Appendix 1

American College of Emergency Physicians (ACEP) Policy

Health Care Guidelines for Cruise Ship Medical Facilities’

Reaffirmed by the ACEP Board of Directors October 2007 and October 2001
Revised and approved by the ACEP Board of Directors titled, "Health Care Guidelines for Cruise Ship Medical Facilities" December 1997
Originally approved by the ACEP Board of Directors titled, "Guidelines for Care of Cruise Ship


Medical Facilities" September 1995

The American College of Emergency Physicians believes that appropriate emergency care and health care maintenance for passengers and crew members aboard ships sailing in international waters are desirable. The cruise ship industry and its medical departments should retain medical personnel who can:

  • Provide quality maritime medical care for passengers and crew members aboard cruise ships;
  • Initiate appropriate stabilization, diagnostic, and therapeutic maneuvers for critically ill or medically unstable patients;  
  • Support, comfort, and care for patients on board ship; and  
  • Assist, in conjunction with the cruise line, in the medical evacuation of patients in a timely fashion when appropriate.

As an adjunct to this policy statement, ACEP’s Section on Cruise Ship and Maritime Medicine has prepared a Policy Resource and Education Paper (PREP) entitled, "Health Care Guidelines for Cruise Ship Medical Facilities", which is an explication of the Policy Statement.

Revised April 2011 (http://www.acep.org/Content.aspx?id=29980&terms=Health%20Care%20Guidelines%20for%20Cruise%20Ship%20Medical%20Facilities - accessed 25 June 2012)

The specific medical needs of a cruise ship are dependent on variables such as: ship size, itinerary, anticipated patient mix, anticipated number of patients' visits, etc. These factors will modify the applicability of these guidelines especially with regards to staffing, medical equipment and the ships' formulary. Medical care on cruise ships would be enhanced by ensuring that cruise ships have: 

 GUIDELINE 1:  MEDICAL FACILITY 

1.1    Contains adequate space for diagnosis and treatment of patients with 360° patient accessibility around all beds / stretchers 

1.2    Has adequate space for storage 

1.3    Examination and treatment areas and an inpatient medical holding unit adequate for the size of the ship. 

1.4    One examination / stabilization room 

1.5    One ICU room 

1.6    Minimum number inpatient beds of one bed per 1,000 passengers and crew 

1.7    Isolation room or the capability to provide isolation of patients 

1.8    Accessible by wheelchairs / stretchers 

1.9     Wheelchairaccessible toilet on all new builds delivered after January 1, 1997 

1.10    A contingency medical plan defining: 

        1.10.1    One or more locations on the ship that should: 

                        1.10.1.1    be in a different fire zone from the primary medical facility 

                        1.10.1.2    be easily accessible 

                        1.10.1.3    have lighting and power supply on the emergency system 

        1.10.2    Portable medical equipment and supplies including: 

                        1.10.2.1    Documentation and planning material 

                        1.10.2.2    Airway equipment, oxygen and supplies 

                        1.10.2.3    IV Fluids and supplies 

                        1.10.2.4    Immobilization equipment and supplies 

                        1.10.2.5    Diagnostic and laboratory supplies 

                        1.10.2.6    Dressings 

                        1.10.2.7    Treatment – medications and supplies 

                        1.10.2.8    Defibrillator and supplies 

                        1.10.2.9    Medical waste and personal protective equipment 

        1.10.3    Communication equipment for each member of the medical staff 

        1,10.4    A clear procedure in case the primary medical facility cannot be used 

        1.10.5    Crew assigned to assist the medical staff 

 GUIDELINE 2: STAFF 

2.1    A ship medical facility with medical staff (physicians and registered nurses) on call 24 hours per day while at sea. 

2.2       Medical staff who have undergone a credentialing process to verify the following qualifications: 

        2.2.1    Current physician or registered nurse licensure 

        2.2.2    Three years of post-graduate / post-registration clinical practice in general and emergency medicine OR 

        2.2.3    Board certification in:  

                    2.2.3.1     Emergency Medicine or 

                    2.2.3.2     Family Practice or 

                    2.2.3.3     Internal Medicine 

2.3       Medical staff with a competent skill level in Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 

2.4       Physicians with minor surgical, orthopedic and procedural skills including suturing, I&D abscesses, fracture/dislocation management, and procedural sedation.  

