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CLINICAL DIVISION

DEPARTMENT OF PEDIATRICS

I. MISSION: To provide quality, efficient and effective medical care delivery to our patients and to enhance the medical expertise and training of its staff and personnel in the field of Pediatrics.

II. VISION: The Mandaluyong City Medical Center Department of Pediatrics is one that is competent, committed, compassionate, reliable, efficient and responsive to the medical needs of the children of the community with concern for Total Quality Care.

III. OBJECTIVES  GENERAL  To provide quality, efficient and effective medical care delivery to our patients through the center’s medical services whenever possible.  To provide better facilities, new technologies and continuing education to our medical staff through training programs in specific field of medicine.  To provide a working environment to enable our support staff to perform their duties with confidence and dignity and to encourage them to do their best and excel.

 SPECIFIC  To provide the best possible total quality medical care to all pediatric patients in the hospital and community.  To provide and maintain excellence in the education of the pediatric residents through training and research.  To be recognized as an accredited residency training program by the Philippine Pediatric Society.  To equip the department with facilities and equipments to promote good quality patient care.  To attend more symposiums, Postgraduate courses, scientific lectures to enhance knowledge on pediatric updates.  To enforce and maintain exclusive breastfeeding in all areas unless contraindicated.  To continue to be a full pledge member of the Metro-Manila East Integrated Residency Training Program.  To disseminate information in the community with regards to preventive pediatric care.  To rotate to different PPS accredited institutions to acquire more knowledge and skills in the management of different pediatric cases.

Mandaluyong City Medical Center CLINICAL DIVISION

IV. GENERAL FUNCTIONS The Department of Pediatrics functions in the following areas:  Provision of well-baby check-up at the outpatient clinic  Provision of ambulatory care for sick baby consultation  Provision of acute and critical care in the emergency and hydration areas  Admission and management of secondary and tertiary pediatric cases in the wards as inpatients.  Admission and management of measles cases and other communicable / infectious diseases like Typhoid, Hepatitis, Chickenpox etc. at the Infectious Wards.  Promotion of breastfeeding program  Provision of critical care at the intensive care unit  Provision of neonatal care  Participation and implementation of a pediatric outreach program  Provision and implementation of an accredited residency training program therefore assuring the community of competent practitioners in pediatric care.

V. ORGANIZATIONAL STRUCTURE  The City Mayor appoints a Medical Director who supervises the professional and administrative services of the hospital being handled by a deputy director. Under the deputy the director for professional services are the different chiefs for clinical, ancillary and nursing services. The deputy director for administration supervices the administrative service and the PDER.  The chief for clinical services services the different clinical departments and services.  Each department is headed by a department chair with its training officer and consultant staffs.The chief resident and the resident staff are directly under the supervision of the training officer and consultants.

VI. HISTORY  In 1986 The Department of Pediatrics in particular started with 4 residents, with DR. DIANA FONBUENA acting, as the first Pediatric Senior Resident while DR. ANGELINA MENDOZA became the first Department Head.  In 1987, DR. VILMA Q. ARIZALA was appointed as Training Officer of the department and 2 more residents were added to the staff to accommodate the increasing number of patients.  In 1992, DR. ANGELINA S. MENDOZA resigned and DR. LORNA E. NAVARRO took over as Training Officer while DR. ARIZALA became the Department Head.  In 1994, Mandaluyong Medical Center – Department of Pediatrics became an observer in the Metro-Manila East Integrated Residency Training Program.  In 1995, the MCMC became a Baby Friendly Hospital with 10 Resident Physician and 5 active consultants.

Mandaluyong City Medical Center CLINICAL DIVISION  At the start of 1996, DR. EUFROSINA A. MELENDRES became the Department Head and DR. ARIZALA as the Training Officer. Nine more specialty consultants were added to the staff. At present, there are a total of 15 active consultants with 7 regular residents.  In June 1997, its Pediatric Residency Training Program was first accredited by the Philippine Pediatric Society Hospital Accreditation Board as Phase I.  Establishment and opening of Pediatric Infectious Disease Ward.  In June 1998, its accreditation was upgraded to Phase IIA.  On 1999, the Department Residency Training Program was reaccredit and upgraded in Phase IIB  In March 2000, the department applied for renewal of accreditation and was subsequently approved to Phase IIA and B up to present.  In October 2003, the department was accredited as a member of the Philippine Newborn Screening Program up to present.  In January – December 2005 the Department became the secretariat of the Metro Manila East Integrated Residency Training Program.  In June 2006 – reaccredited as level I (Phase II A & B) up to July 2008 by the Philippine Pediatric Society Hospital Accreditation Board.

VII. TRAINING PROGRAM The Department of Pediatrics of the Mandaluyong City Medical Center in its pursuit for excellence and competence in service implements and conducts a comprehensive residency training program. It shall adhere to competent provision and supervision of comprehensive health care for children and will uphold and respect human dignity regardless of age, sex, race, creed and affiliations.

 GENERAL OBJECTIVES FOR THE PROGRAM ARE:  To provide the resident physician adequate knowledge, skills, information and expertise in the field of Pediatrics.  To develop good moral values, habits and right attitudes in the practice of Pediatrics.

 TERMINAL COMPETENCIES:  FIRST YEAR RESIDENTS I. To develop and demonstrate proper bedside manners in dealing with patients and proper attitudes with relatives and colleagues. II. To master the different milestones of normal growth and developments of all ages (birth up to 18 years old) III. To be able to differentiate normal from abnormal pattern of growth and development. IV. To familiarize oneself with the common pediatric diseases and their patterns in different age groups.

Mandaluyong City Medical Center CLINICAL DIVISION V. To master the art of proper history taking and to be able to perform a thorough physical examination. VI. To be knowledgeable in the interpretations of the clinical data and the pathophysiology involved.

 SECOND YEAR RESIDENTS I. To develop and execute proper bedside manners and to practice medical ethics in dealing with relatives and colleagues II. To be able to identify and treat common abnormal conditions in the newborn. III. To become an expert in diagnosing and treating pediatric emergencies. IV. To be able to master the art of directing and teaching first year residents with regards to pediatric care. V. To be able to make a retrospective research paper.

 THIRD YEAR RESIDENTS I. To be able to manage critically ill patients and problematic patients in the NICU/PICU II. To be well-versed in ambulatory pediatrics III. To be able to attend and passed the written and oral examinations on Pediatric Advance Life Support (PALS) and Neonatal Advance Life Support (NALS)

 CONTENT OF THE PROGRAM:  Period of training / Staffing Training period is a minimum of 3 years. The resident physician is promoted to the next year level if he or she fulfills the requirements set for a particular level where he or she belongs.

Residency training starts on January of each year. I. Resident staff consist of: a. Chief resident b. 3rd year resident c. 2nd year resident d. 1st year resident

 Rotation of Residents to different Services I. Outpatient Department / Emergency Room 4months a. Well Baby Clinic b. Sick Baby Clinic II. Ward (PICU) 4months III. Nursery ( NICU) 2months IV. Outside Rotation 2months

Mandaluyong City Medical Center CLINICAL DIVISION At present not yet resumed due to manpower problems.

NOTE: But due to manpower problem outside rotation was cancelled since 2003

V. Community Outreach Program a. Located at Barangay Daang Bakal Mandaluyong City held every Wednesday at 8 -10 AM. b. Residents are supervised by consultant on assigned for the day.

 Research / Case Reports: I. 1st year residents are required to submit a written case report at the end of their 1st year residency as well as a research protocol. II. 3rd year residents are required to submit their prospective research paper at the end of their 3rd year residency.

NOTE: Failure to comply with the requirements means an extension of the residency period until such requirements are fulfilled.

Mandaluyong City Medical Center CLINICAL DIVISION

 INSTRUCTIONAL ACTIVITIES: ACTIVITY FREQUENCY AUDIENCE SUPERVISION Endorsement Rounds Daily ( 8:30-9:30 a.m.) Residents Consultant

Admitting Rounds with Once a week Monday (8:30- - do - - do - Training Officer 9:30 a.m.)

Monthly Departmental Once a month last Friday of - do - - do - Audit/Meeting the month Perinatal Mordibity & Once a month 1st Tuesday of - do - - do - Mortality the month Perinatal Mordibity & Once a month 1st Tuesday of - do - - do - Mortality the month - do – Clinicopathological Once a month 3rd Thursday of w/ MME w/ - do – w/ MME (Th) w/ Conference the month MCMC MCMC (Wed)

Journal Club Once a week, Tuesday Residents Consultants Case Discussion 2nd Friday of the month - do - - do - Bedside Conference with Twice a week Mondays & - do - - do - COD Fridays (8:30-9:30 a.m. DEL MUNDO Club Daily (12:00-1:00 p.m.) - do - - do - NELSON Club Once a week - do - - do - Metro Manila East 1st, 3rd, and 4th Thursday of the Integrated Residency - do - - do - month Training Program MANAGEMENT: Once a month Tuesdays (1:30- Pharmacology / - do - - do - 2:30 p.m. Therapeutics MCMC Mortality / Once a month to last - do - - do - Mordibity Wednesday of the month Once a month PULMONOLOGY Lectures - do - Dr. Anjanette de Leon ( weekdays ) Once a month NEONATOLOGY Lectures - do - Dr. Esterlita V. Uy ( weekdays ) Dr.Eufrosina HEMATOLOGY Lectures 2nd Thursday of the month -do- Melendres Once a month NEPHRO -do- Dr. Joselito Matheus ( weekdays ) Once a month NEURO -do- Dr. Ignacio Rivera ( weekdays ) Once a month INFECTIOUS -do- Dr. B. Quiambao ( weekdays )

 DUTIES OF THE RESIDENT PER YEAR LEVEL: Mandaluyong City Medical Center CLINICAL DIVISION  DUTIES AND RESPONSIBILITIES OF FIRST YEAR RESIDENTS: I. Make the daily rounds of all admitted patients sometimes with the consultant-in-charge. II. Gathers relevant information for the history and does a complete physical examination. III. Creates the plan of management and follow-up patients’ progress. IV. Goes on 24-hour duty every three days and under the supervision of a more senior resident. V. Refer any problems to a more senior resident. VI. Once assigned at NICU, does newborn evaluation, completing maternal and obstetrical history. VII. Presents all admissions to the consultant-on-duty. VIII. Attend and participate in all conferences required by the department. IX. Submit at least one case report at the end of the first year. X. To develop clinical judgment and to be able to set properties with regards to management. XI. To be able to perform common pediatrics procedures (venoclysis, blood extractions, CPR, skin testing, PPD/Immunization, NGT insertion/gastric lavage, lumbar tap, umbilical cannulation, endotracheal tube intubation and exchange transfusion) and know the rationale, contraindications and complications of such procedure. All procedures should be done with direct supervision of a more senior resident.

 DUTIES AND RESPONSIBILITIES OF SECOND YEAR RESIDENTS: I. Make daily rounds with consultants and other residents. II. Attends all high-risk deliveries and obtained maternal and obstetrical history. III. Does discharge summary and gives instructions to parents. IV. Performs diagnostic and therapeutic procedures under the supervision of a more senior resident. V. Supervise and assist the first year residents. VI. Answer referrals within the departmental and relays them to a more senior resident. VII. Treats and manages OPD and ER patients. VIII. May be sent as an affiliate resident in RITM. IX. To submit a complete retrospective research papers the end of the second year. X. To submit a prospective research protocol. XI. Added rotations to: a. Radiology;

Mandaluyong City Medical Center CLINICAL DIVISION b. Pathology; XII. Cranial Ultrasound / 2-D Echo at least for 1-2 months. XIII. To evaluate and manage OPD and ER patients. XIV. Evaluate and monitors pediatric patients undergoing surgical procedures at the OR and subsequently manage patients at the Recovery Room if needed.

 DUTIES AND RESPONSIBILITIES OF THIRD YEAR RESIDENTS: I. Does daily bedside and chart rounds with the junior residents. II. Guides all junior residents in performing diagnostic and therapeutic procedures. III. Acquaint him/her all in-patients including seriously ill, manage them after proper consultation with the consultant-in-charge. IV. Acknowledges and attends to all referrals. V. To complete and present prospective research paper.

 DUTIES OF THE CHIEF RESIDENT I. Furnish the Director’s Office, NICU, Ward, OPD and ER with the schedule of duties and assignments of all Pediatric Residents. II. Coordinate with the Pediatric consultants on matters concerning the Departments training program. III. Informs the Pediatric Consultants of any request for a leave of absence or any change of duties. IV. Submits to the Department Head the monthly census of all Pediatric Admissions. V. Coordinates with the pediatric consultant on duty in any interdepartmental referrals. VI. Conducts teaching rounds with the more junior members of the resident staff. VII. Conducts regular chart checking. VIII. Familiarize himself / herself with all in-patients, particularly the critically ill, attends to their needs and responsible for the management after due consult with the CIC. IX. Answer problem cases referred to him by the more junior residents in any of the critical areas X. Schedule scientific activities for the department XI. Responsible for the implementation of department and hospital policies among the resident staff. XII. Acts as Senior House Officer.

 EVALUATION OF RESIDENTS (Appendix A) Residents are evaluated quarterly by the residency training committee. Residents performance evaluation consists of written exams, clinical performance, compliance of requirements, oral presentation in conferences,

Mandaluyong City Medical Center CLINICAL DIVISION attendance and chief residents rating. (Appendix )Residents will not be promoted to the next year level of residency or will not be able to graduate if the requirements are not complied with.

 RESIDENCY TRAINING COMMITTEE: Chair Eufrosina A. Melendres,MD Vice Chair Vilma Q. Arizala,MD Members Suzette A. Bautista,MD Dolores A. Bustamante,MD Lorna E. Navarro,MD Resident Sheila D. Castro,MD

 MINIMUM PASSING LEVELS: FIRST YEAR RESIDENTS 70% SECOND YEAR RESIDENTS 75% THIRD YEAR RESIDENTS 80%

 OTHER UNIQUE FEATURES OF RESIDENCY The department of pediatrics is a member of the Metro Manila East Integrated Residency Training Program (MMEITRP). It is composed of six hospitals namely: Armed forces of the Philippines Medical Center (AFPMC), Delos Santos Medical Center (DLSMC), Mandaluyong City Medical Center (MCMC), Pasig City General Hospital (PCGH), Rizal Medical Center (RMC), and San Juan Medical Center (SJMC).

Another ubique feature of the residency is the presence of the Pediatric Infectious Disease Ward created in July 1997, presently known as the Ciara Marie Abalos Foundation Infectious Disease Ward.

 ROTATIONS TO THE DIFFERENT SECTIONS BY YEAR LEVEL: FIRST YEAR a. Ward 4 months b. OPD / ER 4 months c. NICU / LMA 2 months d. Elective 2 months

SECOND YEAR a. Ward 3 months b. OPD / ER 2 months c. NICU / LMA 2 months d. Subspecialties 4 months e. Community 1 month

THIRD YEAR a. Ward 3 months b. OPD / ER 2 months

Mandaluyong City Medical Center CLINICAL DIVISION c. NICU / LMA 2 months d. Subspecialties 4 months e. Community 1 month

 TEACHING CONFERENCES (Appendix C and D) Bedside rounds are done daily with the ward consultant or consultant on duty. Lecture on different subspecialties are also done once every month. Clinico-pathologic conferences and Grand Rounds are done through the Metro Manila East Integrated Residency Training Program weekly on an alternate basis held every thursday. The Nelson club and journal clubs are done once a week. Daily endorsement rounds are done with the incoming, from duty and pre-duty residents before going to their respective posts for the day. The chief resident together with all the other residents conducts his/her rounds once a week. Mortality and morbidity audits are done once a month.

 PEDIATRIC PROCEDURES At the end of the residency training, each of the residents are expected to be able to perform the following procedures properly and with confidence:  resuscitation  umbilical cannulation  exchange transfusion  bone marrow puncture  lumbar puncture  jugular tap  thoracentesis  abdominal paracentesis

 DUTIES AND RESPONSIBILITIES OF RESIDENTS AT THE DIFFERENT AREAS  DUTIES AND RESPONSIBILITIES OF THE RESIDENT ON 24-HRS. DUTY (8:00 a.m. to 12:00 noon the following day) I. Goes on 24-hours duty alternately with the other residents (regular and assistant residents as Scheduled). II. Make bed-to-bed endorsement rounds of wards with the out- going Residents- on-duty at a.m. III. Perform Pediatric Ward procedures as the need arises. IV. Writes clinical histories and perform physical examination of all admitted patients within hours. V. Outlines plan of management and does daily follow-ups and progress notes on all admitted patients especially critically ill patients. VI. Does the physical examination of all admitted patients in the ward for the duration of his duty, fill up information sheets, writes down orders and complete the history form. VII. Performs discharge PE of ward patients

Mandaluyong City Medical Center CLINICAL DIVISION VIII. Answers referrals in the Pediatric Ward and refers any problem to the Pediatric Consultant-on-duty. IX. Attends and participates in all conferences required by the department but with priority given to immediate referrals or patient’s care. X. Answers ER call after 5:00 p.m. up to 12:00 noon the following day. XI. Makes his second bedside rounds for the day on all patients before retiring at night and checks if all orders have been carried out. XII. Provides himself with a stethoscope, ophthalmoscope / otoscope, neurologic hammer and tape measure and penlight.

 DUTIES AND RESPONSIBILITIES OF THE WARD RESIDENT I. The 2-ward/floor residents shall go on 24 –hours duty every three days. II. Conduct endorsement rounds of all pediatric patients with the out-going ward residents. III. Make bed-to-bed rounds of all patients in the floor twice a day aside from the daily rounds with the consultant-in-charge. IV. Answer referrals in the wards or private rooms at all times within their 24-hours duty. V. Write clinical history and perform physical examination of all admitted patients. VI. Inform consultants-on-duty (COD) or in-charge (CIC) at any time of any problem or admission that needs prompt attention. VII. Make progress notes on all critically ill or problematic patients as developments ensue. VIII. Refer problematic cases to COD or CIC at anytime. IX. Personally talk to the parents of critically ill children to explain the clinical prognosis and the importance of laboratory procedures and medications in the management of their children’s illness. X. Fill up the Census booklet every duty and properly endorse it the following day to the incoming resident. XI. Answer referrals from other departments in the absence of the chief resident.

 DUTIES AND RESPONSIBILITIES OF THE NICU RESIDENT I. Goes on 24 hours duty every 3 days alternately with the other 2 permanent NICU residents. II. Make endorsement rounds of all the babies in the Rooming-In ward with the out-going NICU resident.

Mandaluyong City Medical Center CLINICAL DIVISION III. Make own rounds of all NICU babies 2x/day (morning and evening). IV. Performs NICU procedures as the need arises (umbilical cannulation, endotracheal intubation, femoral tap, lumbar tap, exchange transfusion, NGT insertion, gastric lavage, etc.). V. Personally attends to the delivery of all pregnancies (NSVD or CS). VI. Performs physical examination of all admitted NICU and transient room babies for the duration of her duty, fills up all NICU sheets under her charge (PE, APGAR Scoring, neuromuscular testing), writes down pertinent orders and completes maternal and obstetrical history sheets. VII. Performs PE discharge on all babies due for discharge on that day. VIII. Writes down pertinent progress notes as the case warrants on critically ill or problematic newborns indicating various problems presented with her plan of management. IX. Informs the pediatric Consultant-in-charge or on duty at any time of any problem that needs prompt referral. X. 10. Make rounds with the pediatric Consultant-in-charge or on duty in the NICU. XI. Personally talks with the parents of critically ill or problematic newborns to allay their fear and to explain the importance of laboratory requests or special newborn procedures. XII. All NICU residents will make sure that the NICU census is submitted to the pediatric Chief Resident every end of the month. XIII. Answers all referrals in the NICU at all times within her 24 hours duty

VIII. DEVELOPMENT PLANS:  SHORT TERM PLANS  Creation of an isolation room for highly communicable diseases (e.g. Pertussis, Meningococcemia) prior to transfer to a tertiary hospital.  Staff development sessions to enhance personality and relational skills.

 LONG TERM PLANS  Establishment of an Adolescent Service. We will a lot 5 beds specifically for adolescent patients, and our Resident in Charge will be directly under the supervision of Dr. Nerissa Dando, our Adolescent Medicine Specialist. I. Implementation of the Adolescent Teenage Program.  Establishment of a Hematology-Oncology Service. We will a lot 5 beds specifically for patients with hematologic and oncologic conditions, and

Mandaluyong City Medical Center CLINICAL DIVISION our Resident in Charge will be directly under the supervision of Dr. Eufrosina Melendres, our Hematology-oncology specialist.

These place are highly dependent on the member of Resident Training.

IX. HIRING AND SELECTION OF RESIDENTS:  CRITERIA:  A graduate of an accredited medical school.  Should have passed the Physicians Licensure Examination.  Should be able to present the following academic requirements: I. - transcript of records and diploma from medical school II. - Internship certificate III. - Board rating and certification from the PRC IV. - recommendations from two consultants from medical school or hospitals where he/she have rotated  SELECTION OF RESIDENTS  An interview will be conducted by the department chair, training officer and consultant staff to all aspiring residency applicants.  A pre-residency examination is given regarding general pediatrics.  Applicants will undergo a 6-8 weeks observation period including rotation at the OPD,  ER and ward under the supervision of the consultant on duty and chief resident.  Before the end of their observation period another examination will be given including topics on general pediatrics and cases encountered. A re-evaluation and deliberation will be done by the chair, training officer and consultant staff. (Appendix E) The chosen applicants will be recommended by the department chair to the medical director who in turn will recommend to the city Mayor for final approval.  Once approved by the city Mayor the applicants will then be called back to start his/her residency training.

X. JOB DESCRIPTION  CHAIRPERSON SPECIFIC DUTIES  Creates policies and guidelines for the department in accordance with the objectives of the hospital.  Coordinates with the Medical Director for departmental needs and activities.  Represents the Department in national and local meetings.  Determines and recommends the needs of the department.  Interviews, screens and recommends Postgraduate Trainees.  Implements Philippines Pediatric Society Hospital Accreditation requirements.  Supervises departmental activities. Mandaluyong City Medical Center CLINICAL DIVISION  CRITERIA: I. Licensed Doctor of Medicine II. Had formal training in Pediatrics in a PPS Accredited training institution. III. At least a Fellow of the Philippine Pediatric Society.

 TRAINING OFFICER SPECIFIC DUTIES:  Prepares the Department’s monthly activities and submits them to the Chairman for approval.  Plans, prepares and distributes performance evaluation scheme of Postgraduate Trainees and Residents.  Assists the Chairman in recommending policies of the Department for the improvement of the PGT.  Studies and recommends additional affiliation rotations of PGI to comply with accreditation requirements.  Assists the Department Chairman in the screening and selection of PGT applicants.  Acts as Officer-in-charge of the Department in the absence of the Chairman.  Prepares schedule of the consultants’ activities / schedule in coordination with the chief resident.

CONSULTANTS AND RESIDENTS POSTS:

POST CONSULTANT RESIDENT Breastfeeding/Lactation Dra. Navarro Dr. Balce Community Outreach Program Dra. Arizala Dr. Castro IMCI Dra. Navarro Dr. Castro Research Dra. Bustamante Dr. Conge Library Dra. Bautista Dr. Balce Information Technology Dra. Bautista Dr. Balce OPD/ER Dra. Bustamante Dr. Conge Ward Dra. Bautista Dr. Castro MMEIRTP Dra. Arizala Dr. Conge NICU Dra. Uy Dr. Castro Facilities Dra. Navarro Dr. Conge

XI. MCMC BIOETHICS COMMITTEE  The committee shall provide the moral and ethical principles on the basis of which the committee shall make its decision and which derived ultimately from the Oath and the “Laws” of Hippocrates.  The committee shall act as the formal body for the implementation of these principles and shall take charge of monitoring of the implementation and the compliance by the medical staff of MCMC. Mandaluyong City Medical Center CLINICAL DIVISION  OBJECTIVES: I. To serve as an advisory group to the hospital director and /or the Mayor. II. To implement the moral and ethical principles adopted and in consonance with the tenor of the Oath and “Laws” of Hippocrates. III. To coordinate and collaborate with the Medical Audit Committee and other committees in resolving problems that would have moral and ethical issues addressing extended patient care. IV. To formulate operational policies pertinent to the above functions which would be revised periodically to ensure that they are in consonance with the times.

The members of the committee are appointed by the hospital director upon the recommendation of the director and/or chief of clinics. The chairman is elected among and by the members of the committee. The tenure of each member is a period of 2 years. In case a vacncy occurs within the 2 year period the hospital director shall appoint a replacement likewise recommended by the director and/or chief of clinics One of our active consultant, Dra. Bustamante is at present a member of the committee

XII. CONSULTANTS STAFF ( AS OF 2008)  The Mandaluyong City Medical Center, Department of Pediatrics is complemented with highly competent consultants composed of 4 general pediatricians and 11 subspecialists (5 are active and 10 are visiting).

 ACTIVE CONSULTANT STAFF: Eufrosina A. Melendres, MD,FPPS,FPSO,FPSHBT Hematology and Oncology Vilma Q. Arizala, MD,FPPS General Pediatrics Suzette A. Bautista, MD,FPPS Intensive Care & Pulmonology Dolores A. Bustamante, MD,DPPS General Pediatrics Lorna A. Navarro, MD General Pediatrics

 VISITING AND SUBSPECIALTY CONSULTANT STAFF: Esterlita V. Uy, MD,DPPS Neonatology Siok Son Chan-Cua, MD,FPPS Endocrinology Manuel F. Ferreria, MD,FPPS Allergy and Immunology Felizardo A. Gatheco, MD,FPPS Gastroenterology Joselito C. Matheus, MD,FPPS Nephrology Beatriz P. Quiambao, MD,FPPS Infectious Diseases Ignacio V. Rivera, MD,FPPS Neurology Josefina R. Almonte, MD,FPCS Pediatric Surgeon

Mandaluyong City Medical Center CLINICAL DIVISION Ma. Ronella Fransisco, MD,DPPS Cardiology Nerissa Dando, MD,DPPS Clinical Toxicology and Adolescent Medicine Anjanette de Leon, MD,DPPS Pulmonology

 MINIMUM PPS CERTIFICATION STAFF REQUIREMENTS  DEPARTMENT HEAD: Eufrosina A. Melendres MD Fellow, PPS Fellow and Past Pres. Phil. Society of Hematology and Blood Transfusion Fellow, Philippine Society of Oncology  TRAINING OFFICER: Vilma Q. Arizala, MD Fellow, PPS, General Pediatrics  CONSULTANT STAFF: I. Suzette A. Bautista, MD - Fellow, PPS, Intensive care , Pulmonology II. Siok Soan Chan-Cua, MD - Fellow, PPS, Endocrinology III. Manuel Ferreria, MD - Fellow, PPS, Allergy and Immunology IV. Joselito Matheus, MD - Fellow, PPS, Nephrology V. Beatriz Quiambao, MD - Fellow, PPS, Infectious Disease VI. Ignacio Rivera, MD - Fellow, PPS, Neurology VII. Josefina Almonte, MD - Fellow, Phil. Society of Pediatric Surgeon VIII. Esterlita Uy, MD - Diplomate, PPS, Neonatology IX. Dolores Bustamante, MD - Diplomate, PPS, Genearal Pediatrics X. Felizardo Gatheco, MD - Fellow, PPS, Gastroenterology XI. Ma. Ronella Fransisco, MD - Diplomate, PPS, Pediatric Cardiology XII. Nerissa Dando, MD - Diplomate, PPS, Adolesc. Med. and Toxicology XIII. Anjanette de Leon, MD - Diplomate, PPS, Phil. Acad. of Ped. Pulmo.

 DEPARTMENT HEAD: Eufrosina A. Melendres MD Fellow, PPS Fellow and Past President Philippine Society of Hematology and Blood Transfusion 2008 UP Manila Centennial Professorial Chair Awardee Clinic Hours: Tuesday, Thursday 3-5pm

 TRAINING OFFICER: Vilma Q. Arizala, MD Fellow, PPS, General Pediatrics Clinic Hours: Monday, Tuesday, Thursday, Friday 10-12 noon and 2-4pm

 CONSULTANTS: I. Suzette A. Bautista, MD Fellow, PPS, Intensuve Care, Pulmonology Clinic Hours: Tuesday, Thursday 2-4pm

Mandaluyong City Medical Center CLINICAL DIVISION

II. Dolores Bustamante, MD Diplomate, PPS, General Pediatrics Clinic Hours: Tuesday, Thursday 2-4pm

III. Lorna Navarro, MD Clinic Hours: Tues., Wed., Thurs., Fri. 10-12 noon and 2-4pm

IV. Subspecialty Clinics 3rd Floor Pedia Consultants Office Friday 2-5pm

 CONSULTANT TO RESIDENT RATIO The PPS minimum requirement of consultant to resident ratio is 1:8, here in MANDALUYONG CITY MEDICAL CENTER the ratio is 3:1. There are 15 consultants and 3 residents at present.

