Operation Policy

 

 

 

As'ad Al Hamad Dermatology Center

Al-Sabah Hospital

 

2014

 

 

Mission

 

As’ad Al-Hamad Dermatology center which represent the dermatology department in Sabah hospital,  performs two main functions:

 

 

 

Vision

 

·         Weekly academic meeting every Tuesday.

 

 

 

Functions

 

Referral Policy to As’ad Al-Hamad Dermatology Center:

 

a)              Being a referral specialty, As’ad Al-Hamad Dermatology Center does not allow walk-in patients except in emergencies

 

b)              We are OPD only not urgent care clinics, any urgent  case should be directed to emergency  at Sabah hospital and we can get consulted.

 

c)              Each patient must have a referral letter from his/ her treating doctor, and should come on appointment basis.

 

 

d)              Direct referral from the polyclinics and primary care clinics to specialty units and specialty clinics in the center that provide tertiary care services is not accepted. Such referral should be only through dermatology doctors.

 

e)              Regular patients referred through primary care doctors should belong to the catchment health area of As’ad Al-Hamad Dermatology Center (Appendix 2)

 

f)                Cases referred to As’ad Al-Hamad Dermatology Center for Lab investigation  ( Immuno lab, Histopathology ) or treatment in the various specialty units and specialty clinics are accepted on condition that these cases are referred by a dermatologist from dermatology departments or affiliated dermatology units/clinics. A referral letter from the dermatologist should be given to the patient with a brief history or summary of the case and the requested procedure to be carried out. (New opening file form  Appendix 3 )

 

 

g)              Referral from within the center should be through the doctors using the special forms designed for each specialty unit

 

Appendix 4: Dermatopathology,

Appendix 5: Immunodermatology,

Appendix 6: Mycology,

Appendix 7: Medical Photography

 

 

h)              Cases referred to the center from one of the hospitals of Al-Sabah Specialty Health Area will be seen as a new case and thereafter evaluated by at least a registrar. The doctor will do the consultation, plan will be written and the referral to the  dermatologist in the dermatology  center in which patients are belongs to. the dermatologist at Assad alhamad center can do a service ( skin biopsy, immuno etc ) if not available at the center that patient belongs to.   Thereafter the patient has to be referred to the treating doctor in the patients’ residence catchments area for follow-up.

 

 

 Internal Policy for As’ad Al-Hamad Dermatology Center

 

General

 

a)    All patients who are receiving regular treatment and follow-up in As’ad Al-Hamad Dermatology Center should have a medical file that is used for the same patient whether he/she is followed up in the outpatient clinics, specialty clinics, or the specialty units.

 

b)     Every patient need s a file according  to accreditation guidelines 

 

 

c)    New patients who will receive treatment in the outpatient clinics in As’ad Al-Hamad Dermatology Center are seen in the first 3 visits on casualty paper MR3 but a file must be opened for any chronic disease who require frequent visits and follow up or any patient require special medication according to the list from the pharmacy. ( Appendix 23)

 

d)    All patients who are referred to As’ad Al-Hamad Dermatology Center and will receive treatment and will be followed-up in the specialty clinics or specialty units should open a file

 

e)    Patient referred from outside the catchment  area,  justification should be attached from the referral paper

 

f)     Before referring to specialty clinics or services, the referring dermatologist at the OPD at Asad alhamad should open a file, and no patient will be accepted to do any specialty service without a file.

 

g)    All patients who were referred to As’ad Al-Hamad Dermatology Center from outside the center for treatment in the specialty clinics or specialty units, upon completing their treatment course should be referred back to their treating doctors in the relevant health area according to their residency. A full medical report for these patients should be sent to their treating doctors.

 

 

h)   Surgery:  All patients referred for skin biopsies, should receive information about their surgical procedure that will be carried out (Appendix 11). Post-operative instructions need be given to  these patients and   include: post-excision biopsy instructions(Appendix12),postelectrosurgery/ shave biopsy instructions (Appendix13), and post-subcision surgery instructions (Appendix 14). Information is available in both English and Arabic languages. Skin surgery appointments has to be done through the technician-in-charge (phone: 24831996/7 ext 246). A special booking notice (English/ Arabic) will be handled to the patient (Appendix 15). A questionnaire about patients past history, medications, allergies, and infectious diseases has to be filled out by the patient before carrying out surgical procedures and to be kept in his file (Appendix 15b).

 

 

i)      Photography to be done in the medical photography unit prior to the biopsy after signing the photography consent. If the patient refuses photography, this should be mentioned in his file and the biopsy will be carried out. If the referring doctor will decide not to do photograph then this would be his responsibility.

 

j)     All appointments of the patients should be manually recorded on the special yellow card, and should also be registered in the computer system at the OPD appointment desk.

 

 

k)    The waiting period for new cases should not exceed one week in the OPD and Phototherapy

 

l)     All Dermatology Departments and affiliated Units and Clinics should use special dermatology sheets for the outpatient clinics inside the medical files that have been approved previously by the Council of the Dermatology Departments. These sheets will be added to the patient file for use by the dermatologist

 

m)  The following papers in any OPD file: MR2 ( appendix 16) , MR7 ( appendix 17 A) then MR1 (Appendix 17B), body drawing sheet and prescription sheet

 

n)    The following papers in any Phototherapy file: MR2, MR7, DERM3, DERM4, DERM5 , body drawing sheet then MR1 and prescription sheet

Appendix 18: Photo Therapy  sheet (Derm3)

Appendix 19: Photo Therapy  sheet (Derm4)

Appendix 20: Photo Therapy  PASI sheet (Derm5)

Appendix 21: Body Drawing  sheet.

