiological

investigations

Treatment for

Dengue

Hemorrhagic

fever, support

for

epidemiological

investigations

Treatment for

Dengue

Hemorrhagic

fever, support

for

epidemiological

investigations

12. ARI Clinical

diagnosis,

treatment

Clinical

diagnosis,

treatment, X-

ray, routine

investigations

Clinical

diagnosis,

treatment, X-

ray, routine

investigations

Clinical

diagnosis,

treatment, X-

ray, routine

investigations

Bacteriological

exm., X-ray,

treatment of

severe cases

Bacteriological

exm.,X

treatment of

severe cases

13. Meningitis/

Encephalitis

Refer to

district

hospital/

sub district

hospital

Refer to district

hospital / sub

district hospital

Lumber

puncture,

treatment,

support for

epidemiological

investigations

Lumber

puncture,

treatment,

support for

epidemiological

investigations

Investigations,

culture and

sensitivity

treatment of

complicated

cases

Investigations,

culture and

sensitivity

treatment of

complicated

cases

14. Filariasis Night blood

smear,

treatment of

diagnosed

cases, refer

SDH for

further

treatment

Night blood

smear,

treatment of

diagnosed

cases, refer

SDH for further

treatment

Night blood

smear,

treatment of

diagnosed

cases, refer

SDH/DH for

further

treatment

Complete

diagnosis and

treatment,

surgical

treatment

Complete

diagnosis and

treatment,

surgical

treatment

Complet

diagnosis and

treatment,

surgical

treatment

18

15. Plague Diagnosis of

suspects, refer

the cases to

SDH for

diagnosis,

treatment

Bubo

puncture &

smear

examination,

treatment,

inpatient care

for

Pneumonic

cases

Bubo

puncture &

smear

examination,

treatment,

inpatient care

for

Pneumonic

cases

Bubo

puncture &

smear

management

of referred

cases. for

Pneumonic

cases

Bubo

puncture &

smear

management

of referred

cases. for

Pneumonic

cases

Bubo

puncture &

smear

management

of referred

cases. for

Pneumonic

cases

16. Maternal

care ante,

intra and

post natal

Usual MCH

care to all

cases, refer

high risk

mothers to

CHC/ SDH

Usual MCH

care to all

cases refer

cases of high

risk mothers

if facilities for

cesarean

section are not

available

Usual MCH

care to all

cases, LSCS,

blood

transfusion

Full

component of

maternal care

and

management

of

complicated

cases

Full

component of

maternal care

Full

component of

maternal care

17 neonatal

care

Manage babies

with birth

weight more

than 2000

gms. , refer

babies with

less then 2000

gm to 50

bedded and

above

Manage

babies with

birth weight

more than

2000 gms.

refer babies

with less then

2000 gm to 50

bedded and

above

Care of low

birth weight

babies

(between

1500-

2000gm)

Care of low

birth weight

babies

Intensive care

of low birth

weight babies

Intensive care

of low birth

weight babies

18. Abortions

and

Services

related to

miscarriage

Menstrual

regulation

MTP up to 12

weeks

treatment of

incomplete

abortion

Hysterectomy,

treatment for

incompetent

os, incomplete

abortion

Treatment of

incompetent

os diagnosis

of repeated

abortions,

Incomplete.

Abortion

Treatment of

incompetent

os diagnosis

of repeated

abortions,

incomplete

abortion

Treatment of

incompetent

os diagnosis

of repeated

abortions,

incomplete

abortion

19. Family

Welfare

Services

All four

contraceptives,

Laparoscope’s

on demand

(camp)

Laparoscope’s

regular basis,

treatment of

complications

Laparoscope’s

regular basis,

treatment of

complications

Laparoscope’s

regular basis,

treatment of

complications

Laparoscope’s

regular basis,

treatment of

complications

Laparoscope’s

regular basis,

treatment of

complications

19

GROUP II : #on communicable diseases

20

Neoplasm’s

(Bennie/

malignant).

Suspect,

refer to

sub

district

hospital

or

district

hospital

Suspecting

cervical

cancer, PAP

smear and

biopsy to be

sent at

Histopathology

center.

Diagnosis of

cervical

cancer,

Hysterectomy,

surgery for

benign tumors,

refer for

Histopathology

Diagnosis of

cervical

cancer,

Hysterectomy,

surgery for

benign tumors,

refer for

Histopathology

Diagnosis,

treatment of all

cases,

definitive and

palliative

surgery,

chemotherapy..

On suggestion

of tertiary level

Diagnosis,

treatment of

all cases,

definitive and

palliative

surgery,

chemotherapy.

On suggestion

of tertiary

level

Cancer Management*

Aspect. Primary Level CHC/SDH District Hospital

Prevention I. Educate on a continuous basis (through

IEC) for primary prevention of cancers

related to:

(1) Tobacco

(Avoidance, Cessation Counseling &

enforcement of rulings of the National

Act);

( 2) Unhealthy diet (Avoid Superfluous

calories from Fried food / Sweet);

(3) Regular Physical Activity (Avoid

Sedentary Life Style);

(4) Local hygiene of Genitalia-post coital;

and Cessation Counseling & enforcement

of rulings of the National Act);

( 2) Unhealthy diet (Avoid Superfluous

calories from Fried food / Sweet);

(3) Regular Physical Activity (Avoid

Sedentary Life Style);

(4) Local hygiene of Genitalia-post coital; &

(5) Sun light

II. Refer for tobacco cessation counseling

and treatment in quit-failures

I. Perform all activities of the Primary Level.

II. Establish Tobacco Cessation Clinic.

III. Develop Tobacco Related data base for:

(1) Illnesses; (2) deaths; and (3) Usage

among youth and Pregnant women

IV. Hold regular (at least monthly) cancer

control activities with, local administration,

different community groups and media

I. Perform all the activities of

CHC/SDH Level.

II. Target an annual 5% increase

in quit rate through Tobacco

Cessation Clinic. Collaborate

with t

to control non

diseases (including heart

respiratory diseases and

diabetes) through optimal

controls for:

(1) Tobacco; and

(2) Obesity.

III. Hold regular (quarterly)

CMEs” on Cancer Control with

focus on Tobac

controls.

IV. Networking cooperation

and collaboration with tertiary

care centers within

the State for primary prevention

of the most frequent cancers; for

tobacco control on priority.

20

Detection

I. Propagate Warning Signals of Cancers in

Hospital, Teaching Institutions and

Community (through IEC) on a continuing

basis.

II. Conduct examination “in high risk

groups” of.

(1) Oral Cavity in Tobacco Users

(2) Breast; and (3) Uterine Cervix-through

Visual Inspection with Acetic Acid (VIA

test).

III. Refer all suspicious cases to DH- if

facilities exist for the detection / to the

nearest Cancer Unit (medical college/

private hospital/ cancer center for

confirmation

IV. Follow up of those referred: follow

established referral and feed back policy

norms

I. Perform all the activities of the Primary

Level.

II. Establish Cancer Detection Clinic-Target

for high risk groups for Oral-, Breast-and

Uterine Cervical-Cancers. III. Diagnostic

cytologic (collection only – PAPS, FNAC)

and minor surgical procedures (excisional

biopsy).

IV. Develop database of the cancer pattern

locally.

I. Perform all the activities of

CHC/SDH Level.

II. Establish Early Cancer

Detection Programme for Oral

Breast

cancers.

III. Develop Endoscopy_,

Radio

and ultra

Cytology

Services

IV. Develop District Cancer

Registry.

V. networking cooperation and

collaboration with tertiary care

centers within

State for early detection of

cancers and cancer registry.

Palliation I. Sensitize public (through IEC) to opt for

palliation when appropriate.

II. Communicat-ion in suspicious cases.

III. Cancer Pain Relief (follow WHO

Analgesic Ladder)- ensure regular

availability of oral morphine to all the

needy.

IV. Psychosocial and spiritual care

V. Support to the Families of patients and

bereaved

I. Perform all the activities of the primary

Level.

II. Establish Palliative Care Clinic

II. provide palliative care (terminal illness)

at patients’ home, if feasible.

I. Perform all the activities of

CHC/SDH Level.

II. Establish an In

Palliative Care Unit along with a

Day

III. Extend Palliative Care

Services to patients with oth

non-

AIDS.

IV. Audit Palliative Care

Activities.

V. Networking cooperation and

collaboration with tertiary care

centers within

State including CMEs’ and

workshops.

21

Treatment Follow referral policy for all to either

the DH or the nearest Cancer Unit/

Center

I. Surgical : (1) Excisional biopsy

without need for reconstructive plastic

procedures in oral and breast

precancerous/ suspicious

lesions; (2) Biopsy and Crytherapy of

dysplastic uterine cervical VOA postitive

lesions.

II. Chemotherapy (follow the protocols

prescribed by a medical oncologist):

(1) Adjuvant or palliative chemotherapy

for breast, colo-rectal and other solid

cancers;

(2) Maintenance chemotherapy for

lymphomas and leukemia

III. Refer all for radiotherapy to the

nearest Radiotherapy Center/Unit

I. Perform all the activities of

CHC/SDH Level.

II. Surgical treatment of

respectable cancers of : Oral

Cavity, Breast, Colon and

Rectum, Male

(external)

and Soft tissue, provided an

optimal respectability can be

ensured without a need for

frozen control and a

simultaneous (one

reconstruction procedure (if

required ) can be performed.

III. Refer all for radiotherapy

to the nearest Ra

Center/unit

IV. Networking, cooperation

and colloaboration with

tertiary care centers within

and outside

including CMEs’ and

conferences on surgical

oncology and principles of

radiation

oncology.Rehabilitation I. Stoma Care;

II. Physiotherapy;

I. Perform the activities of Primary

Level.

II. Lymph edema care

I. Perform all the activities of

CHC/SDH Level.

II. Breast, Limb and other

prosthesis.

III. Occupational therapy.

22

21. Cardio

vascular

diseases

including

hypertension

Primary treatment

for rheumatic heart

disease, angina,

refer acute cases

for further

treatment, follow

up treatment of

hypertension.

Confirmation of

diagnosis of

referred cases,

treatment of

uncomplicated

cases of RHD,

hypertension,

follow up

treatment

Confirmation of

diagnosis of referred

cases and their

management

Confirmation of

diagnosis of

referred cases and

their management

Further

investigation and

treatment,

intensive care unit

facility,

management of

complicated case

stress test, 2 D

echo

22. Chronic

respiratory

diseases

Treatment of

mild asthma,

referral for CCF ,

follow up and

treatment

Treatment of

mild asthma,

referral for CCF

, follow up and

treatment

Treatment of referred

cases Investigations and

x-ray

Treatment of referred

cases Investigations

and x-ray

Pulmonary

function tests

bronchoscope

and management

of cases.