 RESIDENCY PROGRAM STAFF PPS REQUIREMENT MCMC CONSULTANTS 3 15 RESIDENTS 4 2

 PHASE IIA and PHASE IIB ACCREDITATION REQUIREMENTS We have in our consultant staff a board certified neonatologist, Dra. Esterlita V. Uy as well as a pediatric surgeon, Dr. Josefina R. Almonte in compliance with the PPS requirement for Phase IIA accreditation.

Aside from a neonatologist and pediatric surgeon, we also have nine (9) PPS certified subspecialists in the following fields: hematologyand oncology, allergy and immunology, gastroenterology, neurology, infectious disease specialist, endocrinology, cardiology, nephrology and adolescent medicine as required by the PPS for PHASE IIB accreditation.

 CRITERIA FOR SELECTION OF CONSULTANTS  BASIC REQUIREMENT:

Mandaluyong City Medical Center CLINICAL DIVISION I. Should be a MD graduate, passed Physician’s Licensure Examination and licensed to practice his/her profession. II. Completed Residency Training in an accredited training hospital, passed both oral and written exams of her/his specialty. III. If he/she has a subspecialty, should be at least a Diplomate or Fellow of said subspecialty. IV. PROCEDURE: a. Applicant should first address his/her application to the Medical Director through the Department Head. b. Application will subsequently be forwarded to the head of the Medical services, and then, the respective Department for evaluation. c. The Department head then forwards appropriate recommendation to the Credentials Committee. d. Credentials Committee after properly reviewing the application should make recommendations to the Medical Director then eventually to the City Mayor for final approval. V. CRITERIA: a. Diplomate or Fellow of the Philippine Pediatric Society.

 COMPENSATION, BENEFITS AND INCENTIVES Active consultants received monthly compensation and visiting consultants received monthly honorarium from the city government. The active consultants also have the privilege to be deck in walk-in private patients and are allowed to hold clinic in the hospital.

 EVALUATION AND PROMOTION All consultant are evaluated annually by the credential committee of the hospital.Recommendations for reappointment and/or promotions will likewise be forwarded by the committee to the hospital director who in turn recommends to the city Mayor for final approval.

 POLICIES AND PROCEDURES FOR ADMISSION, CARE AND DISCHARGE OF PATIENTS  ADMISSION I. All admissible cases are admitted except for those with communicable diseases like diphtheria, meningococcemia, cholera, tetanus, hepatitis, AIDS, and the like. Those with measles are admitted at the PIDW temporarily located at the ground floor. Patients who are unstable and needing close monitoring are admitted at the PICU.

Mandaluyong City Medical Center CLINICAL DIVISION II. Upon admission, charity patients are placed at the Pediatric Ward. If the ward is full, patient can temporarily be placed at the pay or surgical ward but once there is vacancy, patient is then transferred to the Charity Ward. III. Upon admission. Once consented as pay patient, patient is then placed at the Payward. In the absence of vacancy at the payward, patient can temporarily be placed at the charity ward. A subsequent professional fee is already being charged per day. However, once vacancy is available, patient is then transferred to the Payward or per request may stay at the Charity Ward. IV. Service patients who would like transfer of service as pay patients are therefore informed of the contents of the consent to be signed as pay patient. This will be done by the Pediatric ROD and by the NOD consented; PROD informs the consultant- in-charge or on-duty of such admission. V. Guardians are informed that only 1 watcher per patient is allowed and are given 1 chair. All personal belongings lost, the hospital and its staff are not liable to pay for such losses. VI. No children below 7 years of age are allowed to enter the Pediatric Wards. VII. The nurse on duty carries out the admitting orders and at the same time informs Ward NOD of such admission. VIII. Once admitted, the Ward PROD becomes the resident in charge. IX. All admissions should pass the emergency room either pay or service. X. Consent for the parents or guardians duly sign admission. If patient is a private one, a separate consent is given, the Pedia Resident explains the term and conditions enclosed within including charges for professional fees per visit by COD or CIC.

 PRIVATE CASES I. Patients are not encouraged or convince to be admitted as private patients. II. Private patients are admitted on first come – first serve basis. There are no reservations of private beds. III. On admission, private patients are requested to sign consent request form for admission as private patient (please see attached pages) and are oriented to their obligations which include hospitalization fees (daily bed rate) laboratory examination fees, OR-DR fees, medicines and professional fees of attending Consultants/s. IV. Patients admitted as private patients and wish to be transferred as Charity patient must settle first all the expenses incurred as

Mandaluyong City Medical Center CLINICAL DIVISION private patient (including professional fees of the Consultants/s) before being allowed to be so. V. Private patients may be temporarily admitted at the Charity ward if there are no private beds available. If they are discharged without being able to transfer to private rooms, they will still be considered as private patient but room rate will charged on a charity basis.

 CONSENT FOR ADMISSION AS PRIVATE PATIENT (see Appendix)

 DISCHARGE  All confinements will have similar discharge procedure.  All discharges must have discharge order from the attending physician. All information the chart cover must completely (Final Diagnosis, time, date of discharge, condition of patient on discharge, etc.).  The completed chart will then pass through the following sections (for clearance purposes) and to be forwarded by the Ward Nurse.  Finance Section – for the Bill of charges, which include hospitalization bill for the bedroom, OR_DR use if any, medicines & supplies, laboratory examinations, and other diagnostic procedure (like X-ray, Ultrasound, and ECG);  Pharmacy Section – for any unpaid medicines/supplies taken;  Back to Ward Nurses who in turn will advise the patient/relative to go the Finance Section to settle their hospital bills. Professional bills for private patients may be collected by Finance Section or by Consultant (Attending Physician) depending upon the latter’s instruction per agreement with the patient.  At the Finance Section: I. MEDICARE Privileges (upon completion of requirements) will be deducted from the hospital bill and professional fees, and the patient will pay the remaining balance. II. Indigent patients are evaluated and assessed by the Social Worker for proper classification and the discount will be decided upon and given by the Discount Officer. III. Patients who are not able to pay at time to discharge for whatever reasons will be allowed to be discharged from the hospital after signing a promissory note or clearance from the Finance Section (and the attending Consultant /s in cases of private patients). IV. Any hospital payments / donations are received by the Finance Section with corresponding official receipts. Official Receipts for professional fees are issued by the attending Consultant/s concerned.

Mandaluyong City Medical Center CLINICAL DIVISION V. The Bill of Charges and Official receipt of payment are presented by the patient to the ward nurse, who will attach the Bill of Charges to the Chart and will give official receipt of payment to the patient.  Ward Nurse will issue Gate pass to the patient after checking their belongings as well as bed / room inspection. Discharge slip also given.  Security Guard on duty will receive the gate pass and Discharge slip from the patient prior to exit from the hospital. He will then notify the Admitting Section regarding the discharge of the patient by submitting the discharge slip.  Admitting Section Personnel on duty will record at the discharge logbook all discharges for the duty.

 TRANSFER PER REQUEST TO OTHER HOSPITAL  Guardians who will request transfer to other hospital by choice are allowed to be transferred provided that arrangements have been made to the other institution by the relatives and coordinated and confirmed by the PROD to the other hospital.  All transferred patients are then conducted by the ambulance either senior or not to other hospital of choice accompanied by 1 Pediatric Resident and/or otherwise requested.  The Pediatric Resident then makes a clinical abstract. This will contain relevant information from the time patient was admitted up to discharge for transfer to other hospital.  Guardians’ sign the request for transfer then settles the accounts to the finance section after which the NOD gives them a gate pass.  A trip ticket will then be secured from the POS and to be signed by the SHO for that day.

 ER POLICIES  Patients who are less than 18 years (17 years and 365 days old) of age are seen by a pediatric ROD/RIC at the ER.  The ER resident should see and provide the initial emergency care to the following cases: I. Trauma/accident II. Drowning/Near drowning III. Active seizures IV. Moderate to severe respiratory distress V. Active/frank bleeding or hemorrhage VI. CP Failure VII. Unconscious patients due to any cause VIII. Shock regardless of etiology

Mandaluyong City Medical Center CLINICAL DIVISION  The ER pediatric ROD should also see and manage patients who come in as private cases and said cases should be immediately referred to their respective consultants or consultants on duty.  All pediatric patients needing/requesting admission should be admitted under the service of the pediatric resident in charge with the supervision of the consultant on duty or under the service of the attending pediatrician.

 OPD  Work Flow I. Consultation a. Patient secures a number from the guard positioned at the hospital entrance during enlisting hours: 7:30 a.m. – 10:30 a.m. Daily except Weekends 1:00 p.m. – 3:30 p.m. 7:30 a.m. – 10:30 a.m. Saturdays only

II. Once the number is called, guardians proceed to the admitting section secure their respective chart, which are then collected by admitting clerk on duty. III. Admitting clerk then endorses all charts collected to the OPD nurse on duty that in turn does anthropometric measurements and instruct guardians to stay at waiting section on the Annex Building and waits to be called. IV. Ten patients are being called at a time and allowed to enter the OPD area then waits to be called by the Pediatric resident. V. Each patient is examined by the Pediatric resident on duty after which home instructions and medications are given.

 Standard Operating Procedure for OPD I. There are no OPD consultation during Sundays and official public holidays. II. Regular OPD schedules maybe cancelled during special hospital activities like conferences and lectures. Cancellation of OPD consultation for activities other than those mentioned is subject for approval by the chief of Clinics or head of the ER-OPD section. III. OPD medical records shall be accomplished with the SOAP format. IV. Patients’ data with the corresponding diagnosis, impressions or differential diagnosis shall be listed in the OPD Section. V. Patients who are considered for admissions shall be sent to the ER for further evaluation and management and shall be included in the ER census, not OPD census.

Mandaluyong City Medical Center CLINICAL DIVISION VI. If after physical examination the patient is deemed to need hospitalization by the OPD resident, OPD nurse must ask the admitting section for vacancy at the Pediatric Ward. Once available, OPD nurse informs the Pediatric resident who in turn does an admitting order and instructs the OPD nurse and patient to proceed to the Pedia ER. VII. Once at the Pedia ER, unless emergency, relatives are ask to buy IV sets and medications needed. Once available, nurse informs OPD resident or if the Pediatric Resident on duty is at the ER, the resident inserts the IVF.

 HYDRATING UNIT  If after physical examination patient needs to be observed, OPD, ROD does order which the OPD nurse carries out endorses to the ER NOD.  Parents are informed prior to observation by the OPD ROD that a period of 8 hours are given to each patient, if after 8 hours symptoms persist, the patient is subsequently admitted otherwise patient will sent with proper home instructions.  For patient to be admitted follows the workflow for C1 – C4 except subsequent orders are being made by the ER-ROD.  Oral Rehydration Solution is given for patients with some dehydration for 6-8 hours, while IVF is inserted for severely dehydrated patients.  If after 8 hours of hydration patient’s condition worsens he or she is subsequently admitted.  Ambulance conduction is warranted with the following conditions: I. Seriously-ill II. Stable but at any time during transport may become unstable III. Per request IV. Transfer to hospital of choice after being coordinated by Pedia Resident on duty or in charge. V. All patients for transfer must be accompanied by pedia resident on duty or in charge.

 STANDARD OPERATING PROCEDURE FOR ADMISSION AT THE PEDIATRIC WARD  Patients with all types of illness are accommodated at the hospital except communicable diseases and those requiring specific procedures needing special equipments like in open heart surgery, hemodialysis, etc.  Mandaluyong residents are given priority for admissions.  Emergency cases are given priority over elective cases.  All admissions are properly recorded at the admitting logbook and given corresponding Hospital Case Number.

Mandaluyong City Medical Center CLINICAL DIVISION  All Admitted patients are encouraged to use their Philhealth privileges, Insurance coverage, Health Care Maintenance Card, etc.  Patients in the ward are ask to buy their own medicines during confinement. Severely indigent patients are referred to the Hospital Social Worker for assistance.  Patients who wish to be admitted as Pay patients but with no attending Physician are classified as “House Case” and will be placed under the service of the Consultant-on-duty. Likewise, referrals of those patients to other department will be given to the consultant-on- duty of the particular departments to whom the patient was referred.  If there are no more available beds, stable patients are instructed to transfer to hospital of choice. Those that need ambulance transfer may avail of the Hospital Ambulance free of charge.  The hospital does NOT require DEPOSIT for purposes of admission.  All admission is considered charity unless otherwise requested.  Transfer from charity to pay-ward will depend on following factors: I. Vacancies and availability of beds II. Transfer is medically beneficial to the patient III. The patient’s party / guardian voluntarily requested or/and consented for such therefore abiding by the policies of the respected destination ward.  One watcher per patient  No children below 7 years old are allowed to visit at any service wards.  Visiting hours: 10:00 a.m. to 12:00 noon – 4:00 p.m. to 6:00 p.m.

 TRANSIENT ROOM / NOENATAL INTENSIVE CARE UNIT  All newborns delivered within the hospital, if uncomplicated, are admitted and observed at the transient room, located adjacent to the existing NICU, for 30 minutes for NSD and 3-4 hours for Caesarian Section then roomed-in.  Complicated deliveries are placed at the Ward while those deliveries outside the hospital are confined in the Ward or ICU.  All non-problematic babies are roomed in at the Lactation and Management Area.  Premature newborns are placed inside the incubator.  Newborns needing Chest X-ray will use portable X-ray machine  Prophylactic antibiotics are indicated for the following conditions: I. Thickly meconium-stained amniotic fluid II. (-) BOW / PROM outside the hospital III. PROM or (-) BOW – >12 hours IV. Febrile mother V. Mother with UTI VI. Mother with antibiotics VII. Septic deliveries Mandaluyong City Medical Center CLINICAL DIVISION VIII. Umbilical catheterization  All NICU admissions are informed and referred to the house Neonatologist.

 PEDIATRIC INTENSIVE CARE UNIT  Cases admissible to ICU I. Unstable cardiopulmonary conditions (Very severe Pneumonia, Status Asthmaticus, Congestive Heart Failure, Arrhythmias) II. Impaired sensorium from CNS Infections, Metabolic disturbances, etc. III. Acute Renal Failure necessitating dialysis IV. Postoperative states V. Other cases that may need critical care.

 Cases not admissible I. Contagious diseases II. Mentally-disturbed

 Only patients who meet the admission criteria can be admitted.  The admitting resident / consultant will be responsible for requesting admissions / transfer patients to the ICU.  It shall be the full responsibility of the admitting physician to notify the ICU Nurses that a patient is to be admitted to the unit giving at least a verbal summary of chief complaints, admitting diagnosis and what to closely monitor. Generally, no patient should be brought to the unit without proper notification of the ICU staff. This is to allow them to prepare all needed materials before patient is brought in. It is a must that the ICU nurses get a clear picture of what the patient’s serious medical problems.  An S-O-A-P form of admitting notes is accomplished by the Admitting Resident within 2 hours after admission. However, completion of the standard History and PE form should be in the Chart within 12 hours after admission to ICU.  It should be the full responsibility of the Admitting Resident NOT the nurses to notify the Attending Consultant of any ICU admission – giving him / her comprehensive picture of patient’s status.  The Consultant in charge of the ICU must be notified by the Admitting Resident of any admission to the unit ASAP.  All charts entries must be signed completely with date and time.  Progress notes should always be done daily by the resident in charge.  All ICU patients must be seen and examined frequently by the resident in charge and resident on duty as well.

Mandaluyong City Medical Center CLINICAL DIVISION  During the tour of duty, the team leader of the group should take the responsibility of all ICU patients, without necessity of a written order from the Consultant.  At least one relative of each patient in the ICU should always be around.  NO VISITORS ARE ALLOWED, except when explicitly written by the Attending Physician. Only one immediate family member of the patient may be allowed to approach the patient for not more than 10-15 minutes. Patients in the ICU need maximum rest and should be emphasized to the relatives.  Visiting of the ICU patient may be allowed between 12:00 noon - 1:00 p.m., if at all the situation in the unit will permit.  ICU staff should help patients keep their morals high and visitors should be advised before entering the unit to refrain from anything that may upset the patient.  No flowers, sound systems, comics, newspapers are allowed inside the unit. No foods are allowed in the unit, unless the patient’s condition requires it. (Leftovers are thrown in the garbage can outside the unit not in the ICU garbage can.)  No visitor is allowed to eat inside ICU.  Children are not allowed to enter the ICU.  No personal belongings on the patient’s bedside table are allowed.  No chairs / beddings / appliances can be brought by the patient’s relatives inside the ICU as they may get in the way during emergencies.  NO SMOKING AREA AT THE ICU

 INFECTIOUS DISEASE WARD  OBJECTIVES I. To set a separate ward for the care of infectious diseases, non- communicable as well as communicable (such as measles, varicella, etc.) II. To train residents and paramedical personnel in the care of patients with communicable infectious disease.

 STANDARD OPERATING PROCEDURE I. Who can be admitted? a. All patients with infectious diseases who required isolation from other patients and who cannot be admitted in the regular wards may be admitted to the infectious disease (ID) ward. These will include patients with the following illnesses: i. Communicable 1. Measles 2. Varicella

Mandaluyong City Medical Center CLINICAL DIVISION 3. Pertussis 4. Mumps 5. Diphtheria 6. H. influence epiglottis 7. Others ii. Communicable 1. Typhoid fever 2. Dengue fever 3. Viral hepatitis 4. HIV 5. Staphylococcal skin infections 6. Others

II. Cohorting of patients Since there will only be one ward for all ID patients, cohorting of patients is necessary. Only patients with the same illness may be admitted in the ID ward at any one time. E.g. if the ward already has a patient with measles, then patients with other illness such as varicella etc. may no longer be admitted.

In view of the current measles outbreak, the ID ward will prioritize admission to measles patients. Once the outbreak is controlled and the incidence of measles goes down, the admission may be offered to patients with other communicable illnesses.

III. Flow of Admission All patients to be admitted to the ID ward are initially seen either at the emergency room or at the out-patient department. Admitting residents should specify that the patient is for admission to the ID ward after making sure that there is a vacancy. Patients who require radiographic will be brought to the radiology department on their way to the ID ward. Passage will be through the passageway between the Pedia-ER and Hydration unit. This passage will be kept open from 8:00 a.m. to 5:00 p.m., outside these hours, the passage will be kept locked and the key made available to those who need it (i.e. doctors, nurses, aides, etc.)

 GENERAL POLICY IN CADAVER CARE AND DISPOSITION  Only City Health Office, MCMC, NBI, and PNP-accredited Funeral establishments are allowed to transact business regarding cadaver disposition. Those with life plans and as per request by relatives maybe allowed with consent.

Mandaluyong City Medical Center CLINICAL DIVISION  The Director’s Office, Administrative Office, and S.H.O. are the only authorized persons to communicate with Funeral establishment during office hours. After office hours, it shall be the S.H.O.  All Funeral establishments shall apply for accreditation to the hospital other than those that are already accredited by other agencies (e.g. NBI, PNP, etc.).  Accredited funeral establishments shall go on a rotational basis as assigned by the Administrative Office. It must not charge exorbitant fees.  No hospital personnel shall transact or accept any form of “incentives” of favors from any funeral establishments.  All cadavers shall be disposed off immediately and not longer than 6 hour. In the event that no claimant / relative is available within the said period, the deceased shall be entrusted to a funeral prior for safekeeping.  Cadavers that are near to 6 hours of stay shall be reported immediately to Administrative Office / S.H.O. for proper disposition.  Cadavers that are to be released only relatives or to anybody duly authorized, or upon a valid special court order.  All cadavers for releases only shall be I. First logged-in at respective nurses’ area in their record book and official cadaver release forms signed by relative, nurse on duty, and SHO prior to issuance by nurse of gate pass. II. Second at the POS station, once cadaver release forms are presented, also logged-in their record book, again signed by the relative plus funeral establishment representatives and SHO for final release. III. All cadaver release forms submitted to SHO after office hours shall be attached to the SHO 24 hours report for submission to Administrative Office the following day. IV. All cadaver release forms submitted to Administrative Office shall be verified, after which forwarded to Medical Records Section for attachment to deceased patient’s record.

 Once patient has been pronounced as dead by attending physician, proper cadaver care shall be instituted by the nurse and utility personnel with simultaneous coordination with Administrative Office and Senior House Officer.  All cadavers shall be released passing through the backstairs out to the hearse. Cadavers MUST NOT pass through the elevator or main stairs area. Failure of the Funeral Parlor to comply with this directive shall automatically result in cancellation of its accreditation with the hospital.

Mandaluyong City Medical Center CLINICAL DIVISION  All important items owned by the patient shall be turned over to its legitimate relatives through the nurse supervisor on duty. The nurse supervisor shall make an inventory of all items turned over to the relatives with a corresponding receipt from the latter.

 AVERAGE NUMBER OF PATIENT PER AREA PER MONTH YEAR 2004 2005 2006 2007 IN-PATIENTS 968 1,582 1,940 4,138 WELL CHILD 100 163 763 910 OPD AND ER 20,216 24,660 29,885 29,037 NURSERY 2,615 1,726 2,680 1,740

 IMMUNIZATION The Department has also rendered the wholehearted support in the implementation of the programs of the DOH such as the National Immunization Day, Oplan Alis Disease, Oplan Sangkap Pinoy, Mass Deworming and National Polio Immunization. Recently, we participated in the Ligtas Tigdas done last February , 2004

The same procedure for consultation is followed except that, only well- babies or well-children are allowed at the Annex Building every Wednesdays of the month (Well-Baby Clinic).  At the Admitting Section, sick patients are screened and segregated from the well babies. Sick babies are then allowed to stay at the waiting section near the hospital’s entrance door (in front of the hospital canteen) and waits to be called.  Only 5 patients are allowed to enter the Pediatric ER and once called, the Pediatric Resident on duty examines and gives proper home instructions and medications.  Schedule for Well-Baby /Child: I. BCG, OPV, DPT and Measles – every Wednesday II. Measles (Iwas Tigdas) every day OPD Parents are advised on importance of other vaccines like MMR, Hepatitis A & B, when they are supposed to be given and to avail of these vaccines on their own accord.  Babies who are delivered at Mandaluyong City Medical Center are given immunizations only if their mothers continue to breastfeed their babies (MCMC is a Baby-Friendly Hospital) at least for infants of less than 4 months old. Otherwise, they are referred to nearby Health Centers for their immunization.  The OPD-ROD examines all babies before giving immunizations. Only well babies are given vaccines.  Those babies with problems are therefore referred to ER-ROD for further evaluation and re-scheduled to come back for immunizations.

Mandaluyong City Medical Center CLINICAL DIVISION  Once vaccinated, mothers are given baby record books for recording and future referrals. These are being filled-up by the Pediatric Residents with home instructions (follow-up, signs & symptoms to watch out for) and medications.  Pediatric Residents is filling up 1 logbook once patient is vaccinated. Logbook contains the following information: the patient’s name; birthday; address, vaccines given.  Once logbook is completed, it is copied and submitted to the City Health Officer every Tuesday of the month.

 IMPLEMENTATION OF BREASTFEEDING AND ROOMING-IN PROCEDURES  The rules shall apply to: I. All well infants who have coordinated sucking, swallowing and normal breathing. II. Infants with low birth weights but who can suck and swallow. III. Infants of uncomplicated deliveries with weight of 1,700 grams and above, and with AOG of no less than 34 weeks. IV. The Pediatric Resident or the Nursery Nurse shall assist the mother initiate breastfeeding in the delivery room or in “latching-on” after suctioning of secretions. V. Infants delivered vaginally without complications shall be roomed-in with their mothers within 30 minutes to one (1) hour after delivery. a. From the DR, the baby will temporarily be at the Transient Room for his routine newborn care and physical assessment. b. For private patients under sedation, the infants shall be roomed-in with their mothers within eight (8) hours. c. Bathing of babies is not indicated in infants. VI. Infants delivered by Caesarian Section without complications shall be roomed-in with their mothers within eight (8) to ten (10) hours. a. From the OR, the baby will temporarily be at the Transient Room for his routine newborn care and gastric lavage (if Caesarian Section). VII. Deliveries outside the hospital DR or in the OB-IE room and whose mothers have been admitted to the obstetric ward shall be roomed-in and breastfed immediately.

 All admissions of mothers and babies shall be properly entered into a logbook. The mother’s case number, name, age, address and final diagnosis shall be taken cared of by the OB Ward Nurse, the information about the baby (case number, sex, measurements), shall be taken cared of by the Rooming-In Nurse. Likewise, the OB Ward

Mandaluyong City Medical Center CLINICAL DIVISION Nurse shall take care of the mother’s chart and the Nurse, of the baby’s chart.  Breastmilk, especially colostrum, shall be given to all infants who can tolerate oral and tube feeding. EBM can be given by direct breasffeeding or if breastmilk is not available, EBM from selected donors can be given by sip or by dropper. I. Newborns shall not be given pre-lacteal feeding such as sterile water, glucose water or milk formula. II. Infants should start breastfeeding as soon as possible as the infant demands.

 GENERAL POLICIES ON BREASTFEEDING Mother and Child: Mandaluyong City Medical Center’s Concern I. MCMC has a written breastfeeding policy routinely communicated to all health care staff to promote and support breastfeeding. II. The MBFH (Mother-Baby Friendly Hospital) Committee conducts breastfeeding training to all health care staff and carried through every six (6) months for new employees. III. We promptly inform all pregnant patients on the benefits of breastfeeding regularly through a committee on Continuing Education Program who conducts lecture on demonstration twice a week at the OB-GYNE OPD. IV. First and foremost is breastfeeding. All NSD babies are offered breastmilk within thirty (30) minutes to one (1) hour post- partum and six (6) to eight (8) hours post-caesarian section as soon as the mother is fully awake. V. All mothers are taught the correct positioning / attachment in breastfeeding and strictly encouraged to maintain lactation even if they go to work or elsewhere. VI. Breastmilk contains adequate amount of water therefore, prelacteal feedings are not indicated. VII. One of the most important goal in promoting breastfeeding is the bonding between the mother and the child or “togetherness”, hence, Rooming-In is a MUST. VIII. Breastfeeding is per demand and never on a time interval basis. IX. To avoid nipple confusion, pacifiers, artificial teats and the likes are prohibited. Likewise, we strictly enforce the Milk Code. X. Since the mother and child are our concern, we continuously monitor the breastfeeding practice after discharge through home-visits and follow-ups at our lactation center (Pediatric OPD).

Mandaluyong City Medical Center CLINICAL DIVISION  MCMC EQUIPMENTS FOR PEDIATRIC PATIENT CARE INCLUDES:  weighing scale, beam type  clean nursery  isolation nursery  sphygmomanometer with different pediatric cuffs  opthalmoscope-otoscope set  laryngoscope  catheters  oxygen supply  tray with emergency drugs  suction apparatus  ambubags  resuscitator  cutdown set  lumbar puncture set  bililight  incubator/isolette  24 HOURS SERVICES The hospital pharmacy as well as the radiology department both located at the ground floor of the old hospital building is open the whole day ,7 days a week to provide services to our patients. The laboratory and central supply office both located at the 5th floor of the old hospital building were manned in three divided shift for continous delivery of ancillary services.