2.5       Medical staff that is fluent in the official language of the cruise line, the ship and that of most passengers 

 GUIDELINE 3:  CLINICAL PRACTICE  

3.1       Medical operations manual as required by international safety management code 

3.2       Appropriate medical staff orientation to the medical facility 

3.3       Code team is trained and updated regularly 

3.4       Mock code and contingency medical plan drills on a recurrent basis and as recommended by ship’s physician 

3.5       Emergency preparedness plan as required by the international safety management code 

3.6       Internal and external audits 

GUIDELINE 4:  DOCUMENTATION 

4.1       A medical record and communication system that provides: 

        4.1.1    Well organized, legible and consistent documentation of all medical care 

        4.1.2    Patient confidentiality. All patient medical records should be regarded as strictly confidential medical information and should not be accessible to non-medical personnel without the express written consent of the patient. 

 GUIDELINE 5:  EQUIPMENT 

5.1       Airway equipment - bag valve mask, LMA , laryngoscopes ET tubes, stylet, lubricant, suction equipment (portable) 

5.2       Two cardiac monitors 

5.3       Two defibrillators, one of which should be a portable automated external defibrillator (AED) 

5.4       External cardiac pacing capability 

5.5       Electrocardiograph (EKG) 

5.6       Electronic infusion device 

5.7       Pulse oximeter 

5.8       Nebulizer  

5.9       Automatic or manual respiratory support equipment 

5.10     Oxygen (including portable oxygen) 

5.11     Wheelchair 

5.12     Stair chair and stretcher 

5.13     Refrigerator and freezer 

5.14     Long and short back boards with cervical spine immobilization capabilities 

5.15     Trauma supplies 

5.16     Basic laboratory capabilities: 

            5.16.1  Hemoglobin, hematocrit, urinalysis, pregnancy tests, blood glucose  

            5.16.2  Laboratory equipment must undergo all quality control programs as recommended by the manufacturer. 

5.17     Maintenance for all medical equipment as recommended by manufacturer 

GUIDELINE 6:  PHARMACY  

6.1       Emergency medications for management of common medical emergencies, which include: 

            6.1.1    Gastro-intestinal system medications 

            6.1.2    Cardiovascular system medications 

                         6.1.2.1 Sufficient quantities of advanced cardiac life support medications, in accordance with current international ACLS guidelines, for the management of two complex cardiopulmonary arrests  

                        6.1.2.2 Thrombolytic medications sufficient for two patients 

            6.1.3    Respiratory system medications 

            6.1.4    Central nervous system medications 

            6.1.5    Infectious disease medications 

            6.1.6    Endocrine system medications 

            6.1.7    Obstetrics, gynaecology and urinary tract disorder medications 

            6.1.8    Musculoskeletal and joint disease medications 

            6.1.9    Eye medications 

            6.1.10  Ear, nose and oropharynx medications 

            6.1.11  Skin disease medications 

            6.1.12  Immunological products and vaccines 

            6.1.13  Anesthesia medications            

 GUIDELINE 7:  INFECTION CONTROL 

7.1       A TB screening program every two (biannually) years for all medical personnel              

GUIDELINE 8:  IMAGING 

8.1       X-ray machine for ships delivered after January 1, 1997   

GUIDELINE 9:  MEDICO-LEGAL PRACTICE 

9.1       Each ship should carry a minimum of two sexual assault evidence collection kits 

9.2       Ships that fall under the jurisdiction of the Cruise Vessel Security and Safety Act (CVSSA) of 2010 includes all vessels with 250 or more passengers on an international voyage that embarks or debarks in a U.S. port. The CVSSA mandates that ships must: 

             9.2.1      Have a physician or nurse meet the guidelines established by the American College of Emergency Physicians relating to the treatment and care of victims of sexual assault including the use of sexual assault evidence collection kits. 

            9.2.2      Carry sufficient stock of post exposure prophylaxis (PEP) anti-retroviral and antibacterial medications to prevent the transmission of HIV and other sexually transmitted diseases. 

            9.2.3      Prepare, provide to the patient, and maintain written documentation of the findings of such examination that is signed by the patient. 

            9.2.4      Treat all information concerning the examination confidential, so that no medical information may be released to the cruise line without the prior knowledge and approval in writing of the patient, or if the patient is unable to provide written authorization, the patient’s next-of-kin. 