 

o)    Old files should be replaced with new file system by medical record staff

 

p)    Dispensing treatment for the patients from the pharmacy is not allowed except on the formal treatment papers used in the center on MR3. If the patient has a file then the treatment sheet inside the file is used. Patients who are treated temporarily on casualty papers can have medication dispensed according to MOH regulations.
 

q)    Certain medications are only dispensed by the senior registrars or a higher rank. These medications are specified by the Dermatology council and a list of these medications should be available in the pharmacy (Appendix 23).

 

r)     Other, some medications like Roaccutane and Neotigasone/ Acitretin need special informed consent to be filled out by the patient (Appendix 24,  Appendix 25 respectively).

 

 

s)    No files should be handled to the patient at any time and under all circumstances. The file transfer from the reception to the outpatients’ clinics or the specialty units should be arranged by the medical records section. 

 

 

 

t)     On-Call:

 

·         All the staff of the department will have afternoon duties at the rate of once per week (at least)  plus a Friday or a Saturday duty every month.  On these days, all members of the duty will be present physically in the department for at least 3 hours (from 5:00-8:00 p.m on weekdays  and 9 am -12 pm on Saturdays. Ramadan  duty hours are subject to change and delegated by Sabah hospital administration.  Doctors will be on-Call for the 24 hours ( 7 am – 7 am next day ) on their duty day to cover all consultations.

·         the doctor should inform the secretary for any change  in their phone  number.

 

·          Regulations regarding on-call procedures and system will follow the Job Description set forth by the Council of the Dermatology Departments

 

·         Starting from March 2005, a change of the afternoon duties has been set after it was discussed in the Department Council Meeting in February 2005.

 

·         Accordingly, the doctors who are first on call will be responsible for the consultations  (hospital requests) on group basis for the hospitals:

 

1.    First on-call (A) doctor: responsible for requests from Al-Sabah Hospital Departments including Al-Ettisalat and NBK buildings, plus the Allergy Center.

 

2.     First on-call (B) doctor: responsible for requests from Al-Razi, Maternity, Physiotherapy, Infectious Diseases, Psychiatry and Addiction hospitals.

 

3.     First on-call in PUVA (A) doctor: responsible for requests from Cardiology, TB-Chest  hospitals, and Bait Abdulla

 

4.     First on-call in PUVA (B) doctor: responsible for requests from Ibin-Sina, Babtain, Hamed Al-Essa, KCC, Al-Bahar, Al-Naffisi, and Chemotherapy hospitals.

 

5.    In case no First on-call (A) Doctor available , then First on-call  ( B) will cover and visa versa. In case no First on-call PUVA (A) Doctor, available , then First on-call  PUVA ( B) will cover and visa versa. In Case no first on call A and B, then first on call PUVA A and B will cover ( A to A, B to B)

 

6.    No PUVA oncall doctors on Saturday. An exception to the above-mentioned grouping of hospital rule is when there is only one First on-call doctor (as for example in Fridays), in this condition the underlined doctor in the schedule is responsible for requests from ALL  hospitals on that day

 

7.    Trainee doctors including those who are enrolled in the Dermatology Board Program should accompany the second on-call or third on-call doctors during the in-patients round, also they have to accompany the First on-call doctor during the requests round, and then they have to discuss it with the senior doctor in the afternoon duty.

8.    The first oncall doctor may refer to the second  oncall and subsequently third oncall for further consultation if required.

 

 

 

 

 

 

 

u). Reports:

 

 

 

 

 

 

v). Medical board:

 

 

 

w). Statistics:

 

 

x). Consent:

  1. Skin biopsy and other surgical procedures (Appendix 30).
  2. Laser therapy (Appendix 31).
  3. Phototherapy (Appendix 32). 
  4. Medical photography (Appendix 34).
  5.  DPCP therapy for Alopecia Areata and (Appendix 35).

 

z). Emergency :

Z1). Professional issues:

Z2). Complaints from patients:

 

 

 

 

 

 

 

 

 

 

 

 Structure:

 As’ad Al-Hamad Dermatology Center:

This center provides both, secondary dermatology services to the catchments areas and tertiary health care services to all Kuwait. It contains the following:

I)   Secondary Dermatology Health Care Services to the catchments health areas through the general outpatients clinics:

 All clinics are numbered (1-21) and the patients’ files should show the number of the clinic of the treating doctor rather than the name of the doctor. Appointments of the patients are also referred to by the number of the clinic, whether on the appointment yellow card or in the computer.

Some of the outpatient clinics work on certain days of the week because the doctor is involved in running either a specialty clinic or involved in a specialty unit

For details of the doctors names and their assigned clinics please refer to (Appendix 37i).

II)     Tertiary Dermatology Health Care Services to all Kuwait through The specialty outpatients clinics and specialty units:

 

a)       The Specialty Outpatients Clinics:

These are specialty clinics that provide advanced care for certain diseases. Each clinic is run by a registrar (or more, according to the number of patients seen in the clinic) who should be under supervision of a senior registrar (or a higher rank).

All specialty clinics should use special forms for the patients that should be inserted in the patients’ files:

-         Appendix   38: Treatment of Alopecia Areata with  DPCP

-         Appendix 39: Sick-Kids Clinic.

-         Appendix 40 : Psoriasis clinic.

-         Appendix 41 : Bullous Diseases clinic.

-         Appendix 42: Cutaneous T-Cell   Lymphoma cases.

Currently the center contains the following specialty  outpatients clinics:

(i)            Pediatric Dermatology clinics

(ii)          Psoriasis clinics

(iii)         Autoimmine Bollous Diseases Clinics

(iv)         Alopecia Areata clinics

(v)          Contact Dermatitis clinic

(vi)         Sick-Kids clinic

(vii)         Hair Disorders Clinic

(viii)       Connective Diseases Clinic

 

 

 

 

 

 

 

 

 

 

Pediatric Dermatology clinics:

Location

clinic 15 Dr. Arti Nanda

clinic 19 (Dr. Rana Al-Noun)

clinic Dr Haneen AlRagom

The pediatric clinics run at present time on daily basis. These clinics provide dermatology care for all pediatric cases referred by dermatologists or pediatricians.