 ER – OPD  Physical Set up Our emergency room and out patient department has 3 rooms, one main ER with 2 beds and 2 cribs, one hydration unit with 1 bed and 2 cribs and out patient clinic with 2 tables and 1 crib. The monthly census of patient seen at the ER ranges from 800 to 1000 per month and the OPD ranges from 600 to 800 per month. The hydration unit has a monthly census which averages from 100 to 200 patients monthly. The ER is manned by 1 senior resident and 1 firstt year resident per duty day and the OPD is manned by 1 senior resident and 1 junior resident per duty day which is located at the ground floor of the old hospital building. I. Basic Medical Equipments (ER): a. Weighing scale beam type (1) b. Infant scale (1) c. Sphygmomanometer with stand (1) d. BP cuff ( neonate, infant, child, adolescent ) e. Suction machine (2) f. Oxygen tank and guage (3) g. Diagnostic set (1) Mandaluyong City Medical Center CLINICAL DIVISION h. Ambubag (3) (neonates 1, infant 1, adolescent !) i. Ambubag mask (3) ( neonates 1, child 1, adolescent 1) j. Emergency cart (1) k. Laryngoscope (1) Handle, blade 1,2,3 (straight) l. Cut down set (1) m. Droplight (1) n. Umbilical cannulation set (1) o. Infantometer (1) p. Catheter (4) q. Cardiac monitor r. Nebulizer (3)

II. Basic Medical Equipments (OPD) a. BP apparatus with stand and different pediatric cuffs b. Detecto weighing scale c. Infant scale d. Diagnostic set

 PEDIA WARD/INFECTIOUS WARD  Physical set-up The Pediatric ward (A and B) are located at the third floor of the new building. It is composed of:: Ward A, which is the pulmo ward with 17-20 beds and a treatment room where IV insertion and special procedure are done. Ward B which is the miscellaneous ward with 17- 20 beds for CNS, Gastroenterology, Nephrology, Neurology and Hematology cases and a treatment room. The monthly census of both wards ranges from 90 to 150 patients.

The Infectious ward is located at the 2nd floor of the old building with 5 beds. The monthly census ranges from 5 to 13 patients. I. Basic Medical Equipments ( Pedia Ward): a. Infusion pump b. Infant scale (1) c. Sphygmomanometer with stand (1) d. BP cuff (4) (1 neonate, 1 infant, 1child, adolescent 1) e. Suction machine (1) f. Oxygen tank and guage (10) g. Diagnostic set (1) h. Ambubag (3) (neonates 1, infant 1, adolescent 1) i. Ambubag mask (3) ( neonates 1, child 1, adolescent 1) j. Emergency cart (1) with emergency drugs k. Laryngoscope (1) Handle, blade 1,2,3 (straight) l. Cut down set (1) m. Droplight (3)

Mandaluyong City Medical Center CLINICAL DIVISION n. Umbilical cannulation set (1) o. Infantometer (1) p. Catheter (4) q. Nebulizer (4) r. Pulse Oximeter (1) s. Pedia Stetoscope (4) t. Photo Therapy Light (1) u. Height and Weighing Scale (1)

II. Basic Medical Equipments (Infectious Ward): a. Sphygmomanometer with stand (1) b. BP cuff (4) (1 neonate, 1 infant, 1child, adolescent 1) c. Suction machine (2) d. Oxygen tank and guage (3) e. Diagnostic set (1) f. Ambubag (3) (neonates 1, infant 1, adolescent 1) g. Ambubag mask (3) ( neonates 1, child 1, adolescent 1) h. 8. Emergency kit i. Laryngoscope (1) Handle, blade 1,2,3 (straight) j. Cut down set (1) k. Droplight (1) l. Catheter (4) m. Nebulizer (3)

 PEDIATRIC INTENSIVE CARE UNIT  PHYSICAL SET-UP The pediatric intensive care unit is located at the 5th floor of the old renovated hospital building There is 1 big bed, 3 cribs. The average monthly census is between 10 to 15 patients. I. Basic Medical Equipments (Pediatric Intensive Care Unit): a. Infant scale (1) b. Sphygmomanometer with stand (2) c. BP cuff (4) (1 neonate, 1 infant, 1child, adolescent 1) d. Suction machine (3) e. Oxygen tank and guage (5) f. Diagnostic set (1) g. Ambubag (3) (neonates 1, infant 1, adolescent 1) h. Ambubag mask (3) ( neonates 1, child 1, adolescent 1) i. Emergency cart (1) with emergency drugs j. Laryngoscope (1) Handle, blade 1,2,3 (straight) k. Cut down set (1) l. Droplight (3) m. Umbilical cannulation set (1) n. Catheter (4)

Mandaluyong City Medical Center CLINICAL DIVISION o. Cardiac monitor (1) p. Nebulizer (3) q. Infusion pump (2) r. Pulse Oximeter (2) s. ECG Machine (1) t. Pedia Stetoscope (2) u. Height and Weighing Scale

 NEONATAL INTENSIVE CARE UNIT AND INTERMEDIATE CARE UNIT  PHYSICAL SET-UP The neonatal care unit is located at the 4th floor of the old hospital building composed of the neonatal intensive care unit and the intermediate neonatal care unit. All uncomplicated normal and ceasarian section delivered babies are given routine newborn care and are transferred to the Lactattion management Area, also on ht 4th floor for rooming – in with their mothers. Premature infants needing ventilatory care or needed to be placed in an incubator, all potentially septic infants and those newborns who needed monitoring are admitted at the NICU. There are 2 residents manning the unit during office hours and 1 resident on duty after office hours.NICU monthly census ranges from 9 – 12 babies and the monthly deliveries average is between 180 to 250 babies. I. Basic Medical Equipments (Neonatal Intensive Care Unit): a. Infant scale (1) b. Sphygmomanometer portable (1) c. BP cuff (2 neonate) d. Suction machine (2) e. Oxygen tank and guage (3) f. Diagnostic set (1) g. Ambubag (3) (neonates 1, infant 1, adolescent 1) h. Ambubag mask (3) ( neonates 1, child 1, adolescent 1) i. Emergency kit (1) j. Laryngoscope (1) Handle, blade 1,2,3 (straight) k. Cut down set (1) l. Droplight (1) m. Umbilical cannulation set (1) n. Pulse oximeter o. Catheter (4) p. Infusion pump q. Nebulizer (1) r. Phototherapy (Drager) s. Pressure Ventilator t. Infantometer

Mandaluyong City Medical Center CLINICAL DIVISION

 THE DEPARTMENT OF PEDIATRIC OFFICE/LIBRARY  PHYSICAL SET-UP The pediatric office is located at the 3rd floor of the new hospital building where the pediatrics library can be found. It is fully airconditioned and equipped with 1 desktop computers, 1 scanner/printer/photocopier, a sound system, a television set, 1 telephone, 1 refrigirator, 1 slide projector, 1acetate projector and bookshelves for our books and journals. Conferences, endorsements, lectures, journal/case reports and nelson club are held in this room.

I. PPS REQUIRED BOOKS AND JOURNALS: a. BASIC TEXTBOOKS i. Nelson’s Textbook of Pediatrics (18th edition) ii. Textbook of Pediatrics and Child Health by Del Mundo, Estrada, Santos-Ocampo,Navarro (5th edition)

b. JOURNALS i. Philippine journal of Pediatrics ii. Foreign Journals – Journal of Pediatrics

c. PPS PUBLICATIONS i. Anthropometric FNRI ii. Standards of Child Care iii. Handbook of Infectious Diseases iv. Proceedings of PPS annual Conventions v. Manual on Childhood TB vi. CDD Manual vii. Handbook on Newborn Care viii. National Concensus on Childhood TB

d. REFERENCE BOOKS ON PEDIATRIC ORGAN-SYSTEM SUBSPECIALTIES i. Ethics ii. Critical care iii. Emergency Pediatrics iv. Philippine National Drug Formulary v. Poisoning and Toxicology vi. Adolescent Medicine vii. Child Development and Behavioral Problems viii. Diseases of the Newborn ix. Pediatric Infectious Diseases

Mandaluyong City Medical Center CLINICAL DIVISION x. Pediatric Pharmacology and Therapeutics xi. Hematology and Oncology xii. Child Psychiatry xiii. Genetics

 FACILITIES USED BY THE CONSULTANTS AND RESIDENTS  CONFERENCE ROOM: I. The hospital conference room is located at the 2rd floor of the new hospital building where interhospital conferences are done.

 QUARTERS: I. Sleeping quarters are provided both for male and female residents both of which are located on the 2th floor of the old hospital building.

 QUARTERS: I. PHYSICAL PLANT SERVICES: a. proper illumination of all the areas b. proper circulation of clean air c. potable water supply d. sanitary toilet and bath e. fire extinguishers and fire exits f. proper wet and dry waste disposal i. GREEN – non-infectious wet waste ii. YELLOW – infectious/pathologic waste iii. BLACK – non-infectious dry waste iv. ORANGE – radioactive waste v. RED – sharp and pressurized container vi. YELLOW with BLACK BAND – chemical waste g. janitorial and maintenance of facilities h. proper upkeep and maintenance of the building

 RESEARCH PROGRAM  OBJECTIVES I. To promote, develop and implement among the residents the importance of evidence- based healing II. To improve clinical effectiveness and quality of care among residents by searching and implementing evidence-based medicine. III. To be able to integrate epidemiologic and biostatistical ways of thinking with those derived from pathophysiology andpersonal experience.

Mandaluyong City Medical Center CLINICAL DIVISION IV. To teach residents how to utilize the best patient-based, population-based and laboratory –based evidence in clinical health care decisions. V. To be able to apply new-found knowledge from research to clinical practice.

 COMPETENCE FOR RESIDENTS I. At the end of the first year, he/she will be able to discuss and present thoroughly an interesting case based on the completeness of history and thorough physical examination. And should be able to submit a research protocol/proposal for review of the research committee. II. At the end of the second year, the residents should have submitted a retrospective research paper. III. At the end of the third year, the resident must be able to submit a prospective research paper.

 STRATEGIES The Metro Manila East integrated Residency Training Program conducted a two day seminar on research. TIPPS held a workshop on Evidence-based Medicine attended by the residents.

 POLICIES I. The gold standard clinical study is the randomized, double blinded, placebo controlled study which has trial monitoring and pre-study data analysis, all good studies have to comply with the principles of good clinical practice. II. It is important to recognize that patients have no moral,clinical or legal obligation to participate in any study, therefore their safety and comfort is of paramount importance. III. The investigator who is the resident, should: a. Seek and obtain permission from the hospital and ethic committee b. Inform the appropriate staff of the study. c. Obtain the consent, preferably written from participating patients/guardians of patient. d. Respect patient confidentiality.

 BUDGET The residents shall submit their budget proposals for approval and once approved by the head of the research committee, the resident can start their respective research papers. The residents however, are

Mandaluyong City Medical Center CLINICAL DIVISION allowed to get another sponsor to finance their paper especially if the budget given was not sufficient.

 EVALUATION I. The department formed a committee on research to monitor and guide the residents while undertaking the study. II. The committee oversees the progress of the clinical research and ensure that it is conducted according to the protocol without any violation. III. The committee examines and verifies the clinical data and discussed with the residents the progress of the study.

 VENUE FOR RESEARCH PAPER PRESENTATION OR RESEARCH FORUM Intra departmental research paper presentation are held annually participated in by second and third year residents of MCMC, Department of Pediatrics.The winning paper is presented at the hospital’s entry to the MMEIRTP Interhospital research paper presentation.

Interhospital research paper presentation is also held annually through the sponsorship of Nestle which is participated in by residents from the six constituent hospitals of the MMEIRTP.

Another interhospital research paper presentation is held every year ,TIPPS, participated in by winners from the different integrated residency training programs in Metro Manila.

 COMMUNITY OUTREACH PROGRAM The community program of the Department of Pediatrics, Mandaluyong City Medical Center , involves the monthly rotation of Pediatric Residents in an identified community, Barangay Daang Bakal, Mandaluyong City in the delivery of primary health care. The main objectives are training, service, research and the development of proper attitudes and values.

 LOCATION MAP

 GENERAL OBJECTIVES OF THE PROGRAM  Training- To train Pediatric Residents in the practice of pediatrics in a community setting.  Service- To render preventive health care to infants, children and adolescents in a particular community.  Research- To motivate residents to conduct research work that can be beneficial to the community.

Mandaluyong City Medical Center CLINICAL DIVISION  To develop complete pediatricians with the proper attitudes and values of compassion, concern and care for the less privileged members of the community.

 COMPETENCIES FOR THE RESIDENTS  At the end of each rotation to the community the residents are expected to: I. Know the immunization program of the community. II. Know the most common problem of the community. III. Able to diagnose and treat the common illnesses in the neighborhood. IV. Handle and give immunization to well babies. V. Able to recognize early the need to refer patients to the hospital. VI. Able to recognize the common health problems of the community and help the people in its prevention. VII. Able to educate the parents and barangay health workers on proper nutrition, breastfeeding and accident prevention.

 CONTENT OF THE PROGRAM  SCHEDULE/STAFFING I. A second or third year resident is assigned at Brgy. Daang Bakal on a monthly rotation once a week usually on Fridays at 2-4 PM II. Staffing Consultant 1 Resident 1 Volunteer Health Worker 1 Postgraduate Intern 1 (if available)

Residents and interns are supervised by the consultant assigned as rotation on a monthly basis.

 SERVICES OPD consultations, mother’s classes and feeding programs were conducted.Likewise free medicines are given if available.

 RESEARCH The community is also a venue for research project.Residents are encourage to submit research proposals to the research committee for approval.

 LEARNING STRATEGIES

Mandaluyong City Medical Center CLINICAL DIVISION I. Each resident is assigned to the Brgy. Daang Bakal Health Center monthly, holds Out Patient Clinic every Mondays, Wednesdays and Fridays. II. Residents to conduct lectures, Mother’s class research projects and hands in exposure to common childhood illnesses.

 EVALUATION I. Monthly report to be submitted to the department to include patient census, accomplished projects and endorsed projects. II. To present statistics of patients during the month in the monthly department audit.

 DESCRIPTION OF THE ADOPTED COMMUNITY The Department also recognizes the importance of community involvement in promoting health and thus contributing to national development. In this view, the department has adopted a community in Mandaluyong City, with no existing health services, to provide its residents with accessible, affordable and dependable assistance in that field.

The chosen community, Barangay Daang Bakal, is located within the vicinity of the Jose Rizal College ( see attached map ), with a land area of 17.34 hectares, inhabited by 775 families, making up a total population of 4,512 by the year 2000.

The people of Barangay Daang Bakal are mostly blue collar workers, with varying educational backgrounds ranging from elementary education to vocational college, various fields of technology and specialized trade, employed in establishments not far from their residence, such as Foremost Star Garments, SUGECO, et.al. Others rely on small scale businesses such as sari-sari stores, canteens, beauty parlors, etc., to augment their income.

At the core of the community is a basketball court, which also serves as a multi-purpose recreational center, for meetings, get togethers, and the like. No church exists in the barangay so the residents worship at the nearby Don Bosco Chapel. Peace and order is maintained by a group of Barangay Tanods, who patrol the area 24 hours a day. If necessary, problems not settled at this area are referred to the nearest Police Substation. Garbage is collected nightly by a truck, without fail. Water supply is scarce since only a few residents have direct access to the city’s utility services. The rest have to depend on their more fortunate neighbors for their daily water supply, using large covered containers for storage.

Participating to the weekly medical missions dubbed as “ Pamahalaan sa Pamayanan”, held every Saturday, 8am to 3 PM since October 1998, not to

Mandaluyong City Medical Center CLINICAL DIVISION mention other various missions for the San Felipe Neri Parish and the Rizal Medical Society, of which the hospital is an active member, resident physicians need little training, if at all, on handling community service projects. Patient education through seminars, interactive lectures and hands on training is of top priority, followed closely by the establishment of a Nutrition Clinic, aimed at utilizing early intervention to stop and prevent malnutrition.

Mandaluyong City Medical Center CLINICAL DIVISION Appendix A

MANDALUYONG CITY MEDICAL CENTER DEPARTMENT OF PEDIATRICS RESIDENTS PERFORMANCE EVALUATION Name of Trainee: ______Date: ______Consultant Evaluator: ______

I. Written Exams ------15% ( MME Mid & Year-end + MCMC)

II. Clinical Performance ------45% A. INPUT (Affective Domain) ------15% 1. Attitude, professional and public relations (3%) 2. Cooperation ands willingness to accept responsibility and extend help (3%) 3. Initiative, dependability, diligence, resourcefulness, and willingness and ability to refer (3%) 4. Trustworthiness and intellectual honesty (3%) 5. Confidence and leadership skills (2nd & 3rd Year Levels) (3%)

B. OUTPUT (Cognitive and Psychomotor) ------30% 1. Accuracy, conciseness, and organization of historical data gathered (3%) 2. Accuracy and thoroughness of physical examination (3%) 3. Interpretation and integration of clinical data gathered including personal study and research (3%) 4. Appropriate selection of diagnostic test and their interpretation (3%) 5. Management of common problems in primary and secondary care (3%) 6. Recognition and appropriate referral and management of pediatric emergencies (3%) 7. Recognition and management of tertiary care problems (2nd & 3rd year Levels ) (3%) 8. Appropriate approach and successful performance of pediatric procedures (3%) 9. Accurate and ligible recording of data and completeness of data in the patients’ charts (3%) 10. Accurate, organized, and professional oral presentation of clinical data (3%) 11. Completion of and amount of work done on time (3%)

Mandaluyong City Medical Center CLINICAL DIVISION

III. Compliance to requirements ------20% (Case reports; research papers) IV.Oral presentation in conference ------5% V. Attendance ------10% VI. Chief resident’s peer rating/rating as chief resident ------5%

Total Score ------%

MPL: 1st Year 70% 2nd Year 75% 3rd Year 80%

Signature of Evaluator______

Mandaluyong City Medical Center CLINICAL DIVISION Appendix B PEDIATRIC CONSULTANTS

1. VILMA Q. ARIZALA, M.D. Fellow, PPS Active Rotating Consultant Training Officer - Department of Pediatrics Mandaluyong City Medical Center Other Affiliation - Medical Center Manila Our Lady of Lourdes Hospital Manila Doctor’s Hospital Unciano General Hospital Victor R. Potenciano Med. Center Administrative / Teaching assignment Bedside conferences with the Residents Chairman, Clinico-Pathological Conference Committee Member, Credentials Committee, MCMC Chief of Clinics, MCMC Participation in MME Integ. Residency Training Program

2. SUZETTE A. BAUTISTA, M.D. Fellow, PPS Clinical Fellow Queen Mary Hospital Hongkong Pediatric and Neonatal Intensive Care Unit Clinical Fellow UST Pediatric Pulmonary Active Rotating Consultant MCMC Cardinal Santos Medical Center Unit Coordinator CSMC PICU Visiting Medical Staff – Mary Immaculate Heart Hospital Administrative / Teaching Equipment Participation in MME Integ. Residency Training Program First Integrated Residency Training Program

3. DOLORES A. BUSTAMANTE, M.D. Diplomate, PPS Active Rotating Consultant Other Affiliation: Cardinal Santos Medical Center Administrative / Teaching Assignment Bedside Rounds with Residents Participate in MME East Integ. Res. Training Prog. First Integrated Residency Training Program 4. EUFROSINA A. MELENDRES, M.D. Fellow, PPS Fellow, Phil. Society of Hematology and Blood Transfusion Fellow, Philippine Society of Oncologists

Mandaluyong City Medical Center CLINICAL DIVISION Past President, PSHBT Professor, UP College of Medicine Chair, Dept. of Pediatrics, MDH 1991-1994 Chair, Dept. of Pediatrics, MCMC 1996 up to present Hospital Affiliations: UPCM-Phil. General Hospital Manila Doctors Hospital Rizal Medical Center Mandaluyong City Medical Center

5. LORNA E. NAVARRO, M.D. Active Rotating Consultant Other Affiliation: Unciano Hospital VRPMC Administrative / Teaching Assignment Bedside Rounds with Residents Staff Meeting / Case Management / Journal Club Participates in MMEast Integ. Res. Training Program

6. BEATRIZ PUZON-QUIAMBAO, M.D. Fellow, PPS Fellow, PIDSP Member, PSMID, Phil. Hosp. Infec. Control Society, PMA MS III, Research Institute for Tropical Medicine (RITM) Head, OPD and Admitting Section, RITM Chairman, Infection Control Committee, DLSMC Infec. Dis. Consult., RITM, DLSMC, OLLH, SMPCH, MCMC Clinical Researcher, Rabies; ARI

7. JOSELITO A. MATHEUS, M.D. Fellow, Philippine Pediatric Society Fellow, Philippine Society of Pediatric Nephrology Associate Professor, FEU-NRMF Hospital Affiliation: Delos Santos Medical Center United Doctor’s Medical Center Far Eastern University Jose Reyes Memorial Med. Center Mandaluyong City Medical Center

Mandaluyong City Medical Center CLINICAL DIVISION

8. SIOKSOAN CHAN-CUA, M.D. Fellow, PPS Fellow, PSE Hospital Affiliation: Manila Doctor’s Hospital Chinese General Hospital Cardinal Santos Medical Center Mandaluyong City Medical Center

9. MANUEL F. FERRERA, M.D. Fellow, PPS Fellow, Phil. Society of Allergology and Immunology Fellow, PCCP General-Secretary-ASEAN-PACIFIC Society of Allergy And Immunology Chairman, DLSMC, Department of Pediatrics MCU-FDTMF Department of Pediatrics Section Head, Allergy PCMC

10. FELIZARDO A. GATCHECO, M.D. Diplomate, Philippine Pediatric Society Fellow, Phil. Society of Gastroenterology & Nutrition Hospital Affiliation FDTMF-MCU Hospital Delos Santos Medical Center Manila Doctor’s Hospital Mandaluyong City Medical Center

11. IGNACIO V. RIVERA, M.D. Fellow, Philippine Pediatric Society Fellow, Philippine Society of Pediatric Neurology Hospital Affiliation: Our Lady of Lourdes Hospital Cardinal Santos Medical Center Mandaluyong City Medical Center Training Officer- Cardinal Santos Dept of Pediatrics

12. MARIA ESTERLITA VILLANUEVA UY, M.D. Diplomate, Philippine Pediatric Society Fellowship Training in Neonatology Children’s Hospital of Michigan Hospital Affiliation : UP Philippine General Hospital Mandaluyong City Medical Canter Jose Delgado Memorial Hospital

Mandaluyong City Medical Center CLINICAL DIVISION

13. JOSEFINA R. ALMONTE, MD, FPCS Fellow, Philippine College of Surgeons Fellow, Philippine Society of Pediatric Surgeon Fellow, American College of Surgeon Associate Professor, UP College of Medicine Fellowship Training : Royal Alexander Hosp. for Children, Sydney, Australia Hospital Affiliation : Chairman, Children’s Medical Center UP Philippine General Hospital Manila Doctor’s Hospital Manila Sanitarium Hospital Mandaluyong City Med. Center 14. MA. RONELLA FRANCISCO, DPPS Diplomate, Philippine Pediatric Society Fellow, Philippine Heart Association Inc. Fellow, Philippine College of Cardiology Diplomate, Philippine Society of Pediatric Cardiology Member, Philippine Society of Echocardiography Hospital Affiliation Makati Medical Center – Associate Active Staff Philippine Heart Center – Visiting Medical Staff 15. NERISSA DANDO, DPPS Diplomate, Philippine Pediatric Society Fellow in Adolescent Medicine and Clinical Toxicology Hospital Affiliation : UP Philippine General Hospital

16. Anjanette de Leon, MD, PAPP Diplomate, Philippine Pediatric Society Philippine Academy of Pediatric Pulmonology Hospital Affiliations: VRPMC Mandaluyong City Medical Canter

Mandaluyong City Medical Center CLINICAL DIVISION

MANDALUYONG CITY MEDICAL CENTER Pre-Resident Performance Evaluation

Name of Applicant:______School:______Date: ______

Dimensions Rating A. Interpersonal Relations ( 30% ) (Teamwork, skill in relating with peers, superiors, authorities, and patients)  Describe someone you like working with.  What task do you want to do alone? With others? Why?  Do others confide in you? About what? How do you react to it? A. Communication Skills ( 30% ) B. ( Skills in verbal communication – clarity, coherence , fluency organization of thought )  Explain a process or procedure.  Explain to a patient what his illness is. C. Personality and Attitude ( 40% ) 1. General attitude and personality traits. (Honesty, integrity, social inclinations, research inclination) 2. Stress Tolerance  What do you do when faced with a problem you cannot solve?  Do you loose your temper? Why? What do you do about it?  Relate a stressful experience you had. How do you cope with it? 3. Work Standards  What was the highest achievements or goal you aspired for in college  Did you attain it? What did you do to attain it?  Tell us of an achievement which you can be proud of? 4. Flexibility and Adaptability * Clinical situation. D. Problem Solving * Simple clinical judgment (Pronlem analysis, decision making) TOTAL

Mandaluyong City Medical Center CLINICAL DIVISION

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

I. HISTORICAL DATA AND PHILOSOPHY The Mandaluyong City Medical Center is committed to provide health care services primarily for the indigent patients of the City of Mandaluyong. This mission is in accordance with the vision of the former Mayor Benjamin S. Abalos that “NO MAN SHALL BE DENIED ACCESS TO HOSPITALIZATION BY REASON OF POVERTY.

The hospital is the former Annette General bought by the city Government of Mandaluyong in 1984. It was first used as an Out-patient Clinic while the hospital facilities were being renovated.

In 1986, the MCMC started to operate as a fifty (50) bed secondary hospital. It was then that the Department of Obstetrics and Gynecology came to be. With two consultants, Dr. Julieta C. Cadano and Dr. Evelyn O. Rondolo, and four (4) residents, the department started to serve the maternal ang child health needs of the women of Mandaluyong and its environs. In 1995, the entire hospital was physically renovated and the facilities were upgraded. Its bed capacity was increased to 104. Recognizing the need for a bigger and better hospital facilities, the Honorable President Neptali A. Gonzales has alloted P70 M. for the construction of a Multi-story Hospital Extension Building to be housed in the site of the present OPD Building. Ground breaking of the new building was held last August 25, 1999. The new management focused on the development of its human resources and medical staff through continuous training programs to achieve the desired level of patient care. With this in mind. The Department of Obstetrics and Gynecology applied for accreditation of service which was granted under the level II-A category by the Philippine Obstetrics and Gynecology Society in 1996. The hospital bacame Mother and Baby Friendly institution through the hardwork and perseverance of the Department of Obstetrics and Gynecology and the Department of Pediatrics. Its dedication to breastfeeding is part of its commitment to provide both physical and emotional bonding between mother and child.

In 1999, the Department achieved its foremost dream of becoming a PBOG accredited residency training institution. Come year 2006, the department was again revisited and a 3- year accreditation was granted (2000-2002).

It is the purpose of the Department of Obstetrics and Gynocology to provide health care services of the highest quality guided by professional standards of ethics and morality. The department ensures that the medical staff perform their duties with the highest degree of competence and efficacy. Though the first and foremost responsibilty is the patient, the department encourages the training staff to pursue academic excellence, develop the skill to their full potential and contribute to the advancement of the specialty by conducting Mandaluyong City Medical Center CLINICAL DIVISION research studies and utilizing the research outputs for the improvement of the delivery of health care services.

II. DESCRIPTION OF THE RESIDENCY TRAINING PROGRAM This is comprehensive graduated, progressive vertical four-year training in Basic and Clinical Obsetrics and Gynecology to enable the resident trainee to render service in the specialty practice of OB-GYN, capable of providing consultancy service to the community of physicians in the locality of choice. At the end of the training, the resident should have accomplished the minimum requirement set by the Philippine Board of Obstetrics and Gynecology.

III. OBJECTIVE OF THE RESIDENCY TRAINING PROGRAM The primary aim of residency training is further development of the fundamental knowledge, skill and attitude learned in the undergraduate obstetrics and gynecology in order to attain degree of competency, with emphasis on Mastery of pathophysiology as the solid basis for rational management of abnormalities affecting reproductive health and reproductive process. The training program reinforce the basic learned in the

IV. POLICIES AND GUIDELINES  OUT PATIENT DEPARTMENT (OPD)  Schedule I. Monday Gynecology (8:00am – 12:00nn) (1:00pm – 4:00pm)

II. Tuesday/Wednesday Regular Prenatal Check-up (8:00am – 12:00nn) (Uncomplicated Pregnancies) (1:00pm – 4:00pm)

III. Thursday High Risk Pregnancies (8:00am – 12:00nn) (Previous CS, with Medical Complications, (1:00pm – 4:00pm) Teenage Pregnancies, Previous Gynecological Operations).

IV. Friday Family Planning (1:00 pm – 4:00 pm)

 Protocols I. Complete History and Physical Examination by Resident-in- charge for the day. II. Pathologic cases are referred to the Consultant on duty for the week.

Mandaluyong City Medical Center CLINICAL DIVISION III. Ancillary procedures requested. IV. Patients for admission are directed to ER for admission by the resident on duty. V. Those patients not for admission are medically managed and advised OPD follow-up. VI. Complicated patients are referred to the most senior resident before disposing them.

