IAP Intensive Care Chapter College Of Pediatric Critical Care

h Institute,IAP Intensive Care Chapter College Of Pediatric Critical CareAPPLICATION FORM FOR LEVEL III UNIT ACCREDITATION (Non-Teaching)Instructions to fill this form: This form is designed to capture infrastructure and human resource required forrecognition of a unit as Level III unit Non-Teaching Unit by the College of PediatricCritical Care (CPCC). The form must be carefully type-written.Accreditation Level III non-teaching unit: This clause is meant for, units having optimum infrastructure, workload and apediatric intensivist, but the intensivist is not a CPPC accredited teacher. Such a unit too can apply for ‘Level III – non-teaching accreditation’. The current rules state that by virtue of working in such an accredited unit, theintensivist working can apply after a minimum stipulated period for his/her ownteacher-accreditation. This clause is designed primarily for systematically increasing the number of teachersand subsequently also the number of PICUs as training centers, while maintainingstandards of training. Details can be accessed by contacting office.1Please read the application form until the last page and follow all the instructions.

IAP Intensive Care Chapter College Of Pediatric Critical CareInspection form for Accreditation of ‘Level III Non-Teaching’ Units(Please Note: Choose and keep either Yes / No, by carefully strikethrough inappropriate response below e.g. No.) (I) General Information1Name of the institute2Address for Correspondenceh Institute,345a. Telephones (land lines, mobile)b. fax,c. e mail of the PICU In Charge:a. Year in which hospital established:b. Year in which Department of Pediatrics established:c. Year in which PICU established:Status of Hospital: such as private / govt : state, central / voluntaryorganization / any other (write one in the next column)6Is the hospital recognized by MCI or State Medical Council?8Is the hospital recognized by National Boards for Gen. Pediatrics?9Is the hospital recognized by National Boards for any otherSpecialty or super-specialty? If yes, enumerate:9Is the hospital recognized by National Boards for adultCritical care fellowship programme?1011Is the hospital recognized by National Boards for neonatology Fellowship?Is the unit recognized by National Board for PediatricCritical Care Fellowship?Is the unit recognized by any other body for PediatricCritical Care Fellowship?12a. .b.c a.b.c a.b.c.d.2Please read the application form until the last page and follow all the instructions.

h Institute,IAP Intensive Care Chapter College Of Pediatric Critical Care (II) Medical Personnel (Hospital / Pediatrics / PICU )AName of Present Director/ Medical Superintendent of InstitutionBName of Head/ In-charge of Department of PediatricsCNo. of Consultants in Pediatric DepartmentFull Time:Part Time:Information about Head / Director/ In-charge of PICU:Name: Dr. .1. Qualifications2. Postgraduate experience in Pediatrics (at least 8 years)3. Duration of directorship of PICU (at least 3 years)4. Details of PIC training ( Annexure 1)5. Years spent in PIC (at least 4 years)6. Percentage of daily time spent in PICU –a) Administrative:b) Patient care in PICU:c) Neonatologyd) Gen Pediatrics : Indoor& OPD :Number of other qualified intensivists in the unit (if available):CV of other qualified intensivists ( Annexure 2)All the information about each intensivist (similar to the above row namely D)DEF (III) InfrastructureABBCCa.b.c.d.Total no. of beds in PICU (at least 6):Total No. of beds in PICU with ventilation facility:Total No of bed in PICU without ventilation facility:If step down unit / high dependency is not the part of PICU indicate no of bedsavailable in this unit:Isolations area (indicate yes / no) :Total floor area of PICU (sq. ft): Floor area per bed (PICU): Inter-bed distance (PICU):Floor area of step-down ward if separate (sq. ft):Others: (indicate Yes/ No): Dirty Utility room: Accessible hand wash facility: Parents counseling room (indicate Yes/ No): Storage space: Safe exit in case of fire:Power supply back up (indicate generator / UPS / Inverter):3Please read the application form until the last page and follow all the instructions.

h Institute,IAP Intensive Care Chapter College Of Pediatric Critical Care (IV) EquipmentEquipmentAvailable(Y/N)Total NumberAll bedsAvailability 50% 50%Multichannel monitorPulse OximeterEnd tidal CO2 monitorECG monitoringNIBP monitoringInvasive pressuremonitoringContinuous EEGmonitoringIntracranial pressuremonitoringOxygen analyzerVolumetric pumpsSyringe pumpsSuction apparatus-centralNo. of extra suctionmachinesOverhead warmers/BearHuggersAny other Indicate the equipment taken on loan from other sources (specify source) (V) Diagnostic FacilitiesAvailability (Yes / No )Bedside X- ray machineBedside ultrasonography / echocardiographyBedside GI endoscopyBedside flexible bronchoscopyBedside EEGWhole body CT scan available in same hospitalWhole body MRI scan available in same hospitalLab FacilitiesAvailability: 24 HrsHematology ( Coagulation screen) :BiochemistryMicrobiologyABG machine (Location: PICU / central lab / .)Medical gas supplyOxygen : Central / Gas cylinders/ 24 HrsNO: Yes / No*Indicate facilities outsourced (enumerate below and mention the distance from the hospital)4Please read the application form until the last page and follow all the instructions.

h Institute,IAP Intensive Care Chapter College Of Pediatric Critical Care (VI) Therapeutic facilitiesFacilitiesAvailable(Yes/ No)Total NumbersMechanical ventilation (Exclusively for PICU)Ventilators with graphics facilityNoninvasive ventilatorDefibrillator in PICU (24 hours)Temporary pacing in ICURenal replacement ( PD, HD, CVVH )Specify if bedside facility availableCRASH CART (in PICU)Difficult Airway management equipment24 Hrs pharmacyBlood bank facility (on site/ outsourced)24 hours 24 hoursAll blood components available24 hours 24 hrsCardiac cath.lab (VII) Table indicating availability of Support Services:In hospital OutsourcedPediatric surgeonNeurosurgeonPed CardiologistPed Orthopedic surgeonCTV surgeonPed NeurologistPed NephrologistPed GastroenterologistRadiologistPsychiatrist/ PsychologistDieticianPhysiotherapyOccupational therapistSocial workerHematology labBiochemistry labMicrobiologyPathologyCentral sterilization unit5Please read the application form until the last page and follow all the instructions.

h Institute,IAP Intensive Care Chapter College Of Pediatric Critical Care (VIII) Policies and Protocols ( Annexure 3) (IX) Table showing beds capacity of the entire hospital and pediatric facility:No of bedsNo of admissions per yearEntire HospitalPediatric General Ward (30 days-16 years)Pediatric Special RoomsNeonatal ICU (0-30 days)PICUAdult ICUAny other ICU (Pediatric cardiac ICU etc)Any other ICUTotal number of ventilated patients (Invasive and Non-Invasive) per year .Total number of Invasively ventilated patients per year: Name of PICU Director / In-chargeSignatureDatePlease Note: If the unit satisfactorily fulfills prescribed requirements, inspection will be conducted as per thecollege rules. Inspection fee for the New Non- Teaching Unit Accreditation Level 3 is Rs.20000/-and level 2 is10000/- by DD. Draft is to be enclosed with this application form. Application fee is nonrefundable. When a ‘Non-Teaching level 3 Unit’ applies for teaching unit accreditation, additionalfee of Rs. 5000/- will be charged. The travel and stay (Approximately 4-star kind of facility) of the inspectors will be borne bythe institution. An honorarium of Rs. 5000/- is payable to inspector from out of town and Rs. 2000/- ispayable to inspector if he/she happens to be from same town as that of applyinginstitution/ hospital.6Please read the application form until the last page and follow all the instructions.

h Institute,IAP Intensive Care Chapter College Of Pediatric Critical CarePlease send the Demand Draft (DD) (by registered mail/courier)/NEFT detail may be sent by email.Please ensure that correct required fee is paid payable to “IAP intensive care chapter “Payble to “IAP Intensive Care Chapter”DD no.BankDate of Issue (dt) (mo) (Yr)Bank Transfer InformationName of beneficiary - IAP Intensive Care ChapterName of Bank- THE FEDERAL BANK LTD, SATARAType of account & No. – 15840200003657, Current A/cIFSC Code- FDRL0001584Registered Mobile no for bank account 09822057577Mailing Address:Dr. Praveen Khilnani MD FAAP MCCM (USA)Vice Chancellor IAP College council, IAP intensive care ChapterAmerican Board certification in Pediatrics and Pediatric critical care MedicineSenior consultant Pediatric pulmonology and critical careClinical Director,Madhukar Rainbow Children’s Hospital,FC-29, Plot No. 5, Geetanjali Near Malviya Nagar Metro Station,Gate No.1, New Delhi-110017Email:drpraveen.k@rainbowhospitals.in AND collegepcc2016@gmail.comTel: 9111-66888882 ext. (1411)Tel: 91 9810159466All the documents (duly filled application form should be signed, then scanned, andconverted to PDF format. Similarly, all the required annexures (experience letters,degree certificates etc.) to be scanned and saved in PDF format) are required to beE-Mailed to.Dr. Praveen Khilnani,VICE Chancellor, PICC College councilEmail: drpraveen.k@rainbowhospitals.in AND collegepcc2016@gmail.comANDPlease make sure a CC of the e-mail is ALSO sent to.Dr. Bala Ramachandran : mdpicu@hotmail.comDr. Rachna Sharma: rachna9us@gmail.comDr. Arun Bansal: drarunbansal@gmail.com7Please read the application form until the last page and follow all the instructions.

IAP Intensive Care Chapter College Of Pediatric Critical Care Check List of Annexures:(Please number and submit the annexure in the following order; leave a blank annexure if not applicable)Annexure 1Details of PICU training of Head/Director/ In-charge PICUAnnexure 2Annexure 3Number of trained intensivists with qualification and experience in PICUPolicies and protocols of PICUh Institute,8Please read the application form until the last page and follow all the instructions.

Fortis Memorial Research Institute, Sector 44, Gurgaon, Haryana, India 122002 APPLICATION FORM FOR LEVEL III UNIT ACCREDITATION (Non-Teaching) Instructions to fill this form: This form is designed to capture infrastructure and human resource required for recognition of a unit as Level III unit Non-T