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Master of Business Administration

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[PROBLEMS IN THE EMERGENCY DEPARTMENTS OF PAKISTAN]

ADVISOR: MR OMAR AZIZ BABAR

GROUP MEMBERS: ABSHAM MEHBOOB (08-0014) AGHA MUREED AHMAD (08-0636)
HAMZA AHMED JALAL (08-0282) NABEEL ATIQ SYED (08-0141)
SYED ALI HAIDER SHAH (08-0176)

SUBMISSION DATE: 07-05-2012

This project is solely the work of the author and is submitted in partial fulfillment of the requirements of the Degree of Bachelors of Business Administration

EXECUTIVE SUMMARY
Our FYP project is based on the issues in the emergency department of health sector of Pakistan on which we are conducting a research work. As we hear about the problems that occur in this department of health sector and the difficulties that people face we will be looking into the depth of these issues and try to highlight the key points that create such a situation. Our main objective is to find the gap between the perception and reality. We go about in our project first giving a brief introduction of the emergency department of health sector according to the secondary data that we collected. We also discussed the techniques, strategies and standard operational procedures i.e. SOP’s according to which emergencies should operate. Moreover we also discussed emergency ethics that are the first and foremost base to determine how the doctors are expected to behave with the patients and handle their problems. We have also conducted a primary research by observing and interviewing patients to fill out the survey questions. We have also included overviews of the journals taken from the health institutes in countries like USA, and Europe. It will help us get an insight on how these countries emergency departments are operating. The case study on dengue has been included to support our work of what is currently going on with the Pakistani health sector.

LIST OF TABLE 5 LIST OF FIGURES 5 INTRODUCTION 7
Emergency Department: 7
Emergency Medical Services: 8 EMERGENCY MEDICINE 9 EMERGENCY DEPARTMENT AS COMPLEX SYSTEM 10 SOP’S, STRATEGIES AND ETHICS OF “EMERGENCY” 11
Emergency Triage 11
Techniques for Effectively Managing Patient Flow 12
WHO Strategy 12 WHO Strategy on Health Sector Risk Reduction and Emergency Preparedness 13
Emergency Ethics 14
Emergency Ethics in Pakistan 15
Sop’s for Reception and Treatment of Patients in “ED” 17 HEALTH SECTOR OF PAKISTAN 19 EMERGENCY DEPARTMENTS 20
Emergency Medicine Pakistan 21 INTERVIEW OF DR SIDRA MAJEED 22 OUR RESEARCH WORK 27
METHODOLOGY 27
SAMPLING PLAN 28 SURVEY RESULTS 28
Survey Analysis 38 WORLDWIDE EMERGENCY DEPARTMENTS ANALYSIS 39
American Emergency Department 39 How Americans get Emergency Medical Care 40
PROBLEMS IN AMERICAN EMERGENCY DEPARTMENTS 41 Overcrowding 41 Patient Boarding 41 Frustrated Doctors and Overworked Nurses 41
Step Taken to Overcome These Problem 41
Emergency Departments in Canada 42 Medically Accepted Wait Times in Canadian Emergency Departments 43
The European Perspective of Emergency 44 Increasing patient Acuity 45 Inexperienced Medical Staff 45 Staff Shortages 45
How European Overcome these Problems 46 RECOMMENDATIONS FOR PAKISTAN EMERGENCY DEPARTMENTS 46 CONCLUSION 47 OBJECTIVE OF OUR CASE STUDY 47 DENGUE FEVER: IS IT CORRUPTION THAT LURKS ONCE AGAIN OR THE MISMANAGEMENT? “A CASE STUDY” 48
INTRODUCTION 48 Abstract 48 Objective 49 Background 49
LIFE CYCLE OF DENGUE MOSQUITOES “AEDES AEGYPTI” 51
DENGUE IN PAKISTAN 52
ACTUAL VS.PERCEIVED GAP 52 Doctor’s view 52
ACTUAL SITUATION 54
DENGUE FEVER: CORRUPTION AND MISMANAGEMENT 56
ANNOUNCING EARLY 57
FAKE SPRAY 58
CBC TEST 59
COSTLY PLATELET KITS 59
SHORTAGE OF BEDS 59
ELECTRICITY SHORTFALL AND DENGUE FEVER 60
NEGLIGENCE IN TREATING OTHER PATIENTS 60
FINAL VERDICT 60
HEALTH PROBLEMS ENCOUNTERED 61
PREVENTIVE MEASURES 62
SUGGESTIONS FROM MEDICAL WORKERS’ SIDE 63 PROJECT LIMITATIONS 63 REFERENCES 65 REFERENCES OF THE CASE STUDY 66 APPENDIX 68

LIST OF TABLE

Table 1………………………………………………………………….19
Table 2………………………………………………………………….42
Table 3………………………………………………………………….55
Table 4………………………………………………………………….56

LIST OF FIGURES
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INTRODUCTION
Emergency Department:
There is no standard definition of emergency department; however according to a dictionary “ED is that section of a health care facility which provides rapid treatment to victims of sudden illness or trauma”. American Heritage Dictionary of the English Language: Fourth Edition. A Journal by (Rahim Moineddin, Christopher Meaney, 2011) defined emergency departments as “medical treatment facilities that are designed to provide episodic care to patients suffering from acute injuries and illnesses”. James street medical clinic in “South Suite One Hamilton” also try to define the emergency room “a department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate medical attention”. Therefore if we roughly define ER then: it’s a Department within a health care facility that is intended to provide rapid treatment to victims of sudden injury or illness. For lot of people ER is the first step they encounter when they experience some urgent medical ailment to be treated or an accident, whereas for others it is just considered a normal functioning unit of a hospital. The quality of service or care provided by the emergency department indicates the performance level of the entire hospital.
EDs are designed to treat the most critically ill and injured patients and they are part of the first response to public health emergencies such as natural disasters and terrorist attacks. “As according to a book it’s clearly mention that almost every large hospital has an emergency room (known formerly as the casualty ward). The emergency room can prove to be an invaluable resource if properly used, as round-the-clock availability of trained staff, backed by state-of the-art equipment, could mean the difference between life and death” (AniruddhaMalpani, Anjali Malpan, 2000). Therefore we can say that the nation’s hospital emergency departments (EDs) play a vital and increasingly important role in providing healthcare to some million patient visitors every year. Emergency departments serve as the front line of care for the injured and severely ill, and often are the only accessible source of care for uninsured patients or those who otherwise lack access to medical services Emergency Room serves as a front-liner. It is the most accessible unit or area of the hospital for patients to go to because it is open 24 hours and 7 days. It also serves as a link for patients to the different units of the hospital.
Emergency Medical Services:
“Any part of a system designed to respond to medical emergencies and provide pre-hospital or in-hospital treatment.”
EMS is "a comprehensive system which provides the arrangements of personnel, facilities and equipment for the effective, coordinated and timely delivery of health and safety services to victims of sudden illness or injury” (Sultan Al-Shaqsi,2010). The journal by Sultan Al-Shaqsi further elaborate that the aim of today EMS or ED is providing timely care to victims of sudden and life-threatening injuries or emergencies in order to prevent needless mortality.
Today’s world EMS has advanced so much that it contributes widely to the overall function of health care systems. The World Health Organization also regards EMS systems as an integral a part of any effective and practical health care system. Emergency medical service round the world has developed an extended role to upset medical and trauma emergencies utilizing advanced clinical technology. The fast development of medical technology has additionally reformed the international EMS systems with the introduction of multifunctional compact monitoring systems creating the task of monitoring patients manageable in an uncontrolled atmosphere of pre-hospital settings.