 EMERGENCY ROOM POLICIES AND GUIDELINES  ADMISSION FLOW CHART I. Patient in Labor a. Complete history, physical examination including vital signs and pelvic examination done immediately (except for patients with pre-eclampsia or suspected with placenta previa). b. Request ‘stat’ CBC with blood typing and urinalysis if not yet done at OPD. Blood request and subsequent crossmatching request are given to patients. c. Admitting chart to be accomplished by MS/ROD. d. Retrieve OPD record and incorporate to chart. e. Patients in active labor are prepared for admission to Labor Room and transported by wheelchair/stretcher accompanied by ER nurse f. Patients with profuse bleeding are hooked to IVF and a ‘stat’ blood typing and crossmatching is requested. g. Pregnant patients with medical or surgical complications are referred to IM/Surgery for further evaluation and management/clearance. h. Patients for emergency operation (cesarian section and exploraratory laparotomy) are aseptically prepared and prescribed with complete medications and supplies before admission to LR/OR. i. Patients in preterm labor are given initial management such as parenteral tocolytics. Vital signs are monitored. Those for admission are brought to labor room and the rest are sent home with appropriate medications. j. Consent for admission and management are explained well to the patient by the MS/ROD.

II. Patients with Gyne Pathology a. Complete History and Physical Examination including vital signs.

Mandaluyong City Medical Center CLINICAL DIVISION b. Pelvic examination done. No internal examination is done to a patient without/denies sexual history or gives no consent. c. Pediatric patients are accompanied by parents during examination. d. Ancillary procedures needed are requested. e. Patients for admission are prepared and admitted at the Gyne ward by resident in charge. f. Patients who are sent home are given home medications, laboratory request and advised follow-up at OPD- Gyne.

III. Patients for transfer to hospital of patient’s choice or institution for subspecialty management are properly coordinated by ROD to the receiving institution. If consultation is on OPD basis referral slip is accomplished and given to the patient. For emergency referrals, transfer is likewise coordinated and conducted by ambulance to other hospital accompanied by the ROD. IV. All patients seen at the OPD and ER are referred to COD within 24 hours at the latest.

 LABOR ROOM / DELIVERY ROOM POLICIES AND GUIDELINES  Patients who are in active labor are admitted at the Labor Room with the proper endorsement from the ER-MS/ROD. Complete History and Physical Examination reviewed for further evaluation and management.  High risk cases are referred to the consultant-in-charge by the ROD.  Patients are given full body bath and change of patient’s gown.  IVF are given to the patients.  Patients are hooked to fetal monitor.  Progress of labor are observed and monitored by the ROD and properly recorded.  Fleet enema is done to patients with cervical dilatation ≤ 4cm.  Pelvic examination is done every hour for patients in active labor.  Oxytocin is incorporated in the IVF when necessary (not routinely).  Normal spontaneous delivery or outlet forceps extraction are done at the Delivery room.  Postpartum patients are monitored at the LR and pelvic clearance by ROD are done prior to transfer to OB/Payward where postpartum care is continued.  Patients with abnormal labor are referred to the COD for definitive management.

Mandaluyong City Medical Center CLINICAL DIVISION  Indicated abdominal delivery are properly prepared and endorsed to OR.  Proposal for a surgical procedure is accomplished by ROD and submitted to OR nurse.  Get a written informed consent of the patient or next of kin.

 OBSTETRICAL AND GYNECOLOGICAL WARD POLICIES & GUIDELINES  OB patients (includes post NSD, post CS, post D and C and preterm labor) are placed on tandem beds at the OB ward.  Gyne patients (includes post hysterectomy for uterine or ovarian masses, post fractional D and C, abnormal uterine bleeding) are admitted at the gyne ward.  Postpartum care, IV and oral medications are administered.  Complicated cases are closely monitored by resident on duty and referred accordingly to COD.  Patients for discharge should be cleared by the resident in charge and given discharge summary slip for OPD follow-up.

I. STRATEGIES  Recruitment and Selection Criteria: To quality for admission into the training program, a candidate must fulfill the following criteria:  He must be a graduate of an recognized and accredited medical school;  He must have completed one year of postgraduate internship;  He must have passed the medical board examination, and must have a license to practice his profession.  He must have passed the entrance examination given by the department.  He must have passed the interview conducted by the consultant staff;  He must dedicate full time to the training program, therefore, should be willing to give to any outside practice or employment.

 Promotion Criteria: For a resident trainee to be promoted to the next year level, he must fulfill the following criteria:  He must have satisfactorily met the objective cited in each year level as set forth by the Philippine Board of Obstetrics and gynecology (PBOG);  He must meet the technical objectives of this year level as required by the curriculum;  He must have taken the written examinations given by the department and the in-service examination given by PBOG;  He must have submitted a case report or research paper as may be required depending on his year level;  He must have an average rating scale in all performance areas by all consultants of both less than three (3).

Mandaluyong City Medical Center CLINICAL DIVISION  Recruitment and Selection Criteria: To quality for admission into the training program, a candidate must fulfill the following criteria: I. Graduation Criteria: For a residents trainee to quality for graduation, he must fulfill the following criteria: a. He must have finished the four year residency program; b. He must accomplished the minimum number of cases required by the curriculum; c. He must have rotated in Surgical Pathology for three (3) months, and other subspecialties such as Perinatology, Oncology, Endocrinology; d. He must have submitted a prospective research paper duly approved by the chairman; e. He must have an average rating scale in all performance areas by all consultants of not less than four (4).

 Curriculum:  FIRST YEAR At the end of the first year, the resident will be able to render Level I care competently and be equipped with the concepts of Level II care.

 Objective of Level I Care: I. To identify the uncomplicated maternity and abortion cases for admission, labor delivery, and provide adequate services and postpartum care. II. Identify patients at risk and refer promptly for definitive management. III. Institute appropriate emergency measures preparatory to referral to the next level for definitive management. IV. Provide family planning services. V. Develop a community service program. a. Normal Obstetrical Care i. Antenatal Care 1. Physiology of Normal Pregnancy 2. Nutrition in Pregnancy 3. Preparation for breastfeeding 4. Immunizations 5. Hygiene and exercise 6. Preparation for childbirth 7. Psychological changes 8. Family Planning 9. Common Problems a. Infections: Lower genital tract, urinary tract.

Mandaluyong City Medical Center CLINICAL DIVISION b. Bleeding problems: early trimester, late trimester c. Growth and Development: IUGR, genetic, meatbolic, nutritional. 10. Medical and surgical problems 11. Identification of High Risk Pregnancy: risk assessment

Skills to be developed: i. Identification of High Risk Pregnancy: risk assessment ii. History taking and Risk assessment iii. Physical Examination 1. Breast Examination 2. Pelvic and abdominal examination 3. Rectal examination 4. Clinical examination iv. Laboratory examination and Interpretation v. Pap Smears and Interpretation

ii. Intrapartum Care 1. Physiology of Normal Labor 2. Conduct of Normal delivery 3. Assistive, Interventive delivery 4. Vaginal delivery, forceps 5. Resuscitation of the newborn 6. Analgesia and Anesthesia 7. Episiotomy and repair 8. Basic surgical skills, suturing 9. Would healing including problems 10. Common problems of labor and delivery and immediate management preparatory to definitive management. 11. Assessment of progress of labor and problems of power, cervical dilatation and descent. Fetal wee-being distress and fetal growth 12. PROM, meconium staining 13. Medical and surgical complication

iii. Postpartum Care 1. monitoring uterine involution 2. Care of Episiotomy and infection 3. Management of vulvar hematoma

Mandaluyong City Medical Center CLINICAL DIVISION 4. Lacatation management: breasfeeding and common problems 5. Urinary tract infection 6. Puerperal fever 7. Postpartum hemorrhage 8. Family Planning

b. Gynecology i. Office Gynecology ii. Physiology of Menstruation iii. Disorders of Menstruation iv. Physiology of reproduction v. Infertility work up vi. Contraception (family planning) vii. Sexually transmitted Disease viii. Urinary Tract Infection ix. Physiology of menopause x. Benign tumors xi. Malignant tumors xii. Breast pathology xiii. Cytology and colposcopy (principles) xiv. Basic ultrasonography (principles) xv. Pre-op and post-op care: 1. Pre-op evaluation, asepsis and antisepsis 2. Post-op: IV fluid therapy, dynamics of healing and recovery. 3. Complications, diagnosis and management.

Skills to be developed: vi. History Taking vii. Pelvic examination –Bimanual viii. Rectal examination ix. Breast examination x. Collection and interpretation of Pap smear xi. Collection and Interpretation of culture results xii. Ultrasound interpretation xiii. Assistive surgery xiv. Dilatation and currettage xv. Investigative skills: Case Report xvi. Presentation of Case Report

 SECOND AND THIRD YEAR

Mandaluyong City Medical Center CLINICAL DIVISION At the end of the second and third year, the resident will be able to render Level II care competently and be equipped with the concept of Level III care.

 Objective of Level II Care: I. Provides services for Level I. II. Diagnose and admit complicated obstetrical cases for definitive management, surgery, and post-operative care. III. Diagnose and admit complicated gynecological cases for definitive management, surgery and post-operative care. IV. Admit neonates at risk or with complications. V. Provide family planning.

a. Obstetrics: In addition to Level I cognitive areas i. Antepartal care for the pathologic complications or pregnancy (risk assessments) ii. Basic concepts of fetal surveillance in complicated pregnancies iii. Intrapartum care of: 1. Complicated pregnancies 2. medical and surgical complications. iv. Fetal Assessment v. Fetal Monitoring 1. decision-making skills 2. principles of fetal resuscitation a. electronic fetal monitoring b. Biophysical profile vi. Diagnosis and management of pathologic complications of Labor and Delivery. vii. Labor disorders viii. Hemorrhage complications ix. Hypertensive complication x. infectious complications and septic shock xi. Other operative obstetrics 1. Breech extraction 2. Internal podalic version 3. cesarean section:primary and repeat a. Low Segment b. Classical

b. Gynecology i. Office gynecology ii. Physiology of Menstruation iii. Physiology of Reproduction

Mandaluyong City Medical Center CLINICAL DIVISION iv. Infertility work-up v. Contraception (family planning) vi. Sexually transmitted diseases vii. Urinary tract infection viii. Physiology of menopause ix. Benign tumors x. Premalignant tumors xi. Malignant tumors xii. Breast Pathology xiii. Cytology and colposcopy (principles) xiv. Basic ultrasonography (principles) xv. Pre-op and post-op care: 1. Pre-op risk evaluation, asepsis and antisepsis 2. post-op: IV fluid therapy, dynamics of healing and recovery. 3. complications, diagnosis, and management

Skills to be developed: i. Decision making skills ii. Diagnostic examination iii. Pelvic examination iv. Pelvic ultra sound – 1. Interpretation and clinical 2. Correlation v. Cytology – interpretation and correlation

Surgical skills i. Adrenal surgery ii. Uterine surgery – Hysterectomy, Myomectomy iii. Vaginal surgery – AP repair, D & C iv. Laparascopy ( assistive)

Investigative skills i. Research paper – Descriptive or Retrospective

 FOURTH YEAR At the end of the fourth year, the resident will be able to render Level II competently and be eqquiped with Level III basic skills and concepts.

 Objective of Level III Care: I. Provide services for Level I and Level II.

Mandaluyong City Medical Center CLINICAL DIVISION II. Diagnose and manage complicated maternal cases requiring critical care. III. Provide diagnostic and monotoring services and management for any of the subspecialty cases admitted from lower levels of care. IV. Provide training for residents and fellows in any or all specialties as well as the general OB-GYN recidency. a. Diagnosis and management of high risk patients (see level of care Appendix A) b. Principles of fetal resuscitation c. Electronic fetal monitoring d. Biophysical Profile e. Diagnosis and management of malignancies (see level of care Appendix B) f. Management of infertility(see level of care Appendix C) g. Interventive surgery for tertiary care (Oncology and reproductive technology) Skills to be developed: i. Obstetrical skills 1. Breech delivery 2. Internal Podalic Version 3. Cesarean Section

Surgical Skills: ii. Abdominal hysterectomy ii. Cesarean hysterectomy iii. Difficult laparotomies iv. Fistula repair v. Laparoscopy

Organizational and Management skills Surgical pathology Rotation in Perinatology i. Ultrasound ii. Fetal monitoring iii. Amniocentesis Rotation in Oncology i. Colposcopy and other diagnostic examination ii. Staging of malignant diseases iii. Treatment planning and management Rotation in Endocrinology i. Diagnosis and management ii. Endocrine problems iii. Infertility

Mandaluyong City Medical Center CLINICAL DIVISION iv. Menopause  Methods of instruction:  Didactic session (Basic OB/GYN lecture series, Specialty OB/GYN lecture series, Case Management conferences/ Journal Reports) These are conducted once or twice a week with the residents reporting and required topics or interesting cases. A consultant acts as a resource person.  Weekly surgical audit All cases admitted are audited and special cases are discussed. This is conducted every Tuesday morning with the consultant-on-duty for the week acting as the moderator. All patients seen t the OPD are likewise reviewed. This is immediately followed by a census of high risk OB patient seen for the week.

 Pre- op and Post-op conferences These are conducted every Tuesday mornings. Cases to be operated on For the week Fridays) and those operated the prior week are discussed and reviewed. The consultant-in-charge of each case acts as resource person.

 Perinatology conference This is conducted every second Wednesday of the month between the Department of Pediatratics and OB-GYN. The Perinatologist and Neonatologist act as the moderators.

 Instructional Activites: (Schedule)  Intradepartmental Activites: I. Chairman’s rounds- every Friday morning II. Training Officer’s rounds- every Tuesday and Thursday morning III. Chief Residents’s rounds- daily IV. Basic OB lecture series- every first Thursday of the month, moderated by the training officer V. Specialty OB lecture series- every second Thursday of the month, moderated by the training officer VI. Basic Gyne lecture series- every third Thursday of the month moderated by the training officer VII. Specialty Gyne Lecture- every fourth Thursday of the month, moderated by the training officer VIII. Journal Club- every third Wednesday of the month, moderated by the consultant on duty IX. Surgical Audit- every Tuesday morning (weekly) X. Pre-op and Post-op Conference- every Tuesday morning (weekly)

Mandaluyong City Medical Center CLINICAL DIVISION XI. Case Management Conference- every Tuesday morning, moderated by consultant on duty XII. Regular rounds with Consultant on Duty- two to three times a week XIII. Subspecialty lecture series- 1 lecture per subspecialty once a month care of the subspecialty consultant on most convenient time

 Interdepartmental Activities I. Perinatal Conference- every second Wednesday of the month II. Hospital Morbidity and Mortality Conference every fourth Wednesday of the month

 Interhospital Activities: I. Pentamed lectures/ conference- every Monday afternoon

 DUTIES AND RESPONSIBILITIES  The following are the duties and responsibilities of a first year resident: I. he goes on duty as a junior resident; II. act as the first call for patients who come at the ER; III. monitors patients in labor; IV. acts as the first or second assistant in major surgeries; V. does the discharge IE; VI. does all BTL cases; VII. acts as the first call of the ward referrals; VIII. see all the family planning clients for DMPA injections, IUD insertion and follow-up clients; IX. accompanies patient for the transport to outside institutions either for transfer or for out patient procedures, if an intern is not available. X. logs all patient’s information in the OB or GYN logbook; XI. logs all patient’s information at the OPD resident of the day.

 The following are the duties and responsibilities of a second year resident: I. He goes on duty either as a junior or a senior resident of the team depending on the team assignment. II. monitors patients in labor if he is the junior member of the team; III. decides in the management of high risks patients in labor with proper referral to the chief resident; IV. acts either as first call of back-up for patients who come in ER; V. acts either as first call or back-up for ward referrals;

Mandaluyong City Medical Center CLINICAL DIVISION VI. logs in patients’ information in the OB-GYN logbook if he is the junior resident of the team; VII. logs all needed information of all patients data in the OPD logbook if he is the OPD resident of the day; VIII. supervises interns or first year resident of the team; IX. acts as the first and second assistant to the third resident in a major gynecological operation.

 The following are the duty and responsibilities of a third year resident: I. he goes on the duty as a senior resident of the team; II. supervises interns or junior residents of his team; III. makes major decision in the management of high risks patients with proper referral to the chief resident as needed; IV. see or clears patients referred from other departments; V. sees to it that proper recording of patient’s data on the logbook is done.

 The following are the duties and responsibilities of the Chief Resident: I. does administrative functions, e.g. arrange schedules of resident’s and interns’ duties, schedule of activities, etc. II. supervises all residents and interns of the department; III. refers all problematic patients to the Consultant-on Call; IV. makes definitive decisions in the management of high risk or problematic patients with the proper referral to the Consultant- on-Call V. conducts regular rounds with the residents and interns; VI. is the property custodian of the department.

 RULES OF DISCIPLINE:  Offenses and Corresponding Punishment: I. Outright Dismissal for the following: a. Falsification, destruction or mutilitation of or tampering of public documents (hospital records or any paper that has to do with official functions of the hospital shall be considered public documents.) b. Engaging in private practice of medicine anywhere. c. Unauthorized solicitation or collection of money from patients. d. Acts of immortality or conduct or behavior unacceptable to society. e. Substance abuse.

II. ABSENCE

Mandaluyong City Medical Center CLINICAL DIVISION a. From work (may be a hospital, departmental or service duty) i. Unauthorized or unexcused: 1. 1st offense: 3 additional Sunday duties 2. 2nd offense: 6 consecutive Sunday duties 3. 3rd offense: DISMISSAL ii. Authorized or excused: 1. payment with similar duty iii. From schedule activities (conferences, meetings, lectures and official department functions) 1. Excused: a. no penalty 2. Unexcused: a. 1st offense: WARNING b. 2nd offense: One Sunday Duty c. 3rd offense: Two Sunday Duty iv. From Operating Room Duties 1. Unauthorized or unexcused a. 1st offense: 3 additional Sunday duties b. 2nd offense: 6 consecutive Sunday duties c. 3rd offense: DISMISSAL

2. Authorized or excused: a. payment with similar duty

III. TARDINESS a. From Work i. Excused: 1. no penalty ii. Unexcused: 1. less than one hour a. 1st offense: Warning b. 2nd offense: One Sunday Duty c. 3rd offense: Two consecutive Sunday duties 2. More than one hour a. 1st offense: Two consecutive Sunday b. 2nd offense: Three consecutive Sunday duties c. 3rd offense: Four consecutive Sunday duties

Mandaluyong City Medical Center CLINICAL DIVISION

b. From Scheduled Activities(conferences, meetings, lectures, and official department functions) i. Excused: 1. no penalty ii. Unexcused: 1. number of minutes will be cumulative 2. for every 60 minutes—one Sunday duty 3. tardiness shall be times from the beginning of the functions

c. From Operating Room(Tardiness in Operating room assignments or scrubs: Must be in O.R. 15 minutes before scheduled time.) i. Excused: 1. no penalty ii. Unexcused: 1. 1st offense: Warning 2. 2nd offense: Suspension or O.R. privileges 3. 3rd offense: Suspension of O.R. privileges for two weeks 4. More frequent tardiness, penalty will be at the discretion of the department Chairman.

d. Leaving hospital premises during office hours without permission from Chairman or duty designated representative i. 1st offense: Warning ii. 2nd offense: One Sunday Duty iii. 3rd offense: Two consecutive Sunday duty iv. 4th offense : DISMISSAL

IV. DECORUM a. Uniform i. Wearing of inappropriate attire in the O.R. 1. 1st offense: Warning 2. 2nd offense: Suspension of O.R. privilege for one week 3. 3rd offense: Suspension of O.R. privileged for two weeks

ii. Wearing of scrubsiut outside the O.R.

Mandaluyong City Medical Center CLINICAL DIVISION 1. 1st offense: Suspension of O.R. privilege for one week 2. 2nd offense: Suspension of O.R. privilege for two weeks 3. 3rd offense: Suspension of O.R. privilege for three weeks

V. BEHAVIOR a. SMOKING AND GAMBLING Phohibited in the hospital and its premises. i. 1st offense: Warning ii. 2nd offense: Suspension of O.R. privilege for one week iii. 3rd offense: Suspension of O.R. privilegde for three weeks

VI. PATIENT CARE a. Routine calls – 15 minutes response time i. 1st offense: Warning ii. 2nd offense: One Sunday duty iii. 3rd offense: Two Sunday duties b. Emergency calls – 5 minutes response time. i. 1st offense: One Sunday duty ii. 2nd offense: Two consecutive Sunday duties iii. 3rd offense: Four consecutive Sunday duties c. Cardiac Arrest calls – 2 minutes response i. 1st offense: Penalty as 6b.

For routine and emergency calls, a preliminary telephone response has to be made in case the resident is tied up in patients service.

d. Negligence in care and management of patients. i. 1st offense: One Sunday duty ii. 2nd offense: Three consecutive Sunday duties iii. 3rd offense: DISMISSAL

VII. RECORDS a. Negligence in disposition of Surgical specimens i. 1st offense: Suspension of O.R privilege for two weeks ii. 2nd offense: Suspension of O.R. privilege for four weeks iii. 3rd offense: DISMISSAL

Mandaluyong City Medical Center CLINICAL DIVISION

b. Failure to complete medical records within 24 hours from posting of deficiency or proper notification by personal communication. i. 1st offense: Warning ii. 2nd offense: One Sunday duty iii. 3rd offense: Two Sunday duties

c. RECORDS Offenses in the category of violations of the laws of the land will be dealt with the proper authorities.

VIII. For the offenses and/or incidents that may arise and are not covered by the above, the punishment will be at the discretion of the Hospital Director and/or the Chairman of the Department or their authorized representatives.

 Areas of Activities:  OPD: separate and exclusive for OB-GYN with supervision from the OPD consultant* I. Gynecology Clinic and Pap Smear every Monday 8:00 a.m to 5:00 p.m II. Prenatal Clinic (normal) every Tuesday and Wednesday 8:00 a.m to 5:00 p.m., and Saturday’s 8:00 a.m to 12:00 p.m III. High Risk Pregnancy Clinic every Thursday 8:00 a.m to 5:00 p.m. IV. Family Planning every Friday 1:00 p.m to 5:00 p.m V. Specialty Clinics: a. Perinatology Clinic every 1st and 3rd week of the month 1:00 p.m to 3:00 p.m under the supervision of Dr. Mario Bernardino b. Trophoblastic Diseases Clinic 1st and 3rd week of the month 2:00 p.m to 4:00 p.m under the supervision of Dr. Carmen Quevedo c. Ultrasound Clinic every Saturday 8:00 a.m to 12:00 p.m under the supervision of Dr. Laarni Diaz.

* OPD Consultants is the consultant on duty for the week.

 In-service: Areas of Activities I. Admitting or ER (with separate section exclusive for OB-GYN) II. OPD – separate section exclusive to OB-GYN III. Labor room \ separate and exclusive IV. Delivery room / support staff V. Operating room \ shared with surgery VI. Recovery room / Department Mandaluyong City Medical Center CLINICAL DIVISION VII. Critical Care Unit: at hospital Intensive Care Unit VIII. OB-GYN Ward: with rooming – in/ breastfeeding set-up IX. Conference room – shared with other departments. X. Laboratory: within hospital premises XI. Blood storage facilities XII. Surgical Pathology: within hospital premises XIII. Ultrasound – housed in the labor room

 External Rotations I. Surgical Phatology – for 2nd year residents, 3 months, Quirino Memorial Center. II. Perinatology – for 3rd year residents, 3 months, Philippine Children’s Medical Center. III. Oncology/Endocrinology – for 4th year residents, 1 month each, UP-PGH

 LEARNING RESOURCES  Clinical Materials I. Annual Statistics II. Daily Census III. Performance Logbooks IV. Nationwide Statistics

 Library – equipped with basic textbooks, specialty books, foreign and local journal  Hospital Facilities I. Ultrasound II. Fetal Monitor

 YEAR LEVEL COMPETENCIES  FIRST YEAR OF RESIDENCY TRAINING I. Care of uncomplicated pregnancy a. antepartal b. intrapartal c. postpartal II. Diagnosis and management of uncomplicated abortions III. Emergency management of OB-GYN patients at high risk (initial care prior to referral for definitive management), immediate care of newborn. a. Obstetrics patients at risk: i. Hypertensive complications

Mandaluyong City Medical Center CLINICAL DIVISION 1. Pre-eclampsia, Eclampsia, CHVD ii. Hemorrhage complications 1. Ectopic pregnancy 2. Abortion 3. Gestational Trophoblastic disease 4. Late placenta previa 5. Abruption placenta 6. Uterine inversion, uterine rupture 7. DIC 8. Post-operative bleeding iii. Medical Complications 1. Pulmonary edema 2. Heart Failure 3. Infections 4. Septic Shock 5. Anuria, etc. iv. Fetal compromise/fetal distress 1. Cord accidents 2. Abruptions placenta 3. Trauma

b. Gynecologic patients: i. Hemorrhage complications 1. Benign tumors 2. Malignant tumors 3. Dysfunctional uterine bleeding ii. Infectious complications

c. Resuscitation of a newborn

IV. Ambulatory Care (Office gynecology and obstetrics) a. Office Gynecology – common gynecologic problems such as: i. Diagnosis and management of genitourinary tract infections (including STD’s) ii. Diagnostic procedures and their interpretations iii. Diagnosis of benign and malignant tumors (and subsequent referral for definitive management) iv. Menstrual disorders

b. Obstetrical Care: i. Antenatal care for normal pregnancy

Mandaluyong City Medical Center CLINICAL DIVISION ii. Recognition of high risk pregnancy and when to refer for definitive management.

V. Performance of minor surgical procedures for diagnosis and therapy; Assistive surgery. a. Cervical and endometrical biopsy b. Curettage: diagnostic or fractional c. Marsupialization d. Incision and drainage e. Excision biopsy (including use of Keyes punch) f. Cautery either electro or chemical g. Outlet forceps h. Episiotomy and repair i. Repair of Lacerations, evacuations of hematoma j. Manual extraction of the placenta k. Analgesia, local infiltration, pudental block, pain control l. Assistive surgery m. Bilateral tubal ligation

VI. Public Health Services a. Pap smear b. STD control and counseling c. Immunization d. Breastfeeding advocacy and counseling lactation management. e. Family Planning Services (natural and artificial) f. mother’s classes

VII. Case Report

 SECOND YEAR OF RESIDENCY TRAINING I. Care of complicated pregnancies a. Abnormalities of Labor, delivery, and puerperium in normal pregnancies b. Resuscitation of the newborn

II. Diagnosis and management of gynecologic disorders a. Developmental anomalities of the genital tract (imperforate hymen) b. Benign adnexal tumors c. Ectopic pregnancy, ruptured or unruptured, with stable vital signs.

Mandaluyong City Medical Center CLINICAL DIVISION III. Pre-operative and post-operative care, anesthetic care and pain control in OB-GYN patients.

IV. Performance of minor gynecological surgical procedures: a. Culdocentesis b. Culdotomy and drainage

 THIRD YEAR AND FOURTH YEAR OF RESIDENCY TRAINING I. Care of complicated pregnancies a. Abnormalities of labor, delivery, and puerperium in high-risk procedures b. Diagnosis and management of gynecologic disorders i. Benign uterine tumors ii. Premalignant lesions of the cervix, vulva, and vagina iii. Early malignant uterine lesions not requiring tertiary care. iv. Borderline or malignant adnexal tumors v. Abdomino-pelvic infections c. Performance of complicated vaginal gynecologic procedures when indicated. i. Obstetrical 1. Cesarian hysterectomy (total or subtotal) ii. Gynecological 1. Abdominal hysterectomy a. Intrafascial, extrafascial b. Subtotal, total 2. Omentectomy 3. Appendectomy 4. Repair of wound dehiscence, incisional hernia 5. Myomectomy d. Emergency and critical care in OB-GYN patients i. Diagnosis and management of complications ii. Surgical, medical, infectious (sepsis) e. Basic Research – Prospective Study f. Basic concepts and skills of Level III care i. Ambulatory care of infertility problems and menopause 1. Basic skills for diagnostic work-up

Mandaluyong City Medical Center CLINICAL DIVISION 2. Diagnostic procedures and interpretation, and subsequent referral for definitive management. ii. Ambulatory care of pre-malignant and malignant tumors. iii. Ambulatory care and definitive management of high risk pregnancy.