Statistical record of all new pediatric dermatology cases seen since 2000 is maintained. Guidelines of care sheets are given to the parents of children with atopic dermatitis and eczema (Appendix 43 Arabic and English versions).

 

 

 

 

 

 

 

 

 

 

Psoriasis clinic: 

It is run by one consultant  Dr. Hesham Hanafi, Clinic 2

Two Specialists  Dr Fatima Al-Khawajah, Clinic 9, and Dr Huda AlSaffar Clinic 6

Two Registrars Dr. Magdy Clinic 3

Currently it is working once per week (Sundays).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Autoimmune Bollous Diseases Clinics:

Location:

Dr Arti Nanda room 15

Dr Fatema alkhawaja room 10

Dr Eman Almasri room 1

Currently is working once per week (Tuesdays).

Rituximab protocol (Appendix 53)

IVIg protocol ( Appendix 54 )

 

 

 

 

                          

 

 

 

 

 

 

Alopecia Areata clinic:

 Location:

 in the doctors office in the corrective unit.

It is run by one Specialist  (Dr. Rafaat Madbouli).

 When needed, another Registrar runs the clinic (Dr Wageeh Waheeb).

Currently it is working once per week (Thursdays).

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Dermatitis clinic:

 Is run by senior registrar Dr Atlal Lafi and Registrar Dr Jihan Raji

 The doctors of this clinic are responsible for doing patch testing for patients referred from general dermatology and for the employee referred from the General Medical Council. The results of the latter tests should be recorded on a special form (Appendix 44) that will be handled to the patient. A copy of this report to be kept in the clinic.

Currently is running every Sunday & Wednesday

Form:(Appendix  22 A)

Protocol: (Appendix 22B)

 

 

 

 

 

 

 

 

 

 

 

 

Sick-Kids clinic: 

In order to provide better quality care to sick pediatric dermatology cases, this clinic is started on Wednesdays. Location:  clinic 15 

 It is run by one Consultant (Dr. Arti Nanda). This clinic will provide specialized dermatology care services to pediatric patients suffering from:

 

 

 

 

 

 

 

 

 

 

 

 

Hair Disorders Clinic:

This is a specialized clinic for diagnosing hair disorders including: Androgenic Alopecia in males and females, Hirsutism (non-endocrine in origin), Primary Hair Disorders, Alopecia Areata patients failed in the standard therapy, and Acute and Chronic Telogen Effluvium.

The clinic has started operation on February 2003 and is run by a (Dr. Ibrahim AI-Aradi) as a once weekly clinic (on Mondays from 10:30 – 12:30). Referral of the patients should be through a written note in the patient's file and should include brief history, examination and tests done for that patient. Any patient referred without a note will not be accepted. Booking of appointments will be through the nurse-in-charge of this clinic. For the Protocol of this clinic, please refer to Appendix 45.

 

 

 

 

 

 

 

 

 

 

 

 

 

 Connective Diseases Clinic:

The clinic has started operation on November 2010 and is run by Dr Shamayel Al-Snafi (Specialist ) It is run once per week currently (Mondays) and is located in Clinic No 7.

 

 

 

 

 

 

 

 

 

 

 

 

 

                

 

 

The Lymphoma clinic

 Starting from March 2011 Dr Jihan Raji is running a joint clinic in KCC for MF and CTCL cases on Mondays. This clinic was requested by Dr Salem Al-Shimmari and was officially approved. Its for better care of these patients who are jointly treated and followed up by both departments.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b)      The Specialty Units:

  1. Phototherapy Unit:

This is run by 4 registrars (Dr. Ihab Nour El-Dein, Dr. Jihan Raji, Dr Mohammed Taha, and Dr Ahmad Fekry) supervised by one Specialist Dr Fahad AlMotawa and supervised by Dr. Hejab Al-Ajmi, helped by trained nursing staff.

It provides phototesting and phototherapy (Systemic and Topical PUVA, UVB, UVA) for the indicated diseases. Each doctor working in this unit should follow the treatment protocol provided by the center for this unit (Appendix 46).  Topical application of medication for Topical PUVA should be carried out by the nursing staff and not be the patients themselves.

The unit works 5 days a week  and, at present, accepts new cases from Sundays to Thursdays

Phototesting is done on Sundays, Mondays, and  Thursdays for oral PUVA, and  daily except Thursdays for UVB.

The unit also provides afternoon treatment services from 4:30 to 8:30 p.m. for Kuwaiti patients and from 5 – 8 pm to non Kuwaiti patients.

Each patient is given verbal information and instruction about the phototherapy and its possible side effects.

The medical photophysics laboratory

The medical photophysics laboratory is run by 5 assistant physicists and is under supervision of a highly qualified physicist (Dr Hanan Bu-Abbass). The unit is involved in the following activities:

1- Set up of photo physics lab., Workshop, UVA and UVB treatment rooms and phototesting rooms.

2- Training the nursing staff who are involved in the treatment of patients with PUVA and UVB.

3- Calibration of PUVA and UVB units periodically.

4- Calibration of different instrument and detectors in the lab.

5- Photo-testing of patients of different skin types using Applied Photo physics Photo-irradiator and Multiport solar simulator ( Model XPS 200 )

6- Measurement of the absorbency (or light transmission) of sunglasses for patients treated with photosensitizers, to protect their eyes from UVR.

Equipments available in the Phototherapy Unit

(The Treatment Rooms and the Photophysics Lab):

  1. Laser and corrective unit

The corrective unit is a specialized unit to evaluate cases referred by dermatologist for laser Rx.