EMERGENCY MEDICINE
A dictionary defines emergency medicine “The branch of medicine that deals with evaluation and initial treatment of medical conditions caused by trauma or sudden illness” (The American Heritage Stedman's Medical Dictionary). Emergency medicine is a medical specialty within which physicians look after patients with acute diseases or injuries which needs immediate medical attention. Whereas not typically providing long-term or continuing care, emergency drugs physicians diagnose a spread of diseases and undertake acute interventions to resuscitate and stabilize patients.
EM is a comparatively new specialty that has evolved simply over the last quarter of a century. The American school of Surgeons was among the primary teams of physicians to acknowledge the necessity for organized emergency services. The first EM residency was started in 1070 and in 1979 the American Board of Medical Specialties recognized EM as medicine's newest specialty. In the UK, the equivalent specialty of accident and emergency (A&E) medication is currently during a section of speedy development. (R. Rehmani, 2004)
EM is that the medical specialty with the principal mission of evaluating, managing, treating, and preventing sudden illness and injury. Anyone could unexpectedly need medical care at any time. Emergency medical care should thus be accessible twenty four hours every day as an important element of a health care delivery system. (R. Rehmani, 2004)
The specialty of EM is practiced in an exceedingly sort of hospital and non-hospital settings. Emergency physicians are initial contact suppliers. They look after a patient population undifferentiated by age or disease method. They supply fast treatment and stabilization of true emergencies, further as fast differentiation between emergent and non-emergent conditions over the spectrum of disease processes. Their care extends to out-of-hospital assessment, treatment, and transport of patients into emergency facilities by virtue of their management and supervision of emergency medical services.
EMERGENCY DEPARTMENT AS COMPLEX SYSTEM
EDs are a critical component of the health care system. They are important hubs that interact directly with primary care givers, the pre-hospital system, in-hospital care, home care, and long-term care services. EDs often serve as the portal of entry for patients admitted to hospital. As a result, EDs are also an important indicator of how well a community’s health care system is functioning. When resources are reduced in other parts of the system, or demands increase from seasonal pressures, the impact is frequently felt in the ED. “What we propose is that the Emergency Department is a wonderful example of a complex system, a relatively self-contained health care delivery system that is extensive in the scope and richness of both its mission and its processes” (Mark Smith, 1998). If we summaries his article then according to him certain point prove the complexity of ED: * Patients and their diseases behave in unpredictable ways. * Rate of patient intake varies unpredictably. * Physicians interact with patients in complex ways. * Changes in patient status force physicians to adjust and reprioritize tasks.

SOP’S, STRATEGIES AND ETHICS OF “EMERGENCY”
Patient expectation in health care continues to increase and this is something that needs to be managed adequately in order to improve outcomes and decrease liability. But the question arise is that what patients expect from a doctor? Basically patient expect that doctor full fill all the ethical standards during treatment, the SOP’s and to apply all the technique for which doctors are bound to do so. In this section of our report we have mentioned some strategies and ethical standard that doctors have to follow during treatment.
Emergency Triage
Many people assume that patients care in emergency is determined on the first come first serve basis that is not true. In emergency department doctor operate with the system known as “Triage”, which mean that the patient with savior condition will be treated first. The primary mission of the Emergency Room Department is to provide the public access to primary medical care. The Emergency Room Department (ER) fulfills this mission through the use of a "triage" technique. Triage is a system by which patients are assessed and prioritized for treatment. In this system patients are not seen on the "first come, first served" basis. Rather, those with the most serious, or life threatening conditions are seen first. Julia Fuzak and Patrick Mahar, MD from the Children´s Hospital Denver, USA says that "We use triage in the emergency department to identify those patients that need care first". This process is very vital to the effective management of modern emergency departments. These systems not only aim to ensure that each patient should be treated with justice; those need emergency care first serve first, but also to provide an effective tool for departmental organization.
Techniques for Effectively Managing Patient Flow
The National Center for Health Statistics shows that, most people who go to an emergency room (ER) do not need urgent care that’s why we experience lot of patients flow in emergency departments. Author Randolph of Journal “patient flow: the new queuing theory for healthcare”,try to provide certain technique which doctors have follow to overcome problems occurs during patient flow. According to the author patient flow represents the flexibility of the healthcare system to serve patients quickly and efficiently as they move through stages of care. When the system works well, patients flow somewhat like a river, which means that every stage is completed with minimal delay. However writer elaborates that these delays can be reduced through:
(1) Synchronization of work among service stages (e.g., coordination of tests, treatments, discharges processes),
(2) Optimization: which mean scheduling of resources (e.g., doctors and nurses) to match patterns of arrival,
(3) Constant system monitoring (e.g., tracking number of patients waiting by location, diagnostic grouping and acuity) linked to immediate actions.
WHO Strategy
WHO Strategies are based on the recommendations of global consultation held by, WHO on the outcome of subsequent meetings organized by the Health Action in Crises Cluster.

WHO Strategy on Health Sector Risk Reduction and Emergency Preparedness * Risk reduction and emergency preparedness:
These are part of the development process, building the capacity of health sectors in order to reduce the risks from and respond to emergencies requires strong and long-termcommitment and sound managerial and technical programs. * An all-hazard approaches:
This approaches are essential, should have the capacity, the knowledge and expertise to deal and response any type of hazards, should be enhanced to face all types of major risks from epidemics to conflicts, natural disasters to technological accidents. * Risk reduction and emergency preparedness are the responsibility of all national actors:
At the national level the ministry of health is the lead agency of the health sector, which includes among others the armed forces medical services, the International Red Cross and Red Crescent Societies, health-related nongovernmental organizations, private health facilities and professional associations. * Emergency preparedness requires a multispectral approach at the national level:
For reducing the public health impact of emergencies, disasters and other crises requires a multispectral outlook. Proper land use management and design of housing or new health facilities may, for instance, contribute most to decreasing mortality and morbidity.

* Priority on technical assistance:
WHO is a specialized international technical agency, which focuses more on technical support than on funding or the donation of supplies. Such support includes the development of strategies, norms and standards awareness building, capacity building and transfer of knowledge and management skills for the provision of technical advice.
Emergency Ethics
Emergency ethics exist internationally, but there are no clear emergency ethics in Pakistan. Only Medical ethics exists in Pakistan. Patient autonomy, beneficence, and justice are the fundamental ethical principles of an emergency medical service. Ethical conflicts are present in the daily practice of pre-institutional care. Emergency medical services must remain fair and equitable, equally available to those it is designed to serve, regardless of the patient's social or economic status. Establishing priorities for patient care is dictated by medical and operational concerns. While internationally (EMRA) Emergency Medicine Residents Association is an international independent body regulating emergency ethics. EMRA is the largest and oldest independent resident group in organized medicine, founded in 1974. Currently it has over 6,500 members representing over 80% of emergency medicine residents. A recent market analysis estimates its alumni membership at over 18,000 members.
According to (EMRA) Emergency Medicine Residents Association Emergency Physicians Shall: 1. Embrace patient welfare as their primary professional responsibility. 2. Respond promptly, without prejudice or partiality, to the need for emergency medical care. 3. Respect the rights and strive to protect the best interests of their patients, particularly the most vulnerable and those unable to make treatment choices due to diminished decision-making capacity. 4. Communicate truthfully with patients and secure their informed consent for treatment, unless the urgency of the patient's condition demands an immediate response. 5. Respect patient privacy and disclose confidential information only with consent of the patient or when required by an overriding duty such as the duty to protect others or to obey the law. 6. Deal fairly and honestly with colleagues and take appropriate action to protect patients from health care providers who are impaired, incompetent, or who engage in fraud or deception. 7. Work cooperatively with others who care for, and about, emergency patients. 8. Engage in continuing study to maintain the knowledge and skills necessary to provide high quality care for emergency patients. 9. Act as responsible stewards of the health care resources entrusted to them. 10. Support societal efforts to improve public health and safety, reduce the effects of injury and illness, and increase access to emergency services and other basic healthcare for all.
Emergency Ethics in Pakistan
Here in Pakistan no clear defined ethics for emergency exists. But PMDC define some medical ethics which include: * Conduct of Medical practitioner * Competence * Confidentiality * Advertising * Business and contractual obligations etc.
PMDC also take some oath from their medical graduates that include:
OATH FOR MEDICAL GRADUATES
In the name of Allah, Most Gracious & Merciful.
1. I solemnly pledge that I shall abide by the principles laid down in the Code of Medical Ethics of the Pakistan Medical & Dental Council.
2. I further make solemn declaration that:- * I consecrate my life to the service of humanity.

* I will give to my teachers the respect and gratitude that is their due.

* I will practice my profession with conscience dignity and fear of God.

* The health of my patient will be my first consideration.

* I will respect the secrets, which are confided in me.

* I will maintain by all means in my power, the honor and the noble traditions of the medical

* My colleagues will be my brothers and sisters.

* I will not permit consideration of religion nationality, race, party politics social standings to

* Intervene between my duty and my patient.