Table 1. Technical Objectives per Year Level 1ST 2ND 3RD 4TH PROCEDURES YEAR YEAR YEAR YEAR NSDs 50 20 Episiorrhaphy 25 10 Outlet Forceps 2 3 5 5 D and C 20 20 Manual, Placental, Extraction 3 Evacuation of H. mole 1 1 Adnexal Procedures 2 4 4 Cesarean Sections 20 30 Abdominal Hysterectomies 5 10 Vaginal Hysterectomies 1 1 CS Hysterectomies 1 1  The terminal competence at the end of the four-Year residency training program are:  Render competently LEVEL II SERVICE IN OB-GYN and provide the TERTIARY LEVEL cases the necessary basic diagnostic tests and appropriate interim management preparatory to referral to the subspecialist without undue delay, recognizing the limitation of his capabilities of training.  Provide consultancy service in matters pertaining to OB-GYN to the community of physicians, other professionals and the community at large in the locality of choice.

 EVALUATION METHODS FOR TRAINING  Internal I. Formative a. Oral Examination b. Patient management problems c. Record review

Mandaluyong City Medical Center CLINICAL DIVISION d. Comprehensive examinations given every 6 months

II. Summative a. Oral examination b. Rating scale/checklist

 External I. PBOG In-Service II. PBOG Accreditation Team

 FACULTY  CONSULTANT STAFF I. Department Chair: Julieta Cepe Cadano, MD, FPOGS II. Training Officer: Ma. Rosario Laarni Diaz, MD, FPOFS, FPSUOG  ACTIVE TRAINING STAFF: I. Ruth Ringor – Abatay, MD, FPOGS II. Vina Adora Soriano – Jose, MD, FPOGS, FPSUOG III. Hermoine Enriquez, MD IV. Ma. Margarita G. Cuesta, MD, DPOGS  INVITED CONSULTANTS (Honorarium basis) I. Rey delos Reyes, MD, FPOGS – oncology II. Mario Bernardino, MD, FPOGS – Perinatology III. Carmen Quevedo, MD, FPOGS – Trophoblastic Diseases  MEDICAL SPECIALIST: I. Pecos Camarines, MD II. Ernesto Lactaoen, MD III. Brenda S. Rosario, MD IV. Judylaine Aguilar, MD V. Charito Malibiran, MD VI. Arlene G. Villamor, MD VII. Shelma Villanueva – Ramos, MD VIII. Sherry Mamasig, MD IX. Cecilia B. Nogoy, MD

 QUALITY ASSURANCE ACTIVITIES  Weekly Census and Statistics  Weekly Surgical Audit  Perinatal Conference – every 2nd Wednesday of the month  Hospital Morbidity and Mortality – every 1st Friday of the month  Residents Hour – Weekly lecture conference with training Officers; every Saturday, 9 am – 11 am.

Mandaluyong City Medical Center CLINICAL DIVISION

 INSTITUTION PROGRAM EVALUATION  POGS in-service examination by all residents stared 1997.  POGS accreditation team for in-service and residency traininhg accreditation.  POGS in-service training for training whenever given residency training accreditation conferences.

 THE INTEGRATION OF ULTRASONOGRAPHY IN THE RESIDENCY TRAINING PROGRAM IN OBSTETRICS AND GYNECOLOGY

As early as February of 1999, the integration of untrasonography in the Residency Training Program of the department has already been conceived. In line with the view of POGS, phasing of the program includes the following:

a. Training Faculty Ma. Rosario Laarni C. Diaz, FPOGS, FSUOG

b. Equipment and Infrastructure Concurrent with the integration of ultrasound in the Residency Training Program, permission was sought by Dr. Diaz from the hospital administration to allow access of the department to the ultrasound machine. Presently, Saturdays are devoted to the exclusive use of the ultrasound by the department.

The department has also prioritized the acquisition of a department owned ultrasound machine as first among the new equipment to be purchased and installed in the delivery room of the new hospital building. It is hoped that with proper lobbying, adequate budget will be allocated for this.

c. Curriculum The department is full agreement with POGS regarding the implementing guidelines towards the development of knowledge and skills of residents in accordance with their year level. To cite the curriculum advocated by POGS are as follows:

i. Year Level I 1. Understand the basic principle of the technology, ultrasonography, and design of equipment. 2. Demonstrate the functions of the different parts of the ultrasound machine and the proper care and maintenance.

Mandaluyong City Medical Center CLINICAL DIVISION 3. Understand the uses, benefits, indications, limitations and hazards of the technology in the specialty and other concerns of the woman and the girl infant/child. 4. Utilized the technology in understanding normal pregnancy and the different phases of the life cycle of the woman. 5. Recognized the ultrasound pictures of the pregnant uterus, fetus and placenta as well as the pelvic organs from abdominal (pelvic) and transvaginal ultrasonography under normal conditions in the different phases of the life cycle of a woman and girl infant/child. 6. Recognized deviations from the normal that affect interpretation of results of the ultrasound examination.

ii. Year Level II 1. Recognized the ultrasound pictures/images of common pathological conditions in the different phases of life of the woman or girl infant/child as well as in pregnancy and fetal development. 2. Interpret results of the technology in the diagnosis of common pathological conditions. 3. Apply the results of technology to affirm or improve/disapprove clinical diagnosis and management. 4. Cite advantages/disadvantages of ultrasonography in diagnosis and management. 5. Compare the limitation of ultrasonography to clinical diagnosis and other technology in the diagnosis of given pathologic clinical situations. 6. Describe the procedure of ultrasound imaging and the requirement for examination. 7. Identify ethical issue/problems in the use of this technology.

iii. Year Level III 1. Demonstrate the sensitivity to patient’s concern in the performance of the basic procedures. 2. Demonstrate the proper technique of producing the images and accurate measurements in different clinical situations, normal and abnormal. 3. Demonstrate the following: a. Proper utilization of graphs and charts b. Proper reporting of results 4. Discuss the ethical concerns in examination and disclosure of results to patients/referring doctors. 5. Interpret the results of ultrasonography in the light of the current clinical diagnosis and management. 6. Discuss the advantages/limitations of the technology in relation to other methods of diagnosis and effects on management in a given clinical situation.

Mandaluyong City Medical Center CLINICAL DIVISION 7. Describe the procedures/interventions (that have been demonstrated / observed) that can be made under ultrasound guidance.

iv. Year Level IV 1. Exhibit refinement in the basic skills in ultrasonography. 2. Interpret result of ultrasonography in critical situations requiring expeditions, clinical judgement or interventions. 3. Identify oppurtunities for research and investigation in ultrasonography. 4. Observe related or new development that improve/expand the reliability of this technology in clinical diagnosis and decision making. 5. Utilize collective data and interpretation in a research investigation/study.

The only disagreement with the POGS’ implementing guidelines is department’s belief that the development of knowledge, skills and practical application of ultrasonography in a clinical set-up cannot be achieved in a continuous three months rotation. Akin to the training of gynecologic surgeon, these faculties must be developed through a gradual but continuous process.

Because of this current set-up in the ultrasound clinic, mandates that on duty residents not tied up to clinical work be present in addition to the resident-in-charge of the case. Patients are scanned by the resident-in-charge regardless of their year level with help of the trainor. Regular didactins are given during weekdays. Interventional ultrasound as in hysterosonography cases are decked among the most senior resident.

Since the set-up is relatively new, just like the newly accredited Residency Training Program, it is hoped that after a year, the whole department can set together hopes to be able to fully implement the integration of the ultrasound in the Residency Training Program way before the POGS target date.

Ma. Rosario Laarni C. Diaz, MD

Mandaluyong City Medical Center CLINICAL DIVISION

APPENDIX A What the General OB-GYN needs to know and can do in Perinatology?

KNOWLEDGE a. Fetal Physiology b. Fetoplacenta physiology c. Effects of maternal conditions on the fetus (Pathophysiology) d. Correlation of maternal condition, fetal effects and neonatal course. e. Principles of the different technology in fetal assessment indicating their use, their limitations: i. Electronic fetal monitor ii. Ultrasound iii. Biochemical tests f. Principles of fetal resuscitation g. Criteria for referral to perinatologist for counseling.

SKILLS Clinical assessment of fetal growth and well-being (fetal surveillance) Technique of electronic fetal monitoring. Recognition of abnormal test results and correlation of clinical findings as compared to normal in electronic fetal monitoring and ultrasound alter proper interpretation of test results by expert (those in training) Resuscitation of the newborn.

Mandaluyong City Medical Center CLINICAL DIVISION

APPENDIX B What the general OB-GYN should know and can do in Gynecologic Oncology? KNOWLEDGE Pathology and general clinical behavior of malignancies of the pelvic organs (Reproductive tract). Risk factors and their value in early diagnosis. Principles of diagnosis particularly screening procedures and impact on surgical and disease control. Usual modes of spread. Staging – clinical and surgical correlation with survival Basic principles and treatment and follow-up - treatment - indications and criteria for referral - delineation of responsibility – role in management. Prognostic factors Principles of counseling. DIAGNOSTIC PROCEDURES Pap smear/cytology Staging: clinical and surgical Colposcopically guided biopsy Endocervical curretage Multiple biopsies: i. Punch ii. Section iii. Excision iv. Needle aspiration Dilatation and curretage (diagnostic, fractional) Cone biopsy (cold cone, LEEP) Endometrial biopsy Vulvar biopsy (Keyes punch, Section, Excision)

Mandaluyong City Medical Center CLINICAL DIVISION Ultrasound Hysteroscopy and biopsy Tumor markers MANAGEMENT Tumor markers i. Emergency management 1. Hemorrhage 2. Infection 3. Obstruction (GUT or GIT) ii. Definitive (refer to subspecialist) 1. Criteria for referral 2. Counseling iii. Long term follow-up

APPENDIX C What the general OB-GYN needs to know and can do in Gyn Endocrinology and Infertility?

KNOWLEDGE Risk factors for infertility and impact on reproductive health. Pathology and clinical behavior of common endocrinology disorders, or gynecologic problems affecting fertility and/or causing infertility: - DUB - Endometriopsis - Amenorrhea and ovulatory cycles - Infections - Congenital or debelopment anomalities Basic principles of diagnosis and management of infertility and common endocrinologic disorders. Uses of laparoscopy and ultrasonography (and other technology) analysis of result for diagnosis and manegement of infertility Assisted reproductive technology, microsurgery: their indications and basic principles in the management of infertility.

SKILLS Basic skills for work-up of infertility. Diagnosis procedures for determination of ovulation (BBT, Billings, etc.) their interpretation and limitation in their use. Hysterography and other tubal patency tests (tubal insufflation, retrograde instillation of dye, technique and interpretation) Ultrasonography – use and interpretation (follicle monitoring) Hysteroscopy

MANAGEMENT

Mandaluyong City Medical Center CLINICAL DIVISION tubal plasty (microsurgery) Adhesionlysis Ovulary stimulation and monitoring (Clomiphene Ciltrate, hMG-hCG,etc.*)

Diagnostic laparoscopy*

DEFINITIVE MANAGEMENT Cervical Cancer i. Diagnostic/Clinical Staging 1. Stage 0 or CIN I – III, Stahe Ia - Cryotherapy - Conization - Total abdominal hysterectomy with or without BSO ii. Cases to refer to oncologist for appropriate theraphy - Stage IB and later stages - Cervical CA concomitant with pregnancy iii. Follow-up (defines roles)

Endometrial Carcinoma iv. Diagnostic/Clinical Staging 1. Initial management for clinical stage I - Peritoneal washing for cytology - exploration for surgical staging to include lymph node assessment. - extrafascial abdominal hysterectomy and RSO v. Refer to oncologist for appropriate theraphy the following cases: 1. Stage I after pathologic diagnosis for opinion and/or further management. 2. Stage II and later stages 3. Pelvic lymphadenectomy 4. Adjuvant or neo-adjuvant therapy, chemotherapy or radiotherapy or hormonal therapy. vi. Follow-up (defines roles) with training gynecologist

Ovarian Cancer vii. Initial exploration 1. Staging 2. Peritoneal cytology 3. Appropriate surgery: a. Complete Surgery i. TAHBSO ii. Surgical Staging iii. Peritoneal fluid cytology

Mandaluyong City Medical Center CLINICAL DIVISION iv. Lymph node assessment b. Tumor reductive Surgery i. Omentectomy ii. Excisable implants c. Bilateral S & ) d. Consecutive Surgery – USO e. Other indicated procedures

viii. Refer to oncologist for further management of the cases: 1. Patients for adjuvant therapy a. Chemotherapy b. radiotheraphy c. Difficult therapy

ix. Follow-up

Vaginal and Vulvar Cancer x. Biopsy to confirm Diagnosis xi. Refer to oncologist for definitive surgery the following cases: 1. Conservative Surgery 2. Radical hysterectomy and lymph node dissection 3. Adjuvant radiotherapy 4. Other treatment xii. Follow-up (defines roles) xiii. Refer to Specialist 1. Microsurgery, tubal reanastomosis 2. Operative laparoscopy 3. Assisted reproductive technology (AT, IVF, GIFT etc.) 4. Ultrasonography 5. Ovulatory stimulation (cMG-hCG)

*With special training

Mandaluyong City Medical Center CLINICAL DIVISION

DEPARTMENT OF INTERNAL MEDICINE

I. OVERVIEW This manual will serve as guide for the department in general and will orient the user as to its policies and standards. The department's setup will be outlined in accordance to the overall framework of the hospital's structural and operational organization. Individual functions will be clarified so as to promote a smooth department operation in accordance to the hospital standard.

II. DEFINITION Refers to the branch of medical science that specializes on the curative and rehabilitation aspects of non-surgical care of adult patients in the following fields of sub-specialization:  Cardiology  Pulmonology  Gastroenterology  Endocrinology  Infectious  Nephrology  Immunology  Neurology  Dermatology  Toxicology  Oncology  Geriatric Medicine

III. GUIDING PRINCIPLES

Mandaluyong City Medical Center CLINICAL DIVISION The principle and commitment to provide only the best medical service to all patients mainly on the secondary level of healthcare and within its different fields of sub specialties and to serve within the framework of multi-disciplinary care guide the department.

IV. CONCEPTS The Department of Internal Medicine is mainly a service-oriented department. Its functions and operational standards for the different clinical services it offer are geared to answer the medical problems of the patients in the community.

Although the department does not offer a formal residency training in Internal Medicine, it can provide opportunities to resident physicians who carry out serviceoriented tasks to develop interest and a certain level of competency to provide professional care in the art and science of internal medicine.

V. ETHICS The Department of Internal Medicine will discharge its function with a human heart, sense and concern in accordance to the Hippocratic law that each physician is sworn upon. All patients will be given and accorded dignity, privacy and the right to self determine as to the modalities of treatment that the service will suggest and undergo if consented upon.

VI. PHILOSOPHY/MISSION/VISION To provide the community with the best as well as safe medical services mainly in the secondary, and partly in the tertiary levels of health care. VII. OBJECTIVES  To provide expert medical care to the constituents of Mandaluyong City.  To enable our medical residents to practice and develop further their clinical skills and competence as they address health problems in the local setting.

VIII. GENERAL FUNCTIONS  Provision of ambulatory care in the out-patient clinics  Provision of emergency care in the emergency room for medical cases  Admission and Provision of in-patient management of medical cases  Provision of specialized care in conjunction with other multidisciplinary specialties  Accepts and extend appropriate services in any interdepartmental referrals  Provide critical care services for patients needing such in the intensive . care unit

IX. GENERAL POLICIES AND STANDARDS  Guiding Principles regarding Referrals to the Medical Service

Mandaluyong City Medical Center CLINICAL DIVISION  All referrals to the Medical Service must be done formally, i.e. in writing preferably using official referral form. None verbal referrals will be answered by the Senior Medical Resident.  Referrals considered as emerge , such as evaluation of Headaches, Strokes, Seizures, Acute Behavioral Change, Chest Pains, Life-threatening Arrythmia, Heart Murmurs, Hypertension, Hypotension, Acute Abdominal Pains, GI Bleeding, Bleeding Disorders, Acute Renal Failure, and the like must be answered by the Senior Medical Resident within 30 minutes from the time of referral.  Non-emergent referral such as evaluation of Weakness, Non-life threatening Arrythmias, Polycythemias, Joint pains and swelling, Low Back pains, Abnormal Urinalysis findings, Mild acid-base disorders, Fever and the like may be answered by the Senior Medical Resident within 24 hours from the time of referral.  Referring Consultant/Resident must indicate the sub-specialty/ties or the point/s of the referral or must state the problems of the patient/s on the referral forms, which are to be evaluated by the Senior Medical Resident.  Because of our limited facilities, patients with Psychiatric Illnesses, serious Hematologic problems, and others, must be referred, as soon as ppssible to other health institutions for better care, which are more capable of handling such problems.  In cases wherein referred in-patients need intensive care but the hospital ICU is full, all effort must be exerted by the refenin Department in transfening the patient to other institutions. However, if no hospital would accommodate such patients, then we have no option but to manage them in our regular ward, and render them the best care possible.  The Senior Medical Resident who answers the referral must follow-up the referred patients progress regularly, till he decides to sign off or till the patient is discharged.  Transfer of in-patients to the Medical Service maybe done by Wroval of the Senior Medical Resident of the Medical Service.

Mandaluyong City Medical Center CLINICAL DIVISION

X. ORGANIZATIONAL SET-UP/ STRATEGIES and PROCEDURES

 ORGANIZATIONAL STRUCTURE

MAYOR

HOSPITAL DIRECTOR

DEPUTY DIRECTOR for PROFESSIONAL SERVICES

CHIEF of CLINICS

CHAIRMAN, DEPARTMENT OF INTERNAL MEDICINE

MEDICAL WARD INTENSIVE CARE UNIT

ASSISTANT CHAIRMAN or TRAINING OFFICER

CARDIOLOGY PULMONARY GASTROENTEROLOGY

Mandaluyong City Medical Center CLINICAL DIVISION NEPHROLOGY ENDOCRINOLOGY NEUROLOGY ONCOLOGY DERMATOLOGY

SENIOR MEDICAL RESIDENTS

JUNIOR MEDICAL RESIDENTS

 WORK FLOW  Out-patient Clinics I. Please see the OPD section workflow

 Emergency Room I. Please see the workflow of emergency room

 Rounds/Management of In-patients I. To follow

 Referrals

REFERRING SERVICE/DEPARTMENT COMPLETES AN OFFICIAL REFERRAL FORM

REFERRAL WILL BE FORWARDED TO SENIOR RESIDENT ON DUTY

IF EMERGENCY REFERRAL

SROD WILL ANSWER (WITHIN 30 MINUTES) REFERRALS

SROD WILL UPDATE AND INFORM CONSULTANT OF THE REFERRAL

Mandaluyong City Medical Center CLINICAL DIVISION SROD WILL THEN FOLLOW-UP THE PATIENT UNTIL MEDICAL PROBLEM IS RESOLVED

 CLIENTELE  All patients consulting for medical problem at the Out-patient Department.  All patients presenting with critical medical condition at the emergency room3. All In-patients admitted at the medical wards  Referral cases referred to the department for indicated reasons  All patients confined with critical medical indications at the intensive care unit.

XI. STRATEGIES AND PROCEDURES  Standard Operating Procedures of Cardio- Pulmonary Clearance  All patients referred for the CP clearance must have completed History and Physical Examination in the chart, ECG strip and/or result, and chest x-ray films and/or result and pertinent laboratory results in. Patients for Cardio - Pulmonary clearance prior to their contemplated surgical procedures must be 35 years old and above or below 35 years old only if they have significant cardiovascular or pulmonary or other medical disorders.  Patients who are to undergo STAT surgical procedure must be evaluated by the Senior Medical Resident within One (1) hour from the time of the referral.  Patients who are to undergo elective surgical procedures must be evaluated by the Most Senior Medical Resident on OUTPATIENT basis at least TWO (2) days PRIOR TO THE DAY OF OPERATION. The schedule of the CP Clearance is 9:00 a.m. to 11:00 a.m. and 2:00 p.m. to 4:00 p.m. every Tuesday and Fridays. Minimum ancillary procedures that are required are CBC, ECG 12 lead, and Chest x-ray PA. However, other laboratory examinations or ancillary procedure maybe requested by the Senior Medical Resident Service Consultant if such are deemed necessary.  The Senior Medical Resident may suggest to defer the performance of the contemplated surgical procedures if in the course of his/her examination at that time, he/she finds the patient unfit for such operational.  The Senior Medical Resident who grants the CP clearance must be available during the time of operation to answer STAT referrals intraoperatively. In his/her absence, the next Most Senior Medical Resident will assume his/her responsibilities.

Mandaluyong City Medical Center CLINICAL DIVISION  Medical problems that surface post - operatively must be referred back to the Senior Medical Resident or to the Medical Resident on Duty (MROD) by the Attending Surgical Resident.  The medical evaluation shall remain independent of any evaluation by other services, and is not to be construed as superceding any other services opinion, who may concur or assess to the contrary of the given pre-operative clearance.  Intra-operative cardiac monitoring maybe done ad-lib by the Most Senior Medical Resident. If intraoperatively, the Surgical or Anesthesia Consultant decided to have the patient to be monitored cardiacwise, The Senior Medical Resident must see the patient upon notification for the intraoperative cardiac monitoring. Such accommodations may not always be possible. Should cardiac monitoring be needed intraoperatively, on the evaluation of the Surgical/Anesthesia Resident, the matter should be personally discussed with Medical Resident.

 Standard Operating Procedures of Referrals to the Medical Service  All referrals to the Medical Service must be done formally. i. e. in writing preferably using the official referral form. No verbal referrals will be answered by a Senior Medical Resident.  Referrals considered as emergent, such as evaluation of Headaches, Strokes, Seizures, Acute Behavioral Change, Chest Pains, Life Threatening Arrhythmia, Heart Murmurs, Hypertension, Hypotention, Palpitations, Syncope, Dyspnea, Hemoptysis, Hypoglycemia, Acute Abdominal Pains, G1 Bleeding, Bleeding Disorders, Acute Renal Failure, and the like must be answered by the Senior Medical Resident within 30 minutes from the time of referral.  Non-emergent referral such as evaluation of Weakness, Non-life threatening rrythmias, Polycithemias, Joint Pains and Swelling, Low Back Pains, Abnormal urinalysis findings, Mild acid-base disorders, Fever and the like, maybe answered by the Senior Medical Resident within 24 hours from the time of referral.  Referring Consultant/Resident must indicate the sub-specialty/ties or the point/s of the referral or must state the problems of the patient/s on the referral forms, which are to be evaluated by the Senior Medical Resident.  Because of the our limited facilities, patients with Psychiatric illness, Serious Hematologic problems, and others, must be referred, as soon as possible to other health institutions for better care, are more capable of handling such problems.  In cases wherein referred In-patients need intensive care but the hospital ICU is full, all efforts must be exerted by the referring Department in transferring the patient to other institution. However, if no hospital would accommodate such patients, then we have no option

Mandaluyong City Medical Center CLINICAL DIVISION but to manage them in our regular ward, and render them the best care possible.  The Senior Medical Resident who answers the referral must follow-up the referred patient's progress daily, till he decides to sign off or till the patient is discharged.  Transfer of In-patients to the Medical Service maybe done by approval of the senior Medical Resident or the Chief Resident of the Medical Service.

XII. INTENSIVE CARE UNIT  Functions of an I.C.U.:  Detection and treatment of life threatening arrhythmias.  Early detection and management of impending cardiorespiratory arrests.  Prompt detection of serious changes in vital signs and neurological status.  Anticipation of the onset of life threatening complications.  Monitoring the effects of drug therapy.  Maintaining an adequate pulmonary function for patients with pulmo decompensation.  Provision of readily available equipments, drugs, and personnel for the management of medical emergencies and its complications.

 Admission Policies / Procedures  Cases Admissible in the I.C.U. I. Unstable Cardiopulmonary conditions (A.M.I., C.H.F., Arrhythmias, Status Asthmaticus, Pulmonary Congestion, Embolism, etc.) II. Hemodynamic Compromise (Shock states with any etiology) III. Impaired Sensorium from C.V.A.’s IV. Acute Renal Shutdown +/- necessitating dialysis V. Complicated Post-operative states VI. Other cases that may need critical care.

 Cases Not Admissible in the I.C.U. I. Terminally ill II. Mentally disturbed III. Violent Alcoholics

Mandaluyong City Medical Center CLINICAL DIVISION IV. Contagious Diseases

 Procedures I. Only patients who meet the admission criteria can be admitted. II. The admitting Resident / Consultant will be responsible for requesting Admissions / Transfer of patients to the I.C.U. III. Standard Operating Procedures for the I.C.U. Nursing Staff / Admitting Resident should be strictly followed and are identified in the next time.

 S.O.P. for Admission of Patients to I.C.U. I. Admitting Resident / Physician a. It shall be the full responsibility of the admitting physician to notify the I.C.U. Nurses that a patient is to be admitted to the unit giving at least all S-O-A-P summary of patient profile, admitting diagnosis and what to closely monitor. Generally, no patient should be brought to the unit without proper notification of the I.C.U. staff. This is to allow them to prepare all needed materials before patient is brought in.

It is a must that the I.C.U. Nurses get a clear picture of what the patient’s serious medical problems are.

b. An S-O-A-P form of Admitting notes it to be accomplished by the Admitting Resident within 2 hours after admission. However, completion of the standard History and P.E. form should be in the Chart within 12 hours after admission to I.C.U. c. It shall be the full responsibility of the Admitting Physician NOT the Nurses, to notify the Attending Consultant of any I.C.U. admission – giving him/her a comprehensive picture of patient’s status. d. The Chairman of the I.C.U. must be notified by the Admitting Resident of any admission to the unit within the Admitting day, regardless of the service. e. All Chart entries must be signed complete with date and time.

Mandaluyong City Medical Center CLINICAL DIVISION f. All orders must be preceded with a progress note or summary of present Status/Findings that would justify the orders. This is (1) to facilitate inquiries that may be given by the Patient’s Relatives and (2) for the Nursing Staff to have a wider understanding of the case. g. Physician-in-charge must see the admitted patient at least 3 x during the day without the necessity or a written order by the Attending Consultant and progress notes must be in after each visit. At night, the Physician- on-duty is required to see the patient at least twice and progress notes must also be in, - all without the necessity of any written order from the Consultant. h. During night duty hours, the Senior Physician on Duty / I.C.U. Officer automatically takes the responsibility of all I.C.U. patients’ in their respective services, without the necessity of a written order from the Consultant. i. Whenever possible, the I.C.U. Officer / Senior Physician- on-duty should be staying in the I.C.U. if a patient on their service is in the unit.

II. I.C.U. Nurses: a. Prior to any admission of patient into the unit, the I.C.U. Nurse is expected to receive the endorsement rendered by the Admitting Physician taking note of the diagnosis and anticipating what should be prepared before patient arrives. (eg: oxygen, aerosol, monitor, etc.) b. It shall be the duty of the Nurse to (1) Advise patients’ relatives the need for at least one of them to be available anytime and to remind them of the general provisions of the I.C.U. posted near the I.C.U. door. c. As soon as the admitted patient is brought in, the patient may be given sponge bath with assistance from relatives / other Nurses and give I.C.U. gowns. d. Vital Signs should be checked at least every hour without the necessity of a written order from the Admitting Physician / Consultant. e. It should be checked as often as needed when ordered verbally / writing by A.M.D. / R.O.D. f. All untoward findings should be relayed at once to the Physician-on-duty / I.C.U. Officer. g. Relatives of each I.C.U. patient must be instructed to secure the following upon admission: i. Alcohol ii. Thermometer

Mandaluyong City Medical Center CLINICAL DIVISION iii. Soap iv. Tissue Paper v. Cotton Balls

 I.C.U. Apparel I. Nurses must wear the gowns always. II. Physicians entering the unit must remove their coats and wear I.C.U. gowns. III. Patients’ relatives entering the I.C.U. must wear I.C.U. gowns.

 General Regulations of The I.C.U. I. At least one relative of each patient in the I.C.U. should be available on stand-by near the I.C.U. premises. II. NO VISITORS ARE ALLOWED, except when explicitly written by the Attending Physician. Only one immediate family member of the patient may be allowed to approach the patient for not more than 10 – 15 minutes. Patients in the I.C.U. need maximum rest and should be emphasized to the relatives. III. I.C.U. staff should help patients keep their morals high and visitors should be advised before entering the unit to refrain from anything that may upset the patient. IV. No flowers, Sound Systems, Comics, Newspapers are, and will never be, allowed inside the unit. Radios with earphones may be permitted if allowed in writing by the Attending Physician. V. No foods are allowed in the Unit, unless the patients’ condition requires it. (Leftovers are to be thrown in the garbage can outside the unit, not in the I.C.U. garbage can.) VI. No visitor is allowed to eat inside the I.C.U. VII. Children of any age are not allowed to enter the I.C.U. VIII. No personal belongings of the patient are allowed in the patient’s bedside table. IX. No chairs / beddings / appliances can be brought by the patient’s relatives inside the I.C.U. as they may get in the way during emergencies. X. No smoking in any hospital premises. XI. I.C.U. telephone / intercom units shall be for I.C.U. purposes only. XII. Only I.C.U. patients are allowed to sleep in the I.C.U. No one else is. XIII. The unit reserves the right to refuse entry to anyone if in the staff’s opinion the function of the unit may be affected.