The unit is under supervision of a Consultant Dermatologist Dr. Meshal Al Ghareeb.

 The unit is subdivided into Vascular laser clinic and pigment laser clinic.

The patient need to be referred from the OPD. If the referred patient is candidate for laser Rx, he will have detailed consultation about the treatment, the outcome, side effects, and asked to sign a consent.

The patient will be sent for medical photography and referred back to his referring dermatologist to open a file if not it does not exist. The patient will be given an appointment for laser Rx and will be followed up by laser unit for treatments. If the patient finished the treatment or has any other dermatological condition, the patient must consult the referring dermatologist at OPD.

The referring doctor must request Venous Doppler before sending the patient for vascular laser treatment for leg Telangiectasia.

The resurfacing laser cases are treated by both units.

Doctors who want a clinical attachment in the Laser Unit should follow a certain protocol (Appendix 37f). The doctor has to apply a special form (Appendix 37g), and upon approval of his rotation, the doctor has to use a log book (Appendix 37h).

Pigmented Laser Unit: 

Running Mondays and Wednesdays

Q switched laser:

a.   QS Nd-YAG

b.   QS-Alexandrite

c.    QS-Ruby

The cases that are treated are Freckles, lentigines, tattoos, nevus of Ota/ Ito and CALM

The staff for pigmented laser unit:

Vascular  Laser Unit: 

Running Mondays, Wednesdays, and Thursdays

Lasers available and indications:

a.   Pulsed dye laser PDL: Rosacea, Telangiectasia, Hypertrophic scars, Keloids, venous lake, vascular malformation and port wine stain

b.   Nd-YAG: Telangiectasia on face, Nose, lower limbs, acne scars

c.    EXO laser: Lower limbs Telangiectasia

The staff for the vascular laser unit:

Resurfacing lasers:

Indication for resurfacing:

Acne scars, thurmal burn, scar revision, adnexal tumours

Equipments at the Corrective Dermatology Unit:

 

                                                

                                                                                                                             

 

 

 

 

 

  1. Dermatologic Surgery Unit

The unit is under supervision of a Consultant Dermatologic Surgeon (Dr Ibrahim Al-Aradi) and is helped by :

·         Specialist Dermatologic Surgeon (Dr Hamad Al-Abdel Razaque, Dr Huda AlSaffar)

·         Other specialists Dr Iman El-Masry, Dr Hanin Al-Raqam

·         Senior registrars Dr Dalal AlMutairi Dr Anwar AlSomait, and Dr Nadya Naqi

·         Registrar Dr Tariq Karam and  helped by trained nurses.

The unit works on:

Sundays: Dr Ibrahim Al-Aradi, Dr Hamad Al-Abdel Razaque, Dr Dalal AlMutairi and Dr Tariq Karam

Mondays: Dr Ibrahim Al-Aradi, Dr Hamad Al-Abdel Razaque,  Mohs and  Hair clinic

Tuesdays:  Dr Ibrahim Al-Aradi, Dr Hamad Al-Abdel Razaque, and Dr  Huda AlSaffar, Dr Nadya Naqi and Dr Anwar AlSomait

Wednesdays: Dr Ibrahim Al-Aradi, Dr Hamad Al-Abdel Razaque, Mohs microscopic surgery

Thursdays: Dr Ibrahim Al-Aradi, Dr Hamad Al-Abdel Razaque, Dr Hanin Al-Raqam.  And Dr Iman AlMasri

·         The unit has one room for major procedures & two rooms for some minor procedures.

·         Two surgical nurses are assisting the derm-surgeons, Staff nurse Praba Haris and Staff nurse Joby Thomas

·         The unit receives surgical consultations from all dermatology centers in Kuwait and AlBabtain center, and other senior specialists from other specialties.

 Working days schedule

Day

Procedures under L/A

Sunday

  • Electrosurgery,
  • Cryosurgery
  • resistant wart surgery
  • acne scaring corrective surgery (subcision, excision, dermabrasion)
  • chemical peeling for xanthelesma,
  • excision of benign tumors etc
  • keloid injection

Monday

  • Hair clinic and Mohs

Tuesday

  • General skin biopsies and procedures

Wednesday

  • Mohs micrographic surgery for malignant tumors
  • Excision of malignant tumors with postoperative flaps & grafts repairs
  • Surgical treatment of keloids & adjuvant therapy
  • Keloidectomy
  • Vitiligo punch transplant surgery

Thursday

  • General skin biopsies

The surgical check list protocol as follows:

“Time out” immediately before starting the procedure, Time out should be conducted in the OP/ procedure room before the incision. It should involve the entire operative team, use active communication, be briefly documented, such as in a check list

Should include:

a.   The correct patient identity ( triple name and DOB, and match them to the specimen bottle and request form)

b.   Correct side and site ( match identity and site if multiple specimen)

c.   Agreement on the procedure to be done (MR5)

How to do it:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Equipment at the Dermatologic Surgery Unit:

 

  1. Dermatopathology:

This is run by 3 qualified Dermatopathologists:

 Dr Ghanima Al-Omar

Dr. Humoud Al-Sabah

Dr Mohammed Al-Otaibi

working in 2 units and helped by 2 technicians. The units are responsible for dermatopathological diagnosis of skin biopsies.

Routine, special stains, direct and indirect immunofluorescence, and immuno-histochemical staining are done as indicated. If a procedure is not available in the center, the specimen (or tissue block) is sent to Pathology department at Sabah Hospital, to Kuwait Cancer Center, or to the Faculty of Medicine for processing. 

All patients’ information and pathology report should be entered in the computer system by the secretary working in the pathology unit. A print-out of the pathology report should be signed by the doctor in-charge of the pathology unit.