            9.2.5      Provide the patient free and immediate access to a telephone, internet accessible computer and contact information for law enforcement, National Sexual Assault Hotline, the nearest consulate or embassy, and the Coast Guard.  This information must be maintained within the Medical Facility or elsewhere on the ship. 

9.3       Pregnant passengers and crew who have entered the 24th week of estimated fetal gestational age by the last day of the cruise should not be permitted to sail with the ship.  

GUIDELINE 10:  FEEDBACK FROM PATIENTS AND CARRIERS, INCLUDING COMPLAINTS 

10.1     A process whereby passengers prior to embarkation are requested to provide pertinent information regarding medical needs that may require medical care on board.

APPENDIX 2 - A modified Job Description for Ship’s Doctors

 

Reports to: MCH (Hotel Director or Staff Captain)

Basic function: The doctor oversees the administration, operation and fiscal management of the shipboard MC aboard.

Required documents to be presented at sign-on: Photocopies of medical diploma and license; current certificate for advanced cardiac life support training; signed work contract, - as well as original passport with appropriate work visas valid for 6 months after contract end and a company-specific medical pre-employment examination valid beyond contract expiration.

Responsibilities:

Administrative responsibilities:

  • Ensure that the medical staff members meet standards of medical care, maintain accurate records of treatment for all patients, and take corrective action when discrepancies are identified. This includes all details of patient injury or illness noting all contributory conditions such as weight, involvement of alcohol or drugs, weather and sea conditions, as well as complete documentation of services rendered and accurate charges based upon the company’s fee schedule
  • Supervise the administrative procedures for treatment of illnesses, injuries and deaths in accordance with the applicable regulations and company policy.
  • Serve as an adviser to the Master and the MCH in all matters related to medical facility services, passenger and crew health, and hygienic conditions on board.
  • Communicate any violations of good health or safety practices to the MCA.
  • Ensure the correct administration, safekeeping and documented inventory of all medicines in accordance with applicable regulations and company policy.
  • Ensure that all ordering procedures are strictly followed, including ordering within established minimum and maximum parameters.
  • Ensure that all mandatory logs, journals, reports and statement forms are completed.
  • Supervise medical personnel in the maintenance of all medical records and files.
  • Ensure and maintain the confidentiality of all medical information.
  • Prepare budget proposals for the MC, submit requisitions to the MCA for approval and monitor all expenditures via a monthly report.
  • Establish and implement a duty roster for the MC with office hours as directed by the MCA and an after-hours call schedule to maintain 24-hour coverage.
  • Enforce the following policy: When any medical staff member receives a telephone call or otherwise becomes aware of a potentially serious passenger or crew medical issue outside established office hours, this should be followed-up by an "in-person" visit, to be documented accordingly.
  • Ensure that all medical personnel are familiar with all administrative policies and procedures issued by the company and all medical protocols and procedures established by the doctor.
  • Review passenger comment cards relating to the MC and its staff, investigate and take corrective action when necessary, and utilize information in performance appraisals of medical staff when appropriate.
  • Complete performance evaluation of the medical staff members at mid-term and discuss necessary steps of action for improvement during the rest of the contract. Complete performance evaluation of each staff member again at the end of their contracts and have them co-signed by the employee and the MCA before final submission.
  • Ensure that two medically licensed persons are present to conduct and sign the compulsory inventory of controlled substances.
  • Ensure that the nurses obtain water samples from the potable water taps according to established procedures.
  • Monitor the order, cleanliness and general appearance of the MC and take action if necessary.
  • Ensure that all medical equipment is functional and used properly. Keep documentation regarding use, condition and maintenance.
  • Ensure weekly inspection of all diagnostic and life support equipment to insure proper working order, and the daily inspection of all battery operated critical care equipment. Check-lists of these inspections must be maintained, reviewed and initialed on a weekly basis by the doctor. Preventive maintenance program action items must be generated on the ship through utilization of the IT system. Records of past inspections must be maintained by the ship.
  • Ensure that that all first-aid kits, emergency kits and the secondary medical center are stocked and that medications are not outdated. Soon-to-expire medications should be noted when the products are checked and replaced before expiration.