 When Visiting Can Be Allowed Beyond Visiting Hours. I. VISITORS:

Mandaluyong City Medical Center CLINICAL DIVISION a. The general rule is that no visitors should be allowed. A.M.D.’s may allow 1 immediate family members as visitors daily at the designated time only 12:00 NN – 1:00 PM or 7:00 PM – 8:00 PM

II. EXCEPTIONS: a. When patient is in very critical conditions or moribund. b. When the visitors came all the way from province or distant place and are not aware of these visiting hours. c. The limited visiting hours due to nature of work or any inevitable circumstances. d. For post-op patients, immediate family members must be able to see patient, the soonest possible time.

 Utilization of I.C.U. Equipments I. Use of any equipments for I.C.U. patients whether the machine is I.C.U. – based or not, necessitates a properly accomplished charge slip before use, done in duplicate. II. No I.C.U. Equipments can be taken out of the unit without a written request to the I.C.U. Chairman and his subsequent approval. III. In the event that equipments like respirator need to be outsourced from a third party, it shall be the sole responsibility of the equipment provider not the hospital with regards to the safety and efficiency of the machine.

 Utilization of I.C.U. Stock Medications I. To prevent misunderstanding with patient’s relatives, all medications received by I.C.U. Nurses from the patients’ relatives should be entered in a logbook specifically used for this purpose. II. All medications / materials supplied by the hospital to the patient should have a charge slip.

 Signature Specimen / Directory All Hospital Medical Staff members involved or who may be involved in I.C.U. patients must submit an updated calling card and indicate their specimen signatures in the corresponding logbook for this purpose. Better yet, all attending MD should sign on top of their printed names.

 Profile Of Patient Chart The arrangement of forms in each I.C.U. patient chart should be in accordance to the standard procedure.

Mandaluyong City Medical Center CLINICAL DIVISION  Monitoring of Problems In I.C.U.  All problems occurring in the I.C.U. whether patient-related or not or involving the unit or its staff, directly or indirectly, should be entered in the logbook provided for this purpose.  Complainant should / must affix his/her signature and this should be countersigned by the Nurse-on-duty.  Any comments, suggestions, complaints should be relayed to the concerned person AND to the I.C.U. Chairman always at the soonest possible time.  Any actions or relayed intended actions should be entered in the logbook by the relaying nurse.

XIII. ADMINISTRATIVE POLICIES  General/Basic Qualification Standards of the Different Position Levels

 Medical Specialist III I. Should be a Doctor of Medicine II. Experience - 2 years relevant experience III. Training - 8 hours of relevant training IV. Eligibility- RA 1080

 Medical Specialist II I. Should be a Doctor of Medicine II. Experience - 1 years relevant experience III. Training - 4 hours of relevant training IV. Eligibility- RA 1080

 Medical Specialist I I. Should be a Doctor of Medicine II. Experience - 1 years relevant experience III. Training - 4 hours of relevant training IV. Eligibility- RA 1080

 Medical Officer IV I. Should be a Doctor of Medicine II. Experience - 1 years relevant experience III. Training - 4 hours of relevant training IV. Eligibility- RA 1080

 Medical Officer III I. Should be a Doctor of Medicine II. Experience – none required III. Training – none required

Mandaluyong City Medical Center CLINICAL DIVISION IV. Eligibility- RA 1080

DEPARTMENT OF SURGERY

I. INTRODUCTION: The Department of surgery is one of the major clinical departments of the Mandaluyong City Medical Center. Their main purpose is to render service to patients in need of surgical care. The department likewise holds a commitment to have its residents it become skilled and competent surgeons.

II. HISTORICAL BACKGROUND The Mandaluyong City Medical Center started as a maternity clinic when the then municipality of Mandaluyong acquired the property in 1985. After the EDSA Peoples Power of 1986 and with changes in the national and local government leadership, the clinic was improved and became a general hospital. It was in 1987 that the clinical services became departmentalized, thus the Department of Surgery was born. Through the years the department continues to improve its staff and services cathing up with the challenges of the ever evolving science and arts of Medicine in general and of the field of Surgery in particular.

III. DEFINITION As a specialty in the General Medicine, Surgery encompasses a wide variety of subspecialties, i.e., General Surgery, Thoracic and Cardiovascular Surgery, Pediatric Surgery, and Urology. In dealing with the basic forms of diseases – tumors, infections, trauma, congenital abnormalities, etc. – its approach is multimodal and not limited to surgical operations alone.

IV. GUIDING PRINCIPLES In as much as the aims of surgery today are the same four centuries ago; the Department of Surgery of Mandaluyong City Medical Center adopts the teachings of Hippocrates, the author of all medical arts:

Mandaluyong City Medical Center CLINICAL DIVISION “Now a surgeon should be youthful or at any rate nearer youth than age; with a strong and steady hand which never trembles, and ready to use the left hand and as well as the right; with vision sharp and clear, and spirit undaunted; filled with pity, so that he wishes to cure his patient, yet is not moved by his cries, not to go too fast, or cut less than is necessary; but he does everything just as if the cries of pain causes him no emotion.”

V. CONCEPTS The department follows the concept of a perfect chirurgien: the first, that he be learned; the second, that he be expert; the third, that he be ingenious; the fourth, that he be well mannered.

VI. DEPARTMENT NOMECLATURE  PHILOSOPHY The mission and vision of the Department of Surgery is to ease the pain or suffering of the afflicted with utmost care and expertise through sound surgical intervention and care.

 GENERAL OBJECTIVES  To provide quality care to patients through the exercise of sound surgical principles;  To provide an environment conductive to continuing medical education for the entire staff  To encourage academic growth among its constituents by instilling competence, ethical and moral values and a deep sense of responsibility;  To maintain a harmonious relationship with other departments that would ensure smooth and efficient conduct of work in the care of patients and in performing other hospital-related activities.

 GENERAL POLICIES AND STANDARDS  The staff of the Department of Surgery and its operations are governed by policies and standards which is consistent to the general policies and standards of the Mandaluyong City Medical Center. These policies and standards are enumerated on section III of the Department Manual.

 GENERAL FUNCTIONS  As a part of the Clinical Division of MCMC, the department is committed to the service of patients needing surgical treatment and care and other related therapeutic modalities. It has the following sections:

Mandaluyong City Medical Center CLINICAL DIVISION I. Out-Patient Section (OPD) where surgical consultations are done; II. Emergency Room (ER) for the treatment of acutely injured or seriously ill surgical patient; III. Wards (Male and Female) for patients needing confinement; IV. Operating Room (Major and Minor) where surgical procedures are done.

VII. ORGANIZATIONAL SETUP  ORGANIZATION/STRUCTURE The department of Surgery is subdivided into various fields of sub- specialization:  General Surgery  Orthopedic Surgery  Pediatric Surgery  Neurologic Surgery  Plastic/Reconstructive Surgery  Thoracic and Cardiovascular Surgery (TCVS)  Urologic Surgery

At least one consultant and a resident-in-charge man each sub-specialty.

The Section of General Surgery is further subdivided into four services:  GSI Head and Neck Surgery Breast and Esophagus  GSII Stomach, Duodenum Hepato-Biliary, Gall Bladder, Pancreas, Splean  GSIII Jejunum, Ileum, Large Intestines Hernias, Retroperitoneum, Intestinal Obstruction  GS IV All trauma cases

One consultant and at least two residents-in-charge man each service. Due to the existing lack of residents, the various sub-specialties are divided among the first three-GS service as follows:  GS I Neurologic Surgery Orthopedic surgery

Mandaluyong City Medical Center CLINICAL DIVISION  GS II Plastic Surgery Pediatric Surgery  GS III Thoracic and Cardiovascular Surgery Urologic Surgery

 ORGANIZATIONAL CHART(PROPOSED)

CONSULTANTS CHAIRMAN (MS II) GS

VICE – CHAIRMAN (MS I) GS

CHIEF TRAINING OFFICER (MS I) GS

NeuroSurgey Section Thoracic and Cardiovascular Surgery Section Pediatric Section Urology Section Orthopedic Surgery Section Plastic Section General Surgery Section

RESIDENTS CHIEF RESIDENT

MEDICAL OFFICERS MEDICAL SPECIALISTS*

Mandaluyong City Medical Center CLINICAL DIVISION

MO IV or higher MS I GS

MO III

DEPARTMENT SECRETARY

 STAFFING PATTERN  Existing Consultant Staff: I. Chairman – Jose Joey H. Bienvenida, MD, FPCS (MS –II) II. Training Officer – Adolfo Baviera, MD (MS – I)

 Section of General Surgery I. Edgardo Valle, MD II. Mario C. Lato, MD III. George B. Cheng, M.D.

 Section of Orthopedic Surgery I. Antonio Mario L. De Castro, MD II. Chuck Cabuquid, M.D.

 Section of Plastic Surgery I. Hector Santos, M.D.

 Section of Urology I. Jeff Peter J. Jubilado, MD II. Hector A. Jacinto, MD

 Section of NeuroSurgery I. Vacant  Section of Thoracic and Cardiovascular Surgery I. Vacant

 Section of Pediatric Surgery I. Josefina Almonte, M.D.

Mandaluyong City Medical Center CLINICAL DIVISION  Existing Resident Staff : I. Medical Officers a. Guillermo Amigo, Jr. MD b. Cesario C. Hernandez, MD c. Rosario Yap, MD d. Alexander Vuelta, MD e. Leslie B. Inocentes, MD f. Athena Neria-Enriquez, MD g. Carmina D. De Borja, MD h. Mira May G. Magsino, MD i. Rommel Q. De Leon, MD j. Jeejane Ezzel O. Adevoso, MD k. Mark Philip B. Besa, MD l. Liza Mae A. Malixi, MD II. Medical Specialists a. Wilmer M. Macarulay, MD b. Dennis P. Baltazar, MD c. Maj-Maj C. Deriada, MD d. Jose Roberto Q. Melendres, MD e. Timoteo Niel T. Trinidad, MD f. Basilio D. Diego, Jr., MD g. Redomir Roque, MD h. Maria Cecilia T. Leyson, MD i. Ahmaddini L. Alug, MD

 JOB DESCRIPTION OF THE SURGICAL RESIDENT (MO/MS):  The resident shall provide quality care to all surgical patients admitted, referred and seen at the OPD and ER;  He is required to assist or perform operations assigned to him;  He is responsible for the care and follow-up of patients admitted under his service and he is required to make regular rounds to make sure that his patients; needs are attended to;  He is required to actively participate in the department and hospital activities, conference and functions;  He is enjoined to take efforts in the learning process to update his surgical knowledge by reading assigned materials, and perform other pertinent functions delegated to him.

VIII. EQUIPMENT/FACILITIES The following facilities are important in the successful operation of the Department of Surgery:

 Emergency Room , its staff and equipment  Out-Patient Department , its staff and equipment

Mandaluyong City Medical Center CLINICAL DIVISION  Operating Room complex (Major, Minor, Recovery rooms)  Surgical Wards (Male and Female)  Department of Surgery Office and its equipment

IX. CLIENTELE The Department of Surgery, through its different subspecialties and GS sections, caters primarily to patients needing surgical interventions. Most of the patients come from the City of Mandaluyong, but non-residents are also entertained and treated specially in emergency cases.

X. STRATEGIES AND PROCEDURES OF SERVICE/SOP’s  THE EMERGENCY ROOM (ER)  The ER will be manned by at least one MO/MS 24 hours a day, 365 days a year;  Schedule of duties are as follows: I. Medical Officers on fulltime appointment are required to render service at least 40 hrs a week divided as one 24 hr duty and two 8 hours tours of duty. II. Medical Specialist on part time appointment are required to render service at least 20 hours a week equivalent to one 24 hr. duty.  Those on 24 hours of duty shall give priority to one emergency room.  Urgent surgical problems should be dealt with appropriately;  Urgent surgical problems that cannot be handled appropriately at the ER will be attended to at the Operating Room (OR) upon evaluation and recommendation of the Senior Resident on duty or the Consultant- on-Call;  Patients for admission in the ER should have been seen and evaluated by the Senior Resident who gives orders for admission. The Consultant-on-Call or Consultant-in-Charge should be informed about the admission, his instruction/recommendations carried out.  Patients requiring transfer to a more appropriate facility should have been evaluated by the Senior Resident or the Consultant-on-Call and deemed stable and fit for transfer  A record of all patients seen at the ER (outright surgical cases and referrals) should be kept in the separate department logbook (ER logbook) for future reference.

 THE OUT-PATIENT DEPARTMENT (O.P.D.)

Mandaluyong City Medical Center CLINICAL DIVISION  MO/MS are required to hold surgical clinics at the O.P.D. from Monday to Friday  The surgical clinic shall operate based on attached schedule.  Surgical patients with less urgent problems and follow-up shall be seen at the OPD. Patients requiring elective surgical operation should be seen in this area for appropriate work up and cardio-pulmonary clearance before they are scheduled for admission and operation  Management of patients at the OPD should be coordinated with the consultant-in-charge  MO/MS residents will be assigned to the OPD  A record of all patients seen at the Surgical Clinic will be kept in a separate logbook (OPD Logbook_ for future reference

 ADMISSION  Patients admitted under the Pay/Private Service will occupy private rooms under the care of the Consultant-in-charge. In cases when no vacant room available, a pay patient may be temporarily admitted to the ward. MS are not allowed to admit ____ private patients.  Patient admitted under the Charity service will occupy the ward beds under the care of the team on duty (MO/MS)  The need for confinement shall be assessed by the MO/MS on duty  All charity cases should be referred to the appropriate consultant-in- charge  Emergency admissions will take priority over the elective admissions  A record of all admissions (pay or charity) will be kept in a separate census form designed for the Department

 OPERATING ROOM  Patients necessitating emergency surgery will take priority over elective cases  The operating rooms are open 24 hours daily 365 days a year for emergency cases, while elective cases are scheduled from 7:00 AM to 4:00 PM Monday to Friday, and 7:00 AM to 12:00 PM on Saturday  Elective Cases should be scheduled one day prior to the operation. Likewise, each operating department and subspecialties have the following OR schedules: Monday – General Surgery Tuesday – EENT Wednesday – Orthopedics, Urology, Neurosurgery Thursday – General Surgery Friday – OB-GYNE Saturday – Pay patients only (AM) Mandaluyong City Medical Center CLINICAL DIVISION

 Special arrangement may be allowed as long as the department involved is properly notified  The OR staff should be notified prior to the procedure through the OR notification form  The OR coordinator (a consultant surgeon) oversees the smooth operation of the OR complex. Problems, complains and suggestions should be coursed through the OR coordinator.

XIII. ADMINISTRATIVE POLICIES  GENERAL/BASIC QUALIFICATIONS STANDARDS  All members of the surgical staff (MO/MS) should be holding a degree of Doctorate in Medicine and should have passed the Physicians Licensure Examination given by the board of Medicine. Consultants in the different subspecialties should have undergone and finish accredited residency training program of their specialty.

 FUNCTIONS AND RESPONSIBILITIES OF STAFF/ PERSONNEL  JOB DESCRIPTION I. CONSULTANTS a. The consultants are required to attend to patients referred to them both in Private and Charity/Service sections b. They are required to actively participate in department and hospital activities, conferences and functions c. They are enjoined to teach and facilitate learning among other staff members in the forms or rounds, conferences and functions. d. They are encouraged to provide input in the form of suggestions, constructive criticism or other special projects for the improvement of the department e. They will be assigned to handle private and charity cases i. Decking System – a fixed schedule for rotation of consultants will be drafted. The consultant for the day will be assigned as the Consultant-on- Call. The systems of rotation of the COC are applied only to the GS section at present. Since the sub - specialty sections at present have only one consultant per section, the consultant concerned will handle all cases (charity and Private) referred to one particular subspecialty. ii. Service consultant – to provide supervision among the MO/MS in handling elective cases in the Charity Service section. General Surgery

Mandaluyong City Medical Center CLINICAL DIVISION consultants will be assigned to handle particular service (GS I, II, III) on a quarterly basis. Outpatient work-ups should be referred to the consultant of the particular service and his suggestions/orders carried out.

Charity cases admitted to the hospital should be likewise referred to the service consultant aside from the consultant-on-call. The COCA is responsible for the urgent care of the patient (If patient is admitted on an emergency basis) the service consultant gets involved in the care of the patient after urgent measures have been taken. In case of overlap (COC is different from SC) then the patient benefits from having two consultants in charge of his case. iii. Walk-in private patients not needing confinement (outpatient)are referred to the service consultant iv. Subspecialty patients are referred to the consultant-in-charge of the particular subspecialty (charity or private)

II. RESIDENTS IN GENERAL: a. The primary concern of every resident is the welfare of the patient under his care. He should know thoroughly all the cases assigned to him. He should make rounds daily and make progress notes. He should take active parts in the pre-op, intra-op, and post-op care of the patients. b. He shall maintain a high standard of academic knowledge acquired through reading current medical literature. He should read textbooks normally of Surgery but also in related sciences. He must read journals. He shall attend conferences where the department of Surgery is involved. He shall attend post- graduate courses and conventions recognized or organized by the Philippine College of Surgeon. c. He shall record all operations he has done or assisted in a logbook. He shall update his logbook on a daily basis. The logbook shall be checked and inspected at random by any member of the consultant staff. d. He shall maintain good moral behavior and ethical practice of his profession at all times.

Mandaluyong City Medical Center CLINICAL DIVISION e. He shall preserve the nursing regulations seen by the Department and by the Hospital administration. f. He shall maintain good working relations with his co- residents, nurses, consultants and the hospital staff in general. g. He shall discharge his duties and responsibilities for the best of his abilities at all times.

III. CHIEF RESIDENT: a. The consultant staff shall elect the chief resident every six months or every year depending upon his performance. b. Aside from his duties as a Senior Resident, he shall have administrative functions. i. He shall arrange the schedule for 24-hour duties of resident and interns ii. He shall coordinate the rotation of each resident to the various GS service and subspecialties iii. He shall make the schedule of conference, lectures and other department activities. iv. He shall assign cases in the ward and operating room. v. He shall make sure that all patient’s chart are complete vi. He shall presides over the Mortality and Morbidity and also the Monthly Census conferences vii. He shall make the schedule of consultants for walk-in patients and the consultant-on-call viii. He shall instill discipline among his residents. He shall make recommendations for disciplinary actions to the training officer for offenses incurred by the residents. ix. He shall make sure that the schedule of operations for the following duty is in order.

IV. SENIOR MEDICAL OFFICER: a. He shall perform the general duties and responsibilities of every resident. b. He shall act as the Chief of Service in each rotation thereby being directly responsible for each patient admitted

Mandaluyong City Medical Center CLINICAL DIVISION c. During his 24-hour tour of duty, he shall be the acting Chief Resident. He shall make sure that the patients for operation are properly prepared d. He shall assigned in the operating room to assist or to operate under the supervision of the consultant or the chief resident. e. He shall fill out the operating room forms/operative techniques of patients he has operated or assisted. f. He shall teach his junior residents the proper way to manage patients preoperatively, intra-operatively and post-operatively g. He shall make sure that the consultants are properly informed of each referral and that the daily census is properly accomplished. h. He shall accept and perform other duties that may be assigned to him by his superior. V. JUNIOR MEDICAL OFFICER: a. He shall perform the general duties and responsibilities of every resident. b. When on duty, he shall be the first on-call in the ward c. When on duty, he shall stay in the Emergency Room. d. He shall be assigned to the OR to assist or operate under the supervision of the consultant or senior resident e. He shall be responsible for completing the daily census report f. He shall be in-charge of ward work (dressing, removal of sutures, etc.) g. He shall, together with the senior resident, answer referrals from other departments h. He shall relay all problems to his Senior or Chief Resident i. He shall accept and perform other duties that may be assigned to him by his superiors.

VI. MEDICAL SPECIALIST: *In response to the decreasing number of doctors applying as medical officers/residents, we have decided to hire doctors who have finished formal training in General Surgery provided that they are willing to go on 24 hours duty and perform all duties and responsibilities of a surgical resident on duty. The employment of such doctors has improved patient care in both emergency and elective surgery cases. a. He shall perform the general duties and responsibilities of every resident.

Mandaluyong City Medical Center CLINICAL DIVISION b. When on duty he shall act as the most senior resident on duty and shall stay in the ER. c. He is allowed to make decisions on management of surgical patients provided that he has conferred with the consultant on call or consultant in charge. d. He is allowed to perform emergency or elective surgery on patients under his care with the go signal from the consultant on call or consultant in charge. e. He shall inform the consultant on call or consultant in charge of all problems and progress of patients under his care. f. He shall supervise or perform ward work as necessary. g. He shall answer all referrals to the department during his tour of duty and subsequently inform the consultant on call or consultant in charge. h. He shall accept and perform other duties that may be assigned to him by his superiors. i. He is not allowed to engage in private practice.

 RECRUITMENT / HRING / TERMINATION I. RECRUITMENT / HIRING a. Regular b. Contractual c. Casuals

XIV. TRAINING/MANPOWER DEVELOPMENT POSITION LEVELS  RATIONALE  OBJECTIVES  TRAINING AND EDUCATION RESIDENCY

I. Existing (Brief Description on present setup) II. Needs (Rationale/Justification) III. Future Plans (Specific Time Table)

XV. REPORTS/RECORDS/FILES/FORMS

XVI. QUALITY ASSURANCE  DESIRED JOB PERFORMANCE  Per Personnel (Specific Checklist Desired Performance)  Per Service Areas/Sections (Indicators)

 EVALUATION AND METHODS  Per Personnel (Methodology of Evaluation/Performance)

Mandaluyong City Medical Center CLINICAL DIVISION  Per Service Area/Section (Methodology of Evaluation/Performance)

 CODE OF CONDUCT  EVALUATION OF ROTATION At the end of each year, the Consultants will evaluate each resident and his co-residents after which recommendations shall be made to retain, promote or expel a resident.

 GUIDELINES FOR DISPLINARY ACTIONS EVALUATION OF ROTATION  The following guidelines are made to instill discipline among the surgical residents. Each resident should be familiar with his guidelines:  All offenses shall be reported in writing stating the nature, date/time, place and persons involved. Copies shall be furnished to the Department Chairman or Training Officer.  The Consultant Staff shall investigate and pass judgement on the alleged offense  Recommendations for disciplinary action shall be informed in writing  Depending on the severity of the offense, a corresponding punishment shall be applied.

 CATEGORY OF OFFENSES AND PUNISHMENT  SERIOUS OFFENSES : DISMISSAL OR NON-REAPPOINTMENT I. Any criminal activity punishable under the Philippine Constitution II. Engaging in private practice anytime, anywhere III. Channeling of patients (walk-in) to consultant not on-call IV. Absences without official leave V. Falsification, manipulation or tampering of official records (chart, OR records, etc.) VI. Immorality VII. Insubordination VIII. Gross negligence in the care of patients IX. Inflicting physical injuries without provocation

 LESS SERIOUS OFFENSES I. FIRST OFFENSE – 2 Sunday duties plus/or suspension of OR privileges II. SECOND OFFENSE – Double III. THIRD OFFENCE – Dismissal or non-reappointment a. Out-of-patient while on-duty b. Intellectual dishonesty c. Reporting for duty under the influence of alcohol d. Lost specimen for histopath

Mandaluyong City Medical Center CLINICAL DIVISION e. Not informing consultants on-call for charity cases f. Habitual absenteeism g. Failure to respond to calls within a reasonable period of time

 MINOR OFFENSES I. FIRST OFFENSE – Reprimand II. SECOND OFFENSE – Sunday duty (1) III. THIRD OFFENSE – Sunday duty (2) plus/or Suspension of OR privileges IV. FOURTH OFFENSE – Double of third offense V. FIFTH OFFENSE – Dismissal or Non-reappointment a. Habitual tardiness for duty or for OR b. Absences from conferences, meetings, lectures, examinations c. No admitting notes/progress notes d. No operative technique (surgical memo) within 24-hours e. Failure to make rounds f. Failure to make rounds g. Poor academic performance h. Non-updating of Logbooks

Mandaluyong City Medical Center CLINICAL DIVISION

DEPARTMENT OF OPHTHALMOLOGY and ENT

I. OVERVIEW/INTRODUCTION This manual will outline the departments’ policy in accordance to its objectives and guidelines that governs its operations.

II. HISTORICAL BACKGROUND The Department of EENT began as a section as a Department of Surgery in the early 1970’s and was only separated as new department in the early 1980’s and has since been a separated department from then on.

At the Out-Patient Department, its clinic attend to common ophthalmologic cases ranging from diseases of the lid and lacrimal system, disease of ht e interior eye to cataract and glaucoma. Regarding ENT cases, the patients attended to largely otologic suhs as infection of the outer ear and middle ear obstruction of air conduction, followed commonly by allergic rhinitis and sinusitis. The department is complemented with an operating microscope and slip-lamp and lens refractor. The instruments recently acquired are the keratometer, motorized chair and stand.

III. DEFINITION OF TERMS

EENT – Refers to branch of medical service that specialize on the curative and preventive aspect involving the ears, eyes, nose, and throat.

IV. GUIDING PRINCIPLES The EENT service adheres to the hypocratice principle and the code of ethics in the medical profession and upholds human dignity in the practice of medicine.

Mandaluyong City Medical Center CLINICAL DIVISION The department is guided by the principle to provide only the best medical service to the people of Mandaluyong City primarily the indigent patients with eye, ear, nose, and throat problems.

V. DEPARTMENT/ (SECTION NOMENCLATURE)

 PHILOSOPHY  “Quality care and a human touch”

 MISSION  The department’s mission is to promote and provide a sound and comprehensive eyes, ears, nose and throat health care coverage program.

 VISION:  First class EENT departments with complete facilities for ears, eyes, nose, and throat affliction servicing the people of Mandaluyong.

 OBJECTIVES  General I. To provide quality eye, ear, nose, and throat care. II. To implement and operate in accordance to the policy of quality medical service.

 Specific I. To perform surgical operation to conditions that warrants such procedures and especially confined to areas of the eyes, ears, nose, and throat. II. To be able to provide a comprehensive program promoting a preventive awareness against disease of the eyes, ears, nose, and throat. III. To provide quality residency training program to physicians who wishes to practice in the field. IV. To be able to evaluate, plan, implement improvements consistent with the quality care program. V. To clinical research in the upliftment of the service in general.

 GENERAL POLICIES & STANDARDS  Residents should behave in a manner beyond reproach, worthy of the lofty ideals of our noble profession, that is, ethical, humane, compassionate, etc.  Residents are not allowed to have private practice.  The residents should wear the prescribe uniform.

Mandaluyong City Medical Center CLINICAL DIVISION  There should be no changing of duties after it is posted as the residency-training officer has already duly concurred it, and signed by the department chairman.  Residents are expected to be in the hospital from 8:00 a.m. to 5:00 p.m. daily except Saturdays and on official holidays wherein they are expected to be in the hospital from 9:00 a.m. to 12:00 noon.  Residents must attend conferences and/ or lecture given by the department chairman, and/ or any of the consultant staff. I. Ophthalmology monthly scientific conference to be held every last Friday of the month. II. Meetings every Monday from 8:00 a.m to 9:30 a.m. III. Journal club every month either on Monday or a Friday IV. Literature review every month either Monday or a Friday V. Consultant’s hours assigned to the consultant –on –service for the month every last Monday of the month. VI. Research paper protocol beginning February of each year and to be updated every month thereafter. VII. Sub-specialty lectures to be given by invited guest lecturers once a month.  Resident are expected to attend conferences, lectures and/or meetings given by the Mandaluyong City Medical Center in which they are required to attend.  Residents who are not on duty are expected to attend other conferences or symposia given by the Philippine Academy of Ophthalmology or those given by other institution that are related to our field specialty.  Application or leave of absence or LOA should be field accordingly to the Residency Training Officer and concurred to by the department chairman, at least (1) month before the date of effectivity except in emergency cases.  Rotation through fluoresce in angiography session, ocular ultrasound, and ophthalmic lasers offers by outside hospital affiliates should be complied with as instructed by the chairman and residency training officers.  GENERAL FUNCTIONS  The Department of EENT outlines its functions as follows: I. To provide out-patient service and ambulatory care patients with non-emergency condition of eye, ears, nose and throat. II. To provide emergency and critical care/procedures to patients consulting in this institutions with appropriate conditions. III. to provide in patient management and operative procedures. IV. To provide and evaluate the department’s function and end services pursuant to the objectives and policies of the hospital.