Equipment at Dermatopathology Unit 

(The Lab and Doctor’s office):

                   a.   Microtome for cutting paraffin blocks.

                   b.    Embedding machine for embedding the processed biopsy specimen in paraffin.

                    c.   Tissue processor for fixing the biopsy specimen in different steps.

                    d.   Incubator for fixing the slides and incubation (staining).

                     e. Water bath for stretching the cut sections and to take it on slides.

                     f.  Multihead Microscopes.

                     g. One light microscope for examining the quality of the sections.

                     h. Three microscopes in doctor’s office, used for examining and reporting the slides and also photography of the slides when needed plus for teaching purposes.

                     i. Hot Plate for heat fixing the slides.

                     j. Oven for incubation at high temperature.

                     k. Fume Hood for absorbing toxic gases.

                     l. Microwave processor for immunostaining and immediate processing.

                     m. Weighing machine for preparation of various reagents and solutions.

                     n.   Elisa equipments for doing several tests including circulating immune complexes, SS-A and SS-B antibodies, Desmoglein Ab (1 and  3), anti-gliadin Abs, and BP 180

 

 

 

 

 

 

 

  1. Immunodermatology:

This is run by Senior Registrar (Dr. Najla Al-Khrafi) and helped by 2 technicians. It provides diagnostic facilities essential for certain skin diseases including direct immunofluorescence tests, indirect immuno-fluorescence using monkey esophagus, human split skin, direct smear for Leishmaniasis, Immunoblotting using human skin antigens, human epidermal keratinocytes antigen, circulating immune complexes, and antinuclear antibodies using HEp-2 cells, HeLa cells. If a procedure is not available in the center, the specimen is sent to Hamed Al-Eisa Tissue Transplant Center or to the Faculty of Medicine for processing.

The unit accept patients referred from the OPD as well as from other dermatology departments.

All patients’ information and immunology report should be entered in the computer system. A print-out of the immunology report should be signed by the doctor in-charge of the immunology unit.

Equipment at the Immunodermatology Unit:

                       a. Equipments for electrophoresis and immunoblotting.

                       b. Co2 incubator for tissue cultures.

                       c. Microbiological cabinet for sterile preparation of cells and tissues.

                       d.Inverted microscope for cell microscopy.

                       e. Refrigerated Centrifuge.

                       f. Ordinary Centrifuge

                      g. Cryostat for cutting sections for DIF and IIF tests, and Moh’s surgery.

                       h. Two Fluorescent microscopes for reading and reporting DIF and IIF tests, and Moh’s surgery.

                           i. Ordinary microscope.

                       j.  Deep Freezer (-80 C) for long time storing of valuable samples.

                       k. Freezer (-25 C) for short time storing of samples.

                       l. Refrigerator (-15 C  -4 C)

                       m. Analytical Balances

                        n. Autoclave

                        o. Two sets of computers with printers

                     p. Digital Camera DP-70 for recording immunofluorescence and histopathology microscope samples.

 

 

 

 

 

  1. Dermatomycology:

This unit is under supervision of a Registrar with very good experience in Dermato-mycology and he is from Al-Amiri Dermatology Department  Dr. Mostafa Yihea and works in this unit once per week (Wednesdays) together with one Registrar from our center (Dr Magdi Fathallah).

The unit provides diagnostic facilities essential for fungal diseases of the skin including direct scrapings and cultures. A  detailed referral form should be completed by the referring dermatologist. Mycology report should be signed out by the doctor in-charge of the mycology unit.

 

Equipment at the Dermatomycology Unit:

                          a. Two incubators for cultures of mycology specimens.

                           b. Ordinary microscope for examining the direct smears for evidence of fungal infection.

 

 

 

 

 

 

 

 

 

  1. Medical photography:

Being an essential part for dermatology, medical photography of patients is done for follow-up of cases and for teaching purposes. It is run by one registrar (Dr. Khaled Khamis) on Sundays, Tuesdays, and Thursdays, helped by a nurse.

 A special form should be used for each patient to be photographed (Appendix 7) and an informed consent to be signed (Appendix  7).

Information about the photographed patient including name, referring doctor, date, and reference number of photographs is given to the patient in a special sheet (Appendix 49) that should be returned to the treating doctor and kept in patient’s file. For internal use in the unit, a special form is used that will facilitate the filing of the photographs (Appendix 50).

The unit will also help the doctors to keep records of interesting cases and storing them in s presentation format through the use of special forms (Appendix 51 and Appendix 52).

 

 

 

 

 

 

 

 

 

 

 

Equipment at the Outpatient Clinics:

                           a. Birtcher-Hyfrecator in each clinic for removal of warts, skin tags ..etc.

                            b. Liquid Nitrogen drums are used to distribute liquid nitrogen in small containers to be used by the doctor in his clinic for treatment of warts ..etc.

                           c. Hand-held Liquid Nitrogen cylinders

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Pharmacy

This consists of  a dispensing area, lab for preparation of some formulas, and a store. It is under supervision of Main pharmacy at Al-Sabah Hospital, and the chief pharmacist is in-charge of the pharmacy. Several pharmacists or assistant pharmacists (number is not fixed) are working daily in the pharmacy.

The pharmacy works in morning hours and the afternoon duty hours from Mondays to Wednesday. Patients seen in the afternoon duty of Thursday, who need urgent treatment are referred to the casualty medical pharmacy to dispense medication. Otherwise, the patient can dispense the prescribed medication next day.

The pharmacy keys are separate and different from the master keys of the center. These are kept with the chief pharmacist.