Professional responsibilities:

  • Provide medical care to passenger and crew.
  • Rely on his diagnostic acumen, particularly the medical history and physical examination, to assess the passenger or crew problem. When a diagnosis is uncertain or inconclusive, a consultation with the company’s medical consultant) and/ or referral to an appropriate medical provider ashore should be considered for passengers and crew. Government-supported maritime medical advisor services, like Norwegian Radio Medico (via Rogaland Radio) can be consulted free of charge.
  • Request a specialist evaluation, diagnostics, and/or treatment from appropriate providers ashore for any crew or passenger who, in the opinion of the doctor, requires such referral. The ship’s physician is expected to reasonably render all medical care to crew within his areas of medical expertise.
  • Perform crew medical examinations as directed by the MCA. Maintain in the MC files a report of the complete examination of each crewmember.
  • Examine any crewmember whose department head deems an examination is necessary for any reason.
  • Establish and maintain a friendly, hospitable and professional rapport with all patients (passengers and crew).
  • Ensure the presence of a female medical staff member when it is medically necessary to conduct any type of examination of female sexual organs, genitalia, anus and/or breast of a passenger or crew.
  • Provide limited dental service (within level of expertise) before shore-side referral can be made.
  • Provide first-aid instruction for crew as directed by the MCA.
  • Address crew regarding general health concerns, venereal diseases, personal hygiene and related matters.
  • Advise the Master immediately of a death on board, complete all necessary documentation and cooperate fully with the appropriate port authorities.
  • Understand his responsibilities in the safety organization according to the emergency plans and drills.
  • Attend all required training and familiarize self with all shipboard regulations that affect medical personnel, the MC and the ship in general.
  • Participate in all lifeboat drills and emergency drills unless excused by the MCA.
  • Familiarize self with ports, agents and local hospitals to ensure readiness in the event of an emergency.
  • Cooperate with the MHA and the safety or security officer to document the sequence of events in anticipation of future litigation remembering to limit reports to only "facts" when treating passengers or crew involved in accidents.
  • Obtain the passenger's signature on a ‘Letter of Indemnity’ if the passenger is advised by the ship’s doctor to leave the ship for medical reasons and refuses to do so or if the passenger insists on seeking medical treatment ashore in a foreign port against the recommendation of the ship’s physician. If a passenger refuses to sign such a letter of indemnity, it is essential to document this in the patient's records.
  • Recommend that the Master deny passage to a passenger whose medical condition may be hazardous to the passenger or others once the ship is at sea. The company’s risk management may be contacted to assist with such cases.
  • Provide a written request from passengers or crew requiring meals to be delivered to their cabin or to the MC.
  • Carry a walkie-talkie, beeper, or deck phone at all times when on board.

 

 APPENDIX 3 - A modified Job Description for Ship’s Nurses

 

Reports to: Doctor

Basic Function: To assist the doctor with all tasks necessary for the operation of the MC in addition to professional nurse responsibilities.

Required documents to be presented at sign-on: Photocopies of diploma and license as registered nurse; current certificate for advanced cardiac life support training; signed work contract, - as well as original passport with appropriate work visas valid for 6 months after contract end and a company-specific medical pre-employment examination valid beyond contract expiration.

 

Qualifications:

·           RN license, current and in good standing.

·           Experience in Emergency Room, Intensive Care Unit/Cardiac Critical Care Unit,            or Medical/Surgical or any Trauma Unit or anesthesia education.

·           Advanced Cardiac Life Support Certification or international equivalency.

·           Current in cardiopulmonary resuscitation training.

 

Responsibilities:

  • Become fully versed with the policies and procedures of the ship as well as the particular requirements of the doctor under whom the nurse will serve.
  • Serve scheduled time on the "on call" roster.
  • Keep MC open and be present during opening hours.
  • Be available by beeper or deck phone always when aboard.
  • Assist the doctor during passenger and crew consultations both during and outside opening hours, as well as accompany him on all cabin calls.
  • Prepare all patients for their doctor consultation by 1. ensuring that they have properly filled out necessary forms regarding personal data, allergies, past medical history and current medication; and 2. recording the patients’ vital signs (temperature, pulse rate, respiration rate, oxygen saturation, blood pressure).
  • Monitor and nurse patients admitted to the MC and request assistance from the nurse off duty if necessary.
  • Ensure confidentiality of medical information.
  • Oversee the operation, good order and cleanliness of the medical spaces.
  • Ensure that all ordering procedures are strictly followed, including ordering within established minimum and maximum parameters.
  • Maintain a medical log for all crew consultations (crew log).
  • Maintain a medical log of all passenger consultations (passenger log).
  • Keep a separate log of cases of gastroenteritis among crew and passengers. Ensure that the doctor reports the number of cases among crew and passengers to Centers for Disease Control and Prevention 24 hours prior to entering a US port (and to health authorities of other ports when required).
  • Check all new crew members for valid pre-employment medical certificate, including alcohol and drug testing.
  • Schedule and arrange passenger and crew appointments for specialist referrals viaPort Agent.
  • Arrange for crew medical sign-off according to current guidelines.
  • Actively obtain the written report from the specialist ashore from the patient (passenger and crew) returning to the ship after referral or from the port agent and present them to the doctor for his information. Inform the doctor promptly if expected referral results are missing, so that he can take prompt and proper action.
  • File the reports from specialists ashore in the crew member’s file after the doctor has viewed (and acted upon) them.
  • Prepare for Doctor’s approval and distribute a daily illness report for passenger and crew to the ship’s management. Note that no diagnosis should be listed.
  • Deliver to crew members leaving the ship on vacation their medical certificates, while making certain that a copy remain on file in the MC.
  • Maintain proper inventory level of pharmaceutical and medical supplies.
  • Prepare requisitions as needed for doctor’s approval.
  • Maintain an accurate ‘Controlled substance (narcotics) log’. Any use of drugs on the ‘Controlled substance list’ must be recorded in the log with the user’s name and number, and signed by the nurse and the doctor.
  • Prepare list and participate in destruction of expired medication according to current guidelines.
  • Inspect all emergency equipment and supplies weekly throughout the vessel and maintain a log of those inspections:
  • Plan and schedule necessary service on various equipment (X-ray, cardiac, pulmonary, etc.) according to the manufacturers’ recommendations, while taking into consideration the ship’s itinerary.
  • Keep the procedure manuals of all technical medical equipment updated.
  • Call in the doctor and verbally report to the investigating (security or security) officer immediately any injuries regarding passengers or crew.
  • Test the water samples delivered to the MC for this purpose, maintain a water testing log and report positive findings immediately according to the company’s guidelines.
  • Prepare the End-of-Voyage Report from the MC from each cruise for the doctor’s review and signature, with separate details for passengers and crew, such as number of patients, consultations, reported injuries, reported cases of gastroenteritis, patients admitted to the MC, days of ward observation, referrals to specialists ashore, deaths, crew on sick list,   days off duty, and various financial statements.
  • Keep proper files on all incoming and outgoing written material concerning patient and MC matters.
  • Participate in and monitor the progress of the orientation of new nurses and medical secretaries (when indicated).
  • Provide first-aid instruction for crew as directed by the doctor or the MCA.
  • Participate in all lifeboat and emergency drills unless excused by the MCA.
    • Follow the nurse's daily work schedule as determined by the doctor. The duties may include the following:
  •  
    • See patients (passengers and crew).
    • Conduct water tests throughout the ship on a rotational basis.
    • Order medication, supplies and stationery.
    • Check and clean equipment.
    • Prepare daily, weekly and monthly logs, reports and forms.
    • Submit necessary completed forms to the company and to authorities ashore.
    • Triage/Evaluate patients to help the doctor to prioritize emergencies during crowded office hours.

 

APPENDIX 4 – A modified Job Description for Ship’s Medical Secretaries.

 

Reports to: Doctor

Basic Function: Assists doctors and nurses with administrative and clerical work.

Qualifications:

  • Four year college education with an emphasis on medical records or businessadministration.
  • Solid accounting and computer skills (MS Office Programs).
  • Ability to organize and administrate a busy office environment.
  • Ability to speak and read English fluently.
  • Cooperative with flexible personality.
  • Marine background is a plus, but not a requirement.

 

Responsibilities include but is not limited to the following:

 

  • Compile and record medical charts, reports, and correspondence.
  • Answer telephone, schedule appointments, and greet and direct patients and visitors.
  • Instruct new patients in completion of medical history and information forms.
  • Prepare patient bills.
  • Assist medical staff with their administrative duties.
  • Prepare forms necessary to land goods.
  • Assist in the preparation of MC budgets.
  • Assist in the monitoring of monthly financial results.
  • Train and assist medical staff in computer usage.
  • Maintain office filing systems.
  • Assist in the preparation of memos, correspondence, E-mail, reports, etc.
  • Maintain overall office organization.
  • Know and follow all company policies.
  • Participate in all emergency drills.
  • Additional duties as requested by the doctor.