* I will maintain the utmost respect, for human life, from the time of conception; even under

Sop’s for Reception and Treatment of Patients in “ED”
A journal by DR Muhammad Umar MBBS, MCPS, FCPS, FRCP (Glasgow), FRCP (London), FACG, AGAF Chairman & Professor of Medicine define certain standard operating procedures for reception and treatment of patients in emergency department. according to him SOP’s are aimed to provide an objective format for working of professional staff, administrators, paramedics, nurses, and junior doctors etc. he further elaborated that this document is the first of its kind in the public institutions of Punjab, which provides clear guidelines for working of different components of hospital as well as health professionals.
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HEALTH SECTOR OF PAKISTAN
In this section of our report we try look weather our emergency departments operating according to above mentioned strategies and SOP’s or not. If not then where is the gap and how we can remove them? But before discussing Pakistan emergency departments and finding a gap between actual and perceived reality, we do quick analysis of Pakistan health sector. Since the establishment of Pakistan, the medical sector has been further divided into different segments in accordance with the availability of facilities, incentives, and resources. Due to the mix environmental structures in this area, the health sector in Pakistan still remain in crisis, according to the Pakistan economic survey 2009-10, only 27% of the total population in Pakistan enjoys complete healthcare coverage, while the remaining 73% are deprived of even the basic necessities provided in hospitals due to the lack of attention from the concerned authorities and the inclusion of high level of corruption. However if we compare Pakistan medical sector to rest of the world then from 2006 Pakistan health sector haven’t show any growth as shown in table below. TABLE 1 | Healthcare spending, international comparison(% of GDP) | | 2006a | 2007a | 2008a | 2009b | 2010b | 2011c | 2012c | 2013c | 2014c | 2015c | Pakistan | 2.0 | 2.4 | 2.4 | 2.4 | 2.4 | 2.4 | 2.4 | 2.4 | 2.4 | 2.4 | US | 15.8 | 16.0 | 16.1 | 16.3 | 16.0 | 16.2 | 16.2 | 16.2 | 16.2 | 16.2 | Japan | 6.5 | 6.7 | 6.8 | 7.0 | 7.2 | 7.3 | 7.5 | 7.7 | 7.9 | 7.9 | China | 4.5 | 4.7 | 4.7 | 4.7 | 4.7 | 4.7 | 4.7 | 4.7 | 4.7 | 4.7 | Germany | 10.5 | 10.4 | 10.6 | 10.6 | 10.6 | 10.6 | 10.6 | 10.6 | 10.6 | 10.6 | | Source: Economist Intelligence Unit. |

EMERGENCY DEPARTMENTS Pakistan is a developing country in need of effective emergency medical care. Theabove data from Pakistan clearly indicates this need.Lots of studies have revealed the poor conditions in hospital emergency rooms. Like one of the study that is conducted in rural northern areas of Pakistan found that that the reason for poor outcome in many cases of surgically treatable illness included misinterpretation of severity of symptoms by first level providers and miss-triage from the first level facility(Ahmed M, Shah M, Luby S, Drago-Johnson P, Wali S, 1999).Another study showed that the majority of children deaths in emergency were just due to increased time in getting appointment facility(Hasan IJ, Khanum A, 2000). A study also reported less than half of the households who experienced serious illnesses were taken to a nearest clinics mainly because of dissatisfaction from big hospital as reported by participants. According to an article in daily time in 2008 DR Anwar-ul-Haq said that “Hospital emergency rooms in Pakistan were disorganized and chaotic like fish markets”. First we don’t believe on this statement but our visits to Jinnah and some other hospitals prove it.
According to research study “Assessing emergency medical care in low income countries: A pilot study from Pakistan” written by Uzma R Khan from Department of Medicine, Aga Khan University, Karachi, revealed that Pakistan being a developing country not much improved medical sector. Health care in low income or developing countries has not usually focused on emergency medical care. The author of the research study says that the state of health care in Pakistan indicates that the general public health system has never focused on emergency medical care. Emergency medical care has not been a part of policies for health sector at the national or state level in Pakistan. At an equivalent time, emergency medical care has been continues neglected in health analysis within the country. To prove these points they did a quantitative pilot study of a convenience sample a pair of twenty-two rural and twenty urban health facilities in 2 districts Faisalabad and Peshawar in Pakistan. The results of their study revile some statistic; few of them are mentioned here. 91% of people weren't glad with the performance of healthcare facilities and even additional 98% weren't glad with emergency care provided. The foremost common reasons for their dissatisfaction with the emergency care provided were: lack of perceived correct emergency care, and lack of medicines. The foremost common set of expectations by the participants throughout a healthcare visit in an emergency was reported to be: 73% reported there should be competent emergency care workers, while some need free availability of medicines. In short the journal emphasis on the importance of emergency departments in Pakistan.
Emergency Medicine Pakistan
EM is a very important component of any health care system and provides a significant service to the general public. In fact, EM is that the initial specialty to develop directly because of demand by the general public. Alternative specialties are outlined by anatomic region, a specific sort of disease or by a specific age cluster of patients. In distinction, EM encompasses every type of medical and surgical issues of all age teams. EM additionally provides a "safety net" for any national health care system to confirm patient access to needed unscheduled care. Major clinical issues (all of that are common in Pakistan) that are okay managed by EM include the following: trauma, cardio-respiratory sicknesses, toxicology, environmental disorders, and mass casualties from disasters.
EM has a number of useful effects that increase the potency of any national health care system. These include the prompt evaluation of emergencies and also the ability to complete diagnostic work-up for patients during a single visit (R. Rehmani.2004).
EM conjointly provides benefits to the general public. These include reassurance and confidence, convenience, and ensured access to care. EM is also necessary for public education in illness and injury prevention, teaching the general public the way to properly utilize the health care system (R. Rehmani.2004).
INTERVIEW OF DR SIDRA MAJEED After reading different research studies and journals and our visit to Jinnah we come across with following compliance: * The poor environment * Lack of Availability of specialized personal * The level of standards maintained * Low Doctors response to emergent situations * Lack in Availability of staff on the spot * Less No of employees * Lack of medicines * Lack of different Kinds of equipment/machines operational

However to confirm whether these problems actually exits or rather specialization in emergency medicine actually exist in Pakistan , we interviewed Dr. Sidra Majeed (EMO- A & E Dept.) from Mayo Hospital ; one of Pakistan largest public hospital. The purpose of this interview was to confirm the conditions been acknowledged from information through journals and visits to Jinnah hospitals Of Pakistan emergency rooms. Therefore Following questions were considered and:

1) Does specialization in emergency medicine exist in Pakistan or not and up to what extent? Yes specialization in emergency medicine does exist in Pakistan with the same standards and competence as compared to the other countries. There are two basics in which specialization occur one is medical and other one surgical. Furthermore these basics has some sub branches, like sub braches of surgical are orthopedics and plastic surgery and cardiac surgery etc. similarly specialization in medicine also exists, in which there is a specialization in basic medicine and also in every other fields like chest medicine etc. The specialization exists everywhere not only in our hospital. Our specialists follow the international standards. Therefore doctors in Pakistan are well equipped with knowledge and experience as compared to all over the world. They do have the potential to compete with that type of environment in which they are specialized in all over the world. If you ask that up to what extent the international standards are being followed then the answer to this question is that like the procedures followed all over the world after specialization research is taken into consideration and all international standards are taken into consideration at each level.

2) What are the standards maintained in an emergency room? Well in Pakistan in an emergency department the standards maintained are termed to meet international standards. But in practicality the situation is a bit diverse this is due to the type of population who visit the hospitals especially public hospitals. There are some of discrepancies in public and private hospitals like for instance if we consider ICU, then an ideal ICU setup does exist both in public and private hospitals meeting international standards. However sometimes exceptions also occur like if just take example of our mayo hospital then as per due to lack of financial resources we don’t possess equipment’s for MRI, so in such a case we tend to refer the patients to an another hospital like general hospital where such a facility is available. 3) What are the rules and regulations adopted for treating the patients? A triage system is followed in our emergency department, the patient is discriminated first by EMO (emergency medical officer) and then moved forward to the designated then the specified treatment takes place and the patient is not discharged unless and until cured. Triage system is now usually followed in every hospital of Pakistan both public and private. 4) What is the complete procedure of treatment from admission to discharge (from emergency department)? Patients first visit the EMO, the EMO inspects the problem and if it is risk case then the patient is forwarded towards the CMO otherwise the EMO treats the patient. On our question that weathers you follow all SOP’s which we also mention in our report above DR Sidra replied that yes the same procedure is followed by our hospital. We also provide here the copy of these SOP’s and she approved it after some correction. We are attaching that copy in our appendix. 5) Which employees does the emergency department include? An emergency department usually includes Doctors Paramedical staff which includes nurses, ward boys, technicians, lab boys and 3rd category workers. There are usually 4-5 doctors available, a single doctor is usually allotted 2 beds but due to over load there are certain situations that a single beds tends to carry 2-3 patients The management tries to maintain 2:1 of patients to doctor ratio which is an ideal situation but sometimes due to the overcrowding and over load the situation is reversed and then one doctor is operating 4 to 5 patients. However some time due to overcrowding and shortage of beds we have to accommodate 2-3 patients on a single bed. 6) What kinds of equipment’s/machines are used for treating the patients? Usually every kind of machine which are required at an emergency level are available like ECG Machine for cardiac, Nebulizers for respiratory purposes other than this there are separate emergency theater for emergency departments 7) Are the emergency medicines easily available? Yes they are always available with the exception that the medicine is short on wide level otherwise hospitals like Mayo does keep the items in stock. But in Jinnah and some other local area hospitals we found that patient’s relatives had to buy medicine from outside also. This show some hospitals have less medicine available.

8) How to cope up in emergency situations like that happened of dengue or any other sudden disaster?
Yes like in Mayo, action is taken on emergent basis, when the dengue issue was rising a separate counter was setup for facilitating the dengue patients, then similarly when the PIC Drug Scandal raised then such patients who were affected by the Drug were referred to their specific counter which was then setup because of the over whelming load and then such patients were diagnosed separately, the counter was operational unless the issue wasn’t resolved
In emergency situations emergency medicines are usually available, if a shortage is forced then as told before that shortage is said to be acknowledge nation wide 9) Do all Ethical standards exist here in Pakistani emergency department?
Ethics demand that if a patient is admitted, so other than providing him with treatment, the medical personal should also support him morally. But this factor is usually neglected in Pakistan especially in public hospitals due to over load which leads to fuss, or sometimes when the hospital is not able to provide a specified facility. This also creates irritation among the patient. But situation is quite improved as facilities are more widely available now and if the doctor is not available then there are alternate like the EMO’s who are well trained to cope up with the situation. But still sometimes negligence does occur from doctor side due to over load. As you see on media that doctors are misbehaving with patients that was just because of overcrowding. However a check and balance is usually maintained stay away from such kind of situations.

OUR RESEARCH WORK
The interview provide us a snap shoot of the difficulties emergency departments are facing but we also did survey to go into more detail. We will try to analyze the gap that exists between the perception and reality in the health sector. Our research comprises of different methods one of which was be based on questionnaires designed for the patients. The questions asked were being regarding the concern and commitments shown by the emergency personnel towards the patient in order to satisfy them. We also provide detail about the recent outbreak of dengue fever where many people lost their lives and also recommend some activities that should be carried out by both the doctors and the patients in order to stop such a deadly epidemic disease and the measures carried out by the medical institutions to cure the effected ones.
In compliance to ensure that the above mentioned mismanagement and other discrepancies, the purpose of our survey is to test out hypothesis between the perceived gap and HR related issues.
METHODOLOGY
Our objective is to find out the patients perspective in the private and public hospitals of Pakistan and to highlight their views regarding the treatment and services they have been offered in the emergency departments of hospitals. In order to analyze the results and patients perception we used Conclusive research methods, for that we designed a questionnaire based on close ended. We also do some observational research

SAMPLING PLAN
We choose two public sector hospitals and two private sector hospitals, so that our survey is not biased. We opted for convenience sampling. As per the public sector was concerned we selected Jinnah hospital & Mayo, in private sector we selected Sheikh Zayed & Surgimed hospital. The sample size was 100 and we allocated 25 to each respective hospital.
SURVEY RESULTS
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Survey Analysis
As discussed earlier we conducted an interview with the EMO of mayo hospital. As directed by our advisor we designed our survey in light of the interview findings. We conducted the survey to justify this information. The survey is designed to relate the theory & doctor claims about emergency with that of patient’s issues in Pakistan. We will be discussing some important questions in our analysis. Our sample size was 100. We evenly divide it to two government hospitals (Jinnah & Mayo), one semi government (Sheikh Zayed) & one private (Surgimed) twenty-five each. 46% respondents were female and 54% were male subsequently. In the emergency sector majority of the patients came due to an injury or illness. Majority of the patients had to wait in the emergency room between 10-30 minutes. This showed that the waiting time was moderate, not too early or late. About 60% of respondents were satisfied with the cleanliness of the emergency department. An important finding was about the mode & ease of registration process, 70% of respondents were unsatisfied with the registration process. They called it time consuming and difficult. Majority of the patients/relatives agreed that the nurses were knowledgeable, courteous and paid frequent visits. Majority of respondents agreed that Doctors were courteous, gave quality treatment but they were not satisfied with the frequency of Doctors visit. 80% of respondents were dissatisfied with the frequency of doctor visit, it shows both public and private emergency services lack in Doctor’s visit. Respondents were satisfied with machines, number of beds in the Emergency. To another questions 80% responded that the medicines were available at the relative hospital. 60% respondents said that basic emergency medicines were free at the hospital. Majority of the responded agreed that they would recommend the hospital to their friends/family for emergency service. The overall findings which we can summarize are: * Currently Emergency service in Pakistan is of good standard * Doctors & nurses are well qualified and specialized for the job * In routine days (without any disease dengue etc. or disaster) the number of beds are sufficient in the Emergency * Doctors need to pay a little attention to the frequency of their visits * The overall registration process should be simplified

WORLDWIDE EMERGENCY DEPARTMENTS ANALYSIS

American Emergency Department
In America emergency medicines are normally used when a patient suffers from painful injuries and serious signs or symptoms of diseases and mainly used during the crisis. These American emergency departments face severe consequences of overcrowding which is mainly due outdated federal and state policies. A journal Backgrounder: Published by the Heritage Foundation highlights recent trends those are as follows:
Recent trends highlight the challenge in the case: * The emergency medical system is stretched beyond capacity. * In most states, the system could not absorb the surge in demand that would accompany a pandemic, natural disaster, or terrorist attack. * Recent increases in ED demand are driven by patients seeking care for non-urgent problems. * Current conditions degrade the quality of patient care. * Current conditions contribute to the uncompensated care burden on physicians
This information shows that the emergency departments in America are not even ready to treat the patients who require urgent medical attention especially during natural disasters or any epidemic diseases (John S.O’Shea: 2008).
How Americans get Emergency Medical Care
Emergency system and medicine in America is divided into two types: 1. Pre-institutional care 2. Institutional care
Institutional care includes the nationwide 911 emergency system where there is a ground and air transport system to treat the patients at the crisis scene or during transport. The personnel involved in these pre-institutional activities are police, firefighters, emergency medical technicians, and sometimes doctors and nurses. Whereas institutional care includes the emergency departments in hospitals providing both lower and higher level of care.
Making decisions to cater to natural disasters such as hurricanes, earthquakes, and other mishaps according to the author have fallen short and is a big challenge facing the emergency medical systems. There exists also another problem that is of misaligned incentives where the emergency departments in the hospitals and other medical services have evolved without a proper policy making (R. A. Stevens: 1989, pp. 30–39).
PROBLEMS IN AMERICAN EMERGENCY DEPARTMENTS
After reading different journals we identify many problems, some of the journals named “Myths versus facts in emergency department overcrowding and hospital access block” and “Emergency Department Waiting Times” identify certain problems as following:
Overcrowding
As the world population keeps on increasing so does the number of patients visiting the emergency departments increase. According to a survey results given in the case, the number of visits to the emergency departments increased by 18%.
Patient Boarding
This is also connected with the overcrowding and mainly caused due to it. It includes holding admitted patients, and even intensive care patients until a bed comes available. The waiting time as reported by some of the patients was from 4 hours to 12 hours for the bed to become available. This shows that patients who might have needed urgent medical attention were left in danger risking their lives.
Frustrated Doctors and Overworked Nurses
Financial pressures have affected both emergency rooms physicians and specialists who provide on-call services. Another problem that exists is the nursing shortages and it has effects on in-patient capacity. In other areas of hospitals the quality of nursing is not up to level which results in inappropriate care of patients. Due to the shortages the patient to nurses/doctors ratio is large.
Step Taken to Overcome These Problem
According to “American college of emergency physicians” website with regards to the problems few steps are being taken to overcome the problems in America these include: * Instead of admitting patients in the emergency rooms directly, they are also being boarded on the other floors so as to spread the burden throughout the hospital so that overcrowding can be avoided and beds can become available more quickly * Some hospitals are also making up a fast-tracking system to speed up the diagnosis and treatment of patients who are in less critical condition. * Patients are being registered at bedsides to decrease the waiting time and increase the patient flow and processing * Modern technology that tests and diagnosis the patient much quicker reduces the waiting time and is being implemented.
Emergency Departments in Canada
According to journal “Taking Action on the Issue of Overcrowding in Canada’s Emergency Departments” from The Canadian Association of Emergency Physicians mention that in Canadian emergency departments the waiting time is one of the main issues that the patients over there face. The patients over there show a great concern for getting urgent and quality emergency treatment. Canada also faces the common problem faced by the emergency departments in America and other countries that is of overcrowding. According to the case an average of 10 million visits are made to Canadian emergency departments every year.
The journal further elaborates; Emergency department overcrowding is the front line crisis in Canada. The major cause of overcrowding was due to the shortage of hospital beds with the overflow of patients being warehoused, i.e. the patients are made to wait in long turns and only treated when their turn comes endangering their lives. This as a result blocks the treatment of the sickest patient on time. Canada in the past decade has seen a decrease of 40% in overall hospital bed capacity. This issue is further stimulated by the aging and increasingly complex patient population.
Medically Accepted Wait Times in Canadian Emergency Departments To counter the problems Canadian use CTAS techniques. As mentioned in the journal the objectives of CTAS were to more accurately define patients’ needs for timely care and to allow Emergency Departments to evaluate their acuity level, resource needs and performance against certain operating objectives. The table given below shows the Canadian Triage and Acuity Scale as follows:

TABLE 2 The five CTAS triage levels are as follows: CTAS Level | Level of Illness/Acuity | Nursing Response Time | Physician Response Time | Sentinel Diagnosis | Fractile Response | Admission Rate | Level 1 | Resuscitation | Immediate | Immediate | Cardiac Arrest | 98% | 70-90% | Level 2 | Emergent | Immediate | <15 minutes | Chest Pain | 95% | 40-70% | Level 3 | Urgent | <30 minutes | <30 minutes | Moderate Asthma | 90% | 20-40% | Level 4 | Less Urgent | <60 minutes | <60 minutes | Minor Trauma | 85% | 10-20% | Level 5 | Non Urgent | <120 minutes | <120 minutes | Common Cold | 80% | 0-10% | SOURCE: (The Canadian Association of Emergency Physicians: 2005)
The Canadian Association of Emergency Physicians (CAEP) is a national advocacy and professional development organization representing 1,800 of Canada’s emergency physicians. CAEP’s mission is to provide leadership in emergency health care with a goal to enhance the health and safety of all Canadians.

The European Perspective of Emergency
One of the most important issues highlighted in the emergency department in Europe is the shortage of hospital beds, mainly in the ICU units and the telemetry beds. This observation can be held true by the example of hospitals in UK and Ireland where the admissions to emergency department compete for the bed occupancy. Furthermore this scenario is represented by one more fact that even the patients who are discharged from emergency departments is directly to bed occupancy rates and has negative effects on the patient satisfaction and thus increases the cost the hospital has to incur. Over the past few decades the number of acute hospital beds has decreased leading to a serious concern for the emergency departments in Europe. According to the Irish government report titled “Acute Hospital Bed Capacity: A National Review” the beds to population ratio was 5.1per 1000 in 1980 which reduced to 3.1 beds per 1000 population during the last decade, i.e. 2000s. (JayaprakashNamita, O'Sullivan Ronan “Crowding and Delivery of Healthcare in Emergency Departments: The European Perspective”, 2009).
Adding more to the seriousness of these types of issues is the closure of hospitals in Germany which resulted in the reduction of 49,472 beds. The trend is still continuing in Germany where in 2006 the bed count was cut furthermore by 13,000 or 2.5%. There are other factors that affect the bed occupancy which lie outside the premises of the hospitals. These include inadequate community services for appropriate transfer of care of patients back to the community results in long stays at hospitals and blocks acute hospital bed access.(Jayaprakash Namita, O'Sullivan Ronan “Crowding and Delivery of Healthcare in Emergency Departments: The European Perspective”, 2009).
Increasing patient Acuity
The seriousness of illness seen in emergency patients has increased over the past few decades because of the growing age of population. The median age of population has increased by 10 years. The elderly are mostly admitted at hospitals and have a prolonged stay compared to the younger ones.
Patient Self-Referrals
Sometimes the emergency department is used for minor treatments such as slight injuries which decreases the quality of service and increases the costs.
Inexperienced Medical Staff
Junior doctors or doctors that do not have enough experience do not match up to the expertise of more senior staff members. Moreover those who are experienced spend less time with patients and hold fewer studies on the patients’ illness can hence arrive quickly at clinical decisions, whereas inexperienced doctors are slower in decision making.
Staff Shortages
Due to the growing population the shortages of nurses is also another problem facing the European countries. According to a report there is an average of 3.4 doctors per 1000 population. (JayaprakashNamita, O'Sullivan Ronan “Crowding and Delivery of Healthcare in Emergency Departments: The European Perspective”, 2009).
How European Overcome these Problems
Basically in Europe especially in England there is so much overcrowding in emergencies is just because everyone want quickly treatment. Therefore they have divided their emergency sector into sub department like children emergency is separate from adult; above 16. Similarly they have also divided their emergency patient into two categories 1. Minor injuries patient: The patient with disease like flue, fever and minor injuries etc. These Patients should be referred to medical worker of medicine shops. These are known as chemist in England and these chemists prescribed them medicine according to their disease. 2. Major injuries patient: These patient are treated by emergency doctors.
RECOMMENDATIONS FOR PAKISTAN EMERGENCY DEPARTMENTS Different countries face different situation so it is not necessary that a universal solution be implemented in Pakistan but rather the government should review its policies that have a positive effect on crowding and design tailor made solutions depending on the demographics of the region. * Formal training should be provided to those in undergraduate programs and graduate programs undertaking medical training. * Like stated in the foreign journals Pakistani institutions should also scatter the emergency patients on different floors so as to speed up the procedures and enhance the availability of beds. * Every patient should be interviewed in a separate room to avoid overcrowding and that the medical staff should be able to handle the patient load. * Use of modern technology should be implemented to speed up the process of diagnosis * Patients who are in critical condition and who need to be admitted in emergency departments should be registered at the bedsides so that other patients can get their turn quickly.
CONCLUSION
Pakistan is a country where majority of the population are unable to afford expensive treatments. The population of Pakistan has reached 18 crore and still goes up year by year. Therefore overcrowding is also a major issue here like countries abroad. As we have presented the analysis of the foreign emergency departments along with the problems and the actions being taken to counter the problems, same needs to be done In the Pakistan emergency departments in order to improve the effectiveness of the services provided to a wide range of patients. Overcrowding as discussed in the report is one of the major problems which also is the backbone to other related problems like quality of service delivered due to overload of patients and so on. This causes a frustration for the medical staff and also disturbs the proper functioning of procedures. In the primary research that we conducted we came to know that the standards of patient treatment are not up to the mark due to various reasons such as hygiene problems, lack of interest shown by doctors in treating the patients and snubbing them off. This gives a rise to the ethical issues the patients face with the hospital staff and are left helpless to die.

OBJECTIVE OF OUR CASE STUDY
During our project we faced the dengue crisis, due to which whole Lahore was shut down and hospital emergencies are filled with patients. With our advisor & group members consent we decided to designed a case study to know how doctors of emergency are dealing with this dengue outbreak. The aim was to discuss the mismanagement in the whole dengue scenario.
DENGUE FEVER: IS IT CORRUPTION THAT LURKS ONCE AGAIN OR THE MISMANAGEMENT? “A CASE STUDY”

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This paper high lightened the mismanagement that took place behind the dengue fever. The exploratory case study presented in this document is a study to know detail about dengue fever, symptom of this fever and the way to prevent ourselves from this fever. Comments and questions are encouraged. The paper analyzes incentives of people either medical professional or common man for doing corruption and mismanagement also in such situation, where the matter is directly related to life and death.
INTRODUCTION
Abstract Transparency International defines corruption as ‘misuse of entrusted power for private gain’; alternately, it is defined as, “sale by government officials of government property for private gain”. Corruption in the health care system or in the medical sector is widely known, both in the developing and the developed countries. Pakistan is a country which has an organized, structured and planned health care system, but only in theory and on government papers. Now a day’s dengue fever is at its peak in Pakistan, but Pakistanis haven’t stopped doing corruption in such a crucial situation. This shows that they don’t have any fear of Allah. This case study aims to identify and determine the aspects of dengue disease; what actually dengue fever is, how do people get infected by this fever, the symptoms of this disease, the precautions needed regarding it. This case study also highlights the corruption that is lurking in the face of this disease in the hospitals of Pakistan and the factors that motivate doctors/medical professionals in carrying out corruption. In end we can also recommend to government ways to avoid this corruption and also the disease not to occur again. Objective: * To highlight the corruption and mismanagement that lurks behind dengue fever * To highlight the actual and perceived or told situation from the side of medical professions. * To highlight deadly mistake from state Government officials and hospital management in case of this dengue infection. * Pave a way to end corruption and to improve the management issues of the doctors. * To aid the patient taking very cautiously the steps to handle the dengue fever problems independently. * To encourage the patient and motivate them to utilize the health care provided by the health workers. Background: Dengue is a deadly viral disease. It affects millions of people worldwide and is confined to warm climates where the dengue mosquito that transmits the disease thrives. This disease used to be called “break bone” fever because it sometimes leads to a joint and muscle pain that feels like a serious bone break. Health experts are aware about dengue fever for more than 200 years. Unfortunately there is no vaccine or medicine that can prevent this infection and that is why researchers are diligently working to find the cure from then; from 200 years. Dengue fever is usually found during and just after the rainy season in tropical and subtropical like Africa, India, Middle East and Caribbean and Central and South America etc. Worldwide, more than 100 million cases of dengue occur each year. In addition to classic dengue fever, dengue hemorrhagic shock “syndrome of fever” has also increased in many parts of the world. Dengue can be caused by one of the four types of dengue virus: DEN-1, DEN-2, DEN-3 and DEN-4. A person infected with one type of dengue will only be subsequently immune to that type. They will not be immune to other types of dengue disease and will, in fact, be at risk of developing severe symptoms if they contract another type of dengue. You can also get dengue virus infections from the bite of an infected Aedes mosquito. Typical symptoms of dengue usually start with fever within 5 to 6 days after being bitten by an infected mosquito and include: * High fever, up to 105 degrees Fahrenheit * Severe headache * Addicts and muscle pain * Rashes * Eyes pain
LIFE CYCLE OF DENGUE MOSQUITOES “AEDES AEGYPTI” It takes seven days for the Aedes mosquito in stagnant water to become adult Aedes mosquito. The water has to be clean; it only requires 20 cent coin space of water for mosquito to breed in. Its growth begins from an egg to a larva, to a pupa and finally to an adult. Adult mosquito can live for about three to four weeks. Only female aede mosquito bites to take out blood in order to support the production of eggs. If a blood meal is insufficient she has to keep on biting until she gets sufficient blood. On an average she produces three to four batches of eggs in her life time and about seventy to eighty eggs per batch. A male mosquito feeds on plant juices and does not bite as they do not need to suck blood. In her search for blood, a female mosquito is attracted to carbon dioxide and body heat. Figure 23

DENGUE IN PAKISTAN Dengue has become a challenge for the scientists and the doctors across the globe. No one has been able to find any medicine and vaccine for this deadly disease. In Pakistan dengue fever epidemics have become a cyclical nightmare over the last several years. The infection in the previous century was quite less in South Asia, but in the last decade, dengue has become a regular occurrence, usually peaking in September and October. As the population in Pakistan grows, people move around in search of economic opportunity or safety from militant violence, settling in many overcrowded places such as urban slums on the outskirts of cities like Lahore. As mentioned earlier the dengue virus has four types, and all four of them are present in Pakistan. The dengue virus was first diagnosed in Africa and some countries of Asia around 35 years ago. Researchers say that the virus reached Pakistan along with tires kept at the Bangkok harbor imported from Thailand some 17 years ago. The first case of dengue fever was reported in Karachi in 1994. However the dengue virus broke out in Punjab six years ago. The province of Punjab particularly its capital, Lahore has seen a growing number of cases since 2007. But this year a number of people have fell victim to this deadly dengue virus which has increased a lot.
ACTUAL VS.PERCEIVED GAP
Doctor’s view This year as the dengue fever infection had more impact than previous year, hundreds of people made a big line to government hospitals to get their blood tested. People having a high fever, which is a common symptom besides headache; fear a lot for their lives. On the other hand doctors say that the mortality rate from dengue virus is just one percent. A media hype about the dangers of the disease and a politicization of the issue led people to panic. They are now congregating at the hospitals putting a severe strain on the hospital management. Giving an interview to one of news channel Doctor Saluhaddin Khan in-charge of dengue control program at Jinnah hospital says that doctors are working very hard day and night to save the lives of the people highlighting that they have also turned their conference room into a dengue ward. He also says that now there is also gradual understanding of this mysterious virus. As the time is passing by the panic is subsiding. However for some people it is a shamble because they do not know too much about the disease which is why fear creeps in. But the situation in the hospital is totally under control.” The doctors said that out of 4000 tests only 17 turned positive. It is a rumor that thousands are infected by dengue and many of them died due to it is wrong. The hospitals are full of patients and even the corridors are shifted in wards to deal with the crisis. Another doctor “Dr.Mubashir Ahmed Malik” Director Health Services (CDC/Surveillance), while giving interview to local channel “express news” in August said, as for as the preventive measure are concerned Punjab health department has already issue instructions to the EDO health and the medical superintendent of the teaching hospitals regarding prevention and control. As for as the patient is concerned, the patient will get the free treatment and diagnostic services for the dengue case throughout in Punjab province from throughout the District head quarter hospitals and teaching hospitals. Moreover those who have second episode or subsequent episode of dengue fever, there is adequate stock of platelets available in the hospitals. He further told that when the platelets count is less than 1000 only then platelets are indicated. But God has gifted the human being that when this hemorrhagic condition happens the platelets grow bigger in the size. He also stated that the people better go to government hospitals, they have better facilities available there; they don’t have to pay money there for diagnoses.
ACTUAL SITUATION But the real truth is that thousands of people affected by dengue are now days lined up for urgent medical treatment. The provincial capital of Punjab, Lahore, is in the middle of dengue fever outbreak that has taken the lives of more than 200 and more than 16000 have been infected in recent months. The death rate is expected to rise as hundreds of people are reported to overcrowd emergency rooms every day. According to “Punjab health department” this time as dengue fever epidemic is very high that is why more than 500 people are visiting hospitals every day. This deadly infection started this year from the month of August when there was heavy rain everywhere. The people affected from dengue fever were more than 1200, while report published by “Punjab health department” on 31 august told that only 116 cases were reported in just 24 hours. Out of 116 cases, 113 cases are from Lahore and the rest of the three cases are from other cities. Till 30th September more than 12,000 cases of dengue fever and 121 deaths linked to the disease have been reported across Pakistan. This is also confirmed by Nasir Habib from CNN on September 30, 2011 “More than 12,000 have been infected and 125 people have died over the past two months in Pakistan due to dengue fever, told by “health department spokesman”. He further replied that The “World Health Organization” also cited identical figures across Pakistan. The people affected to dengue are not only related to Punjab but some cases of dengue are also reported in other provinces. With the addition of 30 cases on Thursday 29th September, 2011, the total number of dengue cases in Sindh has gone up to 528 informed by “Sindh Health Department’s Dengue Surveillance Cell”. Statistics in up to 15th October say that deaths with dengue fever include total of 235 people, out which 218 are from Lahore. The number of patients affected from dengue in Punjab has crossed 16,000 with over 14,000 from the provincial capital Lahore reported by “Punjab health department”. Table 3 Short summary Dengue fever | AUGUST 30TH (2011) | SEPTEMBER 30TH (2011) | OCTOBER 15TH (2011) | Affected | 1200 | 12000 | 16000 | Died | 31 | 125 | 235 | By giving interview to local TV channel anchor ShahidCh by “Dr. Anjum Jamal from Ganga Ram Hospital,” revealed the mystery of a huge crowd in the hospitals. He said that there is lot of rush in the hospitals, as people are coming to hospitals in huge numbers for their CBC test. We recommend people with platelets count from 30000 to 40000 to do a complete blood count on the daily basis, another reason for huge crowd in the hospitals. We admit people when their platelet’s counts are equal to 20000 or less and keep on checking their platelet’s two times in a day. According to an article by Shefali Srinivas, Jessica Jaganathan Wed, Jul 11, 2007 in “The Straits Times” clearly mention criteria for admitting patients with dengue are when their blood platelet count drops to 80,000 and below, which puts them in danger of hemorrhaging. The platelet count tends to drop when the patient’s fever starts to subside. Platelet concentrates are not routinely administered. Platelets transfusion is useful in the presence of significant bleeding with platelet counts less than 50,000 or as prophylaxis against spontaneous bleeding when platelet counts are below. 20,000/cu mm. Source: “ The 2001 Revised National Consensus on the Case Management of Dengue Fever & Dengue Hemorrhagic Fever” so it is wrong to say that when the platelets count is less than 10000 only then platelets are indicated. According to another report from local news channel in which interviews were taken from patients and their relatives, it is clearly mentioned that private hospitals are charging very high. As the number of people affected from dengue fever increase day by day, hospitals are also benefiting from that. People are going to private hospitals but they are charging from Rs14000 to Rs15000. Reasons for people giving first priority to visit private hospitals is that they provide quality services and have enough space to admit patients compared to the public ones. As stated by one of the patients they went to one of government hospital but they are not admitting their patient due to lack of space. They also went to Fuji foundation but they said “when the patient platelets will come down to very minimum level then you bring that patient”.
DENGUE FEVER: CORRUPTION AND MISMANAGEMENT Corruption is not only just about money, but there are other types and forms of corruption as well. For example: favoritism, authority, tributary, competence etc. These types have more certain subtypes as tributary understand corruption as listeners, bribery and extortion. From competency we mean corruptions like indolence, resistance, cheating and theft etc. Each different type has different characteristics and origin, and therefore requires different solutions. In case of dengue fever lot of mismanagement and corruption has occurred. The main proof of this is the patients from different hospitals and their families have criticized the management of the hospitals for not giving them correct treatment and not properly handling the outbreak of the disease. Some of the thing in which corruption and mismanagement has occur in this case are given below. FIGURE 24

ANNOUNCING EARLY In today's globalized, wired world, info regarding outbreaks is sort of not possible to stay hidden from the general public. Eventually, the outbreaks are going to be revealed. Therefore, to stop rumors and misinformation and to border the event, it's best to announce as early as doable. But here in Pakistan opposite to this is happened; instead of tell to public doctors only informed government officials. Doctor Saluhaddin Khan, who informed government three month before dengue fever outbreak, could also inform public giving just one interview. Because in the end its public who can stop dengue fever by taking preventive measure before outbreak.
FAKE SPRAY James Cook University in Queensland Australia, says control affect target the mosquito that spread dengue. They say that the only way to control it is through the use of pesticides chemicals and perhaps community education. However in Pakistan the major corruption in this case occurs due to the use of fake chemical sprays. In these sprays, a huge quantity is mainly of water or mostly there is only water that sprayed in streets. As according to people no spray has done in their streets, like a person from “Shadaray”, mentioned in one interview to news channel that “spray team came to their area but done spray only on roads not comes to streets.” “While MPA Malik Raiz is also from that area but he didn’t take any action.” In my own area; “Sabzazar Lahore,” no spray has done and no spray team has visited in any block. Punjab Health Secretary “SaeedElahi” may be justified that it was a total misunderstanding about the dengue virus being spread as a result of ‘fake spray’. He said the Punjab government had imported medicine for dengue from India instead of Germany and these medicines were less costly than the German medicine. The sprayed chemicals are not fake. However a question arises here is not about the quality of medicine, but rather that which parts of Lahore have been sprayed? Like in the interview from patients by Shahid Chaudary from NEWS 5 it’s clearly revealed by public that no spray has been done in their area. If the places had been sprayed then the visits to hospital regarding this virus would not have happened. Another person said that reason of not having certain areas sprayed, is that when we go to head of town, the people over there direct them to visit the councilors, while the councilor refer us to the MPA as they are elected by the provincial assembly specially to deal with dengue epidemic. Nevertheless when call the MPA through the telephones/mobile, we find their phones switched off while their PSO tells us that we have only one machine so we can’t go everywhere. On 23,September 2011 Friday the district coordination officer additionally admitted before the Lahore High Court that use of substandard anti-dengue virus spray within the provincial metropolis last year resulted into huge production of mosquito resulting in loss of lives throughout this season (Staff Reporter, DAWN).
CBC TEST Another corruption occurring behind CBC testis those hospitals are charging different rates ranging from 80 to 150. While a patient from Ganga Ram Hospital confirmed that, they charge 150 from them. Similarly according an article “LHC orders labs to charge Rs 90 for CBC tests” in daily times it’s clearly mentioned that Ittefaq Hospital, was also charging Rs 360 for a CBC test.While one of our group members confirmed that different laboratories like AL-NASR Lab and some others are charging 80 to 90 rupees.
COSTLY PLATELET KITS Diagnostic tests were intolerably expensive and hospitals were fast running out of white blood cells manufacturing platelets kits. According to an article some patients’ relatives mentioned that the doctors addressing the dengue fever patients told them either to wait for the kits or purchase them from the market on their own. In the same article “Dengue Fever and Mismanagement of Gov.”, it also mentions that taking advantage of the case and attributable to a scarcity of check and balance, the suppliers of those kits and medical stores had increased the costs several fold. A kit that normally value Rs 9,000 is currently being sold within the black market at an excessive worth of around Rs 30,000.
SHORTAGE OF BEDS One major worrisome detail noted from hospital side was the acute shortage of beds in emergency wards. It is reported that patients were made to wait for their turn to occupy beds, at times. The wards, especially the temporary dengue wards, were full beyond capacity and very suffocating. The hospital was not properly ventilated and the ACs did not work properly, the condition was worsened by the large number of patients flowing into the ward.
ELECTRICITY SHORTFALL AND DENGUE FEVER The government provided the machinery for the cure of dengue fever but many people complaint that there is no electricity available to operate the machinery thus, creating fuss in the patients. However one person infected by dengue clearly said in a report broadcasts from our local news channel, “I want to say to Nawaz Sharif that if you have provided machines to hospitals then you have to provide electricity also to them”.
NEGLIGENCE IN TREATING OTHER PATIENTS Patients with alternative issues are being ignored by the general public sector hospitals because of a special concentrate on the dengue patients. Patients, who had come from other cities for treatment of various other diseases, were suffering due to lack of attention from the doctors.
FINAL VERDICT “Where the nation has been suffering from this hazardous disease and the individuals are killed by Dengue, the doctors and the hospital administrations haven’t been sympathetic, caring and supportive to the patients though currently sensible arrangements are being seen for the protection from this fever by the Punjab government. But the actual fact is the hospital administration proves to be cruel to the patients” (rizwan, newspaper awaz) retrieved from“http://awaz.pk/tag/dengue”. Dengue virus is not something new Pakistan. The government might have combated this virus if correct measures had been taken some months ago since dengue-carrying mosquitoes strike within the summers. Fumigation ought to have taken place before summer so these mosquitoes wouldn’t have been able to breed. Since there’s no vaccine to forestall the outbreak of dengue, it had been the government’s responsibility to launch awareness campaigns beforehand. Currently panic and concern has overtaken the populace, most of whom are even afraid to step out of their homes. Rather than adding to the panic, the government ought to attempt to give correct medical health facilities to cope with this epidemic since applicable medical care will save the lives of these suffering from the dengue virus. Whereas, the government is currently attempting its utmost to regulate the dengue outbreak, it’s still not enough. It is vital that except the general public health sector, non-public health facilities ought to conjointly play their role. This is no time to make profits; it is time to help the people of Pakistan. NGOs involved in providing medical care should also come forward and help end this epidemic in saving lives. Except taking measures which will facilitate combat this disease at the instant, the government and hospitals should admit an attainable future outbreak. However we from our side take some preventive measure to save ourselves from dengue fever. These preventive are mention below.
HEALTH PROBLEMS ENCOUNTERED As earlier mentioned dengue fever start with the bite of mosquito, and then come the flue like symptoms. If it’s not treated quickly the fever arrives. Characteristically the overall vascular system is damaged, and the body ability to regulate itself is impaired. These symptoms are often accompanied by dengue fever. Similarly bleeding also started during dengue fever. However, the bleeding itself is rarely life threatening. While some type of dengue fever also can cause relatively mild illness, many of these can cause life threatening disease. Specific signs and symptom vary by the type of dengue virus, but signs of simple dengue fever include marked fever, fatigue, dizziness, muscle aches, loss of strength, and exhaustion, in dengue hemorrhagic fever patients also start bleeding from nose, mouth and gums, when their platelets fall to minimum level. It’s also started serve stomach pains and frequent vomiting. but the main problem arise from dengue fever is weakness, while ill person also show shock , nervous system malfunction, coma, rapid or weak pulse and difficulty in breathing etc.
PREVENTIVE MEASURES If we as anybody that, Is dengue fever a fatal disease? The answers may come yes, but don’t press the panic button, it can be controlled and treated if handled properly. The first and foremost thing we can do is to remove all the stagnant water, which may be difficult for Pakistanis’ but they have to do this. By this you can deny the any chance of aede mosquito to breed. Usual breeding grounds for dengue fever are: 1. Roadside drain 2. Flower pot 3. Flower pot plate 4. Hardened soil of potted plants 5. Collar of the toilet bowl 6. Roof gutter 7. Gellar trap 8. Air collar tray 9. Water falling from fridge 10. Tree holes Following preventive measure we can take to avoid dengue mosquito to grow, change every other day water in flower vases and remove water from flowerpot plates. Remove water from air conditioner tray. Redirect water from air conditioners to bathroom. At least once a week, clear fallen leaves in drains and gardens. Remove stagnant water collected in the drains. Similarly once a month, clear blockages and put insecticides in roof gutter and add sand or insecticides to places where stagnant water is unavoidable. When not in use turn over all pails and remove water from water storage containers. Cover all the containers that are being used to store water. If you are not in your house for certain days or on vacations, cover the toilet bowls. Cover all gully and floor taps. Wear shoes, socks, long pants and long sleeved shirts. Use mosquito repellents, mosquito coil and net etc.
SUGGESTIONS FROM MEDICAL WORKERS’ SIDE Beside all these preventive measure if a person still remains infected by dengue virus then there are certain do and don’t also suggested by doctors that she or he has to follow. Like take adequate bed rest, take in ample water; more than 5 glasses of plain water per day. Frequent use of juices, soup, milk and fruits etc. is also. Take Paracetamol but not more than 4 gram per day. Try to rest under mosquito net during also day time. Similarly don’t take NSAIDs e.g. aspirin, Brufen etc. Antibiotic are also not required. Do not wait in case symptoms of dengue appear.
PROJECT LIMITATIONS
The limitations we faced in our project were firstly the dengue break due to which we faced difficulty to coordinate amongst the group. While conducting our survey we face some limitations such as we had to limit our sample size to 40. As the patients showed lack of cooperation & understanding. In some cases the hospital administration did not allowed us to conduct the survey and simply refuse to give any information about the hospital. We used convenience sampling in our survey due to the limitation of accessibility. In last time constraint was an important limitation in our project. We had to manage time due to the different timetable of group members, workload of other subjects and of course the midterms were also a hurdle. But overall we didn’t face any major limitation, thanks to all mighty ALLAH and our respected advisor Mr. Omar Aziz Babar.

REFERENCES 1. (Hasan M. Medical ethics–past and present. Paki Heart J 1995; 28:63-72) 2. Article by Amin A. Muhammad Gadit (Discipline of Psychiatry, Memorial University of Newfoundland, Canada) 3. http://waildlives.blogspot.com/2011/08/aedes-mosquito-pics-and-life-cycles.html 4. Randolph W., H. ( June 1, 2006). Patient flow:the new queueing theory for healthcare. Queueing Theory, (OR/MS Today), Retrieved from http://business.highbeam.com/434828/article-1G1-160922445/patient-flow-new-queueing-theory-healthcare 5. WHO. (2007). Risk reduction and emergency preparedness. WHO six-year strategy for the health sector and community capacity development, Retrieved from www.who.int/hac/techguidance/.../emergency_preparedness_eng.pdf 6. Mark Smith, MD Chair, Department of Emergency Medicine Washington Hospital Center journal “emergency department as a complex system”. 1998. 7. Sultan Al-Shaqsi “Models of International Emergency Medical Service (EMS) Systems”. 4 oct 2010: para 1. 8. AniruddhaMalpani, Anjali Malpan: How to get the best medical care... a guide for intelligent patient and caring doctors. Jan 2000: 168. 9. Rahim Moineddin, Christopher Meaney: Modeling factors influencing the demand for emergency department services in Ontario: a comparison of methods. August 2011 10. Hasan IJ, Khanum A: Health care utilization during terminal child illness in squatter settlements of Karachi, 2000. 11. R. A. Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (Baltimore: Johns Hopkins University Press, 1989), pp. 30–39. 12. John S.O’Shea, MD “Backgrounder: Published by the Heritage Foundation: 2006

13. Lewin Group, “Hospital Capacity and Emergency Department Diversion: Four Community Case Studies—AHA Survey Results,” American Hospital Association, April 2004, at www.aha.org/aha/content/2004/PowerPoint/EDDiversionSurvey040421.ppt (May 11, 2007). 14. Interview from “ Doctor Sidra Majeed (EMO- A & E Dept) from Mayo Hospital 15. R. Rehmani: Emergency Medicine: a relatively New Specialty. May,2004
REFERENCES OF THE CASE STUDY 1. Pakistan VOICE. (26, AUGUST 2011). Dengue fever on the rise in Pakistan. Retrieved from http://asiancorrespondent.com/63433/dengue-fever-on-rise-in-pakistan 2. NasirHabib, CNN. (30, SEPTEMBER 2011). Dengue fever kills 125, infects more than 12,000 in Pakistan. Retrieved from http://articles.cnn.com/keyword/lahor 3. Press Release: United Nations. (30, SEPTEMBER 2011). Thousands of dengue fever cases emerging in Pakistan. Retrieved from http://www.scoop.co.nz/stories/WO1110/S00011/thousands-of-dengue-fever-cases-emerging-in-pakistan.ht 4. OnePakistanNews (30, SEPTEMBER 2011). Dengue fever death toll reaches 121 . Retrieved from http://www.onepakistan.com/news/health/123957-dengue-fever-death-toll-reaches-121.htm 5. Staff Report, P. T. (15, OCTOBER 2011). Another seven die of dengue fever . Retrieved from http://www.pakistantoday.com.pk/2011/10/another-seven-die-of-dengue-fever 6. John P. Cunha, DO, FACOEP, (17, OCTOBER 2011). Dengue fever facts. Retrieved from http://www.medicinenet.com/dengue_fever/article.ht 7. karcrush. (27, SEPTEMBER 2011). Dengue: causes and preventive measures. Retrieved from http://www.zimbio.com/BreakboneDengueFever/articles/C9QXXm8KL0g/DENGUECauses-preventive-measure 8. Preventative measures against dengue fever. (n.d.). Retrieved from http://www.expat.or.id/medical/denguefeverindonesia.htm 9. The symptoms and preventive measures of dengue. (11, April 2011). Retrieved from http://health.ezinemark.com/the-symptoms-and-preventive-measures-of-dengue-3229a5a86b7.htm 10. U.S. Army Garrison-Hawaii. (31, March 2011). Dengue fever cases initiate preventive measures. Retrieved from http://www.hawaiiarmyweekly.com/news/2011/3/31/dengue-fever-cases-initiate-preventive-measures.ht 11. Maui News. (19, April 2011). Haiku dengue fever prevention meeting addresses residents’ questions, concerns. Retrieved from http://mauinow.com/2011/04/19/haiku-dengue-fever-prevention-meeting-addresses-residents’-questions-concerns/ 12. VOA. (1, SEPTEMBER 2011). Trying a new way to stop dengue. Retrieved from http://www.51voa.com/VOA_Special_English/Trying-a-New-Way-to-Stop-Dengue--43043.htm

APPENDIX

Questionnaire
Gender: _________ Age: ______
Hospital name: ______________ Public Private

My name is _______________. I am doing my BBA (Bachelors in business administration) from FAST. I and my group members are conducting a research for hr/ management related issues in Emergency Department of hospitals in Pakistan. Our aim is to identify the gap between the expectations and the reality in Pakistan’s Emergency sector. 1) Why did he/she visit the emergency room?

* Injury or accident * Illness * Maternity care * Mental health * Other:

2) What procedures, if any, did he or she have? (Exception)

* Stitches * Operation * Casting for broken bone * Breathing treatment * Other: 3) How long did he or she wait in the waiting area to be seen by ER staff?

* Less than 10 minutes * 10 minutes- 30minutes * More than 30minutes

5) The cleanliness of the examination room? * Very Satisfied * Somewhat Satisfied * Dissatisfied

* -------------------------------------------------
Top of Form
-------------------------------------------------
Questions from the patient related to the registration process and other:

7) How satisfied were you with the ease of registration?

* Very Satisfied * Somewhat Satisfied * Undecided * Dissatisfied

10) The comfort of the waiting area?

* Very Satisfied * Somewhat Satisfied * Undecided * Dissatisfied

-------------------------------------------------
Related to nurses:

11) Was the nurse knowledgeable?

* Disagree * Agree

12) Did the nurse properly explain the procedures, tests, and/or treatments to you?

* Disagree * Undecided * Agree

13) How satisfied were you with the frequency of visits made by the nurse while you were admitted in this hospital?

* Satisfied * Undecided * Dissatisfied

14) Was the doctor knowledgeable?

* Disagree * Undecided * Agree

15) How would you rate the quality of the care you received from your doctor while you were admitted in this hospital?

* Excellent * Good * Poor * Undecided

16) How satisfied were you with the frequency of visits by the doctor while you were admitted in this hospital?

* Satisfied * Undecided * Dissatisfied

17) Was the doctor friendly and courteous?

* Disagree * Undecided * Agree

18) Are the machines used in emergency new and up to standard?

* Yes * No

19) Did you find the number of beds sufficient for the patient? * Yes * No

20) Did you feel neglected at any time in patient treatment? * Yes * No *

21) Are the medicines available within the hospital or you have to get it from outside? * Hospital * Outside

22) Medicines available at hospital are free or charged? * Free * charged

23) Would you recommend this hospital to others for emergency treatment?

* Yes * No * Undecided

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