 

 

 

 

 

 

 

 

 

 

 

 

   Function of the Department Council:

 

1. The Department Council is chaired by the Chairperson of Department (or his deputy) and will have a monthly meeting.

2. Membership of the Department Council:

Setup of the council included all Consultants, Senior Specialists, Specialists, and one Registrar representative for all junior doctors. The latter to be changed on rotational basis yearly. Also, persons in-charge of the Labs, Pharmacist in-charge, person in-charge of the Medical Records, and one representing Nursing staff.

It is held regularly every 2 months.

3. The Department Council will determine the size of the adequate team to run the different units in the department according to the norms set by the Dermatology Council for the dermatology service; where each outpatient-unit normally consists of one senior registrar or higher plus 3 registrars.

4. The council will ensure implementation of the Job Description set forth by the Council of the Dermatology Departments and in accordance with the general rules laid by the Ministry of Health.

5. The council will be responsible for implementation, maintaining, and reviewing compliance with the clinical guidelines of care set by the Council of the Dermatology Departments.

6. The Council will identify, initiate and maintain Bylaws, Rules and Regulations for the proper functioning of the department staff.

7. The Council will identify the problems that might be met with during running of the department and units and should put forward suggestions to solve such problems.

8. The Department Council will suggest to the Chairperson of the department, the needed medical equipments and tools, scientific books and periodicals, and names of consultant visitors. The Chairperson in turn will discuss these matters with his colleagues in the Council of the Dermatology Departments.

9. The Council during its monthly meeting should discuss the detailed statistics carried out by the Person in-charge of the Medical Records regarding various activities of the department and its units, and find out any indicators of deviation from normal and expected findings. Abnormal findings should be discussed and investigated by members of the council and proper solutions to be suggested.

10. The Council should contribute in planning of the Annual Vacations of the department and units.

11. The Department Council should be aware of the steps and principals of the Emergency Plans set by the Council Board of the Hospital and should be able to implement these plans whenever needed (Appendix 62 ). A departmental Emergency Plan has been set that includes an Emergency Team during morning working hours and during afternoon duties. The details of this plan is available through 12 Emergency Circulars (Appendix 54 ).

12. Promotions, shortages, proposed plans, change of structure will be discussed in the Council’s meeting.

13. The Council will review and evaluate on continuing basis the clinical privileges of the staff, to ensure a high level of professional performance by all persons authorized to practice in the department.  Senior members of the Council in a closed meeting will decide on the appropriateness of the professional performance and ethical conduct of members of the department.

14. The Council will support the appropriate utilization of the department resources, and support all clinical and non-clinical activities that serve to promote and maintain accreditation of the department locally and internationally.

15. The Council will discuss the duties of running the day to day business e.g., minor operation theatre, phototherapy, post-graduate and in-service training, the morbidity/mortality, research, the medical records..etc.

16. The Department Council will decide on the appropriate educational setting which will maintain scientific standards and continuous advancement of professional knowledge and skills through the following:

a) The department weekly clinical meeting (for details, please. Refer to the Department Teaching and Training Activities section).

b) The Department Council will encourage the contribution of the staff members of the department in the Grand Clinical Meetings that are held in collaboration with other Dermatology Departments of the Ministry of Health several times a year.

c) The Department Council should encourage active participation of the staff members of the in various scientific meetings inside and outside the country, and should put forward a plan and policy for nomination of the participants in the conferences.

d) The Chairperson will advertise all academic and clinical meetings.

17.  The Department Council should review the accumulated CME/CPD points of staff, and evaluate the CME/CPD activities of the department (for details please refer to the Teaching, Training and Continuous Professional Development CPD/CME section).

18. The Department Council will discuss the outcome of the Medical Records Chart Review (for details, please refer to the       Department Medical Records Chart Review section), and will take the necessary actions

19. Discussion of Incident reports.

20. Evaluation of the operational policy, at least twice per year, and to be updated and re-printed at least once per year. The evaluation should include: Strength, Weaknesses, Opportunities, and Threats.

21. Discussing the Dermatology Audit (refer to The Dermatology Audit section for details).

22. The Department Mortality and Morbidity Committee. Is responsible for discussing mortality and morbidity of in-patients whenever applicable

 

 

 

 

 

 

 

Role of the Chairperson of the Department:

The Chairperson of the department is responsible for  the following activities:

a) All clinically related activities of the department, unless otherwise specially delegated to heads of units in writing.

 b) All administratively related activities of the department other than those specifically delegated to heads of units in writing including the supervision of the performance of the nursing staff, the technicians, and the pharmacists in liaison with the concerned supervisors.

 c) The integration of the department into the primary functions of the hospital and other services of the Ministry of Health. 

 d) The development and implementation of Operational Policies and Procedures in accordance with the updating and reviewing them in the departmental council.

 e) The recommendations for the appointment of adequate number of qualified and competent persons to provide quality care.

 f) Continuing surveillance of the professional performance of all individuals who have clinical responsibilities in the department

 g) Recommending to the Departmental Council the clinical privileges of the members of the department.

h)    The continuous review and improvement of the quality of care and services provided through nomination of Quality Assurance coordinators, and the maintenance of Quality Assurance program in the department. This will be maintained through nomination of a Medical Record Chart Review Committee in the department.  The committee will ensure that all Medical Records are documented accurately and are readily accessible and provide prompt retrieval of information  (for details, please refer to the Department Medical Records Chart Review section).

 i)  The orientation and continuing education of all persons in the department.

 j)   Recommendations for space and other facilities needed by the department.

 k)  Nominating names of the members of  Medical Boards.

 l)   Participating in the function of the Council of Dermatology.

 m) Investigating the complaints submitted to the head of the department, following the procedure mentioned in the Internal Policy section.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Department Medical Records Chart Review Committee and Function:

This should be announced by the Chairperson and includes some of the Senior Registrars, Specialists, Senior Specialists and Consultants

The committee will report to the Department Council at least once per month.