Mandaluyong City Medical Center CLINICAL DIVISION V. To provide and implement departmental plans to maintain an adequate and competent professional services cognizant to the institutional framework and that of the community it serve. VI. To participate in the institutional multi-disciplinary approach of the care thru referrals.

 OBLIGATION SET-UP/ STRATEGIES AND PROCEDURES  ORGANIZATION

CITY MAYOR

HOSPITAL DIRECTOR

DEPUTY DIRECTOR for PROFESSIONAL SERVICES

CHIEF OF CLINICS

EENT CHAIRMAN/TRAINING OFFICER

EENT CONSULTANTS

CHIEF RESIDENT

RESIDENT STAFF

 STAFFING PATTERN

Mandaluyong City Medical Center CLINICAL DIVISION The EENT dept. envisions at least 3 resident physicians with each of them undergoing every 3 days rotation of 24 hours duties. Areas to cover are the following: I. 24 hour duty – Emergency room and ward referrals II. Pre-duty-Out patients department III. From duty-ward and OR electives

 FUTURE PLANS FOR THE DEPARTMENT I. Application for the accreditation of the Residency training ophthalmology not later than December 1996. II. The Department of Ophthalmology to be eventually separated from the section of Otorhinolaryngology. III. The Department of Ophthalmology to have specialty clinics with the supervision of Diplomate Consultants in different subspecialties (ex. Retina, Glaucoma, External diseases of the eye). Hopefully, the will have one after 1 year Glaucoma Fellowship Training of one of the Ophthalmology Consultants, Dr. Edgar Leuenberger abroad starting July 1997.

 STANDARD OPERATING PROCEDURES I. Out-patients Department a. OPD starts at 8:00 am to 12:00 nn then 1:00 pm to 4:00 pm. b. OPD patients are first seen by the 1st year resident and referred to 2nd and 3rd year residents before sending home. c. Complicated patients are referred to the most senior resident before disposing them. d. If a patient cannot be managed by the department, the patient is referred to consultants prior to referring them to hospital of choice for further evaluation and management. e. Patients who need further laboratory work-up, examinations not available in the hospital are referred to other hospitals and to comeback with the result. II. Emergency Room a. Emergency cases (mild) are first seen by the 1st year residents. They provide the initial assessment and management of emergency cases. Then they are referred to senior residents prior to their disposal or sending them home. b. Severe emergency cases are seen by the senior residents together with the 1st year resident. Head trauma

Mandaluyong City Medical Center CLINICAL DIVISION patients are referred for neuro-clearance. Then admitted and observed for 24-48 hrs. c. Gunshot and stab wounds on the area of the face and neck are admitted, worker-up and observed for 24-72 hrs prior to discharge. d. Patients who cannot be managed in the hospital are stabilized first and coordinated to other hospitals before transfer. e. Transferring of patients to other hospital are conducted through an ambulance accompanied by a 1st year resident endorsing the case to receiving hospital on the initial management and work-up done on the patient. III. Admission of Patients a. Admissions are done by the 1st resident and senior residents are informed of the admission. Admitted patients are written on the admission board. b. Ward rounds are done before OPD an after OPD hours on admitted and interdepartmental referrals. c. Consultants are informed of the admission, the nature, and condition of the patient and the plan of the department on the patient. d. If the admitted patient cannot be managed alone by the department the patient is referred to other departments for co-management. e. If the admitted patient cannot be managed in the hospital and needs the service of a specialty hospital, the patient is referred to the said hospital with referral slip and clinical abstract and conducted through an ambulance together with a medical intern or 1st year resident. f. Patients for discharged are seen by the senior residents prior to sending home. Instructions are given to patients on home medications, activity, diet, wound care and follow-up. g. Morbidity and mortality of admitted patients are presented to the staff of the department; the case is discussed with regards to the management and care of patient. IV. Referrals from the Ward a. The referring departments fills up a referral from which is then forwarded by the ward nurse to the EENT clinic not later than 3 o’clock PM after which referrals will be seen by the resident physician on-duty.  CLIENTELE

Mandaluyong City Medical Center CLINICAL DIVISION  Out-patients clients with EENT problem  Patients at the emergency room with eye, ears, nose, and throat problems  In-patients admitted by the EENT service residents and consultants  Inter-department referrals  Referrals from employees clinic and the City Government Offices

 ADMINISTRATIVE POLICIES  Basic Qualification Standards I. Medical Specialist II a. Should be a Doctor of Medicine b. Experience-1 year relevant experience c. Training-4 hours relevant training d. Eligibility-RA 1080

II. Medical Specialist I a. Should be a Doctor of Medicine b. Experience-1 year relevant experience c. Training-4 hours relevant training d. Eligibility-RA 1080

III. Medical Officer IV a. Should be a Doctor of Medicine b. Experience-1 year relevant experience c. Training-4 hours relevant training d. Eligibility-RA 1080

IV. Medical Officer III a. Should be a Doctor of Medicine b. Experience-none required c. Training-none required d. Eligibility-RA 1080

 DUTIES (FUNCTIONS AND RESPONSIBILITIES)  FIRST YEAR RESIDENT I. He stays at the out patients clinics where he is expected to develop the skills in doing or learning about: a. The Ophthalmologic History i. General Information ii. Specific Information 1. Present eye complaints 2. Present eye history 3. Previous eye history

Mandaluyong City Medical Center CLINICAL DIVISION 4. Personal medical history- present and past general illnesses 5. Family medical history-eye problems 6. Drug history-medications and allergies

b. The basic Ophthalmologic objectives and functional examinations: i. External examination ii. Inspection iii. Palpation iv. Auscultation v. Visual acuity determination 1. Distant visual acuity a. Snellen’s chart b. Tests of light perception c. Potential acuity meter d. Macular photostress test e. Macular function test 2. Close visual acuity a. Jaeger chart b. Rosenbaum pocket vision screener c. Lebensohn chart vi. Motor function studies 1. Primary position of gaze 2. Cardinal position of gaze 3. Near point of convergence 4. Stereopsis vii. Color vision testing 1. Ishihara polychromatic plates 2. Stiling 3. Hardy-ritler viii. Anterior segment examination ix. Intraocular pressure and tonography x. Ophthalmoscopy xi. Visual field testing xii. Refraction xiii. Other tests as indicated by history and prior examination 1. Tear film adequacy: clinical tests a. Tear quantity tests b. Schimer test I c. Basic secretion test d. Schimer ii

Mandaluyong City Medical Center CLINICAL DIVISION e. Rose Bengal staining 2. Tear quality test a. Conjunctival biopsy b. Qualitative mucous assay 3. Tear film stability a. Tear break up time 4. Tear secretion tests a. Regurgitation test b. Primary dye test c. Canaliculus testing d. Dacryocystography xiv. Corneal sensation xv. Transillumination xvi. Exophthalmometry xvii. Keratoscopy 1. Placido disk 2. Klein keratoscope xviii. Keratometry xix. Gonioscopy xx. Corneal pachymetry xxi. Specular photomicroscopy xxii. A-scan xxiii. Radiological studies of the eye and orbit 1. Routine radiological views a. Calwell’’s view b. Water’s view c. Oblique view d. Rheese position e. Lateral view 2. Orbital tomography 3. Magnetic resonance imaging or mri 4. Anterior chamber aspiration keratocentesis 5. Prism tests

c. Application of his knowledge in ocular therapeutics i. Introduction of ophthalmic drugs ii. Indications and contraindications for the use of atropine, pilocarpine and steroids iii. Ocular steroids and antibiotics iv. Topical ocular anesthetics v. Modes of drug penetration into the eyes vi. Modes of drug administratioin 1. Topical

Mandaluyong City Medical Center CLINICAL DIVISION 2. Subconjunctival 3. Rretrobulbar 4. Intracameral 5. Systemic

d. Thorough knowledge and skills in the performance of definitive specialized procedures: i. Refraction ii. Retinoscopy iii. Subjective refraction iv. Cyclopegic refraction v. Automated refraction vi. Verification of spectacle lenses

e. Anterior segment examination i. Managing loupes ii. Slip-lamp biomicroscopy of the anterior segment and funds f. Intraocular pressure measurements and tonography i. Finger tension ii. Tonometry 1. Schoitz tonometry 2. Applanation tonometry 3. Pneumotonometer 4. Air puff non-contact tonometer

g. Ophthalmoscopy i. Direct ophthalmoscopy ii. Indirect Ophthalmoscopy

h. Visual field testing i. Amsler grid ii. Confrontation test iii. Perimetry 1. Kinetic perimetry a. Goldman 2. Static perimetry a. Humprey b. Octopus iv. Tangent screen

i. Gionoscopy i. Alan-thrope lenses ii. Golden lenses

Mandaluyong City Medical Center CLINICAL DIVISION iii. Zeiss lenses

j. Prism Test i. Cover Test 1. Cover-uncover tests for hererophoria detection 2. Cover test for detection of hetetotropias 3. Simultaneous prism and cover test ii. Quantitative measurements of strabismus deviation by corneal reflex tests. 1. Hirshber’s test 2. Krimsky method 3. Major anblyoscope iii. Dissimilar image test 1. Maddox rod testing for heterophobia to tropia 2. Red glass test iv. Separate image test 1. Lancaster red-green projection 2. Major amblyoscope

II. The resident sees patients but patients but under the supervision of the second year resident. III. He presidents interesting cases to the out-patients clinics consultants’ on-duty for discussion and management. IV. He is allowed to observe, assist, perform in the OR and learn. a. General routine of patient’s preparation and techniques in assisting. b. Ocular instrumentation. V. He must have attended and completed the basic science course in ophthalmology. VI. He must have a basic working knowledge on the use of computers as an aid in ophthalmology. VII. At the end of his first year, he required to submit and to present a scientific paper that is, retrospective study, and interesting case, or a prospective study.

 SECOND YEAR RESIDENT I. Specific clinical duties a. Supervise the first year residents b. Improve their skills in various diagnostic instrumentation c. Perform all minor surgical procedures assisted by the first year residents until such time the first year residents are allowed to do such procedures.

Mandaluyong City Medical Center CLINICAL DIVISION d. Assist the Chief Residents and/or Senior Residents in the various major surgical procedures. e. Assist the consultants in surgical cases in their private patients. f. Conducts ward rounds with interns, if there are any assigned to the department. g. Presents cases in weekly conferences as per assignment. II. He presents findings of special work-ups in: a. Cataract, pre-operative evaluation b. Glaucoma c. Retina prior to detachment surgery d. Corneal transplant III. The residents prepare an eye for intraocular surgery by doing: a. Smear and culture of eye secretions b. Gram staining c. Studies for fungal infections d. Studies for pseudomonas infections e. Lacrimal duct irrigation IV. The residents further sharpen their diagnosis acumen and skills in doing definitive specialized procedures aside from learning some more advanced ophthalmology procedures: a. Perimetry b. Kerametry c. Ultrasonography i. A – scan ii. B – scan d. Ophthalmodynamometry i. Specular photomicrospy ii. Coneal topography iii. Corneal pachymetry iv. Flourescein angiography 1. Fundus 2. Iris 3. Fundus photography 4. Anterior chamber aspiration or keratocentesis 5. Electroretinography egg V. The residents make a neuro-ophthalmologic evaluation by doing the follwing examination: a. External examination b. Palpebral fissure c. Eom’s d. Pupillary reaction e. Visual acuity

Mandaluyong City Medical Center CLINICAL DIVISION f. Tonometry g. Visual field examination h. Ophthalmodynamometry i. Exophthalmometry j. Argon laser k. Yag laser VI. The residents are required to submit and to present a scientific paper that is, a retrospective study.

 THIRD YEAR RESIDENT I. The Chief Resident, concurrently senior is appointed based on his performance during his first two years. II. The Chief Resident is directly responsible to the department chairman for all clinical activities including seminars and conferences. III. The chief Resident has command responsibility for all clinical and operative schedules. IV. The Chief Resident also has command responsibility for all clinical organization of patients and schedule of duties of the residents and interns. V. The residents answer all ward cases consultations from other departments. VI. The Chief residents assist or designate assistants to all private surgical cases. VII. The residents perform all major, special or complicated surgical cases, which they need to fulfill the ophthalmology Board requirements. VIII. They supervise all follow-up operated cases to see it that the other residents have organized the chart for follow-up cases. IX. The chief Resident sees to it that there is a monthly census of all eye patients seen at the out-patients clinics, emergency room, admission, and surgical cases. X. The residents should further develop their skills and surgical expertise in ophthalmologic major surgery work-up like the preparation of patients for cataract, glaucoma, squint retinal detachment, and other surgical procedures. XI. With regard to their surgical performance, they must make a listing of all their major surgical accomplishments, including one (1) copy of the surgical techniques for each type, which they must be prepared to discuss. XII. The residents are required to submit and to present a scientific paper, experimental in nature, to the hospital as well as to the Philippines Academy of Ophthalmology annual convention.

Mandaluyong City Medical Center CLINICAL DIVISION  DETAILED JOB DESCRIPTION OF ACTIVITIES OF JUNIOR EENT RESIDENTS  Ward Works I. Complete history of assigned cases made within 24 hours after patient’s admission, and typewritten in 48 hours. (Senior Residents checks “rough draft” before typing in official form). II. Routine orders for the patients given immediately, preferably written, including admission note. III. Daily ward rounds made first hour in the morning. These include dressings, making of daily progress notes on patient’s condition, response to medical treatment or to any surgical intervention undertaken. (In eye cases, brief description of eye from 1st to 5th postoperative days). New applicants and interesting clinical laboratory findings are noted down, etc. (Progress notes are subject for review or revision by either the EENT Specialist of Chief). IV. Prosthesis, eyeglasses and other appliances needed by patients should be immediately requested and followed up in order to facilitate issuance. (Discourage patients from doing the follow- up). V. Results of laboratory request, referrals, x-rays, etc…are checked regularly. VI. Prepare narrative summaries for USVA or for discharge purposes as soon as possible duly processed by either the EENT Specialist or Section Chief. VII. Should maintain proper orderly arrangement of the patients chart noting down their identification in every page.

Notes: Residents should always be well-informed and up-to-date regarding any treatment or procedure being done to the patient whether it be within the service or from other sections or services.

 Consultations and Referrals: I. The residents should feel free to consult any staff member at all times regarding his work, any difficulties, etc. II. After careful evaluation of the patient’s condition, pertinent consultation or referrals necessary are requested immediately from the different section or services, coursed thru Section Chief. III. Difficult or problem cases should be worked up immediately with the assistance and guidance of any Senior Staff member. IV. Assist the Section Chief in all consultations or referrals to the Section. Subsequently follow-up by the resident-in-charge op the patient.

Mandaluyong City Medical Center CLINICAL DIVISION  Surgery I. Assist and do minor and major surgical operations according to the discretion of the Section Chief. II. Should arrive in the operating room 30 minutes before the scheduled time of operation. III. Should wear the prescribed operative room attire and follow other O.R requirement. IV. Should make a typewritten report of the operative procedures or techniques after his assigned patient has been operated.  Conferences I. Should prepare cases for clinical discussions, conferences and seminars. II. Should participate in journal clubs, conferences and seminars. III. Should attend the general round or patients by the entire surgical staff.

 Relation with Senior Resident I. Should help the senior Resident in the preparation of monthly statistic. II. Should help the Senior Resident in listing all admitted EENT cases in the logbook. III. All cases in category of interesting, problematic or emergency conditions require immediate notification of the Senior Resident. IV. Should assist the Senior Resident in the Supervision of the outpatient clinic in order to expedite disposition of new and old patients.

 MISCELLANEOUS DUTIES AND RESPONSIBILITIES  Resident’s whereabouts should be posted in the clinic blackboard.  The borrowing of more than 1 chart a time from the Medical Record Section is not allowed unless approve by the Service Chief. Never take home the chart. This will prevent losses.  Problem arising in the ward, clinic and operating room should be brought immediately to the attention of the Senior Resident.  Residents are prohibited to discuss compensation matters with patients or make unsavory remarks (malingering, etc.)  Maintain proper decorum and behavior at all times.  Prescribed uniform and nameplate must be worn in the hospital with emphasis on neatness and cleanliness. No civilian clothes.  JOB DESCRIPTION SENIOR EENT RESIDENTS  Helps in the supervision of junior residents.

Mandaluyong City Medical Center CLINICAL DIVISION  Complete history of assigned cases made within 24 hours after patient’s admission and typewritten 48 hours (Noted: to be discontinued as soon as more junior residents are available).  Routine orders for the patients given immediately, preferably written including admission note:  After careful evaluation of patient’s condition, pertinent referrals necessary are requested immediately from the different services.  Prosthesis, eyeglasses and other appliances needed by patient care immediate requisitioned through EENT Technician.  Responsible for proper entry in the prescribed book, of all cases indicating hospital number, admission and discharged diagnosis, treatment given and prognosis.  Assists in referrals and handles emergency referrals otherwise per instruction of either EENT specialist or section chief.  Should be well informed regarding management being done to patients, whether it be within or from other services.  Daily ward rounds made first hour in the morning. This includes dressings, making of daily progress on patient’s condition, response to treatment, medical or surgical (In eye cases, brief description of eye from the first to the 5th post-operative day). Few complaints and interesting clinical and laboratory findings are noted down.  Resident’s whereabouts posted in clinic blackboard.  Senior Resident should feel free to consult the EENT specialist or section chief at all times, regarding his work, duties, any difficulties, etc.  Prepare narrative summary for USVA or for discharge purposes, duly checked by either the EENT specialist or section chief.  Patients for surgery. I. Take care of pre and post-operative orders. II. Sorts out instruments needed in the operating room the day before surgery. III. Writes down surgical notes, indicating kind of surgery performed anesthesia and pertinent operative findings in progress notes sheet. IV. Writes down kind of surgery performed on temperature chart. V. Responsible for safe return of patients to ward especially this under general anesthesia. VI. Submits a typewritten technique of operation within 48 hours (3 copies) when acting as surgeon or assistant to section chief. VII. Must be in O.R. minutes before the scheduled time.  Out-patient Clinic under direct supervision of Senior Resident, assisted by the junior resident and interns. Priority guide: I. In-patients II. Out-patients

Mandaluyong City Medical Center CLINICAL DIVISION III. Emergencies among employees except referrals or deserving cases. The latter handled from 12:00-3:00 p.m. except Saturday and Sunday. IV. Special request outside office hours.  Prepare a typewritten monthly statistic stating number of operations and consultation and submitted during the first week of succeeding month.  Strict observance of program of daily activities. Has priority except in emergencies.  All serious ocular and EENT cases should be referred to either the EENT specialist or Section Chief.  Doctor’s order and progress notes are subject to review or revision by either the EENT Specialist or Section Chief at all times.  Assists and performs minor and major surgery under supervision.  Prepare or guides the junior resident in case presentations for discussion, conferences or seminar. Check histories of junior residents.  Active participation on a well-round training program for junior resident.  Borrowing of more than one chart at one time from the Medical Record Section is not allowed unless with the 3express approval of section chief. Never take home (to avoid losses).  Helps in the maintenance of strict discipline in ward, clinic and during operations.  Problems arising in the ward, clinic or operating room should be immediate brought to the attention of the EENT specialist.  Residents are prohibited from ultering unsavory remarks (Malingering, etc.) and discussion of compensation matters with patients. Maintain proper decorum and behavior at all times.  Prescribe uniform and nameplate must be worn in the hospital with emphasis on neatness and cleanliness. No civilian clothes allowed.

 DUTIES OF EENT MEDICAL SPECIALIST 1  Direct supervision of Senior and Junior Residents in EENT cases.  Assists Department Head and other staff members in major EENT operations.  Performs minor and major EENT operations.  Checks, corrects and revises the work of residents at all times for EENT cases.  Assists Department Head in supervision of ward and out-patient clinic.  Handles EENT referrals. Emergency and routine per arrangement with Department Head.  Prepares schedule of all EENT operations duly approved by the Department Head.

Mandaluyong City Medical Center CLINICAL DIVISION  Supervises the residents and technicians in Audiometry and other EENT procedures.  Helps in the supervision of ward rounds and clinical conferences.  Contributes actively to a well-rounded EENT residency-training program.  Serves as an EENT consultant.  Maintains strict discipline in the ward, clinic and during surgery.  Professional duties subject to review and revision by the Department Head.  Has responsibility of threshing out all problems arising from the ward, clinic and during the surgery.  Helps Department Head in the requisition of needed instruments for EENT use.  Undertakes basic and clinical researches or studies depending on available facilities.  Takes charge of EENT clinic, OPD and ward patients.  May substitute for the Department Head in the conferences or seminars in other services.  Helps Department Head in designating cases of discussion or conference.  Supervises EENT journal club assisted by Senior Resident.  May assign extra duties as occasion arises on either the Senior or Junior residents to watch cases after a major surgery or in serious cases.

 RECRUITMENT AND HIRING:  Recruitment and hiring will depend on the following factors: I. Availability of vacant and items. II. Manpower needs of the department in accordance to its recognized staffing pattern.  The department will then consider application for residency with the above factors in mind.  The applicant will then submit his application letter and requirements to the chairman.  The chairman will then exercise prerogatives in screening applicants.  Successful applicants will then be recommended to the credential committee for endorsement to the office of the Hospital Director. The Hospital Director will then approve or disapprove such application.

 TERMINATION  Termination will result from: I. Completion of training a. Personal request/resignation b. Disciplinary i. Violation of the Civil Service Code Mandaluyong City Medical Center CLINICAL DIVISION ii. Hospital Policies/Ethics iii. Department Policies/Guidelines/Standards iv. Criminal Acts c. Bearing in mind that due process should be observed. d. Incapacity e. Conflict of institutional interest

 TRAINING/MANPOWER DEVELOPMENT POSITION LEVELS  Rationale  Objectives  Training & Education Residency I. Existing (Brief Description of Present Set-up) II. Needs (Rationale/Justification) III. Future Plans (Specific Time Table)

 REPORTS/RECORDS/FILES/FORMS  Collection of Existing Forms

 QUALITY ASSURANCE  Desired Job Performance I. Per Personnel (Specific Checklist Desired Performance) II. Per Service Areas/Sections (Indicators)  Evaluation & Methods I. Per Personnel (Methodology of Evaluation/Performance) II. Per Service Area/Section (Methodology of Evaluation/Performance)

 CODE CONDUCT

 SCHEDULE OF SERVICES:  OUT-PATIENT DEPARTMENT I. Mondays-Fridays (8:30-11:30 AM and 1:30-4:30 PM) II. Saturdays (8:30-11:30 AM)

 OR DAY (ELECTIVE MAJOR and MINOR SURGERIES) I. Tuesdays (7:00-12:00 NN)

Mandaluyong City Medical Center CLINICAL DIVISION

DEPARTMENT OF ANESTHESIA

OBJECTIVES In our utmost desire to safeguard patients undergoing surgery, the Mandaluyong City Medical Center Department of Anesthesiology adopted the recommendation of the Philippines Society of Anesthesiology Standards for Safe Anaesthesia Procedure

I. MISSION / VISION The first and foremost important component of preanaesthetic care is the continous presence of a vigilant and well-informed anaesthesiology throughout the operative period and post operative period thereafter.

II. ORGANIZATIONAL STRUCTURE

HOSPITAL DIRECTOR

DEPUTY DIRECTOR FOR PROFESSIONAL SERVICES

CHAIR, DEPARTMENT OF ANESTHESIOLOGY

Mandaluyong City Medical Center CLINICAL DIVISION VICE-CHAIRMAN

CHIEF RESIDENT

RESIDENTS

III. GENERAL STANDARDS  Professional Status: The anaesthesiologist is a specialist who has received sufficient training in anaesthesiology, resuscitation, intensive care, acute pain, and chronic pain management.  Professional Organization: Anaesthesiologists should organize themselves at local, regional and national levels, for the setting of standards of practice, supervision of training and continuing education with appropriate certification and accreditation, and general promotion of anaesthesia as an independent medical specialty.  Training, Certification and Accreditation: Three years is the optimum period required to learn the specialty. Importance is given to learning related basic sciences, medical disciplines and development of knowledge and skill in clinical anesthesiology. This will culminate in an acquisition of a certificate of Anesthesiology Residency. The title Diplomate is conferred to one who has passed the written, practical and oral examinations given by the Philippine Board of Anesthesiology. Advanced postgraduate specialty and subspecialty training maybe pursued.  Records and Statistics: A record of the details and course of each anaesthesia should be made and preserved with the patient's medical record. This includes details of the pre-operative assessment and the post-operative course. These data must be collated to facilitate progressive enhancement of the safety, efficiency, effectiveness, and appropriateness of the anaesthesia.  Peer Review: Institutional, regional and/or national mechanisms to provide a continuing review of anaesthetic practice should be instituted. Critical incident reporting is encouraged as a useful mechanism in this respect. Legal safeguards of confidentiality of the review material may be appropriate and should be sought where they do not exist. Mechanisms and protocols should be developed to

Mandaluyong City Medical Center CLINICAL DIVISION ensure that deficiencies in individual and collective practice are identified and rectified.  Workload: A sufficient number of trained anaesthesiologists should be available so that each individual may practice to a high standard. Time should be allocated for professional development, administration, research and teaching.  Personnel: An anaesthesiologist must be dedicated to each patient and must be present throughout each anaesthetic procedure (general, regional or monitored sedation). He should be responsible for the transport of the patient to the post-anaesthesia recovery facility and the transfer of care to appropriately trained personnel. The anaesthesiologist should retain overall responsibility for the patient during the recovery period and should be readily available for consultation until the patient has adequately recovered from anaesthesia.  The anaesthesiologist should ensure, if aspects of direct care are delegated, before, during or after an anaesthetic, that the person to whom responsibility is delegated is both suitably qualified and conversant with relevant information regarding the anaesthetic and the patient.  Facilities and Equipment: Appropriate equipment and facilities, adequate both in quantity and quality, should be present whenever anaesthesia and its recovery is undertaken. It is highly recommended that anaesthesia equipment conform to relevant national and international standards. The anaesthetic equipment must be regularly maintained and in good working condition prior to each anaesthetic procedure. Presence of alarm systems to detect hypoxic gas mixture, disconnections, leaks, overpressure is highly recommended.

 PERI-ANAESTHETIC CARE AND MONITORING  The first and foremost important component of peri-anaesthetic care, including monitoring of the anaesthesia delivery system and the patient, is the continuous presence of a vigilant anaesthesiologist throughout the operative period.  The standards of safe anaesthesia practice would be equivalent for any patient, whether he is under general anaesthesia, regional anaesthesia or monitored anaesthesia care.  The monitoring tasks of the anaesthesiologists include: I. monitoring the patient II. monitoring gas supply and anaesthesia machine III. monitoring the anaesthesia breathing systems and ventilator.

Mandaluyong City Medical Center CLINICAL DIVISION There are three levels of monitoring, namely, routine monitoring, specialized monitoring and extensive monitoring

 PRE-ANAESTHESIA CARE  The patient must be evaluated by an anaesthesiologist prior to induction of anaesthesia.  The anaesthesiologist must ensure that all necessary equipment is in satisfactory working condition prior to the induction of anaesthesia.  The anaesthesiologist must ensure that assistance is available and that the assistant(s) have been instructed in or are competent at the necessary tasks.

 MONITORING DURING ANAESTHESIA  Oxygenation I. Oxygen supply a. Must be available and adequate to include a reserve supply. b. The integrity of the oxygen supply must be assured. c. When nitrous oxide or other supplemental gases are used, the concentration of oxygen in the inspired gas should be checked constantly during the anaesthetic conduct. d. An oxygen supply failure alarm and a device protecting against the delivery of a hypoxic gas mixture are highly recommended. e. A system must be used to prevent misconnection of gas sources. II. Oxygenation of the patient a. Tissue oxygenation should be monitored whenever practicable by visual examination. Adequate illumination and exposure of the patient should be ensured unless appropriate monitor is used. b. The continuous use of a quantitative monitor of oxygenation, such as Pulse Oximetry, is highly recommended.