23. Psychosis

and mental

diseases

Treatment of

minor disorders,

supervision

of cases under

OPD treatment at

higher centers

Treatment of

minor

disorders,

supervision

of cases under

OPD treatment

at higher

centers

Treatment of minor

disorders, organize

extension service

camps

Treatment of

minor disorders,

organize extension

service camps

Full diagnostic

and treatment

facilities,

hospitalization

facility

24. Cataract

Blindness and

other eye-

diseases

Diagnosis and

treatment of

Trachoma and

conjunctivitis

organization of

eye camps

Diagnosis and

treatment of

minor eye

diseases

organization of

eye camps,

refraction

Provide assistance to

PHC for organizing eye

camps, conventional

cataract surgery, extra

ocular surgery and

refraction

Provide assistance to

PHC for organizing

eye camps,

conventional cataract

surgery, extra ocular

surgery and

refraction

Cataract surgery

IOL Squint

surgery corneal

transplant,

treatment of

complication

25. ENT diseases Treatment of

rhinitis and otitis

media, refer to

nearby hospital

for other cases,

treatment of

tonsillitis

Treatment of

Rhinitis and

otitis media

refer to nearby

hospital for

other cases,

treatment of

tonsillitis

Treatment of Rhinitis

and otitis media refer

to nearby hospital for

other cases, treatment

of tonsillitis

Treatment of

Rhinitis and otitis

media refer to

nearby hospital for

other cases,

management of

referred cases, refer

complicated cases

Treatment of all

diseases, ENT

surgery

23

26. Acute

abdomen

Primary

treatment and

refer

Surgical

intervention

such as

appendicectomy

Obstructed Hernia,

Peptic Ulcer,

Ectopic pregnancy

Treatment of

referred and

complicated cases

of Ectopic

pregnancy & others

Treatment of

referred and

complicated

cases of Ectopic

pregnancy &

others

27. Urinary tract

disorders

Preliminary

treatment and

refer to nearest

hospital

Treatment of

urinary tract

infections

circumcision,

hydrocele

Treatment of UTI ,

bladder stone,

circumcision,

hydrocele

Treatment of UTI,

bladder stone,

renal calculus,

circumcision,

hydrocele,

Prostatic surgery

Prostatic, ureteric

surgery,

treatment of

malignancies,

calculus disease,

C/S for infections

28. Disorders of

Genital

system

Refer to nearest

hospital

Refer to

nearest Sub

District

hospital

Diagnosis of male,

female, infertility

Investigations and

management

Investigations

and management

29. Endocrinal

disorders

Diagnosis of IDD,

Advice for iodized

salt, Screening for

Diabetes, Follow-

up

Blood sugar

estimations

treatment of

diabetes

Investigation,

Treatment, routine

follow-up

Investigation,

Treatment, routine

follow-up

Thyroid assay,

surgical

interventi

complete care of

DM

30. Diseases of

CNS

Preliminary

treatment & refer

to SDH/DH

Preliminary

treatment &

refer to SDH/DH

Treatment of

uncomplicated cases

Treatment of

uncomplicated

cases

Detailed

investigation and

treatment

31. Dental & oral

health

Diagnosis & treat

basic dental/oral

ailments, refer

complicated

cases, tooth

extraction

Diagnosis &

treat basic

dental/ oral

ailments, refer

complicated

cases, tooth

extraction

Diagnosis & treat basic

dental/oral ailments,

refer complicated

cases, organize for

extraction

Diagnosis & treat

basic dental/ oral

ailments, refer

complicated cases,

alignment/

orthodontic

treatment, dentures

Diagnosis & treat

basic dental/

ailments, refer

complicated

cases, alignment/

orthodontic

treatment,

dentures

24

GROUP III : Miscellaneous

32. Accidents

& Injuries

Treatment of

superficial

non

penetrating

wounds

Diagnosis and

initiation of

treatment for

simple

fractures.

Suspected

internal injures

closed

fractures, open

fractures,

dislocations,

abdominal and

chest injuries,

blood

transfusion

Suspected

internal

injures, closed

fractures, open

fractures,

dislocation,

abdominal and

chest injuries,

blood

transfusion

Treatment of

all injuries

including head

injures blood

transfusion,

refer cases

requiring

special care

(CAT scan for

head injury

etc.)

Treatment of

all injuries

including head

injures blood

transfusion,

refer cases

requiring

special care

(CAT scan for

head injury

etc.)

33. Disaster

management

First aid,

control of

contagious

diseases,

refer cases

needing

inpatient

care to

CHCs

Treatment of

case, refer

cases

requiring

special care (

#, head injury

etc.), support

to PHCs

during impact

stage

Treatment of

cases, refer

cases (head

injury,

compound #,

deep

incarcerated

wounds etc.),

support to

PHCs during

impact stage

Treatment of

cases, refer

cases (head

injury,

compound #,

deep

incarcerated

wounds etc.),

support to

PHCs during

impact stage

Treatment of

cases, support

to PHCs,

CHCs, during

impact stage,

disaster

preparedness,

Physiotherapy

Treatment of

case, support

to PHCs,

CHCs during

impact stage,

disaster

preparedness,

Physiotherapy

34. Animal

bites

Treatment of

uncomplicated

snake bite

scorpion sting,

& dog bite at

PHCs

Treatment of

uncomplicated

snake bite

scorpion sting,

and dog bite

at

Treatment of

uncomplicated

snake bite

scorpion sting,

and dog bite

at

Treatment of

complicated

snake bite

scorpion

sting, and dog

bite at

Treatment of

all snake bite,

scorpion

sting, and dog

bite , ICU

care

Treatment of

all snake bite,

scorpion

sting, and dog

bite, ICU care

35. Burns Upto 10%

burns

manage

Upto 20%

burns manage

More then

20% manage

More then

20% skin

grafting

physiotherapy

All burns cases,

skin grafting,

physiotherapy,

surgery for

complication

All burns case,

skin grafting,

physiotherapy,

surgery for

complication

36. Poisoning Treat &

Refer to

CHC

Treat,

resuscitate &

Refer

complicated

cases to

SDH/DH

Treat,

resuscitate &

Refer

complicated

cases to

SDH/DH

Treatment of

all referred

cases

Treatment of

all referred

cases

Treatment of

all referred

cases

37. Foreign

body

Removal of

Nose, Ear

and sub

cutaneous &

soft tissue

foreign body

Removal of

Nose, Ear and

sub cutaneous

& soft tissue

foreign body

Removal of

Eye, Nose,

Ear and sub

cutaneous &

soft tissue

foreign body

Removal of

Eye, Nose, Ear

and sub

cutaneous &

soft tissue

foreign body

Refer for

foreign body in

air passages to

DH

All foreign

bodies

including FB

in air

passages

All foreign

bodies

including FB

in air

passages

25

38. Malnutrition Diagnosis

and grading

of

malnutrition,

iron and

vitamin A

supplements,

infection

control,

nutrition

education,

refer for

grade III and

IV

malnutrition

Treatment of

referred

cases,

treatment for

associated

diseases,

Investigations

Treatment of

referred

cases,

treatment for

associated

diseases,

Investigations

Treatment of

referred

cases

treatment for

associated

diseases,

Investigation,

Blood

transfusions

(SOS),

nutritional

rehabilitation

Treatment of

referred

cases

treatment for

associated

diseases,

Investigation,

Blood

transfusions

(SOS),

nutritional

rehabilitation

Treatment of

referred

cases

treatment for

associated

diseases,

Investigation,

Blood

transfusions

(SOS),

nutritional

rehabilitation

39. Health

Education

During field

visits &

during OPD

hours

OPD/IPD &

celebration of

special days

OPD/IPD &

celebration of

special days

OPD/IPD &

celebration

of special

days

OPD/IPD &

celebration

of special

days

OPD/IPD &

celebration

of special

days

* Supplemented by Rajasthan Cancer Foundation, Jaipur

26

(b) Directives for Referral #orms

For developing referral protocols, the services norms at each level of

institutions have been considered. Based on these norms and the capacity of

an institution, Referral norms for common conditions have been developed.

They will be further extended and refined as part of the routine service

delivery during the project.

Suggested Referral Norms are detailed as below, a list of disease and their

treatment level i.e. which disease should be treated at what level

(Primary/Secondary/Tertiary)

Services at Different Levels of Health System

Medicine cases

Intervention Primary Secondary Tertiary

Medical College

MEDICINE CHC SDH DH

Respiratory System

1. URI

Common cold T R

Allergy Rhinits T R

Rhinitis –Acute

Chronic

T R

Sinusitis T R

Pharyngitis

Acute

Chronic

T R

Laryngitis T R

Tonsillitis

Acute

Chronic

T R

Malignancy

tongue

Malignancy

larynx

Sleep Apnoca

27

2. LRI

Breathlessness

Cyanosis

Haemolysis

Actue

bronchitis

T

Chronic

Bronchitis

T R

Bronchial

Asthma

T R

COPD. T R

Consolidation T R

Pleural

effusion.

T R

ILD T R

Pneumothorax T R

Hydro

pneumothorax

R

Malignancy

lung

Lung disease R

Pulmonary

Infarction

Acute &

Chronic Resp.

failure

R

Hypersensitive

pneumonis

pneumoconiosis R

3. Gastroenterology

Vomiting T

Haemetemesis T

Malena T

Diarrhea,

Dsentery

T

Pain abdomen. T

Jaundice T

Bleeding Piles T

Dyspepsia T

Ascitis T

Hepatomegaly T

Splenomegaly T

28

4. Nephrology

UTI T

Haematuria T

Oligourea T

Anuria T

Renal colic T

Nephrolithisis T

5. Endocrinology

Diabetes

Hypoglycemia

Hyperglycemia

T

Thyriod

HypothyroidimHyperthyroidism

T

Primary sterlity T

6. Neurology

Seizure disorder Ts

Headache Ts

Vertigo Ts

Syncope Ts

Coma Ts

Meningitis T

CVA T

Encephalitis Ts

Myclopathy

Peripheral

Neurological

disease

7. Tropical disease

Malaria T

Enteric Fever T

Cholera T

Plague Ts

Dengue Ts

Rabies T

Snake bite T

Kala azar T

29

8. Cardio vascular

disease

Hypertension

Primary

Secondary

R

IHD

Angina

MI

R

Arrhythmias

LVF

CHF

CHD

Cardio

Myopathies

Valvular

Heart diseases

Supp - line2

Peri- Cardial

effusion

R

PVD T R

RTI - & VD

9.. Poisoning Supportive

Treatment

Organophospho

rous

ST

Celphos ST

Kerosine ST

10. HIV +ve case

11. Cases of PUO

12. Rheumatology T

13. Skin diseases T

T = Treatment, S= Secondary Level , R= Refer , ST= Supportive Treatment

30

General Surgery

S.No. PHC CHC 50 bedded hospital District

Hospital

1. Minor Surgical,

Absesses, removal of

FB, managing simple

wounds, Follow up

of surgical cases to a

limited extent

Basic surgical

procedures,

Removal of cysts

L.N., Lip cut etc.