It will assure that all patients who are being followed-up at As’ad Al-Hamad   Dermatology Center must have a medical record according to the Referral Policy mentioned previously.

The content of the medical record should be sufficiently detailed to enable any other on-duty or consulted doctor to provide continuing care to the patient. The committee will use a standard form to evaluate the charts (Appendix 55b).

Minimum information should include: identification data, medical  history of the patient, detailed physical examination of all body systems, presenting problems and other associated problems, diagnostic and therapeutic plan, progress notes (in measurable terms relevant to patient's condition).

Members of the committee will conduct monthly Chart Review of the Medical Records and identify medical record deficiencies accordingly to medical record deficiency check-list (Appendix 56).

They will decide on the non-compliance and refer these cases to the Department Council.

The committee will make sure that the medical records contain sufficient information to assure the continuity of care.

The following standards of review, together with those of the Medical Records Department Review Chart (Appendix 57), shall be utilized making their decision:

1. The record contains the scope and details of information appropriate to the diagnosis.

2. The record substantiates the final diagnosis.

3. The record refers to important abnormalities, laboratory or     other special examinations.

4. The record identifies important risk factors that have a bearing on choice and application of treatment.

5. If admitted, the record should include a concise summary of the reason for admission, listing of problems in chronological order, findings, treatment given or procedures performed condition of the patient on discharge and any pertinent discharge instructions.

6. The record should be signed clearly and stamped by the treating doctor.

The record will consist of:

History: past, present.

Provisional diagnosis.

Investigation plan.

Therapeutic plan.

Progress Note (relevant to patient's problem in measurable terms).

Consultations:

Change of management plan.

Change of therapeutic plan.

 Discharge summary.

 Follow-up appointments.

 Discharge Rx and dietary plan

Re-admission plan.

Operative report.

Consultation Report.

 

Risk management activates  (Patient/ Staff Safety and Incident Report):

1-    It is the responsibility of the person-in charge of each unit in the department to inform the head of the department or the administrative secretary about any problem in the equipments in his unit so as to call the workshop people to repair the equipment so as to ensure the continuity of the service and the safety of the personnel and the patients.

2-    The Infection Control Measures against transmission of HIV and other Blood-borne infections for safety of health-care workers distributed by the Quality Assurance and Infection Control Department, Al-Sabah Hospital (Appendix 58) should be followed-up.

3-    In case of reportable diseases identified,( Appendix 60)  must be filled

4-    In the event of a pin-prick or other blood/body fluids exposure, the policy for Incident Report for Exposure to Blood/Body Fluids that was distributed by the Quality Assurance and Infection Control Department, Al-Sabah Hospital (Appendix 59) will be followed.

5-    Any incident that happens in the department during a treatment procedure should be recorded as an incident report, and inserted in the box assigned for.

·         The Person who is responsible to collect the incident reports, will hand them to risk management committee at Sabah hospital to discuss and make root cause analysis if needed.

·         Then the person who attended the committee will take the minutes and discuss them at the Risk management team at Asa’ad AlHamad center and discuss them with the whole team of doctors at the center

·         Risk management committee on regular bases discussing the incident reports.

 

 

 

 

 

 

 

 

 

 

 

 

Admission and Discharge Policies:

          (a) Admission Policy:

·         As there are no wards for dermatology, the patients are admitted usually to the medical department or pediatric department of the hospital to which the dermatology department is affiliated. For As’ad Al-Hamad Dermatology Center, admission is done to the medical department or pediatric department of Al-Sabah Hospital.

·         The Consultants, specialists or Senior Registrars should approve the admission of patients. The treating doctor (or the doctor on-duty if the treating doctor is not available) will admit the case and is responsible for writing the in-patient sheet including full history and examination notes, together with the investigations to be requested. The Consultants or Senior Registrars/specialists on duty should examine the patient after being admitted on the same day of admission, review the admission chart including the investigations requested, and to write down the treatment plan. After being admitted, the patient must be followed up by the Consultants or Senior Registrars/specialists on call on daily basis. During week-ends and holidays the doctor on duty is responsible for following up the admitted patients and should report to the Consultants or Senior Registrars/specialists on call.

·         Admitting doctor must fill MR4 (appendix 48A), MR7, and MR12 (appendix 48B) , in-patient prescription paper (appendix 48C) , and special drug infusion form (appendix 38D) on the same day of admission.

·         Direct patient to reception before sending the patient to Sabah hospital to register the case with the diagnosis.

           (b) Discharge Policy:

·         It is the responsibility of the Consultants or Senior Registrars/specialists on-call to discharge the in-patients when they are fit for discharge. A discharge summary should be written and a referral letter to the treating dermatologist should be given to the patient for follow-up.

·         According to the diagnosis, the patient is referred to either the general outpatient clinics, the specialty outpatient clinics, or the specialty units for follow-up

·         Discharge form must be filled by the admitting department and the doctor on-call  in dermatology unit that day of discharge using MR13 (appendix 48E).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evaluation of the Departmental Policy: strengths, weaknesses, opportunities, and threats.

Evaluation of the operational policy should be done at least twice each year by the department council. Revision of the policy will be done and suggestions discussed. Input from all the doctors of the department should be encouraged.

Strengths:

1.   As’ad Al-Hamad Dermatology center providing a tertiary care service makes it a unique department of dermatology in Kuwait.

The center provides specialty and subspecialty dermatological care services to the patients allover Kuwait through the available equipments and personnel in the specialized clinics and units.

 

2.   The center is recognized as a teaching and training center for candidates enrolled for the Kuwait Board of Dermatology program.

 

3.  International collaboration for problem cases has been established recently with many centers through the following:

a. Problem pathology slides are sent through the ministry to Dr. Eduardo Calonje in St. Johns Institute of Dermatology in London University in U.K.  for diagnostic consultations and reporting.

b. Consultations on genetic skin diseases are sent to Dr.  John McGrath, professor  and Head of Dermatology Department, Guys and St Thomas Hospital,  University of London, U.K.