 Airway and Ventilation I. Adequacy of airway and ventilation should be continuously monitored by observation and auscultation whenever practicable. Movements of the reservoir bag should be observed. Continuous monitoring with a precordial, pretracheal or esophageal stethoscope is highly recommended. II. Confirmation of the correct placement of the endotracheal tube and the adequacy of ventilation by continuous measurement

Mandaluyong City Medical Center CLINICAL DIVISION and display of carbon dioxide waveform and concentration (Capnography) is highly recommended. III. When mechanical ventilation is employed, a "disconnect alarm" should be used throughout the period of mechanical ventilation.

 Circulation I. Cardiac Rate and Rhythm a. The circulation must be monitored continuously. Palpation or registration of the pulse and / or auscultation of the heart sounds should be continuous. b. Use of a plethysmograph, (as a stand-alone or as a component of pulse oximetry) or an electrocardiograph are highly recommended. c. A functional defibrillator must be readily accessible in the OR complex.

II. Tissue Perfusion a. Adequacy of tissue perfusion should be monitored continually by clinical examination. Continuous monitoring with a plethysmograph or capnograph is highly recommended.

III. Blood Pressure a. Arterial blood pressure should be monitored at appropriate intervals, usually at least every five (5) minutes, and more frequently if indicated -by clinical circumstances. b. Continuous display of arterial pressure is encouraged in appropriate cases.

 Temperature I. Body temperature should be monitored during anaesthesia and surgery. A continual measurement is highly recommended in patients in whom change in temperature is anticipated, intended or suspected.

 Depth of Anaesthesia I. The depth of anaesthesia should be regularly assessed through clinical parameters and measurements. II. Measurements of inspired and expired concentrations of gases and volatile agents are encouraged.

Mandaluyong City Medical Center CLINICAL DIVISION  Neuromuscular Function I. Whenever neuromuscular blocking drugs are administered, the use of a peripheral nerve stimulator is recommended. II. Recovery from neuromuscular blockade must be assessed clinically and if possible, with the use of peripheral nerve stimulator. III. Reversal of neuromuscular blockade is recommended whenever appropriate.

 POST-ANAESTHESIA CARE  Facilities and Personnel I. All patients who have had an anaesthetic affecting central nervous system function and/or loss of protective reflexes should remain where anesthetized or be transported to a location specifically designated for post-anaesthesia recovery. II. The anaesthesiologist is responsible for the transport of patient and transfer of care to appropriately trained personnel. III. The anaesthesiologist retains overall responsibility for the patient during the recovery period and must be readily available for consultation until the patient has adequately recovered from the anaesthetic. IV. Minimum requirements for a post anaesthesia care unit (PACU) are: a. suitable beds capable of head down tilt b. oxygen. supply and appropriate delivery equipment c. emergency cart d. cardiac monitor and defibrillator e. ventilator f. easy and rapid communication to summon medical help g. monitoring equipment: pulse oximetry, non-invasive blood pressure measurement, temperature probes h. suction apparatus V. A discharge protocol should be observed, to include transfer of patients from PACU to the ward or room, and discharge of day-case surgical patients from the hospital. VI. All patients must be evaluated by anaesthesiologist before discharge from the PACU

 Monitoring I. All patients should be observed and monitored in a manner appropriate to the state of their nervous system function, vital signs and medical condition, with emphasis on oxygenation, ventilation and circulation. II. Pulse oximetry is highly recommended.

Mandaluyong City Medical Center CLINICAL DIVISION

 REMOTE ANAESTHESIA  This pertains to the administration of anaesthetics outside the operating room suites. All patients in these areas who are given an anaesthetic are entitled to the equivalent standards of care and monitoring during anaesthesia and recovery as they would receive within the operating room. These areas are: I. obstetric suites: labor room, delivery room II. radiology: CT Scan, Magnetic Resonance Imaging III. radiotherapy IV. endoscopy rooms V. emergency room VI. dental surgery VII. electroconvulsive therapy  Suitable adaptations of techniques and equipment to monitor patient care are required in these areas since close physical monitoring is n ot always possible due to specific hazards.  EQUIPMENT REQUIREMENTS  Basic Requirements I. For anaesthesia administration - an anaesthesia machine and anaesthetic agents : I.V. drugs and inhalation anaesthetic II. For patient monitoring - Stethoscope Sphygmomanometer Light source Thermometer 1. For patient support a. Airway management- oral/nasal airways, masks suction apparatus laryngoscope endotracheal tubes cricothyrotomy set tracheostomy set

b. Ventilatory support- self-inflating bag (ambu bag) oxygen supply

c. Circulatory support- needles, syringes, cannulae, infusion fluids

d. Drug Therapy- basic drugs and medicines for emergency and resuscitation

 Intermediate Requirements - includes the Basic Requirement PLUS: I. For anaesthesia administration- compressed gas supply: 02, N20

Mandaluyong City Medical Center CLINICAL DIVISION calibrated vaporizer anaesthetic circuits

II. For patient monitoring- oxygen supply failure alarm oxygen analyzer oximeter capnography electrocardiogram

III. For patient support- defibrillator laryngeal mask airway

 Optimal Requirements - includes Basic and Intermediate, PLUS: I. For anaesthetic administration - anaesthesia machine with an integrated monitoring of its functions

II. For patient monitoring a. of airwaylventilation- capnograph respiratory volume monitor airway pressure alarm

b. of circulation- automated blood pressure invasive hemodynamic pressure monitoring

c. of administered anaestheic- peripheral nerve stimulator gas analyzer III. For patient support- mechanical ventilator

 Definition of Terms I. Continual - repeated regularly and frequently II. Continuous - without interruption III. Routine monitoring - applicable to all patients, regardless of disease state IV. Specialized monitoring - directed towards a particular pathological problem or for the use of a specialized technique V. Extensive monitoring - applicable to critically ill patients or those undergoing extensive surgical procedures In addition:

Mandaluyong City Medical Center CLINICAL DIVISION I. A separate means of inflating the lungs with oxygen should be available in every anaesthesia location in case of major failure of the anaesthesia apparatus. II. A source of suction will be available at all times with appropriate hand pieces and tracheal suckers. III. Equipment for managing difficult airways. IV. Additional drugs, other than anaesthetic drug, necessary for management of conditions which may complicate anaesthesia, e.g.: Anaphylaxis Hypoglycernia Cardiac arrhythmias Hyperglycernia Cardiac arrest Adrenal dysfunction Pulmonary edema Raised Intracranial Pressure Hypotension Uterine Atony Hypertension Blood Coagulopathy Bronchospasm Malignant hyperpyrexia Respiratory depression

IV. SPECIFIC ANAESTHESIA PRACTICE PATTERNS  Duties of a Specialist Anaesthesiologist The Specialist Anaesthesiologist is required to cultivate and maintain high standards of practice and ethical behavior in relation to anaesthesia, related disciplines and other branches of medicine.  The anaesthesiologist recognizes that: I. Regular clinical involvement of appropriate volume and complexity is necessary to maintain clinical skills. II. Participation in a program to maintain clinical standards is required. Review of skills will be necessary after a period of absence from normal duties or taking up different patterns of practice. III. Maintenance of proper physical and mental health impact on the ability to practice. IV. Chemical dependency is incompatible with proper practice. V. Aging may lead to a decline in standards. Peer review mechanism should be accepted as part of proper practice. VI. Adequate time must be available for education, quality assurance activities, interaction with other colleagues and maintenance of professional contacts. VII. Adequate rest periods and prevention of fatigue are required to maintain high standards of professional care.

 The Clinical Duties of an Anaesthesiologist may include: I. Providing anaesthesia and other consultative services.

Mandaluyong City Medical Center CLINICAL DIVISION II. Ensuring all patients have a pre-operative assessment and continuing management. III. Supervising trainees and other staff. IV. Supervising the Recovery area. V. Organizing and managing an Acute Pain Service. VI. Association with Pain Management Service. VII. Provide an acute resuscitation service. VIII. Involvement with Intensive Care Services. IX. Administrative duties. X. Educational activities of medical, paramedical, community groups. XI. Peer review activities. XII. Maintenance of personal and professional clinical standards. XIII. Contribute to professional bodies and associations and organizations. XIV. Participation in Research.

 The Pre-Anaesthetic Consultation Consultation by an anaesthesiologist is essential for the medical assess- ment of a patient prior to anaesthesia. It provides an opportunity for:  establishing personal acquaintance with the patient and establishing identification.  ensuring optimal medical status of the patient  alleviation of anxiety  education of the patient and relatives in relation to anaesthesia  explanation of anaesthesia techniques  giving the patient a choice of anaesthesia techniques  an explanation of side effects and complications  where appropriate an explanation of costs to the patient  the establishment of a consent to proceed with the anaesthesia  the ordering of pre-operative medication where appropriate  a written summary in the medical record.

Principles I. The pre-operative consultation should (where possible) be performed by the anaesthesiologist who will be giving the anaesthetic. Where this is not practical a mechanism must be available for communicating with the anaesthesiologist. II. The timing of the consultation should leave an adequate interval preoperatively to consider the many factors, allow appropriate tests, seek advice and prepare equipment.

Mandaluyong City Medical Center CLINICAL DIVISION III. Emergency assessment may be necessary but it should not jeopardize the,full physical assessment prior to surgery.

 Statement of Patients' Rights and Responsibilities The Specialty aims to develop and maintain the highest possible standards of practice, teaching and research in anesthesiology, intensive care and other disciplines. Medical management is a partnership between the physician and the patient.

The anaesthesiologist has certain responsibilities, but the patient also has certain rights and responsibilities. These include, but are not limited to I. Patients have the right to: a. be treated with care, consideration, and dignity b. receive appropriate care c. know the identity and professional status of those treating them d. be informed of the proposed care and procedures (including alternatives), known side effects risks, e. an informed consent to anaesthesia, unless precluded by the urgency of the procedure f. know what services are available in the hospital g. a second opinion without prejudice h. know of any involvement in research activity, education and training and that refusal will not jeopardize treatment i. refuse treatment, and be informed of the consequences of such refusal j. know that care will remain confidential k. know (where applicable) the broad financial implication of treatment l. know the nature of premedication, anaesthesia and post-operative care

II. Patients have a responsibility to: a. inform the doctor of relevant medical history b. comply with agreed prescribed treatment c. participate in approved teaching and research activities which may improve the care of future patients (with the right of refusal) d. consider the ability to meet financial obligations in relation to care and therapy.

 Minimum Facilities for Safe Anaesthesia Practice

Mandaluyong City Medical Center CLINICAL DIVISION Standards of anaesthesia equipment will be determined by the designated hospital committee, in cooperation with the chairman of the anesthesiology department.

The specialist anaesthesiologist is obliged to observe every mechanism to ensure the availability, use, maintenance, and purchase of monitors and equipment which conform with current national and international standards.

 GENERAL PRINCIPLES  Anaesthesia should only be administered by an appropriately trained and qualified medical practitioner (depending upon regional variations). Trainees in anaesthesia should be supervised by the consultant anaesthesiologist.  All patients should have a pre-anaesthetic consultation with a trained anaesthesiologist, preferably the person administering the anaesthesia.  All patients will be monitored by the anaesthesiologist during the procedure with the best facilities available according to resources.  Adequate staffing of the operating suite will be available to assist in the conduct of the anaesthetic.

 Minimum Requirements for the Anesthesia Record A complete anaesthesia record is an essential part of the patient medical record. It is a medicolegal document. It should include: I. pre and post-operative management II. intraoperative management and observations III. report of any critical incidents IV. a tabular and graphical recording in logical sequence V. a signature of the responsible anaesthesiologist

Basic Information  Name, number, hospital, age, sex, weight  Date of Procedure  Name of the Anaesthesiologist  Name of the Surgeon  Procedure performed

Pre-Anaesthetic Information  Evidence of pre-anaesthetic assessment  Drug treatment, allergies/sensitivities  History of previous anaesthesia.  Pre-medicant drugs

Mandaluyong City Medical Center CLINICAL DIVISION  Evidence of discussion with patients concerning techniques, complications, expected outcomes and where applicable. cost of anaesthesia service

Intra operative information  Medication, drugs given and responses  Technique, general, regional, sedation  Time of anaesthetic and operative events  Airway, type used and difficulties  Intravenous, type and volume  Blood loss, blood and fluid loss  Position of the patient  Monitoring used and results obtained.

Post-anaesthetic Information  Recovery room record should flow on from anaesthesia record.  State of consciousness, respiratory and cardiovascular function.  Incidents occurring during the post-operative phase.  Specific post operative orders or requirements.

 Minimum Assistance Required for Safe Conduct of Anaesthesia The presence of trained assistants during the conduct of anaesthesia is a major contributory factor to safe patient management. The assistant must have undertaken appropriate training to provide useful support.

I. Principles a. The presence of trained assistants is essential for safe conduct of anaesthesia. b. This requires that: i. An assistant be present during the preparation and induction of anaesthesia ii. They remain under the direction of the anaesthesiologist until no longer needed iii. They be available at short notice intraoperatively iv. They be present at the conclusion of the anaesthetic

II. Deployment of Assistants a. Deployment must be specified in management protocols.

Mandaluyong City Medical Center CLINICAL DIVISION b. The work-load of the anaesthesia department will determine the number and status of assistants. c. Duties are specified in job descriptions. d. While assisting the anaesthesiologist, the assistant is wholly responsible to this anaesthesiologist and the care of patient at that point in time, and he/she should not attend to other activities. e. Assistants must be available for both elective and emergency surgery at all locations where anaesthesia is given.

 Standards for Conduct of Major Regional Anaesthesia I. General Principles a. Major regional anaesthesia is a technique which can produce significant physiological changes or local anaesthetic toxicity. b. It should be undertaken only by suitable, qualified, adequately experienced and trained medical practitioners or by supervised trainees. c. An understanding of the anatomy, physiology, pharmacology and complications of regional anaesthesia techniques, and the ability to promptly treat those complications, are mandatory. d. The situation of one person assuming dual responsibility for performing the regional anaesthesia and the surgery is not sanctioned. e. Major regional anaesthesia entails the presence of secure intravenous access prior to performing the anaesthesia and on-going monitoring with all the facilities available according to resources, laid down in the Standards. f. The anaesthesiologist shall remain in attendance throughout the procedure, or until the chances of toxicity are minimal, the block is successful and vital signs are stable. In addition, the anaesthesiologist must be aware that careful observations must continue as circumstances change in time and critical incidents occur even after long stable periods.

II. Epidural Analgesia in Labor and Delivery Epidural analgesia for labor is safe and effective provided that:

Mandaluyong City Medical Center CLINICAL DIVISION a. Epidural anaesthesia must be performed by trained anaesthesiologists or by anaesthesia trainees under direct supervision. b. Such person must be: i. Available to supervise the on-going management, or delegate that responsibility to another equally trained person following a formal endorsement of the patient. ii. Competent to deal with complications. c. An appropriately trained assistant must be available to assist the anaesthesiologist while performing the epidural block. d. Once epidural analgesia has been safely established, further doses of analgesia agents may be administered by trained medical staff provided that: i. The dose has been prescribed by the anaesthesiologist. ii. The anaesthesiologist delegating the "top-up" medication is absolutely satisfied that those delegated are trained in the task, competent to handle complications and monitor the patient and her fetus. iii. The person performing the top-up is satisfied that they are competent to do so. iv. Appropriate equipment and staff are available to manage complications. v. Written instruction and management guidelines appropriate for the institution are provided. e. Patients undergoing epidural analgesia are monitored in an area that is: i. appropriately equipped and staffed. ii. capable of providing patient and fetal monitoring. iii. staff can detect adverse reactions immediately. f. A detailed record of the procedure and on-going management must be kept. g. An intravenous infusion must be inserted prior to epidural insertion and must be continued for the duration of the block. h. The management responsibility remains with the anaesthesiologist or his delegated colleague.

 Principles for the Care of Patients who are given drugs to produce an Unconscious State

Mandaluyong City Medical Center CLINICAL DIVISION I. Introduction When a drug is given to produce an unconscious state, there is a risk of producing effects which require management by an appropriately trained medical practitioner.

Some of these effects can be life threatening because of: a. Depression of protective reflexes b. Depression of respiration c. Depression of cardiovascular system d. Variation in response in the elderly and infirm.

II. Principles a. Administration of drugs to produce unconsciousness requires knowledge to be able to i. Understand and deal with the actions of drugs being administered ii. Manage any complications iii. Anticipate the modifications of actions by concurrent therapy and disease. b. Every patient shall have a general medical assessment by a medical practitioner with training in anaesthesia. c. The administration of drugs should be directly supervised by a medical practitioner trained in anaesthesia who does not assume the additional role of a surgeon. d. A written record must be kept of the drugs administered and of their effects. e. Monitoring of the patient shall be done according to the accepted published guidelines. f. The full attention of the person, administering drugs to produce the unconscious state must be present until complications demanding immediate attention will no longer occur.

 Sedation for Diagnostic and Surgical Procedures I. Introduction Sedation includes the administration, by any route, of all forms of drugs which result in depression of the Central Nervous System. The objective of sedation techniques is to produce a degree of sedation of the patient, without loss of consciousness.

These techniques are not without risks, because of: a. Depression of protective reflexes

Mandaluyong City Medical Center CLINICAL DIVISION b. depression of respiration c. depression of cardiovascular system d. a wide variety of drugs can be used e. unpredictable absorption, distribution and efficiency of drugs when administered via oral or rectal routes. f. potential for overdosage and toxicity g. individual pharmacologic variability h. wide variety of procedures performed i. different standards of equipment and staffing.

II. Principles a. Patient shall be assessed by a trained medical practitioner and includes: i. complete medical history ii. informed consent iii. preoperative instruction, to include fasting iv. discharge instructiongs, to include activity limitations and anticipated side effects. b. The practitioner administering these drugs requires a basic knowledge to be able to i. Understand the action of the drugs being administered. ii. detect and manage complications (especially airway management and cardio-vascular resuscitation). iii. manage altered drug actions and effects caused by intercurrent disease processes. c. A written record of drugs administered and its dose effects must be kept. d. Staffing: There must an assistant available to the anaesthesiologist i. The surgeon may provide the sedation and is responsible for the case of the patient. ii. If rational communication with the patient is lost, the surgeon must cease the procedure and attend to the patient, until another physician is available to undertake the case and monitoring of the patient. iii. Techniques involving heavy sedation require the continuous presence of an anaesthesiologist. e. Facilities: The procedure must be carried out in a location of adequate size, staffing and. equipment to deal with cprdiopulmonary resuscitatiod, including: i. tilting operating table - suction apparatus

Mandaluyong City Medical Center CLINICAL DIVISION ii. supply of oxygen iii. a means of inflating the lungs, with oxygen iv. drugs for card iorespiratory resuscitation v. pulse oximetry vi. defibrillator f. Discharge: Patients should be discharged only after a period of continuous observation either in the theatre or a place adequately equipped to deal with complications. After authorization, patients are discharged into the care of a responsible adult, who shall be given written instructions.

 RESPONSIBILITIES OF THE ANAESTHESIOLOGIST IN THE POST OPERATIVE PERIOD  The anaesthesiologist has a prime responsibility in the management of the patient recovering from anaesthesia. This covers the period until the patient is ready for discharge from the recovery area.  The anaesthesiologist provides advice for management of: I. Monitoring during recovery. II. Pain relief. III. Fluid therapy. IV. Respiratory therapy. V. Adverse anaesthesia related events. VI. Peri-operative medical problems.  The anaesthesiologists has a responsibility to ensure that: I. Adverse effects related to anaesthesia are recognized, treated and recorded for further review. II. Relatives are kept informed of the anaesthesia outcome.  The anaesthesiologist often has an on-going consult in the postoperative period i.e. management of post operative pain. It is his/ her responsibility to provide a mechanism by which he/she may be contacted at all times and if not on call, to provide a reliever for ongoing management. A roster system must be established and widely circulated so that continuity of care is maintained.

 GUIDELINES FOR THE CARE OF PATIENTS RECOVERING FROM ANAESTHESIA IN THE RECOVERY AREA (INCLUDING DAY CASE SURGERY)  Principles I. Recovery from anaesthesia should take place under appropriate supervision in an area designed for that purpose. II. The area should be adjacent to where the anaesthetic is given. III. The staff working in the areas should be trained in recovery duties and should have access to medical staff promptly.

Mandaluyong City Medical Center CLINICAL DIVISION  Recovery Area I. The area must be adjacent to the OR but must be accessible to medical staff outside the OR who are not in theatre attire. II. "Climate Control" should be to theatre standards. III. Adequate space must be available per bed with easy access to the head part. IV. OR: PACU bed ratio should be 1.5 to 3.0. V. Each space should have oxygen and suction available. VI. Adequate lighting and emergency lighting. VII. Room for equipment and writing space for medical records. VIII. Space for a nursing station and storage of equipment. IX. A wall clock that can be seen from each space. X. An emergency call system and telephone.

 Equipment and Drugs I. Each bed should have access to oxygen, suction, stethoscope and B.P. apparatus. II. Equipment suitable to inflate the lungs with oxygen. III. Intubation equipment. IV. Emergency drugs, and means of administration V. I.V. equipment. There should be easy access to: VI. An E.C.G. VII. Pulse oximeter VIII. Defibrillator IX. Temperature measuring device X. Neuromuscular function monitor XI. Bronchoscope and suction XII. Blood warmer XIII. Refrigeration of Blood / Drugs XIV. Variety of Drugs XV. Diagnostic Services

 Staffing I. Previous training in the care of patients recovering from anaesthesia must be present at all times. II. Trainees must be supervised. III. Trained staff must be sufficient to provide at least one per patient who has not recovered protective reflexes.

 Management and Supervision I. Written protocols for safe management should be established by the anaesthesiologist in charge. II. Written routine should be established for equipment checks.

Mandaluyong City Medical Center CLINICAL DIVISION III. Observations should be recorded regularly, to be included in the medical record and preferably on the anaesthetic chart. IV. All patients should remain in the recovery area until they are assessed as being safe for discharge. V. The anaesthesiologist responsible should: a. accompany the patient to the recovery area and hand over to a responsible member of the staff. b. provide written and verbal instruction to the staff. c. specify the need for oxygen d. remain in the vicinity until the patient is safe to be left in the care of staff e. authorize the patient's discharge from recovery area or delegate this duty to another anaesthesiologist after appropriate endorsement.

 Specific Guidelines for Day Case Surgery Recovery I. The guidelines for general recovery apply to Day Case Surgery Recovery Areas.

In addition: II. Close liaison is required between the anaesthesiologist and surgeon to ensure suitability for discharge as the patient's readiness to travel home may depend upon surgical factors. III. Patients and relatives should have written instructions concerning activities and responsibilities in the early post-operative period. IV. Discharge Instructions shall include: a. name and telephone number of the physician should complications develop b. activity limitation (including driving and operating machines) c. diet and drug restriction, (alcohol, prohibited drugs, etc) d. anticipated side effects

V. Suitable hospital in-patient transfer arrangements must be in place should the need arise to admit a patient for further treatment.

Mandaluyong City Medical Center CLINICAL DIVISION

MANDALUYONG CITY MEDICAL CENTER

CLINICAL DIVISION

Mandaluyong City Medical Center CLINICAL DIVISION MANUAL OF OPERATIONS

TABLE OF CONTENTS

TITLE PAGE NO. DEPARTMENT OF PEDIATRICS 1-49 Mission/Vision/Objectives 1 General Functions 2 Organizational Structure 2 Historical Background 2-3 Training Program 3-5 Instructional Activities 6 Duties and Responsibilities 7-8 Evaluation of Residents 8-9 Rotations to Different Section 9-10 Teaching Conference 10 Pediatric Procedures 10 Duties & Responsibilities at Different Areas 10-11 Duties & Responsibilities of Ward Resident 11 Duties & Responsibilities of NICU Resident 11-12 Development Plans 12-13 Hiring and Selection of Residents 13 Job Description / Criteria Chairperson 13-14 Training Officer 14 Bio-ethics Committee 14-15 Consultant Staff 15-17

Mandaluyong City Medical Center CLINICAL DIVISION Criteria for Selection of Consultants 18 Policies and Procedures Admission 18-19 Private Cases 19-20 Discharge 20-21 Transfer Request 21 Emergency Room Policies 21 Out-Patient 22 Hydrating Unit 23 Pediatric Ward 23-24 Transient / NICU 24-25 PICU 25-26 Infectious Disease Ward 26-27 Cadaver Care 27-28 Immunization 29

TITLE PAGE NO. Implementation on Breastfeeding/Rooming-in 30-31 General Policies Breastfeeding 31 Equipments and Physical Set-up 32-37 Appendix A 43-44 Appendix B 45-48 Appendix C 49 DEPARTMENT OF OBSTETRICS & GYNECOLOGY 50-81 History/Philosophy 50 Description of Training Program 51 Policies and Guidelines Out-Patient 51-52 Emergency Room 52-53 Labor Room / Delivery Room 53 Ward Policies 54 Strategies 54-62 Duties and Responsibilities 62-63 Rules of Discipline 67 Areas of Activities 67-68 Year Level Competencies 68-72 Evaluation Method 72 Faculty 73 Appendix A 77

Mandaluyong City Medical Center CLINICAL DIVISION Appendix B 78 Appendix C 79-81 DEPARTMENT OF INTERNAL MEDICINE 82-94 Overview/Definition/Principles 82 Ethics/Mission/Vision/Objectives 83 General Policies and Procedures 83-84 Organizational Structure 85 Work Flow 86 Strategies and Procedures 87-88 Intensive Care Unit Guidelines 89-93 Administrative Policies 94 DEPARTMENT OF SURGERY 95-109 Introduction/Historical Background/Definition 95 Guiding Principles/Concepts Department Nomenclature 96 Organizational Structure 97-98

TITLE PAGE NO. Staffing Pattern 99-100 Job Description Medical Officer / Medical Specialist 100 Strategies and Procedures Emergency Room 101 Out-Patient 101 Admission 102 Operating Room 102 Administrative Policies 102-103 Functions & Responsibilities of Staff Personnel 103-106 Training/Manpower/Quality Assurance 107 Disciplinary Action Guidelines 107-109 DEPARTMENT OF OPHTHALMOLOGY & ENT 110-128 Overview/History/Principles 110 Department Nomenclature 110-112 Organizational Structure 113 Standard Operating Procedure Out-Patient 114 Emergency Room 114 Admission 114-115 Referrals 115 Clientele 115

Mandaluyong City Medical Center CLINICAL DIVISION Administrative Policies 115-116 Functions and Responsibilities 116-117 Termination 117 Training / Manpower 127 Schedule of Services 128 DEPARTMENT OF ANESTHESIA 129- Mission/Vision/Organizational Structure 129 General Standards 129-130 Pre-Anesthetic Care and Monitoring 131 Pre-Anesthesia Care 131 Monitoring During Anesthesia 131-133 Post-Anesthesia Care 133-134 Remote Anesthesia 134 Equipments & Requirements 135-136 Specific Anesthesia Practice Pattern 137-144 Responsibilities of the Anesthesiologist in the 145-146 Post-Operative Period

TITLE PAGE NO. Staffing Pattern 99-100 Job Description Medical Officer / Medical Specialist 100 Strategies and Procedures Emergency Room 101 Out-Patient 101 Admission 102 Operating Room 102 Administrative Policies 102-103 Functions & Responsibilities of Staff Personnel 103-106 Training/Manpower/Quality Assurance 107 Disciplinary Action Guidelines 107-109 DEPARTMENT OF OPHTHALMOLOGY & ENT 110-128 Overview/History/Principles 110 Department Nomenclature 110-112 Organizational Structure 113 Standard Operating Procedure Out-Patient 114 Emergency Room 114 Admission 114-115 Referrals 115

Mandaluyong City Medical Center CLINICAL DIVISION Clientele 115 Administrative Policies 115-116 Functions and Responsibilities 116-117 Termination 117 Training / Manpower 127 Schedule of Services 128 DEPARTMENT OF ANESTHESIA 129-148 Mission/Vision/Organizational Structure 129 General Standards 129-130 Pre-Anesthetic Care and Monitoring 131 Pre-Anesthesia Care 131 Monitoring During Anesthesia 131-133 Post-Anesthesia Care 133-134 Remote Anesthesia 134 Equipments & Requirements 135-136 Specific Anesthesia Practice Pattern 137-144 Responsibilities of the Anesthesiologist in the 145-146 Post-Operative Period

TITLE PAGE NO. Guidelines for the Care of Patient Recovering 146-147 From Anesthesia in the Recovery Area Specific Guidelines for Day Case Surgery 148 Recovery

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