Other procedures

under local

anaesthesia

All procedures

done in CHC +

Debridement of

wounds.

All procedures

done in 50

bedded and skin

grafting.

2. Major Procedures

Refer

Vasectomy

Tubectomy

circumcisions

Appendicectomy,

Herniotomy

Hernioplasty

Hydrocoele,

haemorroidectomy

Cystostomy,

Suprapubic

Cystolithotomy

All procedures

done in 50

bedded +

Cholecystectom

y, Intestinal.

Obstruction,

Pyelolithomy,

Intussusception,

volvulus

Neoplasm

• Acute Abdomen: At 30 bedded hospitals surgical intervention may be

done if anesthetist services are available. Obstructed Hernia, Intestinal

obstruction, Perforated Peptic Ulcer, Ectopic pregnancy may be

operated at district level hospitals where facility for Blood transfusion

and anesthetist are available.

• Urinary Tract Disorders: Given in the Performa is acceptable except that

for prostate surgery. Now a days TUR is more popular and acceptable

for which facilities are available only in tertiary level i.e. Medical

College.

• Accidents and Injuries: head and serious chest injuries are to be treated

at Medical College level by super specialist only; however chest injuries

with single # rib, Pneumothorax, L-Pneumothorax may be treated at 50

bedded hospitals.

• Disaster Management: Step wise referring the case should be omitted

and cases may be directly referred to district/medical college level

hospitals to provide surgical care at the earliest.

31

Orthopedic cases

S.No Condition Primary Secondary Territory

1. Accident and Injuries Treatment of

superficial and

non

penetrating

injuries.

Diagnoses and

Management of

fractures.

Closed Fractures,

open fractures,

Dislocation’s

Abdominal, Chest,

Head injuries.

Case’s requires

special

investigation like

CT, MRI, Surgery

like-Nerve/Vessel

repair

2. Infections:

Acute and

Chronic Osteomyelitis

Doesn’t need

surgery

Diagnosis and

treatment

Surgery if

required

3. Chronic inflammatory

disorders Tuberculosis

Rheumatoid Arthritis

Ankylosing Spondylitis

Symptomatic

Treatment

Diagnosis and

treatment

Re-constructive

surgery if required

– Joint

replacement

surgery if

required

4. Neo-Plasms:

Benign

Malignant

Symptomatic

Treatment

Diagnosis and

treatment of

Benign Tumor

Diagnosis of

Malignant Tumor

and Biopsy

Cases requiring

special

investigations like

MRI, CT, Brain

scan and spinal

surgery, Radio-

therapy

Chemotherapy

5. Deformities:

Congenital

Acquired

Symptomatic

Treatment

Diagnosis and

treatment

Spinal

Deformation

which needs

corrective surgery

Orthotic,

Prosthetic’s if

required

6. Degenerative diseases

like osteoarthritis

Where only

Analgesics

required

Diagnosis,

Treatment

Physiotherapy

Corrective

surgery if

required

Joint replacement

if required

32

Pediatric cases

A. Referral of Neonatal Cases (C.H.C. to D.H. or Tertiary level)

I. Birth Asphyxia – Hypoxic Ischemic Encephalopathy (HIE) gr II & III

II. Birth weight < 1500 gms

III. Meconium Aspiration

IV. Congenital Anomalies

T.O. Fistula

Meningo & myelocele

Hydropes Factalis

Cong. Heart diseases

Cleft lip and Cleft palates with feeding difficulties

V. Jaundice in 1st 24 hrs. of life

VI. Neonatal convulsions

VII. Severe Anaemic Neonate

VIII. Tetanus Neonatorum

IX. Susp. C.N.S. Infections

X. Neonatal Septicemia

XI. Pneumothorax and Pt with HMD (Hyaline Membrane disease)

B. Referral of Infants and older children

I Diarrhoea – Leading to : ARF

Haemolytic Uraenic Syndrom

Hypernatremic Dehydration

II Respiratory system croup (Epiglotitis)

Empyema

Pneumo thorax

Bronchial Asthma (servere)

III CVS Cong. Heart diseases

IV C.N.S.

Infections – Pyomeningi, C.N.S. TB

Cerebral Malaria

Cong. Anamalies

Hydrocephalus

Micro cepnaly

33

Infantile Hemipligia, Paraplegia, Seizure disorders

G. B. Synd.

Transverse mylitis

Traumatic Neuritis

V Locomotive systems

- Club foot

- Cong. Dislocation of Hip

- Birth Injuries:

- Fractures and Dislocations

VI Vaccine Preventable Diseases

- Diphtheria

- Tetanus

- Measles – Encephalitis

- Whooping – Cough with encephalopathy

- AFP- Poliomeyelitis

VII Nephrology 500ml

- ARF

- AGN Urine output

- Nephrotic Synd – Steroid resistant In 24 hours

VIII Surgical Conditions

- Intussception

- Pyeloric stenosis

- Lump. Abdomen

- Pyo and Pneumo thorax

IX Others

Susp. Hypothyroidism

Susp. Metabolic diseases e.g. Golactosemia

Severe Anaemia Hb < 5 gm%

Lukemia

Thalasseamia

Primary Hyper splenism

Susp. Malignancies

X Posioning

Organo Phosphorus

Hydro carbon pneumonia’s

Kerosene poisoning

XI Animal Bites

Snake bites

Scorpion bites with shock

34

Gynecological Cases

(Pregnant women & Maternal Care – Ante, Intra, Post #atal)

A) ANC:

• Every ANC Care is routinely investigated.

• High risk cases should be detected as early as possible

Detection and Management

1). Anemia: Mild 9-11 gm% - PHC, CHC

Moderate 7-9% - PHC, CHC

Severe – Below 6 gm - DH

2). Pregnancy with hypertension

PH - PHC, CHC

PET- CHC

Eclampsia - DH if. Complications Tertiary

Renal failure Institution

Thrombosis

3). RH incompatibility : Primi No Iso Imm.. Iso Imm.

PHC, CHC PHC, CHC DH, Tertiary

4.) APH : First aid CHC, PHC, Referred to DH / tertiary care

i. I.V. fluid

ii Haemostatic

iii Antibiotics

5.) Abnormal presentation & position at term - Refer to DH

6.) Preg. With previous LSCS at term : DH

7.) Multiple pregnancy at term : DH

35

8.) Preg. With medical illness Refer

Hypo DH & Tertiary

a) Diabetes (endocrinal) Thyroid

Hyper Care

Jaundice

b) Cardiac

c ) Renal

d) Respiratory, etc.

e) Pregnancy with HIV positive

9) Pregnancy with surgical illness

Tumor, Lump, Appendicitis etc. - Refer to DH & Tertiary Care

10) Pre term labor - PHC & CHC

Pre term Delivery - DH (Neonatal care)

11) Pregnancy with IUGR - DH

12) Grand multiparity - DH

(PPH)

13) Bed OH Elderly primi }

Short stature Refer

Early age pregnancy to

IUD DH

Abortions

Atonic

PHC

14) PPH CHC

Traumatic

If not controlled refer – DH

B) Neonatal Care :- Below 2 Kg. - DH

Above 2 Kg. - PHC,CHC

36

C) Abortions

Incomplete: PHC, CHC

Threatened : PHC, CHC DH

(Further investigations USG)

Missed: DH

Habitual: DH

Inevitable: PHC, CHC

D) MTP: Below 12 weeks - PHC, CHC

Above 12 weeks - DH

E) Family Welfare services

Contraception - PHC, CHC DH all levels

Permanent - Tubectomy - PHC, CHC (Camps)

Vasectomy - PHC, CHC

F) Neoplasia : Detection – PHC ,CHC

- Breast lump, ca cx,

- Endometrial ca. Diagnosis & treatment

- Ovarian ca DH & tertiary care

- Fibroid

G) STD - PHC, CHC

PID, Vaginits, UTI - PHC, CHC

37

Ophthalmic Cases

Referral #orms of ophthalmic Services at different levels of Health system

S.No. Intervention Primary CHC SDH DH + Medical College

A. Eye lids

1. Stye Case mang. Case mang.. Case Mang. Case Mang.

2. Chalazion Diagnose

refer

Diagnose

refer

Case Mang. Case Mang.

3. Blephritis Case Mang. Case Mang. Case Mang. Case Mang.

4. Trachoma &

Trichisis

Case Mang. Case Mang. Case Mang. Case Mang.

5. Entropion &

Ectropion

Diagnose &

Refer

Diagnose &

Refer

Case Mang. Case Mang.

6. Ptosis (Dropping

of lids)

Diagnose &

Refer to DH

Diagnose &

Refer to DH

Diagnose &

Refer to DH

Case Mang. DH & at

Medical College

B. Conjunctiva

1. Conjunctival

Xerosis/Bitot’s

spot

Case Mang. Case Mang. Case Mang. Case Mang.

2. Night Blindness Case Mang. Case Mang. Case Mang. Case Mang.

3. Conj. FB Case Mang. Case Mang. Case Mang. Case Mang.

4. Conjunctivitis –

Allergic, Infective

Case Mang. Case Mang. Case Mang. Case Mang.

5. Pterygium Case refer Case refer Case Mang. Case Mang.

6. Episcleritis/

Scleritis

Case Mang. Case Mang. Case Mang. Case Mang.

7. Sub Conj.

Hemorrhage

Case Mang. Case Mang. Case Mang. Case Mang.

C. Cornea

1. Corneal FB –

Superficial

Treat &

refer if deep

FB (IS)

Treat &

refer if deep

FB

Case Mang. Case Mang.

2. Corneal inj. Tear/

perforation

Mang.

Preliming &

Mang.

Prelnning &

Case Mang. Case Mang.

3.

Corneal opacity Refer to

D/H

Refer to

D/H

Refer to

D/H

Case Mang. By Medical

College (Keratoplasty)

38

D. Lens

1. Senile Cataract Diagnose &

Refer

Diagnose &

Refer

Case Mang. Case Mang.

2. Traumatic Diagnose &

Refer

Diagnose &

Refer

Case Mang. Case Mang.

3. Congenital Cat. Diagnose &

Refer

Diagnose &

Refer

Case Mang. Case Mang.

E. Glaucoma Diagnose &

Preliminary

Treat

Diagnose &

Preliminary

Treat

Case Mang. Case Mang.

F. Dacryocystitis

Epiphora/

Discharge

Diagnose &

Preliminary

treat in

acute DC

Diagnose &

Preliminary

treat

Case Mang. Case Mang.

G. Squint Refer Refer to Refer &

Case Mang.

Case Mang.

H. Headache with

decrease of Vision

Diagnose &

Refer

Diagnose &

Refer

Case Mang. Case Mang.

I. Ocular Trauma Preliminary

treat &

Refer

Preliminary

treat &

Refer

Case Mang. Case Mang.

J. Endopthalmitis Refer Refer Case Mang. Case Mang. & at medical

college level

K. Malignancy

RD, Macular Hole

& Post segment

Pathology

Refer Refer Case Mang. Case Mang. & at medical

college level

E#T Cases

Criteria for Referring the cases

A) Emergency Cases -

Emergency cases can be referred directly to any level.

B) Routine Cases -

Routine cases should be referred through referring committee headed

by head of institute.

39

A Emergency Cases needing referrals -

1. Uncontrolled epistaxis

2. Fascio maxillary & associated injuries

3. Foreign bodies in respiratory tract.

4. C.S. O.M. with meningitis & Brain abscess.

5. Post operative complications

6. Ludwig angina

7. C.A. larynx with dyspnoea needing tracheostomy.

B. Routine Referrals -

I. Primary to Secondary level -

Acute tonsillitis

C.S.O.M.

Cervical Lymph node Biopsy

Diminished hearing – audiometry

Fracture of nasal bones

Abscess peritonsillar, pharynged nose, septal

Sinusitis & Vertigo

II. Secondary to Tertiary level -

Nasal polyp, Angio fibroma.

Mastoidectomy

Tympanoplasty

All types malignancy in E.N.T.

Treatment possible at primary level

Rhinitis

Pharyngitis

Chr. Tonsillitis

Wax & Ear ache

Stomatitis

40

Chapter- 5

Feed back and Follow-up

The purpose of this activity is not just for evaluation purpose, but also

for the promotion and sustainability of referral system. The evaluation

of referral system is a critical factor for determining the strength,

weakness and out come of the services. Each user or client should be

viewed as a potential ‘ambassador’ of the referral system. Users who

are satisfied with care and services they received at hospital will

encourage their family, friends and neighbors to use the facility.

Feed back

There has to be a proper feed back from FRU or District level

facilities so that progress of the referred patient is known by the

medical officer who has referred the case. This feed back system will

be ensured by making use of specific card (green) meant for the level

where referral services have been availed by the patient.

The down- referral/ feed back would be made to the referring

institution or facility. It will include investigations carried out, final

diagnosis, treatment given, treatment to be continued and for how

long. Other follow-up instructions to be carried out by the patient or

attendant are given in the appendices in the feedback cards. Follow –

up instructions are given in Hindi and complete so that client can

follow and comply these instructions. To ensure proper follow-up,

detail and complete address must be recorded in the referral register.

This would be of immense help if the patient fails to turn-up on time

and date assigned for follow-up. If the complete address is available

then the patient can be contacted and male or female health worker

can be asked to pay a visit.

Feed back cards may be utilized as a ready reference in forthcoming

ailments of similar course and nature so that the sufferer may be

benefited without wasting time. On the other hand, by using

laboratory investigations and clinical findings the patients illness can

be reviewed accordingly and progress as well as prognosis can be

judged. 41

Follow up

More crucial and important part of treatment is follow up in the light

of instruction / advice given by the treating specialist. Obstetric

emergency and pediatric emergency need special mention in this

context. Client should follow the instructions regarding intake of

drugs prescribed and strictly adhere to the instructions given by the

treating specialist.

The health provider should ensure appropriate follow-up care.

Important aspects of follow-up care includes:

• feedback to - Patient

- family (attendant)

- authorities – i.e., supervisor etc

- care providers at other levels

• future prevention, including the need for the cooperation

of families

• planning, and identification of persons at risk.

Health education, family planning and counseling were considered to

be key issues in follow-up care. For example, in a case of eclampsia,

subsequent monitoring of blood pressure, renal function and general

health is also important. Communication with the family, community

and health care personnel is necessary if support for a woman

following an eclamptic fit is to be provided and maintained.

To provide follow-up care to patients referred to or discharged from

hospital, follow-up has to be planned according to the disease in

question. In certain conditions e.g. diseases where hospitalization is

not indicated might require only one follow-up while in other

conditions patient may have to be followed up more often as in the

case of obstetric surgery, pediatrics, tuberculosis, leprosy,

psychiatrics, etc. For further follow-up the following schedule should

be followed. A case of surgery may thus have follow-up plan as given

below.

42

First follow up: - Soon after the discharge from hospital or

when she/he comes for removal of stitches, which should be

removed by clean and sterile instruments, dressing should be

applied by MO, PHC/LHV or staff nurse may be deputed from

CHC for this work. The incision/formative scar should be kept

clean and dry. Any complain/ side effect /complications should

be given due care.

Second follow up: - After one month or any

discomfort/complaint which ever is earlier. Thorough

examination should be done.

Emergency follow up: - This can be done at any time.

Subsequent follow up: - It will occur if the client has any

questions/ complain / complications.

In tribal, hilly, desert and temperate plane areas, health facilities are

widely scattered and forcing inhabitants have to walk several miles to

avail health care services. The referral feed back and follow up

services have paramount importance to play a pivotal role in

providing easy and rapid access to health care in such areas.

Therefore, distance, road, weather conditions must also be considered

when setting up the referral system. Besides government owned

ambulance, alternative transport system be considered in early stages

of planning. To stream line the referral system in these difficult areas

more inputs are needed in terms of transport at health facilities.

.

43

Chapter- 6

RAJASTHA# STATE ESSE#TIAL MEDICI#ES LIST- 2005

In pursuance of the initiative taken under the WHO India Programme

for the Promotion of Rational Use of Drugs, an endeavour was made

by the State Institute of Health & Family Welfare, Jaipur. Rajasthan,

to launch a similar Programme in Rajasthan in the year 1997. One of

the important steps identified for this purpose was to prepare an

Essential Drugs List for adoption in the state. The Ministry of Health,

Government of India, has already introduced the National Essential

Drugs List for adoption in the country. This list is modeled on the

WHO Essential Drugs List, and follows the general principles

recommended by WHO in the preparation of such lists (Annexure- A)

In Rajasthan, health care is provided by both private and public

sectors. Initially the responsibility was primarily of the public sector

to establish health care institutions accessible to all sections of the

population in all parts of the State so as to provide a whole spectrum

of diagnostic and treatment facilities. However, very sizeable

proportion of health care is now being provided by the private sector

establishments at individual/ institutional levels. In public sector

institutions, medicines are supplied free of cost or against token

payment to the government employees and free of cost to the weaker

sections of the population who avail of the treatment facilities

provided by the Government through primary, secondary or tertiary

level institutions. The drugs are also supplied through National

programmes for control of diseases of high morbidity and endemicity

to all patients who approach the treatment centers established under

such programmes.

The National Essential Drugs List implies that the drugs included in it

are adequate to meet the common contemporary health needs of the

general population and health administrators should ensure abundant

availability of such drugs in the State. The drugs included in the list

are known to be effective and generally safe and are approved by the

Drugs Controller General, India and are currently available at

affordable prices to the general public. 44

The exclusion of any drugs in the State List which is currently

available and recommended by physicians does not imply that they

are less effective or unsuitable for the patients. Their exclusion may

have been influenced by one or more of the following factors : - cost-

benefit ratio, dependence on imports or imported raw materials,

indicated in the treatment of diseases not considered significant in the

State context, insufficient experience with the drugs in India. Not

approved for use in the specific indication by the Drugs Controller

General, India or for which no standard is approved under the Drugs

& Cosmetics Act and Rules. The safety, efficacy and quality of drugs

currently available in India are according to the standards Prescribed

in India and the exclusion of any drug from this list does not mean

that it is less effective in comparison to any alternative drug which h

as found its place in the list.

The State List is not intended as an imposition on the rights of

Government institutions or private healthcare providers. It is meant to

be used as a guideline to the concept of rational therapeutics and as an

indicator of availability in the country. The drugs selected are

considered adequate to treat diseases common to most parts of the

state.

In view of the above facts the State Government constituted a

Committee for preparation of the essential Drugs List (EDLC) in the

year 1999 which would be relevant to the problems peculiar to the

State and would be acceptable to all sections of healthcare providers

both in private and public sectors.

In February 2000, the State Government was pleased to accept the

report of the EDLC and declare the recommended essential drugs list

as the Rajasthan State Essential Drugs (RSEDL-2000) for the State of

Rajasthan. As per its guidelines the doctors of the state working under

government were required to prescribe and use medicines out of this

list only, as far as possible. Similarly procurement of drugs and

medicines in the government hospitals and institutions was to be done

through the approved rate contract for all medicines in the EDL. As

such a beginning was made to rationalize use of drugs through

adoption of EDL.

45

However in pursuance of the fact that the EDL is not static and needs

to be revised periodically to cope with the advances made in the

medical sciences, the government of Rajasthan reconstituted the EDL

committee to review/update RSEDL – 2000 in March, 2000. Its

membership was further revised in February, 2004. The reconstituted

EDLC later invited suggestions for additions/ alterations and deletions

in the RSEDL-2000 from the faculty of the Medical Colleges, District

Health Administrators and Specialists from District and sub district

hospitals. In addition, the core group of the EDLC also visited all the

medical colleges for interaction with the medical community.

Suggestion made during these interactions, and accepted by the core

group, was compiled and computerized. This list was thereafter shared

with one of the WHO expert on essential drugs. The revised Essential

Drugs List (EDL) was finally placed before the members of the EDLC

for consideration, discussion and finalization in its meeting held on

25th March, 2004.

In accordance with the WHO revised concept, the committee has now

decided to recommend that the new Essential Drugs List (EDL)

should now be titled as Rajasthan State Essential Medicines List-2004

(RSEML-2004). The list uses generic names for scientific clarity.

For convenience and easy comparison, the same category numbers

and heading have been used as in the WHO Model List (1995).

However, only the names of the active bases have been used, avoiding

the names of salts and esters, e.g. morphine instead of morphine

suplphate. The quantity mentioned in the strength of the dosage forms

refers to the base unless by established practice or by pharmacopoeial

standards, it refers to the salt or the esters. The quality control

standards are as in the Indian Pharmacopoeia, unless the drugs in not

included in the I. P. Although, a due care has been taken to ensure the

correct nomenclature with strength of each dosage forms, yet for any

error/omission, pharmacopeial recommendation would prevail.

Drugs marked with an asterisk (*) are to be considered as

complimentary drugs i.e., those that are used if the other drugs are not

available or they are required for specific patients situations or

locations for valid reasons.

46

The names of drugs are followed by the letters given below to indicate

their need at various levels of medical care:

P - Primary Health Care

S - Secondary Health Care

T - Tertiary Health Care

U - Universal

WHO Criteria for the Selection of Essential Drugs

Essential drugs are those that satisfy the health care needs of the

majority of the population; they should therefore be available at all

times in adequate amounts and in the appropriate dosage forms.

The choice of such drugs depends on many factors, such as the

pattern of prevalent diseases, the treatment facilities, the training and

experience of the available personnel, the financial resources and

generic, demographic and environmental factors.

Because of differing views on the definition of any essential

drugs in terms of what is meant by the healthcare needs of the

“majority” of the population, the model list has been gradually

expanded since its introduction. Some drugs that are included are

essential only if a therapeutic Programme is planned to address the

diseases for which these drugs are used. For examples, the cytotoxic

drugs (section 8.2 of the model list) are essential only if a

comprehensive cancer treatment Programme is planned. Such a

Programme requires adequate hospitals, diagnostic and clinical

laboratory facilities for its implementation. In contrast, the drugs used

in palliative care (Section 8.4) are always, even when a

comprehensive cancer treatment Programme does not exist.

Only those drugs should be selected for which sound and

adequate data on efficacy and safety are available from clinical

studies, and for which evidence of performance in general use in

variety of medical settings has been obtained.

47

Each selected drug must be available in a form in which

adequate quality, including bioavailability, can be assured; its stability

under the anticipated conditions of storage and use must be

established.

Where two or more drugs appear to be similar in the above

respects, the choice between them should be made on the basis of a

careful evaluation of their relative efficacy, safety, quality, price and

availability.

In cost comparisons among drugs, the cost of the total

treatment, and not only the unit cost of the drug, must be considered.

The cost/benefit ratio is a major consideration in the choice of some

drugs for the list. In some cases, the choice may be also be influenced

by other factors, such as comparative pharmacokinetic properties, or

by local considerations, such as the availability or facilities for

manufacturer or storage.

Most essential drugs should be formulated as single

compounds. Fixed-ratio combination products are acceptable only

when the dosage of each ingredient meets the requirements of a

defined population group and when the combination has a proven

advantage over single compounds administered separately in

therapeutic effect, safety or compliance.

RAJASTHA# STATE ESSE#TIAL MEDICI#ES LIST

S.#o. Drugs Category Route of administration dosage forms and strengths

1.

A#AESTHETICS

1.1

General Anaesthetics & Oxygen

Halothane S, T inhalation

Isoflurane* S, T inhalation

Ketamine S,T Injection 10mg/ml, 50mg/ml

Nitrous Oxide S,T Inhalation

Oxygen U Inhalation

Thiopental Sodium S, T Injection 0.5 mg, 1gm powder

Propofol S, T Injection 10 mg/ml, 20mg/ml

1.2 Local Anaesthetics

Bupivacaine hydrochloride U Injection 0.25%, 0.50% Injection 0.5%+ 7.5% glucose

Ethyl Chloride U Spray 1%

Lignocaine U Injection 1%, 2% + Epinephrine 0.01 mg/ml

Jelly 2%, solution 4%, ointment 5%

Lignocaine with Glucose T Injection 5%, 7.5%

48

1.3 Preoperative Medication & Sedation for short procedures

Atropine Sulphate U Injection 0.6 mg/ml

Diazepam U Injection 5mg/ml, tablet 5mg

Morphine S,T Injection 10 mg/ml

Promethazine U

S,T

Syrup 5mg/5ml

Injection 25mg/ml

Glycopyrrolate T Injection 0.2 mg/ml

Fentanyl S,T 100 microgram/2ml

Midazolam S,T Injection 1mg/ml, 5mg/ml

2. A#ALGESICS, A#TIPYRETICS & #SAIDS A#D DRUGS USED TO TREAT GOUT.

2.1 #on-opioid analgesics

Acetyl Salicylic Acid U Tablet 300 mg

Allopurinol S,T Tablet 100 mg

Diclofenac Sodium U Tablet 50 mg, injection 25mg/ml

Ibuprofen U Tablet 200 mg, 400 mg

Paracetamol U Injection 150mg/ml, Syrup 125mg/5 ml, tablet 500mg

Valdecoxib S,T Tablet 10mg, 20mg

2.2 Opioid Analgesies

Pentazocine S,T Tablet 50mg, injection 30mg/ml, 10mg/ml

Tramadol S,T Injection 50mg/ml, capsule 50mg, 100mg

Buprenorphine S,T Injection 0.3mg/ml

Dextropropoxyphene+Paracetamol S,T Capsule 65mg+400mg

3. A#TIALLERGICS A#D DRUGS USED I# A#APHYLAXIS

Chlorpheniramine U Tablet 4 mg, syrup 2.5 mg/5 ml

Pheniramine U Injection 22.75 mg/ml

Cetirizine U Tablet 10 mg

Dexamethasone U Tablet 0.5mg, injection 4mg/ml

Epinephrine U Injection 1 mg bitartrate/ml

Hydrocortisone Sodium Succinate U Injection 100 mg

Prednisolone S,T Tablet 5mg

Promethazine U Tablet 10mg, 25mg, injection 25 mg/ml

4. A#TIDOTES A#D OTHER SUBSTA#CES USED I# POISO#I#GS

4.1 #on specific

Activated charcoal U Powder

Atropine Sulphate U Injection 0.6 mg/ml

4.2 Specific

Anti snake venom U Injection polyvalent

Anti scorpian venom Injection polyvalent

Desferrioxamine U Injection 500mg (mesylate)

Methyl thioninium Chloride

(methylene blue)

S,T Injection 10mg/ml

Naloxone* S,T Injection 0.4mg (Hydrochloride)/ml

Pralidoxime (2-PAM) U Injection 25mg/ml

Sodium Nitrate* S,T Injection 30 mg/ml

Sodium thiosulfate* S,T Injection 250 mg/ml

Penicillamine* S,T Tablet & capsule 250mg

Magnesium sulfate S,T Injection 500 mg

5. A#TICO#VULSA#TS

Carbamazepine U Tablet 100mg, 200mg

Clonazepam T Tablet 0.5 mg, 1mg, 2mg

Diazepam U Injection 5mg/ml

Phenobarbital U Tablet 30mg, 60mg

49

Phenytoin Sodium U Tablet & capsule 50mg, 100mg syrup 25mg/ml,

injection 50mg/ml

Sodium Valproate U Syrup 200 mg/5ml, tablet 200mg

Midazolam S,T Injection

Lorazepam S,T Tablet 1mg, injection 2mg/ml

6. A#TI – I#FECTIVE DRUGS

6.1.1 Intestinal Antihelmintics

Albendazole U Table 400mg, Suspension 200 mg/ml

Niclosamide S,T Tablet 500 mg

Levamisol S,T Tablet 50mg, 150 mg, oral suspension 40mg/5ml

6.1.2 Antifilarials

Diethycarbamazine U Tablet 50mg

6.2 Antibacterials

6.2.1 Penicillin’s

Amoxicillin U oral suspension 125mg/5ml, capsule250mg, 500mg

Ampicillin U oral suspension 125mg/5ml, capsule 250mg, 500mg,

injection 500mg

Cloxacillin U Capsule 250mg, 500mg, injection 250mg, liquid

125mg/5 mg

Benzathine Benzylpenicillin U Injection 6 lacs, 12 lacs, 24 lacs units

Benzyl Penicillin U Injection 5 lacs, 10 lacs

Procaine Benzylpenicillin U Injection, Crystalline Penicillin (l lac units) + Procaine

Penicilin (3lac units)

Piperacillin T Injection 2gm

6.2.2 Other Antibacterials

Amikacin* S,T Injection 100mg, 250mg, 500mg/2ml

Cephalexin* U Syrup 125mg/5ml, capsule 250mg/500mg

Ciprofloxacin U Injection 200mg/100ml, tablet250mg,500mg

Co-trimoxazole ( Trimethoprim +

Sulphamethoxazole)

U Tablet 40mg +200 mg, 80mg+400mg, l60mg+800mg,

suspension 40mg + 200mg/5ml

Doxycycline U Capsule 100mg

Erythromycin stearate U Syrup 125mg/5ml, tablet 250mg

Gentamicin S,T Injection 10mg/ml, 40mg/ml

Metronidazole U Tablet 200mg, 400mg, injection 500mg/100ml

Norfloxacin U Tablet 400mg

Cefexime S,T Tablet 100mg, 200mg

Ofloxacin S,T Tablet 200mg, 400mg, injection 100ml

Roxithromycin S,T Tablet 50mg, 150mg

Azithromycin S,T Tablet 100mg, 250mg, 500mg

Reserve Antibacterials

Amoxicillin+Clavulanic Acid S,T Tablet 500mg + 125mg, injection

Cefotaxime S,T Injection 125mg, 250mg, 500mg, 1gm

Ceftazidime S,T Injection 125mg, 250mg, 500mg, 1gm

Ceftriaxone S,T Injection 125mg, 250mg, 500mg, 1gm

Vancomycin T Injection 500 mg

6.2.3 Antileprosy drugs

Clofazimine T Capsule 50 mg, 100 mg

Dapsone U Tablet 50mg, 100mg

Rifampicin U Tablet/capsule 150mg, 300mg

50

6.2.4 Antituberculossis drugs

Ethambutol U Tablet 200mg, 400mg, 800mg

Isoniazid U Tablet 100mg, 300mg

Pyrazinamide U Tablet 250mg, 500mg,750mg

Rifampicin U Tablet/capsule 150mg, 300mg, 450mg, syrup

100mg/5ml

Streptomycin U Injection 0.75gm, 1gm

PAS U Tablet1 gm (as sodium salt)

Rifampicin+Isoniazid U Tablet 150 mg +75mg, 300mg+150mg, 450mg+300mg

Rifampicin + Isoniazid +

Pyrazinamide

U Tablet 150mg + 100mg + 500mg, 225mg+150mg

+75mg

RHZ U Tablet R-100mg, H-50mg, Z-200mg

# Ethionamide T Tablet 250mg

# Kanamycin T Injection 500mg, 1gm

# Cycloserine T Capsule 250mg

# Sodium PAS T Granules 100 mg

6.3 Antifungal drugs

Amphotericin T Injection 50mg

Grisecofulvin S,T Capsule/tablet 125mg, 250mg

Clotrimazole P Pessary 100 mg

Fluconazole S,T Capsule 50mg, 100mg, 200mg, injection 2mg/ml

6.4 Antiprotozoal drugs

6.4.1 Antiamoebic & Antigiardiasis drugs

Diloxanide Furoate S,T Tablet 500mg

Metronidazole U Tablet 200mg, 400mg, injection 500mg/100ml

Tinidazole U Tablet 300mg, 500mg

6.4.2 Antileishmaniasis drugs

Sodium Stibogluconate S,T Injection 100mg/ml

6.4.3 Antimalarial drugs

Chloroquine U Tablet 150 mg (base), injection 40mg/ml,

syrup50mg/5ml

Primaquine U Tablet 2.5mg, 7.5mg

Quinine U Tablet 100mg, 300mg, injection 300mg/ml, Syrup

150mg/5ml

Sulfadoxine+Pyrimethamine U Tablet 500mg + 25mg

Artesunate S,T Tablet 50mg, injection 60mg

Artemether S,T Injection 150mg

Mefloquine S,T Tablet 250 mg (as hydrochloride)

6.5 Antiviral drugs

Acyclovir S,T Tablet 200mg, 800mg,syrup 400mg/ml

Zidovudine T Capsule 100mg, 300mg

Lamivudine T Tablet 100mg, 150mg

Stavudine T Capsule 30mg

Nevirapine T Tablet 200mg

7. A#TIMIGRAI#E DRUGS

7.1 For treatment of acute attack

Acetyl Salicyclic Acid U Tablet 325 mg

Dihydroergotamine S,T Tablet 1 mg

Paracetamol U Tablet 500 mg

7.2 For Prophylaxis

Propranolol U Tablet 20mg, 40mg

51

8. A#TI#EOPLASTICS A#D IMMU#OSUPPRESSIVE DRUGS A#D DRUGS USED I#

PALLIATIVE CARE. (THESE DRUGS ARE HIGHLY SPECIALIZED A#D TOXIC DRUGS A#D

SHALL BE PURCHASED O#LY WHE# #ECESSARY A#D FACILITIES FOR HA#DLI#G

SUCH DRUGS EXISTS)

8.1 Immunosuppressive drugs

Azathioprine T Tablet 50mg

Cyclosporine T Capsule 25mg, injection concentrate 50mg/ml

8.2 Cytotoxic drugs

Bleomycin T Injection 15mg (as sulfate)

Actinomycin D T Injection 0.5mg

L – Asparginase T Injection 10000 K.U.

Busulfan T Tablet 2 mg

Cisplatin T Injection 10mg/vial, 50mg/vial

Cyclophosphamide T Tablet 25mg, 50mg, injection 200mg,500mg

Cytosine Arabinoside T Injection 100mg/vial, 500mg/vial, 1000mg/vial,

Danazol T Capsule 50mg

Doxorubicin T Injection 10mg, 50mg

Etoposide T Capsule 100mg, injection 20mg/ml in 5ml

Folinic Acid T Injection 3mg/ml

Fluorouracil T Injection 250mg/5ml

Melphalan T Tablet 2mg, 5mg

Mercaptopurine T Tablet 50mg

Methortrexate T Tablet 2.5mg injection 50mg

Mitomycin T Injection 10mg

Procarbazine T Tablet/capsule 50mg

Vincristine T Injection 1mg, 5mg (sulfate)

Vinblastine T Injection 10mg

Hydroxyurea T Tablet 500 mg

Chlorambucil T Tablet 1mg, 5mg

Flutamide T Tablet 250 mg

Paclitaxel T Injection 30mg, 100mg, 250mg,300mg

8.3 Hormones and Antihormones

Prednisolone S,T Tablet 5mg, injection 40mg/ml (as sodium phosphate or

succinate), injection 20mg/ml

Tamoxifen T Tablet 10mg, 20mg, (as citrate)

9. A#TIPARKI#GO#ISM DRUGS

Trihexyphenidyl U Tablet 2mg

Biperiden* S,T Tablet 2mg, injection 5mg/ml

Levodopa/ Carbidopa U Tablet 100 mg/10mg, 250mg/25mg

10. DRUGS AFFECTI#G THE BLOOD

10.1 Antianaemia drugs

Ferrous salt U Tablet equivalent to 60 mg elemental iron, oral solution

25mg elemental iron/ml

Folic Acid U Tablet 1mg, 5mg

Iron Folic Acid (Large) Folic Acid

+ Exsiccated Ferrous Sulphate

U Tablet 0.5 mg+ 200 mg

Iron Folic Acid (Small)

Folic Acid + Exsiccated Ferrous

Sulphate

U Tablet 0.1mg/67mg

Iron Dextran U Injection 50mg iron/ml

Vitamin B12 U Injection 1mg/ml

52

10.2 Drugs affecting coagulation

Heparin Sodium S,T Injection 1000 IU/ml, 5000 IU/ml

Protamine Sulfate S,T Injection 10mg/ml

Vitamin K S,T Injection 10mg/ml, tablet 10mg

Acenocoumarol* S,T Tablet 1mg, 2mg,4mg

Warfarin S,T Tablet 5mg

11. BLOOD PRODUCTS A#D PLASMA SUBSTITUTES

11.1 Plasma substitutes

Dextran 70 U Injection 6% solution

Dextran 40 U Injection 10% solution

Polygeline S,T Injection 3.5% solution

11.2 Plasma fraction

Albumin S,T Injection 5%, 20%

Factor IX complex ( coagulation

factors II, VII, IX,X)*

T Injection dried

12. CARDIOVASCULAR DRUGS

12.1 Antianginal drugs

Diltiazem S,T Tablet 30mg, 60mg

Glyceryl Trinitrate U Sublingual tablet 0.5mg, injection 5mg/ml

Isosorbide 5 Mononitrate U Tablet 10mg, 20mg

Isosorbide dinitrate T Tablet 5mg, 10mg

Propranolol U Tablet 10mg, 30mg, 40mg, 60mg

12.2 Antiarrhythmic drugs

Amiodarone S,T Tablet 100mg, 200mg

Diltiazem S,T Tablet 30 mg, 60mg, injection 5 mg/ ml

Lignocaine S,T Injection 2%

Isoprenaline S,T Injection 1mg/ml

Mexiletine S,T Capsule 50mg, 150mg, injection25mg/ml

Procainamide S,T Injection 100mg/ml, tablet 250mg, 500mg

Quinidine S,T Tablet 200mg

Verapamil S,T Tablet 40mg, 80mg, injection 2.5mg/ml

Adenosine T Injection 6mg/2ml

12.3 Antihypertensive drugs

Amlodipine S,T Tablet 2.5mg, 5mg, 10mg

Atenolol U Tablet 50, 100mg

Lisinorpril U Tablet 2.5mg, 5mg,10mg

Chlorthalidone U Tablet 25mg, 50mg

Methyldopa U Tablet 250mg

Nifedipine S,T Capsule/tablet 5mg, 10mg

Propranolol U Tablet 40mg, 80mg

Sodium Nitroprusside* T Tablet 40mg, 80mg

Losartan S,T Tablet 25mg, 50mg

Prazosin S,T Tablet 2.5mg, 5mg

Ramipril S,T Capsule 1.25mg, 2.5mg, 5mg

12.4 Cardiac glycosides

Digoxin S,T Tablet 0.25mg, injection0.25mg/ml elixir 0.05mg/ml

12.5 Vascular Shock drugs

Dopamine S,T Injection 40mg/ml

Dobutamine* S,T Injection 50mg/ml

12.6 Antithrombotic drugs

Acetyl Salicylic Acid U Tablet 50mg, 100mg

53

Urokinase* T Injection 500000 IU, 1000000 IU

Streptokinase* S,T Injection 1500000 IU, 750000 IU

13. Dermatological drugs (topical)

13.1 Antifungal drugs

Benzoic Acid + Salicylic Acid U Ointment or cream 6% +3%

Miconazole U Ointment or cream 2%

13.2 Anti-infective drugs

Framycetin Sulfate U Cream 1%

Methylrosanilinium Chloride

(Gentian Violet)

U Topical solution 0.5%

Povidone Iodine U Solution or ointment 5%

Silver Nitrate U Lotion 10%

Silver Sulphadiazine U Cream 1%

Acyclovir S,T Cream 5%

Fusidic acid S,T Ointment 2%

13.3 Anti – inflammatory and Anti-pruritic drugs

Betamethasone S,T Cream or ointment 0.1% w/w

Calamine U Lotion

Clobetasone S,T Cream/lotion/ointment 0.05%

13.4 Keratoplastic and Keratolytic drugs

Coal Tar U Solution 5%

Papdophyllin S,T Cream 10%

Dithranol* T Ointment 0.12%

Glycerin U Solution

Salicylic Acid U Solution 5%

13.5 Scabicides and Pediculicides

Gamma Berrzene Hexachloride U Lotion 1%

Permethrin U Cream 5%

13.6 Anti acne drugs

Tritinoin S,T Cream 0.05%, 0.025%

Benzoyl peroxide S,T Cream 2.5%, 5%

White soft paraffin U ointment

Salicylic Acid S,T Cream 12%

Erythromycin S,T Cream 4%

Clotrimazole S,T Cream 1%

13.7 Antihypermelanosis drugs

Hydroquinone S,T Cream 2%,4%

13.8 Melanogenic drugs

Methoxsalen S,T Tablet 10mg

14 DIAG#OSTIC AGE#TS

14.1 Ophthalmic drugs

Fluorescein S,T Eye drops 1%

Tropicamide S,T Eye drops 1%

14.2 Radio contrast media

Barium Sulfate S,T Suspension 100% w/v 25%w/v

Sodium Meglumine Diatrizoate S,T Injection 60% w/v (iodine con= 292mg/ml), 76 w/v

(iodine cone = 370mg/ml)

Iopanoic Acid S,T Tablet 500 mg

Meglumine Iothalamate S,T Injection 60% w/v (iodine cone = 280mg/ml)

Sodium Iothalamate S,T Injection 70%w/v( iodine cone = 420mg/ml)

54

Meglumine lotroxate S,T 5-8gm iodine in 100-250ml

Iohexol T Injection 160mg/240mg/300mg per ml

15. DISI#FECTA#TS A#D A#TISEPTICS

15.1 Antiseptics

Chlorhexidine U Solution 5% (concentrate for dilution)

Cetrimide U Solution 20% (concentrate for dilution)

Hydrogen Peroxide U Solution 6%

Povidone Iodine U Solution 5%, 7.5%, 10%

Ethyl Alcohol 70% U Liquid

Tincture benzoin Compound U Tincture

Gentian Violet U Paint 0.5%, 1%

Acriflavine + Glycerin U Solution

15.2 Disinfectants

Bleaching Powder U Powder

Formaldehyde U Solution

Glutaraldehyde * S,T Solution 2%

Potassium Permanganate U Crystals

Chloroxylenol U 4.8% solution

Sodium Hypochlorite U 4% solution

16. DIURETICS

Furosemide (frusemide) U Injection 10mg/ml, tablet 40mg

Hydrochlorothiazide U Tablet 25mg,50mg

Mannitol* U Injection 10%, 20%

Spironolactone S, T Tablet 25 mg,100 mg

Amiloride S,T Tablet 5mg

17. GASTROI#TESTI#AL DRUGS

17.1 Antacids and Antiulcer drugs

Aluminium Hydroxide U Tablet 500mg

Ranitidine Hydrochloride U Tablet 150mg, 300mg, injection 25mg/ml

Omeprazole S,T Capsule 20 mg

Pantorprazole S,T Tablet 20mg, 40mg, injection 40mg vial

Sucralfate T Tablet 1gm, gel 1gm/5ml

17.2 Antiemetic drugs

Metoclopramide U Table 10mg, injection 50mg/ml, syrup 5mg/5ml

Prochlorperazine U Table 25mg, 5mg,

Promethazine U Tablet 10mg, 25mg, injection 25mg/ml, elixir, syrup

mg/5ml

Domperidone U Tablet 10mg, 20mg suspension 1mg/ml

Ondansteron T Injection 2mg/ml

17.3 Anti-hacmorrhoidal drugs

Local anaesthetics, Astringents and

anti inflammatory drugs, e.g.,

Lidocaine/Cincocaine + Hydrocortisone

U Ointment / suppository

17.4 Anti-inflammatory drugs

Sulfasalzine T Tablet 500mg

17.5 Antispasmodic drugs

Dicyclomine Hydrochloride U Tablet 10mg, drops 10mg/ml

Hysocine Butylbromide U Tablet 10mg, injection 20mg/ml

17.6 Cathartics

Bisacodyl U Tablet/ suppository 5mg

Ispaghula U Granules

55

Lactulose S,T syrup

Senna S,T Tablet 7.5mg sennosides

Paraffin S,T liquid

Saline + Glycerine U enema

17.7 Drugs used in diarrhea

Loperamide* (contraindicate for

pediatric use)

S,T Capsule 2mg

Oral Rehydration Salts U Powder sachet

18. HORMO#ES, OTHER E#DOCRI#E DRUGS A#D CO#TRACEPTIVES

18.1 Adrenal Hormones and Synthetic analogues

Dexamethasone S,T Tablet 0.5mg,injection 4mg/ml

Hydrocortisone S,T Injection 100mg/ml (as Sodium succinate)

Methylprednisolone S,T Injection 40mg/ml

Prednisolone* U Tablet 5mg, 10mg

18.2 Androgens

Testosterone* S,T Injection 10mg/ml, 25mg/ml

18.3 Contraceptives

Condoms with or without

Spermiciede

U

IUD containing Copper U

Centchroman U Tablet 30mg

Ethinylestradiol + Norethisterone U Tablet 35 µg + 1mg

Ethinylestradiol + Levonorgestrel U Tablet 30 µg + 150 µg, 50µg + 250µg

Clomiphene citrate U Tablet 25mg, 50mg

18.4 Estrogens

Ethinylestradiol U Tablet 50 µ g

Conjugated oestrogen Tablet 0.62mg

18.5 Insulins and other antidiabetic agents

Glibenclamide U Tablet 5mg

Insulin injection (soluble) U Injection 40 IU/ml

Intermediate acting insulin

(Lente/NPH insulin)

U Injection 40 IU/ml

Insulin 30/70 U Injection 40 IU/ml

Metformin U Tablet 500 mg

Gliclazide U Tablet 40mg, 80mg

Glimepiride U Tablet 1mg, 2mg, 4mg

18.6 Progestrogens

Norethisterone U Tablet 5mg

17 Hydroxy progesterone acetate S,T Injection 250mg

Carboprost S,T Injection 125mg, 250mg

18.7 Thyroid hormones and Antithyroid drugs

Carbimazole S,T Tablet 5mg

Levothyroxine S,T Tablet 0.1mg

Propyl thiouracil S,T Tablet 50mg

19. IMMU#OLOGICALS

19.1 Diagnostic agents

Tuberculin, Purified protein

derivative

U injection

19.2 Sera and Immunoglobulins

Anti-snake venom U Injection 10ml

56

Anti-D Immunoglobulin (human) S,T Injection 0.250mg, 0.350mg

Anti-Tetanus Immunoglobulin

Human

S,T Injection 250 IU, 500 IU

Diphtheria Antitoxin S,T Injection 10000 IU, 20000 IU

Rabies Immunoglobulin S,T Injection 150 IU/ml

19.3 Vaccines

B.C.G. Vaccine U Injection

D.P.T. Vaccine U Injection

Hepatitis B Vaccine U Injection

Measles Vaccine U Injection

Oral Poliomyelitis Vaccine (Live

attenuated)

U Solution

Rabies Vaccine U Injection

Tetanus Toxoid U Injection

Dual antigen U injection

20. MUSCLE RELAXA#TS (PERIPHERALLY ACTI#G) A#D CHOLI#ESTERASE I#HIBITORS

Atracurium* S,T Injection 10mg/ml

Vecuronium T Injection 2mg/ml

Neostigmine S,T Injection 0.5mg/ml, 2.5mg/ml, tablet 15mg

Pancuronium S,T Injection 2mg/ml

Succinyl Choline S,T Injection 50mg/ml

21. E#T A#D OPHTHALMOLOGICAL PREPARATIO#S

21.1 Anti infective agents

Chlormaphenicol U Drops/ointment 0.5%, 1%

Ciprofloxacin U Drops/ointment 0.3%

Sulfacetamide U Drops 10%, 20%, 30%

Framycetin U Drops 0.5%

Miconazole U Drops 1%

Fluconazole S,T Ointment 3%

Acyclovir T Ointment 3%

Tobramycin Drops 0.3%, ointment 0.3%

Tobramycin + Dexamethsone sod.

Phosphate

S,T Drops0.3%+0.1%, ointment 0.3%+0.1%

21.2 Anti inflammatory agents

Prednisolone U Drops 0.5%

Xylometazoline U Drops 0.1%, 0.05%

Flurbiprofen S,T Drops 0.03%

Disodium Chromoglycate S,T Drops 2%

21.3 Local Anaesthetics

Tetracaine U Drops 0.5%

Lignocaine U Drops 4%

21.4 Mioties and Antiglaucoma drugs

Acetazolamide S,T Tablet 250mg

Pilocarpine S,T Drops 2%, 4% solution0.5%

Timolol S,T Drops 0.5%, 0.25%

Hydroxyl propyl methyl cellulose S,T Solution 20mg/ml

Hyaluronidse T Injection 1500 IU

21.5 Mydriaties

Atropine U Drops/ointment 0.5%, 1%

Homatropine U Drops 2%

Phenylephrine U Drops 5%

Tropicamide S,T Eye drops 1%

57

22. OXYTOCICS A#D A#TIOXYTOCICS

22.1 Oxytocics

Methyl Ergometrine U Tablet 0.125mg, injection 0.2mg/ml

Oxytocin S,T Injection 5 IU/ml, 10 IU/ml

22.2 Antioxytocies

Terbutaline S,T Tablet 2.5mg, injection 0.5mg/ml

Isoxsuprine S,T Tablet 10mg, injection 5mg/ml

23. PERITO#EAL DIALYSIS SOLUTIO#S

Intraperitoneal Dialysis Fluid T

24. PSYCHOTHERAPEUTIC DURGS

24.1 Drugs used in Psychotic Disorders

Chlorpromazine U Table 25mg, 50mg, 100mg, syrup 25mg/5ml, injection

25mg/ml

Haloperidol S,T Tablet 1.5mg, 5mg, 10mg, injection 5mg/ml

Risperidone S,T Tablet 1mg, 2mg

Thiordazine S,T Tablet 25mg ,50mg

Olanzapine U Tablet 5mg, 10mg

24.2 Drugs used in Mood Disorders

Imipramine U Tablet 25mg, 75mg

Fluoxetine* S,T Capsule 20mg

Lithium Carbonate S,T Tablet 300mg

Sertraline Tablet 50mg, 100mg

24.3 Drugs used for Sedation and Generalized Anxiety Disorders

Diazepam U Tablet 2mg, 5mg, 10mg

Alprazolam S,T Tablet 0.25mg, 0.5mg

Lorazepam S,T Tablet 1mg, 2mg, injection 2mg/ml

24.4 Drugs used in Obsessive Compulsive Disorders and Panic Attacks

Clomipramine* U Tablet 10mg, 25mg

Fluvoxamine T Tablet 50mg, 100mg

24.5 Drugs used for Deaddiction

Chlordiazepoxide S,T Tablet 5mg, 10mg

24.6 Depot Antipsychotics

Fluphenazine Deconate S,T Injection 25mg/ml

25. DRUGS ACTI#G O# THE RESPIRATORY TRACT

25.1 Antiasthmatic drugs

Theophylline Compounds U Tablet 100mg, 200mg

Aminophylline U Injection 25mg/ml

Etophylline + Theophyline U Injection 169.4mg +50.6mg/2ml

Beclomethasone U Inhalation 0.050mg, 0.200mg/dose

Salbutamol U Tablet 2mg, 4mg, injection 0.5mg/ml, syrup 2mg/5ml,

inhaler 100µg/dose, dry powder 200mg/dose, nebulizeer

solution 5mg/ml

Ipratropium Bromide S,T Inhaler 20 µg/dose, dry powder inhalation 40µ g/dose,

nebulizer solution 250µg/ml

Bromohexine U Tablet 8mg

Fluticasone S,T Inhaler 50µg/dose

Salbutamol+Ipratropium S,T Inhaler 100 µg+20µg/dose

Budesonide Inhaler 100µg/dose, 200µg/dose, dry powder inhalation

100µg/dose, 200µg/dose, 400µg/dose, nebulizer

solution 0.25mg/2ml, 0.5mg/2ml

Salmetrol T Inhaler 25µg/dose, dry powder inhalation 50mg/dose

58

25.2 Antitussives

Dextromethorphan U Tablet 30mg

Codeine S,T Tablet 10mg, syrup 25mg/5ml

26. SOLUTIO#S CORRECTI#G WATER, ELECTROLYTE A#D ACID-BASE DISTURBA#CES

26.1 Oral

Oral Rehydration Salts U Powder

26.2 Parenteral

Dextose U Injection 5% isotonic, 10% isotonic

T 50% hypertonic 100ml, 25% 100ml

Dextose with Sodium Chloride U Injection 5% + 0.9%

Ringer Lactate U Injection

Normal Saline U Injection 0.9%

Potassium chloride U injection

Multiple electrolytes G S,T injection

Multiple electrolytes P S,T injection

Electrolytes E S,T injection

Electrolytes M S,T injection

Electrolytes R S,T injection

26.3 Miscellaneous

Sterile water for injection IP U Injection 2ml, 5ml, 10ml

27. VITAMI#S A#D MI#ERALS

Ascorbic Acid U Tablet 50mg, 100mg, 500mg

Concentrated Vitamin A Solution U Injection 1.5lacs IU/ml

Nicotinamide U Tablet 50mg

Pyridoxine U Tablet 5mg

Retinol U Tablet/ solution 50000 IU, 10000 IU

Thiamine U Tablet 5mg, 10mg, 50mg

Vitamin B Complex with

Multivitamins

U As per Schedule V/ National Formulary

Vitamin D3 (Ergocalciferol) S,T Capsule 250 µ g, 1mg, 1.25mg oral solution 75mg/ml

Calcium gluconate U Injection 100mg/ml in 5/10ml ampoules

• Complementory Medicines, i.e. those required for specific patients, situations or

locations for valid reasons

# Medicines to be use only when national Programme or state policy approve’

ensorse such ususage in the state

59

APPE#DICES

Manpower #orms (Availability of specialist and supportive staff)

Incharge PHC/CHC/SDH should have the complete knowledge of

sepcialist,other supportive staff and the facilities avaiable at higher centres

like blood storage,laboratory services,pharmacy services and support services

at various higher levels so that, patients referred are attended and managed by

the sepcialist with no waiting time. Deployment of the staff is given as below:

Staffing Pattern for Hospitals (30 Beds and above)

Cadre 30

Bedded

Hospital

50

Bedded

Hospital

100

Bedded

Hospital

150

Bedded

Hospital

300

Bedded

Hospital

Senior Specialists

Medicine - - 1 1 1

Surgery - - 1 1 1

Gynae - - - 1 1

Pediatrics - - - 1 1

Ophthalmology - - - 1 1

Radiology - - - 1

Anesthesia - - - 1

Microbiology pathology - - - - 1

Dentistry - - - - 1

Skin VD - - - - 1

Psychiatry - - - - -

Forensic Med. - - - - 1

Orthopedics - - - 1 1

ENT - - - - 1

Junior Specialist

Medicine 1 1 1 1 2

Surgery 1 1 1 1 2

Gynae - 1 1 1 2

Pediatrics - 1 1 1 2

Ophthalmology - 1 1 1 1

Radiology - - 1 1 1

Anesthesia - - 1 1 1

Microbiology/Pathology - - - 2 (1 +1 MB) 1

Dentistry - - 1 1 -

ENT - - 1 1 1

Skin VD - - - 1 1

Psychiatry - - - 1 1

Forensic Med. - - - 1 -

Orthopedics - - 1 1 2

TB - - - 1 1

Medical Officers

Senior Medical 1 1 3 4 (3+1*) 5 (4 +1*)

Medical Officer 5(2+3#) 5 8 12 30

#ursing Staff

Nursing Supdt. Gr. I/II - - 1 1 2 (1+1)

Nurse Gr. I 1 2 (1F +

1M)

8 10

(3F+7M)

20

(5F+15M)

Nurse Gr. II 9 (6+3 #) 14

(4F+10M)

28 30

(10F+20M)

60

(20F+40M)

Technical Staff

Radiographer/ Assistant

Radiographer

1 1 2 (1+1) 4 (2+2) 4 (2+2)

Lab. Technician 1 1 2 4 (3+1**) 5

Dental Technician - 1 1 1 2 (1J+1S)

Physiotherapist - - - 1J 1S

Pharmacist 1 1 1 1J 1S

Ophthalmic Assist - 1 1 2 2

Administrative Staff

Office Superintendent - - - - 1

Office Assistant - - - 1 -

Accountant - - - 1 1

Junior Accountant - - 1 1 2

UDC 1 1 2 2 3

LDC 1 1 4 4 5

Support Staff

Driver (Contract

Services)

- - - - -

Ward Boy 9 10 15 33 66

Sweeper 1 2 5 8 10

* Deputy Controller (SMO Cadre), ** Senior Technician, J Junior, S Senior,

MB Microbiologist, # Round the clock, F Female, M Male.

PHC to CHC

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gLrk{kj

jsQjdrkZ fpfdRld

fp-v-@o-fp-v-@d-fo-@o-

fo-

vLFkkbZ fpfdRlh; funku -------------------------------

---------------------------------------

jsQj djus dk dkj.k--------------------------------------------

----------------------------------------------

tkWap@ijke’kZ@’kY;--------------------------------------

-----------------------------------------------------

uSnkfud ¼fDyfudy½ fVIi.kh ,oa mipkj dk fooj.k

¼ijh{k.k] tkap] mipkj] jksxh dh fLFkfr ,oa le;½

SDH to DH

jktLFkku ljdkj

fpfdRlk LokLF; ,oa ifjokj dY;k.k foHkkx

jsQjy dkMZ ch-i h-, y - dkMZ/kkjh

gkWa@ugh dkMZa ua- ----------------------

, e-, y -l h- gkWa@ugh

ua- -----------------------------------

1- jsQj djus okyh laLFkk dk uke-----------------------

--------------------------

2- jksxh dk uke-----------------------------------------

------mez ,oa fyax-------------

3- firk@ifr dk uke-------------------------------------------

---------------------------------------------

4- irk---------------------------------------------------

---------------------------------------------------

5- laLFkk dk uke tgka jsQj fd;k x;k--------------------

--------------------------------------------------

-------------------------¼fo'ks"k foHkkx gks rks

jsQjy fpfdRlky; ds izkIrdrkZ fpfdRld dh fVIi.kh

gLrk{kj

izkIrdRkkZ vf/kdkjh dk uke o in

fnukad %

le; %

uksV%¼mijksDr lHkh fooj.k fpfdRlk laaLFkk ds jsQjy jftLVªj esa

vafdr fd;s tk;s½

layXu ,Dl&js] bZ-lh-th- bR;kfn

gLrk{kj

jsQjdrkZ fpfdRld

fp-v-@o-fp-v-@d-fo-@o-

fo-

vLFkkbZ fpfdRlh; funku -------------------------------

---------------------------------------

jsQj djus dk dkj.k--------------------------------------------

----------------------------------------------

tkWap@ijke’kZ@’kY;--------------------------------------

-----------------------------------------------------

uSnkfud ¼fDyfudy½ fVIi.kh ,oa mipkj dk fooj.k

¼ijh{k.k] tkap] mipkj] jksxh dh fLFkfr ,oa le;½

DH to TECHI#G HOSPITAL

jktLFkku ljdkj

fpfdRlk LokLF; ,oa ifjokj dY;k.k foHkkx

jsQjy dkMZ ch-i h-, y - dkMZ/kkjh

gkWa@ugh dkMZa ua- ----------------------

, e-, y -l h- gkWa@ugh

ua- -----------------------------------

1- jsQj djus okyh laLFkk dk uke-----------------------

--------------------------

2- jksxh dk uke-----------------------------------------

------mez ,oa fyax-------------

3- firk@ifr dk uke-------------------------------------------

---------------------------------------------

4- irk---------------------------------------------------

---------------------------------------------------

5- laLFkk dk uke tgka jsQj fd;k x;k--------------------

--------------------------------------------------

-------------------------¼fo'ks"k foHkkx gks rks

jsQjy fpfdRlky; ds izkIrdrkZ fpfdRld dh fVIi.kh

gLrk{kj

izkIrdRkkZ vf/kdkjh dk uke o in

fnukad %

le; %

uksV%¼mijksDr lHkh fooj.k fpfdRlk laaLFkk ds jsQjy jftLVªj esa

vafdr fd;s tk;s½

layXu ,Dl&js] bZ-lh-th- bR;kfn

gLrk{kj

jsQjdrkZ fpfdRld

fp-v-@o-fp-v-@d-fo-@o-

fo-

vLFkkbZ fpfdRlh; funku -------------------------------

---------------------------------------

jsQj djus dk dkj.k--------------------------------------------

----------------------------------------------

tkWap@ijke’kZ@’kY;--------------------------------------

-----------------------------------------------------

uSnkfud ¼fDyfudy½ fVIi.kh ,oa mipkj dk fooj.k

¼ijh{k.k] tkap] mipkj] jksxh dh fLFkfr ,oa le;½

jktLFkku ljdkj

fpfdRlk LokLF; ,oa ifjokj dY;k.k foHkkx

QhMcSd dkMZZ

, e-, y -l h- gkWa@ugh

ua- -----------------------------------

, e-, y -l h- gkWa@ugh

ua- -----------------------------------

1- laLFkku dk uke-------------------------------------------------------

-----------------------------------

2- jksxh dk uke----------------------------------------------------------

--------------------------------------

mez ,oa fyax--------------------------------------------

3- firk@ifr dk uke-------------------------------------------------------

--------------------------------

4- irk----------------------------------------------------------------------

-----------------------------------------------------------------------------

-----------------------------------------------------------------------------

-------------------------

5- laLFkk dk uke]ftls QhMcSd fn;k x;k------------------------------

---------------------

---------------------------------------------------------------------------

layXu ,Dl&js] bZ-lh-th-]bR;kfn

ijke'kZ

¼Qksyksvi ,Mokbt½

gLrk{kj

fpfdRld dk uke ,oa in

fnukad ,oa le;

LFkkbZ fpfdRlh; funku

tkap@ fn;k x;k mipkj

¼tkap] ijh{k.k] fn;k x;k mipkj ,oa okilh ij ejht dh fLFkfr½

State Institute of Health & Family Welfare Rajasthan, Jaipur

Training on Referral System

Program

Day 1

9.30 -10.00 Hrs. Registration

1st Session

(10.00 - 11.30 Hrs.) RHSDP - Introduction, Goals, Objectives

and Structure of organization

2nd

Session

(11.30 - 1.00 Hrs.) Referral norms for Medicine and Psychiatric

cases

1.00 - 2.00 Hrs. Lunch

3rd

Session

(2.00 -3.30 Hrs.) Referral norms for Surgical and Orthopedic

Cases

4th

Session

(3.30 -5.00 Hrs.) Referral norms for Obs. & Gynae diseases

Day 2

1st Session Referral norms for Pediatrics cases

(10.00 - 11.30 Hrs.)

2nd

Session

(11.30 - 1.00 Hrs.) Referral norms for E#T and Ophthalmology

cases

1.00 - 2.00 Hrs. Lunch

3rd

Session

(2.00 -3.30 Hrs.) EML Orientation

4th

Session Orientation on Referral, Feed back Cards and

(3.30 -5.00 Hrs.) Referral register

Expectation from trainee

_________________________________________________________________

Courtesy : Ms. Aparna Arora

Project Director, RHSDP, Jaipur

Concept : Dr. Shiv Chandra Mathur

Director, State Institute of Health & Family Welfare,

Jaipur

Edited by : Dr. B.#. Sharma

Prepared by : Dr. J.P. Jain

Contribution : Dr. S.C. Gupta

Dr. P.S. Bhatnagar

Published by : State Institute of Health & Family Welfare

Rajasthan, Jaipur

May, 2005

___________________________________________________________________