 

4.   An electronic calling system is available for calling the patients in the out-patients area and the Phototherapy area.

 

5.   The available computer network permits a modern service through registering patients’ information and appointments, follow-up of patients by their electronic medical files, and writing the patients reports retrieved from their electronic medical records. Various statistics including the diagnoses of patients based on the ICD 10 protocol became available through the computer system. At present there are several software modules available for the following applications:

 

a.      Patient registration (at Reception).

b.    Patient electronic medical files (available for all the doctors in the general and specialty clinics).

c.     Phototherapy program (available for the photo therapy unit).

d.    Pathology program for pathology reports.

e.    Mycology program for mycology results and reports.

 f.     Biopsy Appointments.

 6.   Advanced audiovisual facilities are available in the center including digital cameras and data show that, together with the computer network, enable presentations of clinical cases and  pathology slides in the weekly and grand meetings. Also these facilities are used to present problem cases seen by visiting professors and consultants in seminars held for all dermatologists to attend the comments of these visitors regarding these cases. In addition, there are facilities for conference slides processing and for publications.

 8.  Wi Fi  Internet connection in the center is available all the day for all the doctors to facilitate scientific and medical search of literature and internet services in the medical field.

 9.   There is a web site for the center on the internet (www.dermakuwait.com) that provides  link to vast dermatology services worldwide. Also, this operational policy and the treatment guidelines for the ten most common skin diseases are available in the site for viewing and for downloading.

10.  Appointments schedule by internet is now available through the center website for the patients to request their appointments.

11.  The health issue magazine is produced 3 times per year and is addressing mainly the patients about various dermatology diseases.

 Weaknesses:

1.   As’ad Al-Hamad Dermatology center is a secondary and tertiary care service center will not allow walk-in of non-emergency cases. Also, all referred patients should come on an appointment bases. This is not always the case, and in many instances we are obliged to treat such patients because of lack of ministry support.

2.   In spite of the spacious nature of the center, recently and because of expansion of the services in the center, we are in need for extra rooms to be used as stores and rooms for sorting the non-clean laundry. We have suggested building extra rooms in a space that is available outside the building of the center near the employee parking.

3.  There is discrepancy between the catchments areas of As’ad Al-Hamad Dermatology center and those of Al-Sabah Hospital. This leads to problems in interdepartmental co-operation and interdepartmental policies. Unifying the catchments areas for both should be considered.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Continuous Professional Development CPD/ CME

Teaching, Training and Continuous Professional Development CPD/CME:

1.   Department teaching and training activities:

 a) The center will have a clinical meeting at least once per week. The weekly clinical meeting will be a minimum of 2 hours session that is held currently on Tuesdays, starting at 12:00 noon. All the doctors of the department will participate. Active participation of the Registrars and Assistant Registrars must be encouraged. The activities will include presentation of problem cases, lectures and journal club. Problem cases are seen physically in the outpatients. Special form for each patient should be filled out by the presenting doctor (Appendix 60).  All patients should be photographed by the doctor in charge of the photography unit using the special photography form (Appendix 7). The cases are then reviewed and discussed in the clinical meeting room through retrieval of the patients photographs using the computer network in the center. This meeting has been accredited by the KIMS as Category II CME program. During this weekly clinical meeting, discussion of the in- patients admitted to the medical wards will be carried out regarding various investigative procedures and management of these cases.

b) The staff members of the center participate in the Grand Clinical Meetings that are held in collaboration with other Dermatology Departments of  the Ministry of Health 4 times a year.

 c) The staff members of the center should have active participation in various scientific meetings inside and outside the country.

 d)   The center is involved in teaching a pediatric dermatology course for the 6th undergraduate students, and a general dermatology course for the 7th year medical students through the clinical tutors approved by the ministry.

 e)    The center, through the senior registrars and higher ranks, are also involved in medical training and teaching of the family doctors and trainees of Kuwaiti board of Medicine and Pediatrics sent for this purpose by the KIMS. Also, they are responsible for postgraduate doctors sent for Canadian board in Dermatology, in General Medicine, or in Pediatrics who spend an elective course in dermatology in the Center whenever assigned by the KIMS.

After the daily round with the senior staff, the candidates might be distributed to the outpatient clinics (general or specialty clinics) or the specialty units to build up clinical experience in dermatology.

 f)   Since 2003 the center is involved in teaching and training the Candidates of Kuwait Board of Dermatology. Details of the teaching schedule of these doctors are available on KIMS website.

2.  Continuous Professional   Development CPD/CME:

The department council will organize and maintain the following:

            1.  The annual CPD/CMEs of the department.

             2.  The minimum score of CPD/CME points for each member of staff.

                   3.  Evaluation of the efficacy of the CPD/CME programmers, and the quality of different components (Departmental lectures, seminars, workshops, clinical rounds, teaching rounds, clinical review meetings..etc)

 

 

 

 

 

 

 

 

 

 

The Dermatology Audit:

 Clinical Auditing. This can be a function of The Department Medical Records Chart Review. It should include the following:

                          1.     Number of readmissions within one month.

                          2.    Number of incidents of unauthorized drug use.

                          3.     Number of medication errors.

                          4.     Accuracy of diagnosis.

                          5.    Number of patient/family complaints regarding drug therapy.

                          6.     Length of stay of in-patients more than 30 days.

                          7.    Patient satisfaction questionnaire result.

                          8.     Number of requests where the response was delayed more than 24 hours and the reason for that delay.

                          9.     Number of treatment refusals by the patient.

9.    The appropriateness of investigations.

 

Dermatology Department committees: