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Guide 4 Body - World Health Organization

1. manual change over introducing a significant delay in restoring power from tens of minutes to several hours automatic change over with interruption of power introducing a delay of about 10 minutes automatic change over without an interruption in power using a UPS There are various types that can switch over immediately or within fractions of a second see Annex 2 5 5 2 Electricity Many countries have a voltage supply system based on 230V at a frequency of 50Hz However countries in the Americas use a different standard of 110V at 60Hz You may live in the first type of country and buy or receive equipment designed for the American standard Then between the mains supply and each piece of equipment like this you will have to install a step down transformer to reduce your 230V to 110V you may have to install an electronic inverter stabilizer or online UPS to increase your 50Hz to 60Hz depending on the advice in the equipment documentation 5 5 3 Laboratory Hazards Safety in the laboratory is essential because staff are exposed to biological chemical and physical agents with the risk of infection poisoning and injury Many of these issues relate to the equipment used both because it is in contact with infectious organisms and also because it can be a danger in itself Infection Risks Infections can be spread more easily in laboratories because of the large amount of organisms present and because infectious m
2. On site disposal Health facilities at remote places out of reach of any municipal waste management structure have to dispose of their own waste Transport to centralized waste handling facilities Normal dumps are sufficient for general waste of type A and the ash from incinerators To avoid any danger of infecting the neighbouring population these landfill sites should be fenced and locked Organic solid waste such as vegetable matter can be composted on site Untreated infectious waste type B and pathological waste type C require specially designed waste pits which guarantee that nobody is able to come into contact with the waste Toxic waste type D should never be disposed of on site but transported to authorized collectors Soakpits and drainfields are used for wastewater after treatment Various open vehicles can be used for general waste as long as they are covered with a net plastic foil tarpaulin etc to prevent the loss of waste during transportation Examples include animal carts tractor and trailer conventional truck Infectious chemical or radioactive waste should only be transported in locked vans or lorries 87 5 4 2 Managing different types of waste BOX 31 Strategies for Disposing of Sharps Strategy Countries should i Change behaviour by encouraging patients and healthcare workers to e Reduce overuse of adopt safe practices and avoid unnecessary injections injection
3. Most methods are dependent on a certain exposure time to be effective Bad practice will make the methods ineffective such as adding an additional contaminated object to a solution that is already treating items Use of chemicals can pose a significant danger to operators and the environment 63 64 5 3 1 Decontamination Thus it is advisable to make use of expert advice to discover the best methods that you can afford to implement for different purposes see Annex 2 The common use of various decontamination methods for different purposes and for different types of equipment are shown in Box 19 BOX 19 Use of Different Decontamination Procedures Recommended process Suitable for supplies and items Cleaning Using water soap or detergent in contact with intact skin not in contact with the patient of low infection risk to be disinfected or sterilized Bed frames mattresses with impermeable covers trolley tops before use work surfaces Disinfection By boiling or chemical disinfection Note there are a wide variety of chemical disinfection methods see Box 22 Sterilization Using autoclaves to provide steam under pressure this is the preferred and most common method Note in contact with intact skin or intact mucous membrane contaminated with readily transmittable organisms of medium infection risk in contact with broken skin or broken mucous membrane that penetrate
4. Send staff to other locations which have already developed the skills required Other facilities workshops or teams may already have developed skills that you need Here your staff can either attend specific training courses or have a period of secondment in order to obtain skills through on the job training work experience or work exchange visits Link the provision of training to the procurement process When equipment is purchased from a company you can ask them to provide training at the time of commissioning see Guide 3 on procurement and commissioning Who covers the cost of the training and where it will take place are negotiated as part of the procurement contract and may be dependent on the type and total cost of the equipment Run in house on the job training sessions You can make use of local national or regional experts who are maintenance and or clinical staff It may be necessary to send some staff for training abroad so that they can become the local trainers experts Make use of regular clinical professional meetings Make use of academic courses at various levels These can be used as a forum to introduce staff to particular equipment concerns They can be run at facility district central or international levels These are useful for gaining additional specialist skills They will be available nationally regionally and overseas Approach local colleges to develop run and accre
5. Sometimes donors have an ongoing relationship with the fund and provide the equivalent in foreign currency for the local currency paid into it Country Experience Planners often fail to realise that equipment operating costs have a much greater financial impact than the initial procurement cost and can account for anything from 5 to 100 of the procurement cost per year For example health staff in Germany discovered that an infusion pump which cost US 24 000 to run over its 10 year lifetime mainly due to the cost of the continuous supply of infusion sets required However many health service providers have not calculated and budgeted for the real operating requirements of their equipment 116 6 1 General discussion on accessories and consumables Procurement Issues Different brands of accessories and consumables are not necessarily interchangeable and cannot always be used with all makes and models of equipment For example different makes and models of equipment will use different X ray film cassettes different pipe connectors different lead connectors they can be the identical shape but have different wiring configurations different threads on gas connectors different widths of chart recorder paper different test strips for blood glucose monitors different printer cartridges different photocopier toner packs Therefore when ordering equipment see Guide 3 on procurement and comm
6. When necessary clean the refrigerator inside and out with a damp cloth Use a mild detergent only clean the door gasket and powder it with some talcum If you have a kerosene refrigerator turn off the burner and allow it to cool then clean the burner chamber with a soft brush and relight the burner If you have a gas and electric operated absorption refrigerator clean the flue if the flame has been smoking follow the correct procedure for checking the gas line connections for leaks If you have an electric compressor refrigerator turn off and unplug it clean the compressor with a soft brush check the mains lead and plug for damage and loose connections then plug back in and switch on check that the warning notice saying Do not switch off is in place next to the socket outlet and that tape is placed over the plug and switch to ensure it is left permanently on Annually Ifyou have a gas and electric operated absorption refrigerator clean the gas burner and gas jet clean the flue and baffle 7 2 User planned preventive maintenance PPM There may currently be very little user PPM undertaken in your health facility Thus it will be necessary to find ways of encouraging staff to carry out PPM and to improve any existing attempts You can significantly reduce equipment related problems by implementing a user PPM system Figure 15 provides some strategies for doing this Figure 15 Strategies for Mak
7. aAoge sojdweLx UJ porod own wy Ul sypuow Jo Joquuinu porod own e ur posn ponssi sonnuenb pezo OWN 1NO YJOM PUB Sp1099I INOA 38 YOO puewop UI SUONEILA Jeuosvas Jo JUNOD IJL 01 SYUOU Jo ponad e 1940 poiefNgyeO ST SYL yluow yora p sn p nss w971 ue Jo Aiuenb oseiaaer DWV uonduwnsuon AJYJUOWN 9 LIIAV SYIUOU 9 SI 9J330q 10 7 2942 q yuow si 19ded Joy yr oy e ouunsse aaoqe sojdwexo UJ syqUOUW UT sty ssordx7y 11 SUIAID9N0I pue JOpIO Ue SuTOR d UsaMI0q OWN IYI INO JOM PUL sp1099I INOA 18 YOO WO 07 WYU Wor AIBA IM pure poajoaul saoinos orddns pue aodsuesy souvIsIp Y UO puddap IAM sty oW AIDATTOp L1 9w peon ZI OGL Sny Avak e aou0 porJopio ore s9y110q uonons q OGL Sny ousenb ev s0u0 poyopio si Jaded 19p109931 e sounsse oyduexd 104 sojdurexy sy2UOUW UT sty ssordxy yluoW L 90U0 JO Taqzenb g a0u0 IBI 90U0 o duwexa 10 Topo ue IDLjd ued noA UdIJO MOY 1NO YIOM pue SUOTIL NSII spI0IOI INOA 18 YOO uone WY poou nod UYM pur se wn Aue ie sarddns 13p10 ued noA s1910 UJ g Npoyos Je NsoI B 03 SUIPIOIOR SIOPIO sorjd asnu nod suoneziuegIo SWOS UT a dioulig sennuend pue sew Kuuapioay 9 e NdjeD 0 MOH LS XO Surapso Jo Aouonbayy Inok s21 yorym ponad Ayddns OGL SP10 umg SUIT uoruyoq W3 Aj ddng 133 6 3 Calculating usage rates and reorder levels yoois UT
8. gt gt UM planned preventive maintenance PPM for users Section 7 2 Maintenance staff will also need to obtain many of these skills In addition there will need to be training for maintainers in PPM and repair these requirements are discussed in Guide 5 on maintenance management Remember that training should not be an activity that only happens once Training is required at various times throughout a member of staff s career Induction training when staff are new in post move to a new department or facility or to a new location with different responsibilities Training at the commissioning of equipment when new equipment first arrives Refresher training to update and renew skills throughout the working life of staff 41 42 3 5 Developing staff skills The provision of such training must be addressed seriously by the health service provider There are a number of options available for developing skills in service and each health service provider has to pursue a combination of strategies for sourcing the training required Whatever options prove to be the most feasible a skills development programme is vital As explained in Section 2 2 the training needs of staff at every level should be addressed by the overall Equipment Training Plan which is an ongoing rolling programme of in service training We suggest that the HTM Working Group or possibly a smaller training sub gr
9. Examples use reusable articles whenever possible as long as they have not been contaminated by hazardous chemicals radioactive substances or infectious organisms use products with minimal packaging give preference to products which are made of environmentally friendly materials use less harmful chemicals if these are available Segregating waste at source offers the opportunity to separate hazardous waste from non hazardous waste to recover material for reuse or recycling to ensure the correct handling for each type of waste see Box 30 Utilization Waste can be a source of secondary raw materials in other words items that can be reused or recycled If items are cleaned and uniformly separated they are easier to use again Waste should be sorted at source by those who know the dangers such as doctors and nurses Reuse Some medical items can be reused only if the necessary precautions regarding disinfection cleanliness sterilization and safety are taken If these hygiene requirements are followed items such as infusion bottles and some sharps can be reused Bandages can be reused only if they have been washed at over o 90 C Infusion sets catheters etc should not be reused Recycling If articles are broken dirty or contaminated so that reuse is no longer feasible it is still possible to use some waste as raw material for processing and manufacturing
10. How to Manage Series for Healthcare Technology Guide 4 How to Operate Your Healthcare Technology Effectively and Safely by Caroline Temple Bird Healthcare Technology Management Consultant Ziken International Consultants Ltd Lewes UK Manjit Kaur Development Officer ECHO International Health Services Coulsdon UK Andreas Lenel Health Economist Consultant FAKT Stuttgart Germany Willi Kawohl Financial Management Consultant FAKT Stuttgart Germany Series Editor Caroline Temple Bird Healthcare Technology Management Consultant Ziken International Consultants Ltd Lewes UK Contents CONTENTS Section Foreword Preface Acknowledgements Abbreviations List of Boxes and Figures 1 1 1 1 2 2s 2 1 2 2 3 31 3 2 Bal 3 4 3 5 4 4 1 4 2 4 3 5 5 1 5 2 5 3 5 4 Introduction Introduction to the Series of Guides Introduction to this Specific Guide Framework Requirements Framework Requirements for Quality Health Services Background Conditions Specific to this Guide How to Ensure Equipment is Utilized Effectively Accountability General Good Behaviour Towards Equipment Efficient Use of Equipment Access to Information and Reference Materials Developing Staff Skills How to Ensure Correct Operation How to Operate Equipment The Correct Application Care and Cleaning How to Ensure Safe Operation General Discussion on Safety Safety During Equipment Oper
11. The goals and plans will also enable staff and managers to monitor their own performance and progress with regard to the operation and safety of equipment as well as their wider range of clinical activities 8 1 Setting goals annually for equipment operation and safety Every department or team can benefit from an Annual Action Plan which contains clear specific goals relating to its key activities An action planning process should take place once a year as standard practice This is an opportunity for the members of the team to agree the range of activities initiatives and changes they want to implement because they believe the activities will improve their working environment their performance the service they provide There are boundaries and limitations to this planning process The need for major investments in equipment should be discussed outside the annual action planning process through activities such as the Equipment Development Planning exercise see Guide 2 on planning and budgeting Similarly ongoing shortages of staff or money are usually excluded from the annual action planning process and should be addressed instead by higher authorities who can influence such issues Instead we suggest that annual action planning should focus on improvements and changes that staff can undertake themselves and that can be achieved with existing staff equipment facilities and other resources Staff involved in
12. The number and type of accessories and consumables that you decide to own and stock depends on the type of work you perform and the way in which you work There are several things to consider and Box 50 provides the basic calculations required to work out how much you should own Remember these calculations will have to be done for each type of accessory and consumable and for each type of equipment that you operate You will also then need to multiply these quantities by the unit price for each accessory or consumable in order to find out the overall cost of your needs and whether you can afford them in your budget also see Guide 5 on maintenance management for similar calculations for PPM spare parts requirements BOX 50 Steps for Calculating Annual Requirements of Accessories and Consumables Step 1 Consider the Type of Accessory Consider The different uses you will make of the equipment and therefore the different types of accessories you may need The different applications for your equipment and therefore the different varieties of each types of accessory you may need Example Do you need high speed as well as low speed dental drill handpieces Do you need bipolar coagulation forceps as well as monopolar hook electrodes for your diathermy machine Do you need 40x microscope objectives as well as 100x oil immersion objectives Do you need pulse oximeter probes for use on the ear the finger or the
13. Water Energy Transport GTZ Eschborn Germany This book aims to raise awareness and provide advice for healthcare waste management in order to improve the overall environmental conditions at health facilities Part one of this practical guide provides advice on healthcare waste generation and related hygiene risks waste management and factors influencing its effectiveness at health facilities in developing countries Part two presents a series of detailed worksheets with illustrations to provide the reader with practical solutions suitable for immediate implementation Available from GTZ GATE Safe management of wastes from health care activities Pruss A Giroult E and P Rushbrook 1999 ISBN 9241545259 A comprehensive and practical guide covering all aspects of the management of health care waste The book defines waste categories and characteristics describes the planning needed collection segregation storage transport and disposal of waste There is also chapter on training and a section on simple and safe waste management techniques for emergencies and small rural facilities It is relevant to hospitals in developing countries and health centres Available from WHO Electricity supplies and safety A guide to power conditioning and power back up Huys J 1996 FAKT Basler Mission and HEART Consultancy This document is an introduction to guide you through the terminology and information regarding power conditioning and powe
14. necessary to create an hygienic workplace Most of this work can be done with readily available cleaning agents see Box 27 for examples Fresh water must be used for cleaning no surface can be cleaned with dirty water 5 3 3 Ensuring the workplace is clean It is a waste of money to use chemical disinfectants for all cleaning Disinfectants are not cleaning agents they do not remove dirt nor do they increase the cleaning power of cleaning agents Where a chemical disinfectant is to be used it is more effective applied to a clean surface Some germicidal or bactericidal cleaning agents have a disinfectant already added to them Box 27 shows examples where disinfectants are recommended The importance of simply using water must not be underestimated For example flushing lavatories with water is more effective for decreasing microbes and reducing smells than the use of chemical disinfectants This is true for facilities with piped water such as water closets and also for facilities attached to pits or septic tanks such as pit latrines and aqua privies where you can usefully dispose of waste water to flush the toilet pan squat hole The greatest infection hazard in lavatories is transmission by hand Thus the most important strategy is to provide some form of toilet paper as well as hand washing facilities with clean water and soap In order to clean the health facility effectively it will be necessary to address an
15. poor positioning of electrodes or the patient against metal parts of the operating table can cause burns to the patient not replacing the safety guards after maintenance leaves the operators at risk from fast moving parts poor cleaning of the cabinet promotes the growth of bacteria in the humid atmosphere which the infant will breathe in not using blindfolds on babies can lead to retinal damage allowing them to boil dry so that there is dry heating without water will damage the contents and the sterilizer and the operator can be burnt operating them when the steam release valve or safety valve is faulty means that the pressure vessel cannot release trapped steam and will explode insufficient care of the hot surfaces or naked flames will cause burns not sterilizing the machine before maintenance work is started means maintainers can possibly be infected by the body fluids not covering cuts or abrasions not wearing gloves and sucking or blowing into any part of the machine can lead to maintenance staff being infected allowing mineral lubricant to come into contact with the water being pumped will contaminate the water not wearing proper welder s goggles mask will cause retinal damage 61 5 3 Equipment related infection control 5 3 EQUIPMENT RELATED INFECTION CONTROL Internationally the term infection control has come to mean control of a wide range of practices processes and procedures in the clinical
16. 155 156 8 How to undertake action planning and monitoring of progress 8 1 The main outcome of the planning and review process is that you are able to evaluate your performance This is important for ensuring the quality of your work quality assurance which is an essential component of quality management Aims of Quality Management client satisfaction cost efficiency e compliance with laws We recommend that quality management is introduced into the health management systems of all the decentralized levels of the health service It can help to improve staff attitudes and this in turn can help staff handle the challenges connected with the many reforms and new management tasks they face such as those described in this Guide Important elements of quality management are a management team approach supervision and evaluation participative leadership individual responsibility and initiative methods for encouraging staff control measures such as performance measurements and impact analysis community participation SETTING GOALS ANNUALLY FOR EQUIPMENT OPERATION AND SAFETY Purpose It is necessary for each user department safety sub group to have goals and plans which set out their priority activities The goals and plans must be clearly defined so that they guide the work of the department sub group its staff the health facility the health service as a whole
17. Although recycling is not the task of a health facility collecting and selling recyclable material might generate some additional funds Typical articles for general reuse within or outside the health facility are glass or plastic bottles and containers cardboard or timber boxes sheets and bags made of paper or plastics plastic or rubber tubes lead batteries Typical examples of recycling that can occur Recovery of silver from the fixing baths of X ray film processing Metals and plastics separated by type Glass sorted according to colour Paper All material leaving the facility must be properly disinfected Continued opposite BOX 29 Strategies for Waste Management continued Hierarchy Disposal Waste is treated before final disposal to lower its hazardous potential 5 4 1 Waste management philosophy Strategies e Treatment of healthcare waste It is important to segregate different types of waste see Box 30 then the majority is no more harmful than solid waste and does not need to be treated Only the fraction which is hazardous will need to be treated Final disposal of healthcare waste The final disposal method depends on the type of waste thus segregation is again important There are four types of healthcare waste Examples General waste and non infectious healthcare waste can be disposed of untreated For infec
18. Landscaping 10 Turf artificial 5 Lawn sprinkler system 15 Underground utilities Parking lot open wall 20 Sewer lines 25 Parking lot gate s 3 Ver kines 25 ks Waste water treatment system 20 Parking lot striping 2 Water wells 25 Paving including roadways walks and parking Asphalt 8 Yard lighting 15 209 210 Annex 8 Typical equipment lifetimes Table 2 Buildings Buildings are structures consisting of building shell exterior walls interior framings walls floors and ceilings The asset cost would include a proportionate share of architectural consulting and interest expense for newly constructed or renovated facilities In assigning the estimated useful lives in this table the following factors were considered the type of construction the functional utility of the structure recent regulatory or environmental changes and the general volatility of the health care field Item Boiler house Garage Masonry Wood frame Guardhouse Masonry building reinforced concrete frame Masonry building steel frame Fireproofed Nonfireproofed Masonry building wood metal frame Table 3 Building Components Years 30 25 15 15 40 40 30 25 Item Metal clad building Multilevel parking structure Reinforced concrete building common design Residence Masonry Wood frame Storage building Masonry Metal garden type Wood frame Years 20 25 40 25 25 25 10 20 Building components
19. Their aim is to develop local capacity in transport and logistics management They produce a newsletter Hub and spoke and have developed the Transaid transport management handbook Tropical Health Technology THT 14 Bevills Close Doddington March Cambridgeshire PE15 OTT UK Tel 44 1354 740825 fax 44 1354 740013 email thtbooks tht ndirect co uk website www tht ndirect co uk Charity concerned with supporting and improving laboratory services in the developing world Primary focus is laboratory services information and technology Specializes in supply of laboratory equipment books bench aids slide sets and microscopes 199 200 Annex 2 Reference materials and contacts UNAIDS 20 Avenue Appia CH 1211 Geneva 27 Switzerland Tel 41 22 791 3666 fax 41 22 791 4187 email unaids unaids org website www unaids org The joint UN programme on HIV AIDS publishes an extensive range of materials including practical and technical guidelines For information about programmes and activities and materials contact country based staff UNICEF United Nations Children s Fund UNICEF House 3 UN Plaza New York 10017 USA Tel 1 212 326 7000 fax 1 212 887 7454 email jando unicef org website www unicef org It provides a wide range of resource materials journals books videos games and posters for children s programmes Your regional or field office will offer advice on all aspects of child health care and UNICEF mater
20. amp Dick test with a readymade test pack on each large autoclave once a day use heat sensitive tape to seal the drums for every load during the day keep a record of the results for referral at any time if a query is made about the sterility of a particular load If the tests cannot be performed this often start with once a week and increase the frequency when a more regular supply of ready made Bowie amp Dick tests can be guaranteed and staff are familiar with the regular recording process Continued opposite 5 3 1 Decontamination BOX 25 Strategies for Monitoring Sterility continued Frequency for small autoclaves Ideally users of small autoclaves such as dental clinics eye clinics and small health facilities will register pressure temperature and time for every cycle of each autoclave and validate it against the correct process profile puta TST strip in every load placed into each bench top autoclave If tests cannot be performed this often start with once a day on those days when you use the autoclave and increase the frequency when a more regular supply of TST strips can be guaranteed and staff are familiar with the regular recording process Validation and frequency by maintainers Maintenance staff will be responsible for obtaining correct process profiles either from the manufacturer or by checking and modifying downloaded ones or by creating their own using a kit containing
21. and this can lead to a more effective and efficient healthcare service 1 1 Introduction to this series of guides Purpose of the Series of Guides The titles in this Series are designed to contribute to improved healthcare technology management in the health sectors of developing countries although they may also be relevant to emerging economies and other types of country The Series is designed for any health sector whether it is run by government such as the Ministry of Health or Defence anon governmental organization NGO such as a charitable or not for profit agency e a faith organization such as a mission a corporation for example an employer such as a mine who may subsidize the healthcare a private company such as a health insurance company or for profit agency This Series aims to improve healthcare technology at a daily operational level as well as to provide practical resource materials for equipment users maintainers health service managers and external support agencies To manage your technology effectively you will need suitable and effective procedures in place for all activities which impact on the technology Your health service provider organization should already have developed a Policy Document setting out the principles for managing your stock of healthcare technology Annex 2 provides a number of resources available to help with this The next step is to develop wri
22. built in 15 Lockers built in 15 Cabinet biological safety 15 Mailboxes built in 20 Canopy ventilating for laundry ironer 15 Medicine preparation station 15 Central dictation system 10 Mirrors traffic and or wall mounted 10 Coat rack 20 Narcotics safe 20 Conveyor system laundry 10 Nurses counter built in 15 Cooler walk in 15 Pass through boxes 15 Curtains and drapes 5 Patients consoles 15 Emergency generator set 20 Patients wardrobes and vanities built in 15 Generator controls 12 Projection screens 10 Hood fume 15 Sink and drainboard 20 Fire protection in hoods 10 Sterilizer built in 15 ICU and CCU counters 15 Telephone enclosure 10 Illuminator Multifilm 10 Single 10 Table 5 Building Services Equipment overleaf Building services equipment refers to mechanical components or systems designed for the building s including air conditioning electrical elevators heating lighting plumbing sprinklers and ventilating The asset cost would include a proportionate share of architectural consulting and interest expense for newly constructed or renovated facilities 211 Annex 8 Typical equipment lifetimes Item Years Item Years Air condition equipment Fire protection system Centrifugal chiller 15 Fire alarm system 10 Compressor air 15 Fire pump 20 Condensate tank 10 Smoke and heat detectors 10 Condenser 15 Sprinkler system 25 Controls 10 Tank and tower 25 Cooler and dehumidifier 10 Furnace domestic 15 Cooling to
23. decisions on healthcare technology management issues part of the HTM Service Infection control Installation Inventory Laundry and kitchen equipment Life cycle cost Lifetime Maintainers Maintenance staff Manager Medical electrical safety Medical equipment Office equipment Office furniture Operative Pending Plant general PPM schedule Annex 1 Glossary Internationally this term means control of a wide range of practices processes and procedures in the clinical work of the health facility as a whole in this Guide the discussion only covers the equipment issues which contribute to infection control The process of fixing equipment into place can range from building equipment into the fabric of a room to simply plugging it into an electrical socket A systematic listing of stock or assets held An annual inventory is prepared at the end of each year following a physical inspection and count of all items owned by an organization The list gives details such as location reference number description condition cost and the date the inventory was taken Equipment required for kitchen or laundry activities such as cookers cold rooms washing machines hydro extractors roller ironers The recurrent cost required to keep equipment going throughout its life for example fuel consumables maintenance training disposal Lifespan life expectancy For equipment the likely length
24. email itpubs itpubs org uk website www itdgpublishing org uk International Atomic Energy Agency IAEA Wagramerstrasse 5 PO Box 100 A 1400 Vienna Austria Tel 43 222 2360 fax 43 222 230 184 website www iaea org Offers regionally based training courses in the field of nuclear medicine International Centre for Eye Health ICEH International Resource Centre Institute of Opthalmology University College London 11 43 Bath Street London EC1V 9EL UK website www iaea org Tel 44 20 7608 69 23 10 06 fax 44 20 7250 3207 email eyeresource ucl ac uk website www ucl ac uk ioo Advises and publishes information on all aspects of eye care including prevention of blindness Produces the Community eye health journal distributed free to developing countries an annual standard list of medicines equipment instruments and optical supplies for eye care for developing countries and teaching slides text sets and videos International Federation of Hospital Engineering IFHE Website http home enter vg ifhe main html This body enables national engineering professional organizations to join in a world wide federation It encourages and facilitates exchange of information and experience in the broad field of hospital and healthcare facility design construction engineering commissioning maintenance and estate management It arranges an International Congress every two years at different locations in conjunction with a healthca
25. fax 44 0 20 7383 6455 e mail orders bmjbookshop com website www bmjbookshop com BOC Medical Customer Service Centre Priestley Road Worsley Manchester M28 2UT UK Tel 44 800 111 333 fax 44 800 111 555 email bocmedical uk gases boc com website www boc com or bocmedical co uk Annex 2 Reference materials and contacts BOND British Overseas NGO s for Development Website www bond org uk A network of more than 260 UK based voluntary organisations working in international development and development education BOND works to promote the exchange of experience ideas and information by acting as a broker for a variety of relationships and by collating and distributing information Commonwealth Secretariat Marlborough House Pall Mall London SW1Y 5HX UK Tel 44 207 747 6500 fax 44 207 930 0827 website www thecommonwealth org publications html contactus asp This website provides access to the publications produced by the Commonwealth Secretariat DFID Department for international development Website www dfid gov uk UK government s department for international development assistance Eastwood Park Training and Conference Centre Falfield Wotton under Edge Glos GL12 8DA UK Tel 44 1454 262777 fax 44 1454 260622 email training eastwoodpark co uk website www eastwoodpark co uk This centre offers e a wide range of scheduled and tailor made short courses in healthcare engineering estates and facili
26. international information and opinion on the possible hazards of these other emission sources see Annex 2 Some reported problems are shown in Box 40 BOX 40 Reported Radiation Risks From Other Emission Sources Ultra violet sand in the eyes symptom of conjunctivitis sources Lasers eye lesions Ultrasonic cleaning threat to hearing baths and skin lesions if hands are immersed in the bath cell disruptors f respiratory infections from aerosols generated Visual display units physical strain from poor positioning VDUs risks to pregnant women may be possible but as yet are unconfirmed eye strain from poor lighting Microwave ovens burns to hands if the source does not automatically switch off when the door opens 108 5 5 5 Fire 5 5 5 Fire Box 41 describes the various issues that have to be considered when managing fire risks BOX 41 Issues to Address When Managing Fire Risks Fire hazards gt gt gt boilers incinerators cooking equipment poor electrical wiring bypassing of fuses safety trips or circuit breakers overloading of equipment systems socket outlets and extension blocks electrical machinery burning waste gas cylinders chemicals and flammable materials such as laboratory and cleaning agents X ray films and developing chemicals workshop lubricants and fuels Fire fighting the presence of adequate fire fighting equipment such
27. only use correct mattress and accessories for table avoid placing sharp objects against mattresses pads or radiographic table top always lower table top completely before cleaning always leave head and leg sections fully lowered when table is not in use DON T pull a table always push it lift a table by its top push a table over rough surfaces use a trolley or lift drop a table or individual sections when transporting it drop heavy objects onto the table especially the radiographic top spill oil ether or other chemical fluids on mattresses pads Any member of staff who sees a problem arising with the treatment of equipment should fill in an Incident Report Form for the HTM Working Group so that the problem can be addressed Section 8 2 3 3 EFFICIENT USE OF EQUIPMENT To obtain the maximum benefit from your equipment it is best to use it efficiently There are a number of issues to address if you want to be efficient How Much is Your Equipment Utilized Some ways of utilizing equipment are more economical than others Your main aim is to make the most of your investment in the equipment For example it is more efficient use of an X ray machine to do at least 50 exposures a week than to do just two Thus how much use you will make of a machine may determine whether you want to purchase one in the first place It may be better to share an X ray machine with several neighbouring facilities These are is
28. proper grounding and only use the correct plug for the socket for example never put a two pin plug into a three pin socket Section 5 5 2 do not start equipment that requires water for its operation without checking that the water supply is available use the machine only with the correct type and quantities of water oil fuel etc always handle accessories carefully as these are the most easily damaged component of equipment always use the correct consumables without wasting them always respond to alarms and check what is causing them ensure that the relevant waste pipeline is not blocked before allowing equipment to discharge its contents into the waste water sewage system or special container for hazardous material Section 5 4 if the electricity power supply is cut off switch off all electrical equipment to protect it from electrical surges which may occur when the power is restored Once power is returned ensure that vital equipment such as refrigerators is switched back on ensure that any mains powered equipment which will be required to work off batteries during a power failure defibrillator vital signs monitor ICU ventilator etc is always plugged into a live socket and left switched on so that its batteries are continuously charged when oxygen and other gases are no longer required turn off the supply so that gas is not discharged into the atmosphere and wasted Each type of equipment has specific operating i
29. such as insecticide treated net projects It can be accessed on website www malariaconsortium org Medical Research Council South Africa MRC SA PO Box 19070 7505 Tygerberg South Africa Tel 27 21 9380911 fax 27 21 9380200 email info mrc ac za website www mrc ac za The MRC SA s mission is to improve the nation s health status and quality of life through relevant and excellent health research aimed at promoting equity and development They have a WHO Collaborating Centre for Essential Technologies in Health at website www mre ac za innovation whocollaborating htm Medicine hygiene prevention publishing house mhp Verlag GmbH Wiesbaden Germany Website www mhp verlag de Produces a number of publications including the Central service Zentral sterilization bilingual journal Medicines and Healthcare Regulatory Agency MHRA Hannibal House Elephant and Castle London SE1 6TQ UK Tel 44 0207 972 8000 email devices mhra gsi gov uk website www mhra gov uk Offers guidance advice and regulations on medical device quality safety performance use and standards Ministry of Health and Social Services Namibia Dr N Forster Under Secretary Health and Social Welfare Policy Private Bag 13198 Windhoek Namibia Email nforrster mhss gov na MSc Envirohealth Products 25 Reedbuck Crescent Corporate Park PO Box 506 15 Randjesfontein Midrand 683 South Africa Tel 27 11 314 7540 fax 27 11 314 7535 email scaine mweb c
30. 0 333 722116 This is a practical training manual for all first line PHC workers It gives guidance on how to diagnose and treat the most common illnesses how to prescribe rationally and deliver good patient care with scarce resources It is based on a series of training courses developed by VSO national doctors and health workers It can be used as a self study guide and as a reference manual Available from TALC District health care Challenges for planning organization and evaluation in developing countries 2 4 edition Amonoo Larston R Ebrahim G Lovel H and J Rankeen 1996 MacMillan ISBN 0 333 57349 8 This book contains practical support and advice intended for those in the planning management and evaluation of health services at district level It covers a wide range of topics based on country experience including staff motivation teamwork developing management skills managing change managing conflicts and staff development managing finances monitoring and evaluation as well as district health needs plans organization and management Available from TALC Healthcare technology Training skills for hospital technicians and engineers FAKT 1999 FAKT Technical Library Data Sheet This paper discusses the major objectives of training both on and off the job It then provides practical guidance on how to undertake on the job training effectively by using the PESOS procedures prepare explain show observe supervise I
31. 1992 Healthlink formerly AHRTAG ISBN 0 907320 07 4 Provides practical guidelines for care and maintenance of a range of kerosene gas electric and solar refrigerators Available from Healthlink Worldwide Instrumentation for the operating room A photographic manual 5th edition Brooks Tighe S 1999 ISBN 0323003508 Colour photographic reference manual illustrating in detail a range of instruments for major surgical procedures endoscopic neurosurgery ophthalmic orthopaedic and oral maxilla and facial surgery Also includes a section describing the care and handling of instruments from cleaning to sterilization inspection and testing Available from major internet bookshops La maintenance dans les systemes de sant Maintenance for health systems 4th GTZ Workshop Dakar Senegal September 1993 Halbwachs H and R Schmitt eds 1994 GTZ This document reports the results of intensive work by 67 national and international experts brought together from health services and support agencies to strengthen equipment maintenance measures in the health sector It includes papers with country examples on the benefits of maintenance the place of maintenance in the district health system maintenance management and organization energy management photovoltaic systems networking and computers and training This document has sections written in both French and English Available from GTZ Maintenance and repair of laboratory dia
32. 1998 Tropical Health Technology ISBN 0 9507434 4 5 District laboratory practice in tropical countries part 2 Cheesbrough M 2000 Tropical Health Technology ISBN 0 9507434 5 3 Practical laboratory manual for health centres in East Africa Carter J and Olema O 1998 AMREF Practical laboratory manual providing information necessary to establish select and use laboratory tests for patient management Also includes material on implementation of safe working practices reporting and recording test results keeping an inventory of supplies and equipment ordering supplies and maintaining equipment Available from AMREF Annex 2 Reference materials and contacts Supplies and Stores Management This material covers issues in Section 6 such as supplies management and stock control It is listed alphabetically by title How to manage a health centre store Battersby A 1994 Healthlink Worldwide formerly AHRTAG Describes in detail the structure and organization of a store or dispensary methods of arranging stocks stock control and basic dispensing Available from Healthlink Worldwide Medical supplies and equipment for primary health care A practical resource for procurement and management Kaur M and S Hall 2001 ECHO International Health Services Ltd ISBN 0 9541799 0 0 Spare parts and working materials for the maintenance and repair of health care equipment Report of workshop held in L beck August 1991 Halbwac
33. 2 4 13 29 33 36 37 40 43 44 47 50 51 53 55 56 57 6l 64 65 67 68 69 72 74 77 80 81 84 Box 30 Box 31 Box 32 Box 33 Box 34 Box 35 Box 36 Box 37 Box 38 Box 39 Box 40 Box 41 Box 42 Box 43 Box 44 Box 45 Box 46 Box 47 Box 48 Box 49 Box 50 Box 51 Box 52 Box 53 Box 54 Box 55 Box 56 Box 57 Box 58 Box 59 Box 60 List of boxes and figures Strategies for handling waste Strategies for disposing of sharps Safety issues relating to incinerators Strategies for the safety of gas cylinders Common problems with electrical installations Strategies for providing good quality electrical installations and a decent earth Power conditioning strategies Laboratory infection risks and strategies to avoid them Safety strategies when using X ray machines Strategies for dealing with the hazard of radioactive sources Reported radiation risks from other emission sources Issues to address when managing fire risks The most common causes of fires Typical causes of accidents Summary of procedures in Section 5 on ensuring safe operation Advantages and disadvantages of disposables and reusables How a revolving fund works Responsibilities for recurrent materials Strategies for storing equipment related items Strategies for creating suitable store rooms Steps for calculating annual requirements of accessories and consumables How to calculate reordering times and quanti
34. 4 taking advice from the Infection Control Committee and any other relevant safety sub group of the HTMWG placing the remaining unusable parts of the equipment outside at a specially designated site within the grounds of the health facility or workshop which is a secure site that is fenced off and locked The HTM Manager ensures that the record of the written off items e is removed from the Equipment Inventory see Guide 2 e is removed from the maintenance files see Guide 5 e is used to update the Equipment Development Plan see Guide 2 The local Board of Survey auctions off only the remaining equipment items which are safe to reuse e any remaining materials for which scrap value can be obtained for example scrap metal Section 7 summary Box 58 contains a summary of the issues covered in this Section BOX 58 Summary of Procedures in Section 7 on Ensuring Continuous Operation Health Service Provider e address the practical issues involved in implementing the equipment and Health Management security strategies see Box 53 Teams introduce the security strategies to Section Heads and explain their implications Section Heads introduce the security strategies to their staff and train them in their application monitor that their staff are adhering to the equipment security procedures All Staff e make it their responsibility to guarantee the security of equipment Health Management e allocate the user departm
35. ALY 1942 NOA JUNOWP WNWIXEW 3Y PUL S9 110q XIS SI YOOIS DATISII AJOJeS INOJ 9 110q pZ 10 19p10 ue ade d noA Joos UI JOT DIB S9J10q QT Udy SNY OATE 02 syIUOW XIS IYL Ady PUL TedA L I9UO WY JOpsJO TBA L UT 9 I10q UOTIONS pZ ISN NOK q UI DALY JOAD NOA JUNOW WNWIXBLU 3Y PUB S OI INOJ SI YOIS DAIOSII AIOJES INOK S OI pZ 10 JOpso uv dovjd nod yooIs UI Io oe so 110q O SI S JOI QZ SI yoo1s S JOI Z USY SNY L sare 01 YIUOW JUO aye Ady pue IoqeNb L IOUO WAY JopsO syIUOUT XIS UT SJJO1 Jaded 19p10991 Bp SN NOJ E Arewumg ojdwexg s j20q Of p 9 XN 4 s jor loded 8 He h XN dA0qe So dwexo UT ApIe Nsa1 poyo oq 01 spoou U OS sasueyo 98I FLSN INOA se asuBY 2 sulapso 19A0 nod syuaAold outa Aue 38 DALY 00 SY I AroArfap L SUIA 1943F Asnf JOA M nos JUNOWe wnwrxeu muenDb 19p10 4901s JMOSI wnwixew 3y savy juo noA jensq LXen oso umwe s m0q pZ Z1 XZ 004 sjjor 1 ded pz X 8 O 940q s jdwe xo UJ s jdw exy poalaoal st s 1jddns jo AIoAT ap IX9U oy aun Sy 249 Y90Is arosoI Y ponad Ayddns OLL X ONV AOE SY201S UTEJUTEW 01 PdIE NITed 9q QUO UI p sn aq 01 posops0 sJopio Ud9MI0q JUNI X Isnw Y sJopso UI9MI79q SWI ay UT dn S1 yey suo Jo Auenb uonduinsuoo AjyuOUW oseIoAR posn oq IM posopso Aimuenb oy sy OO AmmueNH 1 p10 uonepmojep jdound uoruyoq woz Aj ddng p nu uos s nnueno
36. HOW TO OPERATE EQUIPMENT Operation of equipment means using the correct physical methods to get the equipment to work In order to do this successfully the user needs to know the specific operating characteristics of a machine the operational procedures that make the machine work how to use its various functions how to make it perform its customary cycles and routines o how to change the bulb paper roll batteries etc The equipment manufacturer s user manual is often the best source of this information Other sources include awide range of reference material see Annex 2 written resources from staff training sessions experienced colleagues Guidance from colleagues can be summarized as a one page poster laminated card or sheet of paper in a plastic pocket Section 3 5 which can then be mounted near or on the equipment itself Copies of reference materials should be kept in the library Section 3 4 49 50 4 1 How to operate equipment Box 12 provides some examples of general strategies when operating equipment BOX 12 General Strategies When Operating Equipment make sure you have the authority and knowledge to operate equipment before you start refer to the manufacturer s operating manual for correct advice always follow the safety procedures specific to the machine Section 5 only connect a machine to an electrical socket outlet which has been checked by the electrician for
37. The best information regarding the care and cleaning of equipment is usually contained in the manufacturer s user manual and or service manual A wide range of reference material is also available see Annex 2 In addition staff should have written resources from their training sessions and in some cases posters which provide the guidance and experience of their colleagues Section 3 5 If staff do not have personal copies of these resources they should be available in the library for reference Section 3 4 Box 15 provides some examples of general strategies when caring for and cleaning equipment In addition Section 5 3 discusses the safety implications of the various cleaning methods and materials available Source Lee P 1995 Get it Right A Guide to Maintenance Safety Precautions amp Hygiene of Medical Equipment ECHO International Health Services Ltd UK unpublished Experience in Vanuatu When a maintainer was visiting a remote health facility the nurse practitioner said that she had a small gas stove in the maternity ward that had not worked for 12 months and that she needed a new one The stove was filthy so the maintainer dismantled the burners and started to clean it The burners were full of debris including gecko eggs When she removed the eggs and finished cleaning the stove it looked new and worked perfectly If the nurses at the health centre had kept their stove clean they could easily have prevented t
38. a variety of topics that appear in several Sections of this Guide The first time they appear in this list they are described in full For each subsequent entry only the basic details are provided Healthcare Technology Management Framework Issues This material covers issues in Sections 1 and 2 such as healthcare technology management definitions policy regulations guidance and services It is listed alphabetically by title Further detailed information on this topic is provided in Guide 1 Developing healthcare technology policy Health care technology management No 1 Health care technology policy framework Kwankam Y Heimann P El Nageh M and M Belhocine 2001 WHO Regional Publications Eastern Mediterranean Series 24 ISBN 92 9021 280 2 This booklet is the first in a series of four titles It introduces the ideas of and behind health care technology management defines terms relating to and sets objectives for health care technology management policy It examines what should go in to such a policy and the national policy framework and organization Capacity building and human resources issues are considered as well as economic and financial implications Attention 1s also given to legislation safety issues cooperation nationally and between countries implementation monitoring and evaluation See Guide 1 for information on the three further titles in this Series covering regional strategies policy formulation and implementation
39. about 90 is non hazardous general waste type A and doesn t need special treatment However if it is mixed with hazardous waste then it all needs special treatment Thus it is very important to segregate different types of waste in order to reduce the cost of its treatment and disposal 85 5 4 2 Managing different types of waste 5 4 2 Managing Different Types of Waste Box 30 discusses the appropriate handling technologies required for gt gt collection and separation of waste transportation within the health facility intermediate storage on site treatment on site disposal transport to centralized waste handling and disposal facilities One particular category of infectious waste type B is sharps These are items such as scalpel blades needles syringes razor blades or even broken glass Not only are these items hazardous in themselves they can cut the handler or be the cause of stick injuries but they also may be contaminated with body fluids that can be transferred to the handler Thus both the safe handling and the safe disposal of sharps is very important Box 31 overleaf provides some strategies for their disposal and Annex 2 lists additional reference material BOX 30 Strategies for Handling Waste Issues Strategies Collection and separation Waste has to be collected wherever it is generated According to the principle of segregation at source diffe
40. abuse Should fines be deducted from the salary of staff by instalments In the case of more expensive items should penalties be incurred in the individual s terminal benefits Should persistent loss or abuse result in suspension or termination of employment Should equipment and accessory damage caused by the incorrect use of chemicals for disinfection be chargeable to the individuals responsible Should chemical damage caused by the purchase of incorrect products be charged to the Purchasing and Supplies Officer responsible Another option is to take a disciplinary approach and establish mechanisms so that damage and breakages can be charged to staff This method aims to make staff more accountable for their actions in the same way that maintainers are often charged for damage to tools see Guide 5 on maintenance management Serious negligence may lead to suspension for example for crashing an ambulance due to reckless driving and persistent offending may result in termination of employment If you choose to take such a route the system should be fair and only target those who abuse equipment intentionally Section 2 1 Each case should be assessed individually using formal disciplinary hearing procedures Finance and salary departments should base fines on realistic quotes for replacing equipment However any approach taken to enforce rules for general staff is only workable if it takes place in the right
41. accidents related to equipment which can befall staff patients and visitors These are shown in Box 43 Local health and safety at work legislation and inspectors may cover these issues and provide guidance 110 5 5 6 Accidents BOX 43 Typical Causes of Accidents Hazardous operation of equipment such as e clothing caught in moving parts of machinery equipment which by its nature is dangerous such as lathes drills circular saws welding machines operation which requires protective clothing such as eye goggles safety guards etc e lack of attention by operators such as poor driving of health vehicles Hazardous condition of facilities and equipment such as brickwork falling down on someone 9 broken windows holes in the ground which can trip people up flooding from blocked drains loose wires providing electric shocks from sockets and switches etc Hazardous practices such as ss e leaving equipment in corridors for people to fall over e undertaking maintenance in a place where people will slip on oil spills e wet or highly polished floors etc Box 44 contains a summary of the issues covered in this Section BOX 44 Summary of Procedures in Section 5 on Ensuring Safe Operation Health Service develops safety policies for all risk areas Provider e provides sufficient and appropriate resources both financial and material to tackle all safety issues HTM Working consult
42. achieve this the Stores Controller needs to know when to reorder goods and how many should be reordered A number of factors will affect these calculations for different types of items The rate of use of each item for example 20 per day six per week This will be affected by patient attendance figures the frequency of particular clinics or equipment sessions timetabled care and cleaning schedules and the likely breakdown rate life of an accessory estimated from past experience and records The lead time for each item that is the time taken for goods to arrive from the supplier or central stores once ordered e How often you can place orders the frequency of ordering The cost of each item The shelf life of the item First you will need to identify what is worth holding in stock and how much is required based on the type of work you perform Secondly it is necessary to continually restock so that you always have sufficient items to carry out the necessary work This calculation is based on rates of consumption The following sub sections discuss how to do this 127 128 6 3 Calculating usage rates and reorder levels Annual Requirements What to Have in Stock First the user departments need to get an idea of how much of each type of accessory consumable they are using a discussion on spare parts for user PPM can be found in Guide 5 on maintenance management If such goods have not been stockable items up t
43. and mobile facilities Equipment issues are covered in the section on equipping by Cooper Poole and radiology by Palmer Available from WHO Approaches to planning and design of health care facilities in developing areas Vol 4 Kleczkowski B and R Pibouleau eds 1983 WHO Offset Publication No 72 ISBN 924 170072 6 This volume addresses the issue of hospital design in terms of the building structure itself The design of a hospital is discussed in the context of geographic and demographic data utilisation costs and available resources It is a useful resource for planners architects and administrators This volume covers small health care facilities laboratory facilities transport systems local construction materials health service management training commissioning and engineering and maintenance services Medical equipment is covered in the sections on commissioning by Steele and on engineering and maintenance services by Mehta Available from WHO 179 180 Annex 2 Reference materials and contacts Design for medical buildings 4th edition Mein P and T Jorgnesen 1988 University of Nairobi Housing Research and Development Unit African Medical and Research Foundation Construction guidelines for medical buildings with special reference to appropriate designs for developing and tropical countries Relationship diagrams flow of patients linkages between different units and services Available from WHO AMREF D
44. any equipment related problems 168 Acceptance process Administrative level Central level Cleaning Commissioning Communication equipment Decentralized authorities Decommission Depreciation Decontamination Dioxins Disinfection Donor Earth Electrical safety Energy sources Equipment related supplies Equipment users Annex 1 Glossary ANNEX 1 GLOSSARY Activities undertaken when equipment arrives at an health facility at the end of which the equipment will be operational and officially belong to the facility such as receipt unpacking installing commissioning initial training entering into stores and onto records payment See decentralized authorities Highest authority of your health service provider such as Ministry of Health or Board Removal of visible dirt and reduction of the number of some infectious micro organisms A series of tests and adjustments performed to check whether and ensure that new equipment is functioning correctly and safely before being used Any equipment that is used for sending or receiving information such as telephones two way radios nurse call systems paging systems Local units of an organization which have had authority transferred to them from the central level of the organization For example district regional provincial or diocesan health authority Take out of service dismantle and make safe board The
45. are assets that are a part of the building shell or interior construction The asset cost would include a proportionate share of architectural consulting and interest expense Item Canopies Carpentry work Caulking Sealants Ceiling finishes Acoustical Gypsum Plaster Computer flooring Corner guards Cubicle tracks Designation signs Doors and frames Automatic Hollow metal Wood Drapery tracks Drilled piers Floor finishes Carpet Ceramic Concrete Hardwood Years 15 15 5 5 10 12 10 10 10 10 20 15 10 40 20 20 10 Item Floor finishes continued Quarry Sealer Terrazzo Vinyl Folding partitions Loading dock bumpers and levelers Magnetic MRI shielding Millwork Overhead doors Partitions interior Partitions toilet Railings Freestanding exterior Handrails interior Roof covering Skylights Storefront construction Wall covering Paint Wallpaper X ray protection Years 20 5 15 10 10 10 10 15 10 15 15 15 15 10 20 20 10 Annex 8 Typical equipment lifetimes Table 4 Fixed Equipment Fixed equipment includes assets that are permanently affixed to the building structure and are not subject to movement but have shorter useful lives than that of the building The asset cost would include a proportionate share of architectural consulting and interest expense Item Years Item Years Benches bins cabinets counters Laminar flow system 15 and shelving
46. are performed Thus it is important to have some method of collecting information such as the numbers of equipment not functioning consumable usage rates equipment shortages e training deficiencies It may be possible to incorporate this data gathering into any existing Health Management Information System see Guide 1 on organizing HTM This will enable evidence based planning to take place i Statistics Heads of Department Chairs of Sub Groups need to gather and compile statistics regularly These will provide information on the progress of their team and its work performance in relation to equipment They need to gather this data in order to be better managers improve the running of their departments provide information to other people and bodies who need to know how their department is functioning Thus the Head of Department Chair of Sub Group needs to analyze any incident report forms see below in order to extract information about problems with equipment procedures or staff use data from attendance records and departmental work records to compile statistics about equipment use and availability review the User Department Maintenance File to obtain feedback on progress with maintenance requests Section 7 4 produce brief informed and accurate written reports for the Health Management Team on pertinent equipment operation issues 165 8 2 Monitoring progress with equipment operation and sa
47. as a reserve stock for times when disposables are not available To help you to decide what type is most suitable for your health facility you should consider the following issues The national policy The resources available to you for sterilization Whether a regular supply of stocks of these items is available It is usually easier and more practical to follow any existing national or local policy regarding the use of disposables or reusables The policy makers should have taken into account the cost implication of their recommendation and should make satisfactory recurrent budget provision for the regular supply of these essential inputs However health facilities in remote areas are advised to have a stock of reusable supplies that will help them when disposable supplies are received late or are not available Finance Your aim is for equipment to remain operational and to be available to support your clinical workload Thus it is necessary for sufficient budgets to be calculated and allocated for the purchase of the required accessories and consumables This cost will be relevant over the whole lifetime of the equipment Thus continually finding the money for these items will be a challenge over the life of the equipment Guide 2 on planning and budgeting provides guidance and procedures on budgeting for the recurrent costs of equipment 115 6 1 General discussion on accessories and consumables Many ac
48. as sand blankets water extinguishers hoses sprinklers its regular maintenance training in its use Procedures in case of fire the suitability of the buildings in terms of fire exits the use of alarms the use of fire drills training of staff in the evacuation of patients and visitors Safe storage of flammable materials store away from heat sources and not in direct sunlight store in well ventilated areas ensure materials are clearly labelled display signs prohibiting smoking and the use of naked flames Electrical installation regularly check the electrical installation for frayed or damaged rat eaten cables water debris dirt etc prohibit the use of coiled cables extension leads adaptor blocks and adaptor plugs Experience in Southern Africa The boiler that supplied the steam for all heating hot water laundry kitchen and autoclaving needs for a hospital broke down The hospital accepted the cheapest quote from a local man who said he was an electrical contractor He got the boiler working again but only by bypassing all the safety features This caused a tremendous fire and both the boiler and the boiler house burnt down 109 5 5 5 Fire Advice on all these issues should be available from experts such as building inspectors government occupational safety officers municipal regulatory bodies fire fighting bodies etc Section 2 2 and reference materials see Annex 2 Box 42 highligh
49. ash collect it in a covered metal container Handle unburnt residues from the incinerator with care as they may still be infectious Safeguarding the environment Consider the prevailing wind direction when siting the incinerator Attempt to separate PVC from waste where possible to avoid production of toxic gases Check whether you can meet local environmental regulations on pollution control Dispose of ash and unburnt residues in landfill sites DON T load with too much waste at one time load with waste that is too wet burn polyvinyl chloride PVC as it produces toxic gases including dioxins add liquid fuel directly to the fire when using the incinerator add whole bottles filled with liquid fuel as they can explode open waste bags or handle the waste as it is hazardous open observation or loading doors to look inside during operation as you can sustain eye injuries let smoke pollute the health facility or neighbouring areas assume the emissions are not hazardous depending on the waste burnt they may contain dioxins metals furans 5 5 5 5 1 5 5 Control of other hazards CONTROL OF OTHER HAZARDS Besides each type of equipment having its own operational safety issues and procedures Section 5 2 equipment can present hazards in general This Section discusses the hazards of gases Section 5 5 1 electricity Section 5 5 2 laboratories Section 5 5 3 radiation S
50. background conditions specific to this Guide Section 3 Managing effective utilization of equipment Section 4 Managing correct operation Section 5 Managing safe operation Section 6 Managing the materials used during your work Section 7 Managing continuous operation Section 8 Monitoring the progress made on all these fronts 11 1 2 Introduction to this specific guide Who Does What in Operation and Safety We suggest that the HTM Working Group has a large role to play in advising the Health Management Team on all equipment matters Depending on the size of your facility or what level of the health service you are operating at your HTM Working Group may like to set up a number of smaller sub groups In this Guide we suggest various safety sub groups which should have appropriate members that can develop policies and practices for various safety issues such as radiation fire and accidents Infection Control Committees are also required at district level and at facility level depending on its size Ideally these comprise e amicro biologist or a medical doctor as chair an Infection Control Officer e members from all relevant departments such as laundry kitchen pharmacy cleaning services equipment maintenance central sterile supply department CSSD theatre wards and teaching departments A stock sub group
51. chart for the HTM Service will vary depending on the size of your country and your health service provider organization and whether you are just starting out However Figure 5 provides an example of the relationship between HTM Teams and HTM Working Groups Section 1 1 that we envisage How to Manage Change The regulatory requirements presented in this Section may appear somewhat idealistic compared to the reality in many health systems However the aim is not to highlight the deficiencies of existing systems but to provide a blueprint for a functioning healthcare technology management system Hopefully this will enable you to get the right framework conditions in place and thus improve the effectiveness and the safety of your health services We are not recommending that your health service provider throws out all its current HTM strategies and starts again e makes sudden and sweeping changes that are likely to fail if they are over ambitious Rather it is better to take a step by step approach introducing changes gradually with a careful review process Io implement an HTM system with all the complexities described in this Series of Guides will take several years and to try to achieve everything at once could be disastrous However for healthcare technology management to improve it is important to act 2 1 Framework requirements for quality health services ice uoddns eOlUYoo s eey tional Chart fo
52. community Rozendaal J 1997 WHO ISBN 92 4 1544945 Provides practical information on all major disease vectors and pests and on effective control methods suitable for rural and urban environments Intended for health workers and auxiliary staff as well as health planners and aid organizations Available from WHO Waste management De Montfort medical waste incinerators Information on the De Montfort University incinerators designed by Prof DJ Picken can be obtained from a website It contains copies of drawings and instructions for the building operation and maintenance of various incinerator models The range of DMU incinerators has been developed for use by rural PHC facilities and designed to be constructed on site using local materials There may be a small charge to cover the cost of printing and postage of the plans Available from website www mw incinerator info en 101_welcome html How are we managing our health care wastes Coad A and J Christen 1999 SKAT This document looks at management of health care waste in low income and middle income countries using case studies from 6 cities in Africa Asia and the Middle East Consists of a series of questions with comments to guide health care waste management Available from ITDG Publishing Management of solid and liquid waste at small healthcare facilities in developing countries Jantsch F and H Vest 1999 GATE Information Service Division 44 Environmental Management
53. continuous supply of these consumables The alternative is to undertake registration and Bowie amp Dick tests as frequently as possible over specified periods of time daily weekly or monthly on the understanding that if the machine fails to pass the tests it means that you could not be satisfied with the sterility of any loads since the last test in other words for the last day week or month Therefore the longer the gap between tests the greater your uncertainty about sterility will be Box 25 provides some strategies for monitoring sterility BOX 25 Strategies for Monitoring Sterility Use of registration and e Ideally your health facility will use Bowie amp Dick tests a recorder to register pressure temperature and time on a special recording pad ready made Bowie amp Dick test packs for large autoclaves small TST strips for bench top autoclaves heat sensitive tape for sealing drums If the recorder and ready made tests are not available CSSD staff will manually record pressure temperature and time make up home made Bowie amp Dick tests The Health Management Team must ensure adequate supplies of the necessary materials are available and that staff are trained to understand their roles Frequency for large Ideally CSSD staff will autoclaves register pressure temperature and time for every cycle of each autoclave and validate it against the correct process profile undertake a Bowie
54. contribute to improved efficiency within the health sector This will result in improved and increased health outcomes and a more sustainable health service This is the goal of healthcare technology management the subject of this Series of Guides 1 1 Introduction to this series of guides Figure 1 The Place of Healthcare Technology Management in the Health System Health Sector Organization and Management Human Resources Healthy Facilities 5 Population Healthcare Technology AYY Health Consumable Supplies oe E rovision What Do we Mean by Healthcare Technology The World Health Organization WHO uses the broader term health technology which it defines as including devices drugs medical and surgical procedures and the knowledge associated with these used in the prevention diagnosis and treatment of disease as well as in rehabilitation and the organizational and supportive systems within which care is provided Source Kwankam Y et al 2001 Health care technology policy framework WHO Regional Publications Eastern Mediterranean Series 24 Health care technology management No 1 However the phrase healthcare technology used in this Series of Guides only refers to the physical pieces of hardware in the WHO definition that need to be maintained Drugs and pharmaceuticals are usually covered by separate policy initiatives frameworks and colleague
55. correctly so as not to overload or unbalance the system provide separate circuits for lights normal socket outlets and special loads such as stoves water heaters air conditioners etc use the correct colour codes for the cables used for earth live and neutral parts of the circuits so that they can be easily identified label all the circuits in the distribution board for easy fault finding later on use proper cable terminations at all times for safety Correct socket outlets There are many different styles of electrical socket outlets and plugs in use throughout the world They all use different pin configurations and different colour coding of wires and cables for the earth the live and the neutral conductor It is essential that the electrician or electrical contractor ensures that e enough socket outlets are available and located conveniently the use of long leads overloaded adaptors or makeshift extension blocks is dangerous the earth may become disconnected and the risk of electrocution increases sockets are at least 2 metres from any source of water a basin for example and sockets should never be placed in a bathroom or shower room an earth wire is provided in the socket outlet and the plug if you have a three wire and three plug system some equipment has only two wires in the power cable such as the double insulated items and do not need an earth connection the correct plug is fitted to your equipmen
56. decide what healthcare technology is needed and prioritize the actions required to develop its stock of equipment It is unhelpful if lots of individual health facilities pull in different directions with no coordinated plan for the health service as a whole The central authority of each health service provider should be responsible for considering what sort of healthcare should be offered at each level of their health service Preferably they will collaborate with the Ministry of Health or follow their guidance if regulated to do so If there is no health service plan there is no framework on which to base decisions Guide 2 provides further information on developing a vision and planning your healthcare technology stock Standardization of Healthcare Technology Standardization also known as rationalization normalization and harmonization the process of reducing the range of makes and models of equipment available in your stock by purchasing particular named makes and models Introducing an element of standardization for healthcare technology will help you to limit the wide variety of makes and models of equipment found in your stock By concentrating on a smaller range for each equipment type your technical procedural and training skills will increase and your costs and logistical requirements will decrease see Guide 1 It is easier to achieve standardization if equipment
57. dependent on how Sa consumables You can order various quantities such as busy you areand yout ripe of use How Much e boxes of 10 rolls of paper or cartons of 100 rolls you Duy a a pack size tor e 100g tubes of ultrasound gel 1 litre bottles these products p or 50 litre containers Continued opposite 130 6 3 Calculating usage rates and reorder levels BOX 50 Steps for Calculating Annual Requirements of Accessories and Consumables continued Step 4 Calculate Quantities Consider a Accessories with a long life Simply buy the basic set required for each machine b and c Accessories with a short life as well as disposable accessories and consumables Buy multiples of the items in your basic set by taking into account the life of the items or their consumption rate Use the following calculations Examples For example i A suction pump jar accessory A may have a life of six months L4 6 months ii A reusable pulse oximeter finger probe accessory B may last four months Lg 4 months ili A box of 50 diathermy disposable patient plates disposable accessory C may last one week Le 0 25 month iv A 100g tube of electrode contact gel consumable D may last two weeks Lp 0 5 month i Quantities according to lifetime Find out the life of the part in months or how quickly it is used up life of item A La This type of information can be obtaine
58. e 1 2 Introduction to this specific guide Depending on the size of your organization and how many levels of decentralized authority exist you may have just one Central Board of Survey or you may have Regional District Boards of Survey you may even have Boards of Survey at facility level Facility level Boards of Survey could be comprised of the following types of staff Purchasing and Supplies Officer HTM Manager e Maintenance staff Head of Support Services Other relevant co opted members There may seem to be a large number of sub groups but the aim is to spread the work around different members of staff so that the HTM Working Group Section 1 1 doesn t have to do everything If you have a small health facility with few staff the groups that form to oversee operation and safety can be much smaller Try to use relevant staff with experience and those who show an interest in the task Since equipment that is well looked after lasts a long time it is important for operation and safety to be seen as a collective responsibility in the health service Thus many people have a role to play as shown in Box 3 BOX 3 The Collective Responsibility for Operation and Safety Equipment Users are key to successful operation and safety are accountable for the equipment they use Section 3 1 follow good practice and behaviour around equipment Section 3 2 ensure they have the necessary skills to apply the equ
59. electrical and mechanical trustworthiness is discussed in Section 7 This Section describes some commonly accepted ideas and standards for the safety issues listed above and the procedures staff should follow Your health service provider needs to develop policies for these areas of safety Once that has been done they will need to expand this field further to cover any other hazards and safety issues discovered National and international bodies can offer guidance and regulations on these safety issues see Section 2 2 and Annex 2 59 60 5 1 General discussion on safety Tip 5 2 We suggest that the central HTM Working Group or its smaller safety sub groups Section 1 2 should be responsible for considering the issues policies and procedures required for the different safety areas The district and facility HTM Working Groups or safety sub groups must follow this guidance in order to implement good safety practices Staff will need written guidelines and training to assist them in the safe use and maintenance of equipment The development of such guidelines and their use for staff training is described in Section 3 5 of this Guide We suggest that each health facility has some formal method of reporting problems accidents and adverse incidents in all these safety areas Some type of Accident Record Book or Incident Report Form can be used so that staff can report whenever any type of incident occurs All adv
60. electrical and mechanical trustworthiness Figure 18 Strategies for Safety Testing ee ee Health Management Teams should buy safety testers as and Obtain adequate safety test when funds are available so that the HTM Team can carry out instruments regular mechanical electrical and medical electrical safety testing as part of their PPM activities Monitor th f Staff should notify the HTM Team if they notice anything wrong onitor the state of equipment with the physical condition or trustworthiness of equipment The HTM Manager and In Service Training Coordinator should Train staff ensure that all maintenance staff have been trained to use the relevant test instruments Section 3 5 The HTM Manager should ensure that maintenance staff undertake mechanical electrical and medical electrical testing as appropriate e during the acceptance procedure for newly arrived equipment e whenever problems are suspected e at the end of every repair and PPM task Undertake testing regularly 7 4 FAULT REPORTING Besides PPM there will be faults and breakdowns needing repair and maintenance work requiring more skills than the users have Equipment users and their Section Heads are responsible for reporting all equipment faults promptly to the HTM Team We suggest that fault reports are made by completing some style of Work Request Job Form Relying solely on telephone calls or radio communication can mean that there is no physical
61. enclosure leakage current test patient leakage current test patient auxiliary current test gt gt gt mains voltage on the applied part test 99 5 5 2 Electricity Figure 11 IEC Symbols on Equipment Labels Showing the Level of Safety Protection A gt ATTENTION CONSULT PROTECTIVE FUNCTIONAL ACCOMPANYING DOCUMENTS EARTH EARTH PROTECTION CLASS amp Il EQUIPMENT NOTE THERE IS NO SYMBOL FOR CLASS EQUIPMENT CLASS II EQUIPMENT ANAESTHETIC PROOF ANAESTHETIC PROOF EQUIPMENT CATEGORY G A At TYPE B EQUIPMENT TYPE B WITH DEFIBRILLATOR PROTECTION J TYPE BF EQUIPMENT TYPE BF WITH DEFIBRILLATOR PROTECTION g 0 TYPE CF EQUIPMENT TYPE CF WITH DEFIBRILLATOR PROTECTION Note Class III equipment relies on protection from a supply at Medical Safety Extra Low Voltage MSELYV and is rarely encountered now Equipment that is battery powered is not described as Class I II or III Source Deller A 1994 Notes on Electrical Safety Centre for Medical Electronics St Bartholomew s Hospital London unpublished Variations in Supply When you have a mains electricity supply it is preferable to have an emergency back up generator When there are interruptions in the main supply power cuts the generator cuts in to ensure that electricity continues to be supplied to key areas If you are used to having electricity 24 hours a day it becomes crucial for the working of so
62. handling Section 4 on operation care and cleaning of equipment and Section 7 2 on user maintenance It is listed alphabetically by title Anaesthesia at the district hospital 2 edition Dobson MB 1988 Nuffield Department of Anaesthetics John Radcliffe Hospital Oxford UK ISBN 92 4 1545275 A practical manual designed to help medical officers in small hospitals acquire competence in the use of essential techniques for inducing anaesthesia for both elective surgery and emergency care of the critically ill Addressed to doctors having at least one year of postgraduate clinical experience the book concentrates on a selection of basic techniques procedures and equipment capable of producing good anaesthesia despite the limited resources usually found in small hospitals The manual was prepared in collaboration with the World Federation of Societies of Anaesthesiologists Available from WHO Anaesthetic equipment Physical principles and maintenance 2 4 Edition Ward C 1985 Bailli re Tindall ISBN 0 7020 1008 1 This book provides a comprehensive and practical coverage of the wide range of equipment used in anaesthetic practice It allows the reader to understand the mode of operation and maintenance of equipment and how to cope with common causes of mechanical failure Suitable for trainee and established anaesthetists intensive care specialists anaesthetic nurses and theatre and maintenance technicians Available from book sup
63. including Managing healthcare technology Temple Bird C pp 57 60 Available from Commonwealth Secretariat International seminar for hospital technicians engineers February 1998 Moshi Tanzania Clauss J ed 1998 FAKT This document reports the results of intensive work by 38 national and international experts brought together from faith public and private agencies to strengthen equipment management measures in the health sector It includes papers with country examples on healthcare technology management financing maintenance workshops and tool requirements cash control equipment standardization networking structures of health care technical services training communication technologies modification of medical and hospital equipment and energy supply and photovoltaics Available from FAKT International workshop on healthcare technology management 2 6 October 2000 Catholic Pastoral Centre Bamenda Cameroon Clauss J compiler 2000 FAKT This document reports the results of intensive work by 35 national and international experts involved in setting up and operating systems for the sustainable management of healthcare technology It includes papers with country examples on healthcare technology management the role of stakeholders public private partnerships for providing HTM cost effective maintenance and repair services and acquisition and utilisation of healthcare technology Available from FAKT Medical equi
64. management Figure 9 provides some strategies for guaranteeing a safe water supply All these strategies can be undertaken on a small scale for particular needs or on a large facility wide scale WASTE MANAGEMENT Not only does equipment use and maintenance produce waste products for example disposable electrodes X ray fixer laboratory reagents machine oil but also many waste management strategies involve equipment such as incinerators biogas plants Proper waste management is therefore required in order to reduce risks to health staff who for example may be injured by sharps risks to support staff who for example handle infectious linen and materials risks to maintenance staff for example plumbers unblocking sewers who may have little understanding of the infectious nature of the material they are handling exposure of any staff to toxic or hazardous chemicals exposure of patients and visitors to any of these risks risks to the environment and neighbouring population through contamination of the soil and pollution of groundwater or air risks for landfill workers and waste pickers Waste Management Philosophy In order to dispose of waste effectively you will need to address and make decisions about issues such as the identification and handling of different categories of waste from the health facility the methods for treating different types of waste and the documentation required to monitor it
65. newsletters for a list contact website www who int library reference information newsletters index en shtml Ziken International Consultants Ltd Causeway House 46 Malling Street Lewes East Sussex BN7 2RH UK Tel 44 1273 477474 fax 44 1273 478466 email info ziken co uk website www ziken co uk A consultancy organization working worldwide in many aspects of health care development including healthcare technology management For information on the wide range of international professional bodies representing different aspects of clinical and hospital engineering see Guide 1 or 5 201 202 Annex 3 Process profile for common sterilizers ANNEX 3 PROCESS PROFILE FOR COMMON STERILIZERS Figure 21 Example of a Process Profile Common to Many Sterilizers Pressure kPa 300 200 atmospheric pressure vacuum e mje Time pre vacuum steam pulses sterilization post vacuum gt a gt lt air removal sterilization drying air admission Notes 1 2 3 Typical profile for a sterilization process by steam for porous loads The sterilizer should be equipped with a vacuum system for creating the pre and post vacuum Timing air removal by pre vacuum 5 minutes then three pulses followed by 10 minutes sterilization and post vacuum for drying 15 minutes It will be necessary to validate the process in your own sterilizer with the most difficult load and packag
66. not enough simply to establish these standards they also need to be adhered to For this reason you should establish a national supervisory body that has the power to ensure that health service providers comply with the standards in force To be effective such an enforcement agency must be allocated sufficient financial and personnel resources It should also be linked or networked with corresponding international bodies Much healthcare technology in developing countries is received through foreign aid and donations but such products don t always meet international standards Therefore your country will need to negotiate with external support agencies The best way to do this is to develop regulations for donors that supply equipment see Annex 2 and Guide 3 on procurement and commissioning 17 18 2 1 Framework requirements for quality health services The legal system plays an important role in enforcing such standards by ensuring that any infringements can be effectively prosecuted It is therefore essential that the legal system is allocated sufficient financial and human resources to enforce claims against any institution operating equipment that does not meet the prescribed standards Developing Policies for Health Services Every country needs to establish wide ranging policies covering all aspects of health services National health policies are usually developed by the Ministry of Health If these policies are l
67. of time that an item will work effectively dependent on the type of technology and parts used in its manufacture See maintenance staff Staff responsible for maintenance of equipment such as craftspeople artisans technicians technologists engineers Any staff involved in the management of equipment related activities This could include administrator nurse in charge medical superintendent chief executive director health secretary medical practitioner maintenance manager policy maker The guidelines practices and procedures to ensure that people are protected from the fatal electrical risks posed by medical equipment stricter requirements than for electrical safety as medical equipment comes into direct contact with patients bodies Equipment used for medical purposes including X ray units diathermy units suction pumps foetal doppler scales autoclaves infant incubators centrifuges Equipment used in an office such as computers photocopiers calculators record systems Furniture used in an office such as desks chairs or filing cabinets A skilled worker a skilled equipment user Awaiting an outcome waiting for something to take place Machinery such as boilers lifts air conditioners water pumps or compressors Planned preventive maintenance protocol or list of activities describing the work to be carried out on equipment at specified regular intervals in order to prevent breakdowns and ensure
68. process of condemning or writing off equipment and disposing of it The amount by which the monetary value of an asset is reduced over a period of time due to its everyday use wear and tear or due to the fact that it could not be sold second hand for as much as it originally cost the asset is said to depreciate in value The process of making items safe for handling and reuse A pollutant that is emitted from burning incineration of healthcare waste which is hazardous to people and the environment The reduction of a population of harmful micro organisms on any surface without achieving sterility in other words not all bacterial spores present are destroyed See external support agency Provide an electrical connection from electrical devices to the ground which is regarded as having zero electrical potential The guidelines practices and procedures to ensure that people are protected from the fatal electrical risks posed by electrical supplies installations and equipment A source of energy or power such as generating sets solar panels or transformers Items which are essential for equipment use such as consumables accessories spare parts and maintenance materials used with equipment All staff involved in use of equipment such as clinical staff eg doctors and nurses paramedical staff such as radiographers and physiotherapists and support services staff such as laundry and kitchen workers 16
69. quantities of accessories and consumables used and kept in stock The department s storesperson should be responsible for keeping these records You can either obtain a stock control ledger from your Health Management Team or make one yourself using a separate page to keep records for each type of item Figure 14 shows two different sample layouts for the ledger 6 3 Calculating usage rates and reorder levels je m no penunuoy s jnoq 8I 9X7 9 WNW 4 sj Joded cl 1X8 gt UW oaoqe soyduwexo uy UTX OWY SU dW ped SULINP pasn yd01s Y90Is IASI AyIe NSII poyo aq 01 spoou 11 os s gueyo doInos Jorjddns pure o1v1 osesn Inod se OFULYI ITM I sotjddns jo 1J0Yys SUTUUNI pIOAL 02 JOA SIY yoRal NOA UIYM JOpIOdI ISNU NOJ Topso ue d0vyd 01 poou nok SOIOIPUT IY IAI YO07S Y SpIOM 19170 UI OAD JOPIOI un oso cnr z s moq 9 9X7 SU z sjjo1 1oded p X 8 SY E 940q sojdwe xo UJ 7 TTX OW oun peaj y zey ul posn Aanuenb sy sarddns JUITA ul Avjap amp 10 puewop UI OSLU poioodxoun ur SI 9I9YI Udy SINOYOONS ou oe JIU dINsud 01 pornbal sorddns v11x9 OY SII OAdT s14 MOTIqG ley 01 pomoge oq 10u prnoys sonMuENG WOT YOLI 10 Y901S Jo PAI ISOMOT Y spIOM 1910 UI 001S 19JJNq Jo Ayayes Su 42019 sasosoy Z ZI OWN soy IW g UI p sn o S NOq pZ q 8 9 87 OWY Sny syiuow 9 UI pasn F sJjo1 Joded gp e ouunsse
70. record of the request made In many instances reporting a fault to the HTM Team by telephone or radio is justifiable and the only quick method available however this process must be followed up by the prompt submission of a Work Request Job Form in order to provide a written record of the reported fault You need a way of recording how many requests for maintenance support are made and how each request is progressing You could keep some form of Maintenance Book but the HTM Service may be using a Work Request Job Form system such a system is described in Guide 5 on maintenance management Annex 7 gives an example of a triplicate Work Request Job Form which has multiple uses in the maintenance record system The user department fills in the top half of the form and keeps the top copy to create their own set of records 148 7 4 Fault reporting We also suggest that each user department establishes a User Department Maintenance File to keep track of whether jobs were attended to Such a file could be divided in half so that it becomes a record of all the maintenance work that the department has asked for as well as a record of those jobs that have been completed The Work Request Job Form can be moved from the front of the file to the back when the job has been completed so that the two halves work as follows The front of the file is the pending section and is a record of all the jobs reported to the HTM Team organized
71. representative wholesaler salesman Additional types of staff in the health service besides medical personnel such as planner finance officer procurement officer stores controller human resource officer Equipment required when running training courses such as overhead and slide projectors video and tape recorders See equipment users Any conveyance used for transporting people goods or supplies in the health service such as ambulances cold chain motorbikes mobile workshops lorries buses Items used to aid mobility such as wheelchairs zimmer frames crutches Any plant used to treat waste including incinerators septic tanks or biogas units A group of people set up to be responsible for a particular subject area such as a standing committee select committee or sub committee Equipment used in a workshop such as hand tools bench tools test instruments See health service provider Annex 1 Glossary BOX 63 WHO s Definition of the Technology Management Hierarchy Equipment support undertaking maintenance and repair Equipment management using the equipment database inventory and maintenance history to help you make decisions for improving equipment support Asset management including cost and utilization information life cycle cost analysis in the equipment database to help you make decisions on replacement and acquisition Technology assessment reviewing past current and future techn
72. resources Obtain information available internationally which can be paid for as one off items or by annual subscription depending on the material type and source This material may come as a hard copy or as part of a software package text books relevant to different professional disciplines laboratories theatres laundries physiotherapy child health etc manufacturers operator and service manuals equipment hazard reports and safety literature journals data reference books and reference materials internationally available advice on operation and safety of equipment etc Try to get hold of these resources consider subscribing to them and look for help to pay for them Make sure you order relevant literature when purchasing all your new equipment see Guide 3 on procurement and commissioning operator manual service manual which should include care and cleaning instructions and safety guidance when the manuals arrive store the original copies in a safe place such as the HTMS library the facility library or the workshop library make photocopies of the operator manuals and give one copy to the relevant user department and one copy to the HTM Team or relevant workshop make photocopies of the service manuals and give one copy to the HTM Team or relevant workshop Continued opposite 3 5 Developing staff skills BOX 8 Strategies for Exp
73. responsible for the equipment they use be accountable for their actions and practise good behaviour when handling equipment To obtain maximum benefit from the equipment you own it must be used efficiently In order to respond to the rapid changes in equipment design and utilize equipment effectively you need to introduce an ongoing skill development programme for equipment operators It is necessary to monitor how effectively equipment is utilized Proper equipment usage leads to the following advantages e Equipment is operated safely both for patients and users Equipment lasts longer You will achieve maximum benefit for any financial investments Equipment which is kept in good working order helps health staff to do their work and deliver better services to patients In this Section the effective utilization of equipment is discussed through the following issues e Making staff accountable for their actions with equipment Section 3 1 Encouraging staff to practise good behaviour when handling equipment Section 3 2 Using equipment efficiently Section 3 3 Providing access to information and reference materials Section 3 4 e Developing staff skills Section 3 5 It is useful for your health service provider to develop an Equipment Usage Policy This could be based on the procedures and good practice provided in Sections 3 to 8 of this Guide Once a policy has been developed staff should be trained to
74. service store for the majority of the stock designate a separate section where all equipment related items can be stored together This separate section would contain equipment spare equipment accessories equipment consumables equipment spare parts and maintenance materials In this way it is possible to ensure that the small quantities of many varied technical items do not go missing and unrecognized amongst the bulk of general items kept in the stores Ensure that the correct technical item is used for the correct application There are various possibilities All equipment spare parts required for user PPM could be issued only with the signature of an HTM Manager or his deputy If there is any uncertainty concerning which is the correct part accessory or consumable to be issued used for a certain application seek the advice of the HTM Manager or Head of Department or consult the equipment manual The old part should be returned to the HTM Manager for inspection and disposal Any store should have an identification code system for the items in stock If such a system already exists for general and medical items it can be extended to cover equipment related supplies Some equipment items will be covered by relevant codes for existing categories and some will require new ones to be set up For example there will usually be e existing codes for surgical items etc e an existing code for hardware whi
75. services in general These will cover areas such as a Standard a required or agreed level of quality or attainment set by a recognized authority used as a measure procedures and training construction of facilities healthcare technology drugs and supplies safety the environment gt o norm or meus J quality management Since drawing up these standards can be both time consuming and expensive governments may often choose to adopt acceptable international standards such as ISO rather than develop their own However they must be suitable and applicable to your country situation and fit in with your country s vision for health services The adoption of suitable international or national standards for healthcare technology is of particular relevance to this Guide Such standards would cover areas such as manufacturing practices performance and safety operation and maintenance procedures environmental issues such as disposal These are important since countries can suffer if they acquire sub standard and unsafe equipment Again in the majority of cases ministries of health would save money and time by adopting internationally recognized standards For more information on introducing internationally recognized standards into your procurement procedures refer to Guide 3 on procurement and commissioning It is
76. technically evaluate equipment to assess its fitness to continue in service This can happen at any time e when there is a fault see Guide 5 e during the annual Equipment Inventory updating process see Guide 2 e during the Equipment Development Planning EDP process see Guide 2 ior maintenance staff from your local workshop consider four issues and judge hether the equipment fulfils any of the valid replacement criteria defined in the Replacement Policy as scribed in Box 55 hat the internationally advised typical life time is for the equipment see Annex 8 e equipment s track record and state of health as documented in its service history records see Guide 5 hether it will be necessary to override the average expected lifespan and condemn early or even to extend the lifespan For expensive equipment it may be helpful to obtain an evaluation from the supplier If the equipment is condemned because it is unreliable damaged or in any way unsafe the maintenance staff take it out of service immediately for safety reasons and to prevent its return to use inform the Head of the User Department take unsafe moveable items to the maintenance workshop or arrange for unsafe fixed equipment to be disassembled if there is to be a delay with either of these actions leave notices on the equipment and make them inoperable for example by removing the accessories or the mains connection HTM Manager of your
77. the equipment is operational and safe 171 172 Annex 1 Glossary PPM timetable Quality control Service supply installations Standard Standardization Sterilization Stock Supplier Support staff Training equipment Users Vehicles Walking aids Waste treatment plant Working group Workshop equipment Your organization A calendar showing the days when PPM tasks should be performed according to the PPM schedules in order to ensure that they occur at the required frequency A system of maintaining standards testing a sample against specifications Supply installations such as electrical installations water and sewage pipelines gas supplies A required or agreed level of quality or attainment set by a recognized authority used as a measure norm or model for all aspects of health services and healthcare technology Rationalization normalization and harmonization In other words reducing the range of makes and models of equipment available in stock by purchasing particular or named makes and models The destruction or removal of all living organisms on any surface to produce an absolute a sterile object an item cannot be nearly sterile In stores this is the goods held by an organization for its own use The equipment stock is all the equipment assets owned by an organization Someone who provides equipment such as manufacturer manufacturer s
78. the necessary skills see Guide 5 on maintenance management Health Management Teams at facility district regional and central level and their HTMWG address the practical issues involved with implementing all the equipment usage and safety policies ensure sufficient financial and human resources are available to guarantee the continuous effective operation and safety of equipment see Guide 2 on planning and budgeting train staff to understand their responsibilities towards equipment Section 3 5 ensure equipment is replaced when it reaches the end of its life see Guide 2 on planning and budgeting ensure annual goals and plans are set and monitored to improve the operation and safety of equipment Section 8 Finance Officers take into account the calculations of accessory consumable and spare part usage rates when calculating recurrent budgets see Section 6 3 Guide 2 on planning and budgeting and Guide 5 on maintenance management allocate sufficient funds for all operational and safety costs see Guide 2 on planning and budgeting Purchasing and Supplies Officers promptly procure the required accessories consumables and spare parts so that equipment remains functioning see Section 6 1 and Guide 3 on procurement and commissioning Stores Controllers make equipment accessories and consumables stockable items in the stores system Section 6 2 use a stock control system to reorder goods before st
79. the use and safety of equipment should devise a wide range of initiatives and goals for all aspects of their work such as obtaining information about new products improving operator skills in using equipment establishing safety guidelines improving stock control of accessories and consumables improving user PPM The planning process and the plans themselves should be clear and straightforward This assists participation and produces goals that can be understood and used by all staff Staff who are involved in setting goals and preparing plans are more likely to be committed to carrying them out Thus the planning process should incorporate representatives of all different types of staff from all relevant disciplines We suggest that you hold an action planning seminar once a year Such seminars can be held in various ways Either across a horizontal level of the health service in other words planning for the health service as a whole with participation from all disciplines undertaken by your health facility or by your district health authority Or across a vertical professional programme within the health service such as the laboratory service or maintenance service In this case representatives would meet from all the laboratory departments for example in your district or region or throughout the health service as a whole 157 158 8 1 Setting goals annually for equipment operat
80. thermocouples etc validate each autoclave using the kit when a machine first arrives after each maintenance repair job during the annual service or a more regular service and if a new type of load or pack is to be used undertake a Bowie amp Dick test every time PPM or repairs are carried out on any autoclave before the autoclave is handed back to the users Bad results If any registration fails to match the correct process profile or any Bowie amp Dick test produces a non uniform colour change the autoclave requires adjustment and the users will know that the load or pack is not sterile know the sterility of all loads or packs since the last test cannot be guaranteed and warn the relevant users contact the HTM Team for assistance Ifa ready made Bowie amp Dick test pack was used the maintenance staff or supplier s technical representative will be able to use it to diagnose the problem in other words to establish whether the problem was with steam penetration steam temperature time of steam penetration air leaks air evacuation non condensible gases superheat or over saturation of steam Once the autoclave has been repaired by the technical staff the validation process and the Bowie amp Dick test will be repeated 75 5 3 2 Linen handling 5 3 2 Linen Handling All washable fabrics can easily be disinfected either by hot water if the correct temperature is used for the correc
81. to give praise for good progress or to find out what might be causing shortcomings or problems and then seek a solution If solutions are quite impossible it may be necessary to change the plans If common indicators were used for different departments groups and staff it will be possible to compare their progress Once planning and financial systems are established it is also possible to link annual planning with the process of setting the health facility s budget For example the fact that a department achieves its goals could play an important part in justifying the budget allocations they request from the Health Management Team see Guide 2 on planning and budgeting 164 8 2 Monitoring progress with equipment operation and safety Monitoring Progress in General Monitoring equipment related activities can help to identify problems and needs Thus the results of monitoring are useful for providing feedback to staff and senior management By receiving feedback on their activities and answers to their queries staff benefit from experience and feel a part of the system as a whole In this way staff will be informed can obtain support will feel involved and empowered can be encouraged to take responsibility Regular monitoring of activities and services is also essential for improving the quality of healthcare Management need facts so that they can plan effectively and need to know how equipment related activities
82. tube to keep in store not only are they expensive but they will deteriorate if not put to use As the battery pack for battery powered machines may store enough power to give a life threatening electric shock keep all metal tools away and do not wear metal watches watchstraps bracelets or necklaces whilst working around it 107 5 5 4 Radiation hazards BOX 39 Strategies for Dealing with the Hazard of Radioactive Sources Skin contact Wear overalls and gloves If skin contact occurs wash with soap and tepid water taking care not to spread the contamination to the eyes for example until monitoring shows that the radiation levels are acceptable Ingestion Ban mouth pipetting Ban eating drinking smoking and applying cosmetics in the work area where these substances are used Spillage Put on the protective clothing from the emergency kit Place contaminated articles and waste in plastic bags Decontaminate and dispose of this radioactive waste in the correct way Section 5 4 Wash contaminated areas with water taking care not to spread the agent any further until monitoring shows that the radiation levels are acceptable Other Radiation Risks There could also be potential radiation risks from other emission sources such as microwaves ultrasound infrared ultraviolet etc Little is known about the actual hazards from some of these sources and it is necessary to monitor and keep up to date with
83. use of hospital equipment Skeet M and Fear M 1995 VSO ISBN 0 9509050 5 4 This book provides practical advice for health service staff about proper management of the type of equipment found in district hospitals or health centres It includes guidelines on preventive maintenance and servicing simple user instructions checklists for correct and safe use of equipment and basic technical information for training of first line maintenance staff The information is easily accessible to those without a technical background It includes advice on many topics relating to safety and testing such as checking power supplies gas cylinders disinfection and sterilization as well as a basic tool list Available from TALC VSO District laboratory practice in tropical countries part 1 Cheesbrough M 1998 Tropical Health Technology ISBN 0 9507434 45 A valuable resource aimed at those responsible for the organization and management of district laboratory services but can also be adapted for use by health centres Covers selection and procurement of laboratory equipment and supplies as well as their use care and maintenance It covers parasitological tests clinical tests and training of personnel as well as all types of safety issues for laboratories Available from TALC THT District laboratory practice in tropical countries part 2 Cheesbrough M 2000 Tropical Health Technology ISBN 0 9507434 5 3 Covers microbiological haematological and
84. which evaluates the recurrent stock requirements for equipment accessories and consumables could have the following types of members Purchasing and Supplies Officer HTM Manager Stores Controller Representatives from equipment user departments appropriate to the equipment being considered A training sub group which considers equipment related training issues could include the following types of staff Human Resource Manager Head of Medical Services Head of Support Services HTM Manager In Service Training Coordinator gt Infection Control Officer senior users and technicians as appropriate to the equipment being considered Most organizations have a body which is authorized to oversee the process of condemning old and unsafe equipment In this Guide such a body is referred to as a Board of Survey This body has the authority to officially condemn the property and assets of your organization take it out of service and dispose of it It has the authority to auction off condemned equipment and sell materials for scrap The monies generated must usually but not always be returned to the central financial body of your organization such as the treasury These responsibilities are very important if your Board of Survey does not function promptly and effectively your health facility will contain a large graveyard of old equipment _ cC _ oO O O O c x _ z Tip
85. whole enables you to provide the health services required Thus HTM is a field that requires the involvement of staff from many disciplines technical clinical financial administrative etc It is not just the job of managers it is the responsibility of all members of staff who deal with healthcare technology This Series of Guides provides advice on a wide range of management procedures which you can use as tools to help you in your daily work For further clarification of the range of activities involved in HTM and common terms used refer to the WHO s definition of the technology management hierarchy in Annex 1 Box 2 highlights some of the benefits of HTM BOX 2 Benefits of Healthcare Technology Management HTM Health facilities can deliver a full service unimpeded by non functioning healthcare technology Equipment is properly utilized maintained and safeguarded Staff make maximum use of equipment by following written procedures and good practice Health service providers are given comprehensive timely and reliable information on the functional status of the equipment the performance of the maintenance services the operational skills and practice of equipment user departments the skills and practice of staff responsible for various equipment related activities in a range of departments including finance purchasing stores and human resources Staff control the huge financial investment in equipment
86. wo gt 9 o o o 2 7 7 ea Ea e AE A a aE Ea e Q I c lt o 203 204 Annex 5 Entering items into the stock control system ANNEX 5 ENTERING ITEMS INTO THE STOCK CONTROL SYSTEM Guide 3 on procurement and commissioning describes the procedures involved when you receive equipment supplies on site and undertake the Equipment Acceptance Process The information here summarizes the steps involved During the acceptance process the Commissioning Team compiles the following information from the available contracts packing lists or invoices in order to complete a Register of New Stocks form for each new piece of equipment received according to a standard format see example in Figure 23 Type of equipment Equipment name model Name and address of manufacturer Name and address of supplier agent if relevant Price of equipment Manufacturer s part numbers for ordering purposes Lists of all consumables accessories and spare parts received including the quantity of each the part numbers for ordering purposes and the price of each At the successful completion of the initial training sessions this is the training of users and maintainers undertaken when new equipment arrives the Commissioning Team issues the accessories and consumables for immediate use to the relevant user department together with the new equipment The Commissioning Team gives a copy of the Regist
87. work of the health facility as a whole In this Guide we only cover the equipment issues that contribute to infection control Proper infection control relating to equipment can be achieved by making decisions about a number of different issues Decontamination through appropriate use of cleaning disinfection and sterilization methods as well as monitoring sterility Section 5 3 1 Linen handling Section 5 3 2 Ensuring the workplace is clean Section 5 3 3 Many strategies in these topic areas are covered in this Section but additional ones may need to be developed Associated infection control issues relating to waste management are discussed in Section 5 4 Information and advice must be sought from the relevant national body that is responsible for infection control Section 2 2 since national policies should have been established to ensure that risks are reduced We suggest that the central HTM Working Group or its smaller sub group the infection control committee Section 1 2 should be responsible for establishing policies and guidelines to prevent contamination through exposure to blood body fluids body parts and infectious agents 5 3 1 Decontamination It is important to correctly treat equipment that is contaminated with body fluids and toxic substances so that infectious diseases are not transmitted to users maintainers and patients who come into contact with equipment In order to decontaminate equ
88. 0 aunumnnt Sw ON N NNNN Item Years Blood gas analyzer 5 Blood gas apparatus volumetrics 8 Blood transfusion apparatus 6 Blood warmer 7 Blood warmer coil 7 Bone surgery apparatus 3 Breathing unit positive pressure 8 Bronchoscope Flexible 3 Rigid 3 Carbon monoxide recorder detector 10 Cardiac monitor 5 Cardioscope 8 Cart Emergency isolation 10 Medicine 10 Caspar ACF instrument and plate system 7 Cassette changer 8 Cautery unit Dermatology 7 Gynecology 7 Cell freezer 7 Cell washer 5 Centrifuge 7 Centrifuge refrigerated 5 Cerebral function monitor 7 Child immobilizer 15 Chloridiometer 10 Chromatograph gas 7 Clinical analyzer 5 Clopay wrapping machine 10 Coagulation analyzer 5 Cold pack unit floor 10 Colonoscope 3 Colorimeter 7 Colposcope with floor stand 8 Computer clinical 5 Continued opposite Annex 8 Typical equipment lifetimes Table 8 Diagnostic and Treatment Departments continued Item Computer assisted tomography CT scanner Conductivity tester CO oximeter Cryoopthalmic unit with probes Cryostat Cryosurgical unit Cyclotron Cystic fibrosis treatment system Cystometer Cystometrogram unit Cystoscope Decalcifier Deionized water system Densitometer recording Dental drill with syringe Dermatome Diagnostic set Diathermy unit Digital fluoroscopy unit Digital radiography unit Diluter Dispenser alcohol Distilling apparatus Doppler Dose calibrator Dryer sonic Duodenoscop
89. 24 131 132 6 3 Calculating usage rates and reorder levels Regular Monitoring When to Restock Once the accessories and consumables are in store with stock cards the stores staff can record the weekly issue quantities and monitor the departmental usage rate Other types of information need to be filled in on the stock cards see Figure 13 this data covers issues such as when to reorder e how much to reorder how long the delivery time is how low stocks can fall Box 51 shows you how to calculate the data that should be put on each stock card From experience over time the Stores Controller should be able to help you to calculate this data The purpose of recording this information on the stock cards is so that the stock control system will prompt you when it is necessary to buy more stocks Then the Stores Controller can automatically order the items to ensure that you don t run out of the materials you require for the work in your department Once a month the information on the stock cards is transferred to a stock control ledger stores record book It is simpler to make an order using the summary in the stock control ledger than using all the individual stock cards The stock control ledger is also a useful tool for analyzing stock management and reviewing the accuracy of stock levels A stock control ledger stores record book should be kept by every departmental store in order to keep track of the
90. 5 15 15 20 15 10 15 10 10 15 10 15 15 10 215 216 Annex 8 Typical equipment lifetimes Table 8 Diagnostic and Treatment Departments Diagnostic and treatment departments consist of ambulatory surgery anesthesia cardiac rehabilitation catheterization laboratory CT scan ECT EEG EMG emergency employee health enterostomal therapy GI laboratory hemodialysis hyperbaric medicine in vitro medicine IV therapy inpatient pharmacy laboratory lithotripsy mobile air care medical oncology MRI noninvasive cardiology obstetrics occupational therapy physical therapy postanesthesia care unit radiation therapy radiology respiratory therapy speech therapy and surgery departments Item Accelerator Alternating pressure pad Amino acid analyzer Amplifier Anaerobe chamber Analyzer haematology Anatomical model Anesthesia unit Ankle exerciser Apnea monitor Apron lead lined Arthroscope Arthroscopy instrumentation Aspirator Audiometer Autoclave Autoscaler ionic Bacteriology analyzer Baci incinerator Balance Analytical Electronic Precision mechanical Basal metabolism unit Bath Fluidotherapy Paraffin Serological Water Biochemical analysis unit Biochromatic analyzer Biofeedback machine Biomagnetometer Bipolar coagulator Blood cell counter Blood chemistry analyzer automated Blood culture analyzer Years 7 10 7 10 15 7 10 7 15 7 47 5 3 10 10 10 10 8 5 10 1
91. 55 Example of User PPM Instructions for Any Type of Refrigerators these may vary or require additions depending on the make and model Note the daily duties of checking the temperature the burner flame and the gas fuel level fall under care of equipment activities Section 4 3 Weekly Check the ice formation on the evaporator If the ice on the freezing compartment walls is more than 5mm 14 inch thick defrost the refrigerator Otherwise your refrigerator will not work properly Note Some modern gas and electric refrigerators defrost themselves so you do not have to do it If you are finding it necessary to defrost every week the door is probably not sealing properly You should refer to your training notes and take corrective action to check the door seal and adjust the hinges Check that the refrigerator is level and adjust as necessary Ifyou have a kerosene refrigerator clean the flue the baffle and the burner and trim the wick Also check whether the kerosene tank needs cleaning Note if the tank needs cleaning every week you are not filling it correctly Monthly e Clean the condenser coils at the back of the refrigerator with a brush If the coils are dirty the refrigerator will not work properly Be careful as the coils are hot Check the outside of the refrigerator for damaged paint work If you find some clean the damaged surface remove all the rust and repaint the damaged area
92. 9 170 Annex 1 Glossary External support agency External support agency staff Fabric of the building Facility Fire fighting equipment Fixtures built into the building Furans Head of section Health facility Health facility furniture Health management team Health service provider Health system HTM Manager HTMS HTM Team HTM Working Group A body responsible for providing money equipment or technical support to developing countries on various terms such as international donors technical agencies of foreign governments non governmental agencies private institutions financial institutions faith organizations People working for external support agencies that health workers come into contact with such as a country representative desk officer consultant coordinating agency director Items which are part of the integral structure or framework of a building such as doors windows or roofs See health facility Equipment used to put out fires such as fire blankets buckets extinguishers hose and sprinkler systems Items which are not part of the integral structure of a building but are installed into the fabric of the building such as ceiling mounted operating theatre lights scrub up sinks and fume cupboards A pollutant that is emitted from burning incineration of healthcare waste which is hazardous to people and the environment Departmental manager such as
93. ART can assist with training requirements Available from HEART Consultancy Refrigerators use maintenance and repair series Expanded Programme on Immunisation EPI 1984 1987 WHO EPI LOG 84 14 19 21 22 25 26 and EPI TECH HB A H This series is grouped into two sub series 1 User and how to look after handbooks and 11 Repair technicians handbooks The user s handbooks are comprehensive illustrated guides that contain information on installation the components operation schedules for daily weekly monthly care fault finding basic maintenance procedures and conversion to electric operation The how to look after handbooks contain task sheets for different maintenance tasks with information on the tools and materials required and step by step action required for the tasks written as training modules The technician s handbooks have the same format as the user material but cover much more complicated maintenance procedures They are meant to be used in conjunction with the manufacturers own maintenance and repair manuals Available from WHO Selection of basic laboratory equipment for laboratories with limited resources Johns ML and ME El Nageh 2000 ISBN 9290212454 This book provides a framework to help laboratory workers supply officers and decision makers to choose and buy laboratory equipment and consumables Includes information on maintenance and energy requirements for laboratory equipment quick re
94. Action PPM schedules and timetables are usually written by the equipment manufacturers and can be found in their operator or service manuals Some PPM schedules and timetables have already been developed by international agencies and other sources see Annex 2 Try to get hold of as many of these as possible using the strategies presented in Box 8 Try to get hold of these resources see Box 8 for strategies All these documents and systems can be modified by technical and clinical staff to suit local conditions Meet with your colleagues and draw on your own experiences to adapt the resources to local needs and realities Expand the written resources and establish a library of user PPM schedules The HTMWG s training sub group Section 1 2 could be made responsible for this Some organizations have developed computer software programs which help with planning PPM They generate requests for PPM according to timetables and keep records of the work and results Some systems also provide generic PPM schedules for different equipment types see Annex 2 Investigate this software if your organization wishes to use computerized maintenance systems see Guide 5 on maintenance management PPM Timetables and Wall Calendars PPM work must be carried out at specified intervals as detailed in your schedules The HTM Managers and Heads of User Departments should liaise to draw up timetables to ensure
95. ERC website is an electronic information resource and communication service for health managers containing more than 150 ready to use management tools in various languages A key feature is The health manager s toolkit includes spreadsheet templates forms for gathering and analyzing data checklists guidelines for improving organizational performance and self assessment tools that allow managers to evaluate their organizations Tools cover areas such as strategic planning developing information systems cost and revenue analysis and sustainability WHO Health technology and pharmaceuticals website www who int technology This WHO site provides information on pharmaceutical and health technology developments with a particular focus on developing countries It includes links to blood transfusion safety and clinical technology essential drugs medicines vaccines and biologicals WHO Injection safety website www injectionsafety org This WHO site focuses on safe injections and the elimination of injection associated transmission of blood borne pathogens WHO Management of health services MAKER website www who int management This WHO site provides information publications and country experiences on all types of management issues for health services such as facility management resource management and district management 193 194 Annex 2 Reference materials and contacts ii Organizations Sources of Publications
96. Ensure that cylinders are used in strict rotation by date Keep empty cylinders separate from full ones Replace the protective covers or caps onto the valves of empty cylinders Ensure that empty cylinders are returned to the suppliers In the event of fire Raise the alarm and unless life is endangered attempt to move the cylinders away from the area If personnel are not trained to use fire fighting equipment leave cylinders in the fire zone and carry out statutory fire drill procedures Only allow trained personnel to handle cylinders that have been affected by fire or excessive heat store cylinders in direct sunlight as this can cause the gas to expand and the cylinder pressure to increase excessively use excessive force to shut cylinder valves tighten by hand tool only e let people gather near any areas where cylinders are stored when there is a fire Continued opposite 5 5 1 Gases BOX 33 Strategies for the Safety of Gas Cylinders continued DO DON T Use aaaaaa e Ensure cylinders are not damaged point pressurized gas or rusted QOOOQOQC towards anyone QOOOOO Ensure cylinder valves have their use more than one Bodok washer protective caps or seals in place and on a pin index valve connection that their threads and pin indexes are in good order attempt to remove the regulator Ensure the correct cylinder valves are fitt
97. HS NHP 90 7 ISBN 0 903354 79 9 British Medical Association 1989 Code of practice for sterilisation of instruments and control of cross infection BMA London UK ISBN 0 7279 0274 1 CEN European Norm EN 285 Steam sterilizers large sterilizers Committee European de Normalisation www cenorm be CEN European Norm EN 554 Sterilization of medical devices validation and routine control of sterilization by moist heat Committee European de Normalisation www cenorm be Centers for Disease Control and Prevention USA CDC website www cdc gov Collins C ed 1988 Safety in clinical and biomedical laboratories Chapman and Hall London UK ISBN 0 412 28370 0 Cripps N 1990 Sterilization in UK hospitals in 11th IFHE Congress 1990 International Federation of Hospital Engineering David Y and T Judd 1993 Medical technology management BioPhysical Measurement Series SpaceLabs Medical Inc Washington USA ISBN 0 9627449 6 4 Deller A 1990 Notes on electrosurgery Centre for Medical Electronics St Bartholomew s Hospital London UK unpublished Deller A 1994 Notes on electrical safety Centre for Medical Electronics St Bartholomew s Hospital London UK unpublished ECHO 2001 Medical supply catalogue 2001 02 ECHO International Health Services Limited Coulsdon UK ECRI 2005 Health devices alerts database Emergency Care Research Institute Pro
98. OX 18 Some Examples of Common Safety Hazards During Equipment Operation Air conditioning ventilation systems Autoclaves Centrifuges Electrosurgical diathermy units Engines Infant incubators Phototherapy units Pressure cooker type sterilizers Stoves Suction pumps Water pumps Welding equipment not cleaning and drying the filters and checking the air flow regularly can lead to the growth of bacteria and the spread of airborne infections inadequate venting of the chamber so that air pockets remain inside leads to a failure to sterilize the infected material will not have been made safe and staff handling it are at risk lack of care when opening the door before the contents have cooled down leads to steam scalds and when sterilizing fluids can cause the bottles to explode absence of gloves or unloading tongs for hot contents can lead to burns use with water with a high mineral or salt content that has not been treated softened leads to a build up of scale which blocks the safety valves use of unstoppered tubes instead of screwcapped ones means infectious fluids can fly out when the machine is started or stopped use of unsealed buckets instead of sealed ones means that when tubes break infectious aerosols and slivers of broken glass are released over a large area failure to balance the load or locate the trunnions and buckets properly means these heavy objects can be spun off and ejected
99. Off Equipment 10 Source Material Bibliography Contents 91 91 93 103 106 109 110 113 113 121 127 137 137 139 146 148 149 155 156 164 169 169 174 202 203 204 206 208 209 224 225 Foreword Foreword This Series of Guides is the output from a project funded by the UK government s Department for International Development DFID for the benefit of developing countries The output is the result of an international collaboration that brought together researchers from Ziken International and ECHO International Health Services in the UK and FAKT in Germany e an advisory group from WHO PAHO GTZ the Swiss Tropical Institute and the Medical Research Council of South Africa reviewers from many countries in the developing world in order to identify best practice in the field of healthcare technology management The views expressed are not necessarily those of DFID or the other organizations involved Garth Singleton Manager Ziken International Consultants Ltd Lewes UK Preface The provision of equitable quality and efficient healthcare requires an extraordinary array of properly balanced and managed resource inputs Physical resources such as fixed assets and consumables often described as healthcare technology are among the principal types of those inputs Technology is the platform on which the delivery of healthcare rests and the basis for provision of all health interven
100. Series of Guides and this Guide in particular the people the Guides are aimed at the names and labels commonly used in HTM in this Series The Series of Guides is introduced in Section 1 1 and this particular Guide on effective operation and safety is introduced in Section 1 2 1 1 INTRODUCTION TO THE SERIES OF GUIDES Healthcare Technology Management s Place in the Health System All health service providers want to get the most out of their investments To enable them to do so they need to actively manage health service assets ensuring that they are used efficiently and optimally All management takes place in the context of your health system s policies and finances If these are favourable the management of health service assets can be effective and efficient and this will lead to improvements in the quality and quantity of healthcare delivered without an increase in costs The health service s most valuable assets which must be managed are its human resources physical assets and other resources such as supplies Physical assets such as facilities and healthcare technology are the greatest capital expenditure in any health sector Thus it makes financial sense to manage these valuable resources and to ensure that healthcare technology is selected appropriately is used correctly and to maximum capacity e lasts as long as possible Such effective and appropriate management of healthcare technology will
101. Use them in a separate room to normal work Store them in locked cupboards Ensure monitoring equipment is available Ensure emergency kits are available containing protective clothing equipment neutralizing agents and information Ensure that the room and staff are part of the routine radiation monitoring system used in the X ray department Dispose of them according to your Waste Management and Hygiene Plan Section 5 4 Such substances are not usually handled in large quantities Good practice is required to deal with the three main hazards as shown in Box 39 overleaf BOX 38 Safety Strategies When Using X Ray Machines Installation 5 5 4 Radiation hazards Earthing is essential connect the generator to the main earth if agreed by the electricity authorities and follow the local regulations exactly if not specified by local regulations connect to an independent earth electrode close to the X ray department never connect the X ray generator to the water piping system All X ray equipment must be installed by the manufacturer or their local representative for warranty and safety reasons and it must be checked before acceptance When equipment is being relocated it is essential that any workers you hire have experience of X ray installation Incorrect installation may be both dangerous and expensive Operation Users and maintainers must be aware of the risks asso
102. a set that is cumbersome heavy and difficult to sterilize Make up bowl packs into major and minor categories and linen packs into major and minor categories Secure and seal the drum closure flaps with heat sensitive tape after packing so that the lids do not fly open upon removal from the autoclave thereby risking the loss of sterility the tape can be checked for the correct colour change to show sterilization was achieved see Box 24 Label the packs with details of the owner content sterilization date and person responsible Ensure there is a sterile chain Set up a quality control system for each of the following steps cleaning set assembly wrapping loading sterilizing and sterile storage correct conditions and duration Organize the routing of goods through the department to ensure separate areas for cleaning wrapping and sterile storage there is no crossing of flows of the sterile and non sterile goods It is necessary to ensure that autoclaves are working properly otherwise sterilization will not have occurred Monitoring for sterility is therefore essential Monitoring Sterility In order to obtain sterility autoclave cycles need to incorporate three factors time steam under pressure and temperature known as TST For steam to penetrate into large or porous loads and achieve sterility throughout the load the autoclave must be designed to provide pulses of steam In addit
103. according to the date the report was made The back of the file is the completed section and is an ongoing record of all the jobs that have been completed organized according to the date they were finished When a job is completed and the equipment is returned the Section Head goes to the User Department Maintenance File retrieves the Work Request Job Form from the pending section relevant to that job signs it to acknowledge completion o moves it to the completed section To see how the overall maintenance record system works and the responsibility of the user department in it refer to Guide 5 on maintenance management Whatever method is used the department or facility initiating the job needs to keep a record of the number of requests made and monitor their progress By reviewing the User Department Maintenance File regularly at least once a month the Section Head can monitor the progress of maintenance requests Section 8 2 Experience in Pakistan The Director of Maintenance at the Aga Khan University Hospital in Karachi successfully introduced a telephone based fault reporting system where a written record of each telephone request was also made as a back up After evaluation he found that a greater number of faults were reported as a result of the new system and in a shorter time 7 5 DECOMMISSIONING DISPOSAL AND REPLACEMENT OF EQUIPMENT Discussion When a piece of equipment comes to the e
104. ack from 23 experts from 16 different country backgrounds Rather than providing exact lifetimes this approach provides a range for the lifetime which depends on the quality of the initial equipment and how well it has been maintained Available from GTZ Spare parts and working materials for the maintenance and repair of health care equipment Report of workshop held in L beck August 1991 Halbwachs H and C Temple Bird eds 1991 GTZ Eschborn Germany See Guide 5 on maintenance management for more information on maintenance schedules that include safety tests Annex 2 Reference materials and contacts Accessing Information These websites are sources of information concerning many aspects of health service delivery They are locations where there is or may be information about healthcare technology management and equipment operation and safety Africa online Health website http bamako africaonline com afol index php Provides links to health information sites related to Africa The links are organized into the following categories health information health news events African organizations international organizations schools and hospitals in Africa projects publications and health services AFRO NETS African networks for health research and development website www afronets org Forum for exchanging health research information in and between East and Southern Africa AJOL African journals online website www inas
105. action planning seminar If the seminar is a large one in other words it covers many health facilities or many departments in a professional service the Department Head or Chair of Sub Group may have to nominate a couple of senior knowledgeable and responsible members of staff to be their representatives at the meeting Depending on the number of people attending the seminar may be a one or two day event as described in Box 60 For each priority problem area identified delegates at the seminar will consider and discuss the issues raised and come up with suggestions for solutions For each solution or improvement representatives write new targets recommendations and longer term objectives as well as indicators for the coming year as described above The Annual Action Plan developed should state the agreed goals who is responsible for achieving these goals how they will be measured the resources required and the timescale by which they should be achieved Once the plan is ready it needs to be communicated to all staff 8 1 Setting goals annually for equipment usage and safety BOX 60 Strategies for Running an Annual Action Planning Seminar in the Health Service All managers including Heads of Department and Chairs of Sub Groups ensure that their nominated representatives attend the annual action planning seminar Process Actions The first half day to one full day Participants are divided into working grou
106. ager or in your library if you have one Section 3 4 3 5 Developing staff skills Experience in Africa In a number of government central referral hospitals in Zambia senior doctors nominate members of staff to be special equipment operatives For example ECG recorder attendants are given responsibility for always setting up and running ECG recording sessions In addition the Biomedical Engineering Unit of the Central University Teaching Hospital has a training centre where senior maintainers teach medical staff how to use specialized equipment such as those from intensive care units operating theatres and special care baby units The MOH in Ghana trains equipment users as application specialists for various service areas such as Clinical laboratory life support systems and imaging devices These people are selected from their specific clinical area seconded to the HTM Service part time given formal technical training and sent on training of trainers programmes Whenever new technologies are introduced by the MOH into these clinical areas the specialists are always available to give application training to new users Another strategy pursued by the Ghanaian MOH is to set up a skills laboratory where examples of new devices are installed and linked to simulators for the purpose of training new users and technical personnel These laboratories are manned by the application specialists Training Special Equipment Operative
107. aintenance and repair of health care equipment Nicosia Cyprus 24 28 November 1986 Geneva Switzerland WHO SHS NHP 87 5 WHO 1998 District hospitals Guidelines for development 2nd edition WHO Regional Publications Western Pacific Series No 4 Manila Philippines ISBN 92 9061 117 0 WHO 1994 Maintenance and repair of laboratory diagnostic imaging and hospital equipment WHO Geneva Switzerland ISBN 92 4 154463 4 WHO 2000 The world health report 2000 Health Systems Improving Performance WHO Geneva Switzerland ISBN 92 4 156198 X Annex 10 Source material bibliography WHO 2004 Health care waste management website www healthcarewaste org WHO Department of Health Service Provision Presentation slides on healthcare technology management WHO Geneva Switzerland WHO Expanded Programme on Immunisation EPI 1984 Logistics and cold chain for primary health care Technician s handbook for compression refrigerators Part D How to keep stocks of spare parts No 20 WHO Geneva Switzerland EPI LOG 84 20 WHO Expanded Programme on Immunisation EPI 1984 1987 Refrigerator use maintenance and repair series WHO Geneva Switzerland EPI LOG 84 14 19 21 22 25 26 and EPI TECH HB A H 229
108. al care patient education physician on call rooms public relations quality assessment and improvement social services and volunteer services departments Item Beepers paging Bench metal or wood Binder punch machine Bookcase metal or wood Bulletin board Cabinet file metal or wood Camera Cathode ray tube CRT Chair Arm Conference Executive Folding Guest Side Check signer Clock Collator electric Computer Laptop Large Micro Mini personal Computer disk drive Computer networking equipment Controller Hub Modem Mux unit Server Token ring Years 3 15 10 Oa Ww um un Ww A UAA on Item Computer printer Computer software Computer terminal Credenza Data printing unit Data storage unit Mechanical Nonmechanical Data tape processing unit including controller drive and tape deck Desk metal or wood Dictating equipment Display cases Duplicator Facsimile transmitter Files Electric rotary Legal Regular Filing system portable Imprinter Address Embossed plate Integrator Intercom Label maker Library furniture Mailing machine Microfilm unit Years 5 3 5 15 5 10 15 5 20 5 20 5 3 15 15 15 15 20 5 10 10 10 10 20 10 10 Continued overleaf 213 214 Annex 8 Typical equipment lifetimes Table 6 Administrative Departments continued Item Microphone Microprojector Organ Paper burster Paper cutter Paper shre
109. als that staff may need develops and funds an Equipment Training Plan see Section 2 2 and Guide 2 provides inputs for the in service training programme coordinates training scholarships considers bonding issues for staff sent for training HTM Working Groups or Training Sub Groups Skills Development investigate and use the broad range of training sources available see Box 9 develop training materials see Figure 7 identify and train suitable staff to be trainers identify and train suitable staff to be special equipment operatives receive and act on any prompts which indicate that staff need training see Figure 6 provide the necessary resources when running training courses themselves see Box 10 4 How to ensure correct operation 4 HOW TO ENSURE CORRECT OPERATION Why is This Important If staff operate equipment correctly the equipment is less likely to become damaged and staff will therefore get the best performance out of it Staff can gain maximum benefit from equipment by knowing how to use it apply it in different situations take care of it 4 1 This Section covers how to ensure correct operation by discussing how to operate equipment Section 4 1 the correct application Section 4 2 care and cleaning Section 4 3 For all these issues there are likely to be national and international bodies which can offer guidance and regulations see Section 2 2 and Annex 2
110. amination Method 1 Cleaning It is essential to clean all contaminated items since the cleaning process makes the subsequent disinfection and sterilization more effective Cleaning gets rid of all visible dust and dirt removes organic matter which can reduce the action of disinfectants or sterilizing agents removes the breeding ground for surviving micro organisms protects against corrosion and rusting if the item is dried adequately ensures free movement of equipment parts Therefore it is important to observe the following strategies after use and before cleaning all items which can be immersed in water should be soaked to prevent deposits drying up and becoming more difficult to remove as different materials should be cleaned with either water only water and soap or water and detergent refer to the manufacturer s manual national guidelines and expert advice see Annex 2 after cleaning and before sterilizing or disinfection all items should be rinsed thoroughly with clean water and dried Method 2 Disinfection The two main disinfection methods are boiling and chemical disinfection The boiling method is chosen for items which can be immersed in water e can withstand high temperatures e can fit into a container for boiling If your items cannot meet these criteria the chemical method is used a Boiling This usually takes place in a special boiling pan boiler or a saucepan with a clos
111. analyzer Years 10 10 10 10 10 10 10 10 10 15 10 10 10 10 10 10 10 10 20 aon UO a Continued opposite Annex 8 Typical equipment lifetimes Table 8 Diagnostic and Treatment Departments continued Item Pulmonary function equipment Pulsed oxygen chamber Pulse oxymeter Pump Infusion Stomach Suction Surgical Vacuum Radiation meter Radioactive source cobalt Radiographic duplicating printer Radiographic fluoroscopic combination Radiographic head unit Rate meter dual Refractometer Refrigerator blood bank Resuscitator Retractor Rhinoscope Rinser sonic Rotoosteotome unit Saw Autopsy Neurosurgical Surgical electric Scale Bed Chair Clinical Scale metabolic Scintillation scaler Sensitometer Seriograph automatic Shaking machine vortexer Sharpener microtome knife Sigmoidoscope Signal averaged EKG Simulator Single photon emission computed tomography SPECT Scanner Sinuscope Skelton Years 8 10 Item Years Slide stainer laboratory 7 Spectrophotometer 8 Spectroscope 10 Sphygmomanometer 10 Spirometer 8 Stand Basin 15 Intravenous 15 Irrigating 15 Mayo 15 Steam pack equipment 10 Stereo tactic frame 5 Sterilizer movable 12 Steris sterilization system 7 Stethoscope 5 Stress tester 10 Stretcher 10 Hydraulic 7 Surgical shaver 5 Tank Cleaning 10 Full body 15 Hot water 10 Therapy 15 TDX analyzer 7 Telemetry unit cardiac 5 Tele
112. and country situation analysis Available from WHO Interregional meeting on the maintenance and repair of health care equipment Nicosia Cyprus 24 28 November 1986 WHO 1987 WHO document WHO SHS NHP 87 5 This document provides a comprehensive discussion of the problem of non functioning equipment and of proposed solutions The major policies recommendations and strategies proposed by the conference on the issue of maintenance and repair of health care equipment are presented It includes four Working Papers which cover in detail maintenance and management of equipment the proposed health care technical service manpower development and training Available from WHO Annex 2 Reference materials and contacts Management of equipment DHSS UK 1982 Health Equipment Information No 98 The aim of this booklet is to recommend a system of equipment management that if fully implemented would ensure that all equipment used in the British National Health Service was suitable for its purpose was maintained in a safe and reliable condition and was understood by its users Its recommendations and procedures are structured into sections on equipment selection acceptance procedures training servicing maintenance repair and modification and replacement policy It also covers the management of inventories equipment on loan servicing long term commercial contracts and infection hazards Available from Her Majesty s Stationery O
113. and storage tanks e Place hard water pads inside equipment such as pressure cooker type autoclaves to reduce the build up of scale Guaranteeing a Safe Water Supply The main water supply for many health facilities whether piped or from pumps is safe to drink in others it must be treated first to get rid of bacteria However this supply of water will not be sterile The water supply always contains some microbes and if it is allowed to stand for several days their numbers will increase Thus water for drinking and cleaning should always be drawn fresh and cleaning equipment should be stored clean and dry Even water that has collected in soap dishes usually holds high levels of bacteria Some clinical processes require pure water in the form of distilled or de ionized water As water purification is expensive it is necessary to know the level of purity required and to use precious pure water only for purposes that need it Depending on your geographical area your main water supply may be hard water water that has a high mineral or salts content These substances build up inside pipes and any equipment using water causing scaling furring and equipment corrosion Such effects can be a safety hazard such as blocking valves and can damage the equipment In order to prevent this build up hard water may need to be softened or a source of soft water such as rain can be harvested 5 4 5 4 1 5 4 Waste
114. anding Your Library see Annex 2 continued Strategy Type of Material Information Action Investigate other suppliers Make use of internet world sources for getting manufacturers local representatives wide web contacts where literature and possible as this method will international agencies information which you become more and more do not have links with health facilities abroad important in future If material is no Investigate these alternative longer available on sources of information Make paper find a more copies and print outs of the accessible format material and make it available to other facilities Scan single copies of user manuals Scan these documents into printed documents senice manuals your computer system and into a computer and make them more easily keep them as available to maintenance electronic copies technicians at many locations 3 5 DEVELOPING STAFF SKILLS Since so many new makes and models of equipment are coming out almost every year staff both users and maintainers need to continually update their skills Training for equipment operators will need to cover good practice when handling equipment basic dos and don ts Section 3 2 how to operate equipment Section 4 1 the correct application of equipment Section 4 2 care and cleaning Section 4 3 safety procedures Section 5 management of stocks and stores Section 6
115. any significant effect Therefore strategies may be required to bring about cultural and behavioural change For example When materials are short instead of focussing upon breakages and loss place more emphasis upon the importance of staff working hard and putting in the hours Favour good managers who are seen to be present and doing what they preach e Encourage an atmosphere where staff are praised for good work rather than a culture of judgement and criticism Introducing rules and administrative procedures alone will not be sufficient to bring about cultural change You will also need to find ways of increasing performance and productivity and acknowledging rewarding good behaviour is essential For example itis better to break a tool while actively undertaking maintenance rather than breaking nothing but never doing any work itis better to break a rule in an emergency such as withdrawing stocks from stores rather than stick to the rules and risk the possible death of a patient Annex 2 has some examples of useful reference materials Io bring about such changes you will require skills in managing change staff motivation effective communication encouragement o supportive training with demonstrations 2 2 2 2 Background conditions specific to this guide All parties involved in the network of HTM Teams and HTM Working Groups need to participate in developing the HTM Service This
116. ar inventory checks to look for missing equipment and accessories made responsible for conforming to the local security regulations for the facility and its site Section 7 1 ensure their staff have sufficient skills to operate and care for equipment correctly and safely and help them to access appropriate training or reference materials Sections 3 4 and 3 5 Operators in Charge during every shift made responsible for undertaking functional checks on the equipment as part of user Planned Preventive Maintenance PPM schedules Section 7 2 Equipment Users made responsible for the state of the equipment accessories and consumables they handle and use take personal responsibility for ensuring they operate equipment correctly and that they know the correct operating techniques and applications Sections 4 1 and 4 2 take personal responsibility for using the correct consumables in a non wasteful way Section 6 take personal responsibility for ensuring they operate equipment safely and knowing the proper safety procedures Section 5 made responsible for the daily care and cleaning of the equipment they use with the correct cleaning chemicals Section 4 3 made responsible for monitoring that equipment is functioning properly and is providing the type of results expected and reporting any faults immediately to the HTM Team through their Head of Section Section 7 4 ensure they have been specifically trained to underta
117. are simpler incinerators that are designed for smaller facilities such as a ready made two chamber pyrolytic incinerator the more traditional brick incinerator preferably with two chambers or a specially designed drum incinerator although this will be less efficient These types can be effective if certain technical principles are followed see Annex 2 The aim of incinerators is to provide high temperature combustion around 800 C with good ventilation over a long enough period to destroy infectious organisms This also reduces the volume and weight of waste down to ash ensuring that aesthetically offensive waste components such as blood materials soaked with body fluids or body parts are destroyed beyond recognition However poorly functioning incinerators do not achieve the desired results Box 32 overleaf discusses some issues to address in order to ensure safe incineration also see Annex 2 Country Experiences In Indonesia implementing strategies which have changed people s behaviour has resulted in a substantial and sustained decrease in the overuse of injections In Burkina Faso increasing the availability of clean disposable injection equipment through community pharmacies has almost eliminated unsafe injection practices Ina pilot project in C te d lvoire the introduction of small scale locally built incinerators and at the same time training of healthcare workers have successfully eliminated da
118. arts mechanical stage coarse and fine adjustments and the condenser focusing will need to be cleaned and lubricated with a drop of oil This can be done as part of user PPM Section 7 2 when other parts and alignments will be checked Staff will need to ensure they know the correct care and cleaning techniques for all the equipment they use or maintain and that they ask for help and training when necessary The HTM Working Group must consider care and cleaning training when purchasing new equipment and the possibility of incorporating such information and training into the package of inputs purchased with the equipment see Guide 3 on procurement and commissioning Box 17 contains a summary of the issues covered in this Section How to Operate Cc O 2 a ok lt x O oO _ _ O O Care and Cleaning Section 4 summary BOX 17 Summary of Procedures in Section 4 on Correct Operation Health Service allocates the user departments with sufficient consumable resources for the Provider operation of equipment Section 6 HTM Service ensures that all necessary service supplies electricity gas water etc are available are appropriate and are in a good condition before equipment is used Equipment Users ensure they know the correct operating techniques for the equipment they use Section Heads and ask for help and training if unsure and HTM Teams refer to operator manuals for guidance as wel
119. aterials are being handled Whether or not an infection occurs depends on a number of factors including the means of entry into the body the number of organisms entering the body and the immune status of the worker Figure 12 overleaf provides some strategies for establishing barriers that will block the routes of infection The extent of these barriers depends on the nature and to some degree the amount of the micro organisms that are handled in the laboratory Those that are unlikely to cause human disease require little more than good laboratory practice more to protect the work than the worker Those that cause serious disease require very strict containment using highly effective barriers Infections can spread through a number of routes Box 37 describes these routes and some strategies to avoid them BOX 37 Laboratory Infection Risks and Strategies to Avoid Them Entry through the skin Do the following e Cover all obvious cuts and abrasions with waterproof dressings Wash hands frequently but do not scrub them Use barrier creams Use disposable gloves Wear overalls Entry through the eye To avoid entry via the conjunctivae do the following Try to avoid splashes into the eye e Avoid rubbing the eyes with infected fingers Consider wearing safety glasses Continued overleaf 103 104 5 5 3 Laboratory hazards BOX 37 Laboratory Infection Risks and Strategies to Avoid Them continued Inhalati
120. ates and reorder levels Section 6 3 The procedures required for purchasing accessories and consumables are discussed in Guide 3 on procurement and commissioning This Section is aimed at anyone responsible for ensuring that adequate supplies of accessories and consumables are available Equipment users are most commonly responsible for this though in health systems where these needs have been neglected the HTM Service may have taken over this responsibility GENERAL DISCUSSION ON ACCESSORIES AND CONSUMABLES Besides accessories and consumables staff will also need access to equipment spare parts and maintenance materials Equipment operators need to use these items when undertaking user PPM planned preventive maintenance and the health facility may be responsible for their storage The specific discussion on equipment spare parts and maintenance materials is provided in Guide 5 on maintenance management However the discussion here on accessories and consumables covers similar issues of availability and storage procedures Health service providers must also ensure they supply staff with adequate safety gear needed to do their jobs such as gloves goggles masks overalls and boots In some health systems these items are purchased as general supplies and paid for out of administrative costs see Guide 2 on planning and budgeting and therefore are not strictly considered accessories and consumables 113 6 1 General discuss
121. ation Equipment related Infection Control 5 3 1 Decontamination 5 3 2 Linen Handling 5 3 3 Ensuring the Workplace is Clean Waste Management 5 4 1 Waste Management Philosophy 5 4 2 Managing Different Types of Waste Page ili vii 15 16 25 31 32 35 37 39 41 49 49 52 53 59 59 60 62 62 76 78 83 84 86 53 Control of Other Hazards 5 5 1 Gases 5 5 2 Electricity 5 5 3 Laboratory Hazards 5 5 4 Radiation Hazards 5 5 5 Fire 5 5 6 Accidents 6 Howto Ensure the Availability of Accessories and Consumables 6 1 General Discussion on Accessories and Consumables 6 2 Storage System and Procedures 6 3 Calculating Usage Rates and Reorder Levels 7 Howto Ensure Continuous Operation 7 1 Security 7 2 User Planned Preventive Maintenance PPM 7 3 Testing for Electrical and Mechanical Trustworthiness 7 44 Fault Reporting 7 5 Decommissioning Disposal and Replacement of Equipment 8 Howto Undertake Action Planning and Monitoring of Progress 8 1 Setting Goals Annually for Equipment Operation and Safety 8 2 Monitoring Progress With Equipment Operation and Safety Annexes 1 Glossary 2 Reference Materials and Contacts 3 Example of a Process Profile Common to Many Sterilizers 4 Example of a Supplies Order Form 5 Entering Items into the Stock Control System 6 Safety and Calibration Testing Instruments 7 Maintenance Work Request Job Form 8 Typical Equipment Lifetimes 9 Form for Registering Written
122. ation about the type of problem within the autoclave An alternative method when sterilizing fluids instruments or glassware is to use sterilizer control tubes containing fluid The fluid in the tube changes colour depending on whether the correct temperature was obtained for the correct time However these tubes cannot verify that steam was present Another drawback is that the sterilizer control tubes must be kept in a cool place preferably a refrigerator There are a number of ways of obtaining the correct process profile Validation means that the users compare Inthe case of new automatic machines the process profile their recorded results with a should be provided by the manufacturer correct process profile You can find and download common process profiles from the the results for a similar test load made in the same autoclave where sterilization was successfully achieved internet world wide web However as the profile needs to be specific to your machine the maintenance staff may need to check and alter it for your autoclave Annex 3 shows a process profile that is suitable for many types of common autoclave 5 3 1 Decontamination Figure 8 How to Make Up Your Own Bowie amp Dick Test Pack Do not use cloths that have been autoclaved and not laundered once again as they will lack natural moisture The cloths must be freshly laundered but without the use of fabric conditioner The cloths must be
123. ator or service manual but may need to be requested separately from the supplier see Guide 3 on procurement and commissioning PPM Schedules PPM schedules protocols or lists of activities need to be developed separately for both users and maintainers They should provide simple guidelines for all types of equipment covering the tasks to be undertaken in the following areas Care and cleaning Section 4 3 Safety procedures Section 5 Functional and performance checks e Maintenance tasks These guidelines should include timetables showing the frequency with which the activities must take place 144 7 2 User planned preventive maintenance PPM Box 56 provides some strategies for expanding your library of PPM schedules and hence your PPM work Another important task for Heads of Department or the training sub group is to convert the user PPM schedules into some or all of the following e Posters which can be placed on the wall beside the equipment Paper copies in plastic pockets attached to hung from the equipment itself This is known as an equipment card and should be kept permanently with the equipment It will also show the date of the next service due from the HTM Team see Guide 5 Laminated cards for the staff to carry around and refer to when carrying out PPM see Section 3 5 and Figure 7 BOX 56 Strategies for Developing PPM Schedules Type of Material Information
124. be cheaper than type B However the annual running costs for infusion sets for type A may be much more expensive than those for type B Thus it would be worth the higher initial cost to purchase pump B so that you can benefit from the lower running costs When choosing equipment which uses consumables you should try to use oper rather than closed procurement systems Open systems mean that anyone can supply the consumables for your equipment and different manufacturers consumables can fit your machine this competition leads to lower cost consumables Closed systems mean that the equipment and its consumables are only made by one manufacturer and you are limited to one supplier only this monopoly leads to more expensive consumables see Guide 3 on procurement and commissioning Other issues which will affect the functioning and cost of running your equipment are the availability of spare parts e a functioning in house maintenance service see Guide 5 on maintenance management the presence of a local representative of the manufacturer who can offer you support If there is no local support or source of supplies it will be much more expensive to continually get help and materials from abroad These issues should be considered when products are compared during the procurement process see Guide 3 on procurement and commissioning ACCESS TO INFORMATION AND REFERENCE MATERIALS It is important for staff to have ac
125. be taken if equipment is missing or abused and if particular individuals are the persistent cause of problems Good or bad performance when using equipment can then be used in the staff appraisal process Section S 2 Your response to good and bad performance will depend on local human resource policies and procedures your strategies for motivating staff Section 2 1 and whether you take a positive approach a disciplinary approach or a combination of the two One option is to take a positive approach which encourages good behaviour Staff who consistently treat their equipment well and take care of it are given a reward as an incentive This could be the chance to attend a skills development course or perhaps nomination as a trainer of others the strategies chosen would depend on the type of equipment involved For example individual staff members may be issued with diagnostic sets which are checked once a week or once a month Anyone who has a complete set every three or six months is given a bonus some batteries for example After five years the diagnostic set could perhaps become the property of the staff member 3 1 Accountability BOX 5 Strategies for Making Staff More Accountable Type of Staff Strategies Heads of Section given overall responsibility for the equipment in their section according to their inventory see Guide 2 on planning and budgeting for a description of the inventory and undertake regul
126. blood transfusion techniques required at district level Available from TALC THT Emergency Care Research Institute ECRI USA products This organization produces a variety of products on healthcare technology They are available as hard copy and as software regularly renewed by subscription with special rates for developing countries They cover various issues such as Inspection and preventive maintenance system Health devices alerts database international database of medical hazards problems and recalls of equipment Health technology monitor newsletter Healthcare product comparison system Health devices source book Health devices system Available from ECRI 181 182 Annex 2 Reference materials and contacts General surgery at the district hospital Cook J Sabkaran B and A Wasunna eds 1998 Dept of Surgery Eastern General Hospital Edinburgh Scotland ISBN 92 4 154235 7 Arichly illustrated guide to general surgical procedures suitable for use in small hospitals that are subject to constraints on personnel equipment and drugs The book presents an overview of basic principles and detailed information on simple but standard surgical techniques for the face and neck chest abdomen gastrointestinal tract urogenital system and paediatric surgery Lists of essential surgical instruments equipment and supplies are included Available from WHO How to look after a refrigerator Elford J
127. cal soil conditions and the depth of the water table Installation protection If the chosen method is a driven earth system the quality of earth is inconsistent because it is dependent upon soil conditions Thus the electrical installation needs further protection from some form of residual current device RCD that disconnects the supply when it detects small leakage currents to earth of between 10 and 300 milliamperes The RCD can be fitted at one of the following points At the main electrical incoming point for the whole installation Simple and cost effective protection but in the event of a fault the entire installation is disconnected On each distribution board DB More expensive but provides more localized protection and makes faults easier to find On each circuit The most expensive option but the most localized protection making faults easiest to find Advisable for sensitive areas with several pieces of medical equipment or the risk of using equipment near water Note earth leakage circuit breakers ELCBs sense current flowing from equipment to earth and automatically disconnect the supply when it exceeds a pre set value But if the equipment s earth connection has failed perhaps because it broke the ELCB does not work Thus RCDs are gradually replacing ELCBs RCDs work independently of the earth connection measure small imbalances in current flow to and from circuits and disconnect the supply when th
128. cess to written references to help them with their work It is common for such data to be missing from health facilities and for manuals arriving with new equipment to go missing We suggest you develop a library of professional literature reference materials and equipment manuals Box S provides some strategies for developing such a library although we recognize that following these recommendations will require time staff input and money 39 40 3 4 Access to information and reference materials BOX 8 Strategies for Expanding Your Library see Annex 2 Strategy Obtain literature which is usually available free of charge Type of Material Information manufacturers care and cleaning guidelines from manufacturers and their representatives safety guidance for specific machines from manufacturers and their representatives operation and safety guidance from national bodies Medical Nursing Council National Laboratory Fire Service etc see Section 2 2 For existing equipment find as many of these as possible Obtain literature from neighbours which with negotiation may be available for the cost of photocopying and postage operation and safety guidelines copies of manufacturers operator and service manuals for older machines Contact as many other health facilities and health service provider organizations in your country and neighbouring countries as possible to obtain existing
129. cessories and consumables come from abroad therefore you will need access to foreign currency Some organizations set up a revolving fund to help with the continual purchase of equipment related supplies spare parts accessories etc sometimes with assistance from external support agencies donors see Box 46 BOX 46 How a Revolving Fund Works The aim of a revolving fund is to keep a pot of money full so that you can buy equipment related supplies regularly The health service provider places initial capital in the fund so they can buy the supplies Local health facilities buy the supplies from the health service provider as they require them Their payments are put back into the fund in order to refill it Thus the fund is always available for further purchases of equipment related supplies A revolving fund can be set up to operate using local currency foreign currency or a mix of the two Seek assistance from external support agencies if necessary The fund can be primed pre financed with foreign currency in order to purchase equipment related supplies from abroad The initial priming of the fund with foreign currency can be done by your health service provider or with help from donors Either the health facilities which purchase the supplies pay for them in foreign currency if this is possible or the health facilities pay a local currency equivalent amount which is converted back into the foreign currency
130. cessory consumable cleaning material essential Can you work with the majority of your patients samples etc without this item Is there somebody available who is skilled enough to use the accessory consumable cleaning material You will need to order large quantities of items that are frequently used and fewer of items that are only used occasionally It is preferable not to stock items that are rarely used since it is not good to tie up your money in stocks that sit on shelves for years doing nothing Ordering too little understocking results in shortages your health facility will be unable to provide effective treatment and care as a result and staff and patient confidence in the service will be undermined Ordering too much overstocking results in a build up of stock and wastage of items that are not used before their expiry date for example or that become spoiled if left unused for too long as well as tying up valuable funds unnecessarily 6 3 Calculating usage rates and reorder levels The quantity of replacement accessories and consumables that you order depends on factors that you can anticipate such as e how much stock is normally used seasonal demands gt 6 how much work is planned or can be expected how often you place an order the storage capacity of your store You may also need to order a limited quantity of extra stocks of some items so that you can deal with unexpected events
131. ch could cover spare parts and maintenance materials an existing code for fuel and lubricants which will cover some maintenance materials a new code required for equipment accessories a new code required for equipment consumables any new code as required Develop an illustrated catalogue This should show equipment related items with descriptions and photographs or drawings together with their stores code Use a proper stock control system This ensures that you use some form of Stock Card in order to keep track of the stocks ordered and issued see below Ensure work orders clearly show the supplies required In this way you can check the amount and rate of use of supplies against the stock left at the time of the annual audit 123 6 2 Storage system and procedures BOX 49 Strategies for Creating Suitable Store Rooms Provide a space which is secure clean dry free from pests not too hot or cold well ventilated and not exposed to direct sunlight Provide enough space to store all the equipment related supplies and materials on shelves in cupboards or in containers such as bins If no shelving is available make your own shelves using planks of wood supported on bricks or crates Make use of the space in the middle of the room for shelves putting shelves only around the walls takes up a lot of space and wastes the space in the middle of the room Organization Organize the store in a s
132. chine is in the correct position Is it upright ona level surface Are the ventilation grills free of obstructions The jar has been sterilized and is undamaged If it is dirty cracked or chipped change it The float valve can move freely If it can t try cleaning it or get technical help from the HTM Team The filter is not wet or discoloured If so change the filter The patient s anti static suction tube has been sterilized If not get a new sterile one The jar lid or its rubber gasket is not broken or perished __ If it is change it The patient s suction tube is connected Attach it to the inlet nozzle on the jar lid The tubing is straight Ensure there are no kinks or knots in it There is no visible damage to the electrical lead and plug If there is call the HTM Team Connect the machine correctly to the electrical supply Plug it into the socket and switch on All connections are tight Ensure there are no obvious leakage points An appropriate vacuum suction rate is selected Turn the vacuum control knob and check the pressure gauge The vacuum gauge reading is not permanently low Discontinue use and obtain a replacement machine To use the suction pump do the following 1 Take the sterilized part which will enter the patient metal hand piece or suction catheter and attach it onto the free end of the patient s tube 2 Remove excess fluids from the patient as required 3 Stop sucking when
133. chnological knowledge of organizations and individuals involved in poverty alleviation projects and to develop information and knowledge management systems of organizations Global alliance for vaccines and immunization GAVI website www vaccinealliance org This global alliance produces a wide range of information including factsheets and the Immunization FORUM newsletter providing updates and topical debate about key immunisation issues Healthcare waste website www healthcarewaste org WHO site for health care waste management Health exchange website www healthcomms org Explores issues ideas and practical approaches to health improvement in developing countries and provides a forum for health workers and others to share viewpoints and experiences in this area HealthNet news website www healthnet org medpub Weekly newsletter distributed to health professionals in Africa Asia and Latin America Features current practical clinical and public health information HIF net at WHO discussion group Discussion list dedicated to issues of improving access to reliable health information in resource poor settings To join email your name affiliation and professional interests to health inasp info HINARI Health inter network access to research initiative website www healthinternetwork net WHO initiative offering free discounted access to journals from six leading publishers HNP flash website www worldbank org hnpflash A free monthly elect
134. ciated with the use of X rays and operate the X ray equipment accordingly The operator must use the correct X ray exposure techniques kV and mAs The operator must adjust the collimator to the size of the film The operator must use protective devices for the patient when appropriate The operator must protect him or herself behind the protective screen The operator must allow no one other than the patient in the X ray room during the exposure if the patient must be held or supported a lead apron and gloves must be worn by all who do this The operator must process the film according to good practice techniques following especially the time and temperature guidelines In the case of battery powered machines the operator must know how to regularly care for the batteries Maintenance Except for minor maintenance only specially trained and experienced service technicians or engineers should carry out maintenance and repair Do not service the equipment unless the main electricity supply is turned off Do not open the generator control console to attempt to make repairs Never use a fuse of a different rating or type from that recommended by the manufacturer If a fuse blows regularly inform the HTM Team or the manufacturer s representative Check protective lead aprons and gloves every six months for tears and cracks if necessary doubtful areas can be examined by X ray or fluoroscopy Do not purchase a spare X ray
135. countries use working groups while others call them standing committees and essential service packages may be called basic healthcare packages elsewhere For the purpose of these Guides it has been necessary to pick one set of terms and define them You can then modify them for your own situation The terms used throughout the text are outlined with examples in the Glossary in Annex 1 We appreciate that you may find it hard to pursue the ideas introduced in these Guides Depending on your socio economic circumstances you may face many frustrations on the road to achieving effective healthcare technology management We recognize that not all of the suggested procedures can be undertaken in all environments Therefore we recommend that you take a step by step approach rather than trying to achieve everything at once Section 2 1 2 Introduction to this specific guide These Guides have been developed to offer advice and recommendations only therefore you may wish to adapt them to meet the needs of your particular situation For example you can choose to focus on those management procedures which best suit your position the size of your organization and your level of autonomy For more information about reference materials and contacts for healthcare technology management see Annex 2 1 2 INTRODUCTION TO THIS SPECIFIC GUIDE The Importance of Operating Equipment Safely Healthcare technology is such an important part of healthca
136. ction 7 3 Fault reporting Section 7 4 o Decommissioning disposal and replacement of equipment Section 7 5 7 1 SECURITY Health Management Teams need to provide adequate security measures in order to ensure their equipment is always available for use A number of strategies should be pursued in order to try and prevent the loss and theft of equipment Box 53 lists some possible strategies depending on conditions in your country 137 138 7 1 Security BOX 53 Possible Security Strategies to Consider The compound The buildings Health facility compounds should have only one entrance if this cannot be achieved additional security guards will be required to cover all entrances Health facilities should have security guard cover 24 hours a day the Health Management Team will need to review the availability capacity and coverage of these guards Security guards should check vehicles leaving the compound All windows on the ground floor should have security grills bars fitted Upper storey rooms which contain expensive equipment and are vulnerable should have grill doors fitted As part of planned preventive maintenance PPM the HTM Team should ensure that doors and locks are trustworthy and in good condition at all times Room occupancy In the case of all departments or rooms used only during the day dental laundry kitchen main laboratory main pharmacy outpatient day clinics offices
137. d from the manufacturer their literature or your experience Then calculate the quantity used as follows Number of accessory Z used per year Numberz 12 months 12 7 Life of item Z or rate of use Lz In the examples above i Number of jars used each year Number 12 6 2 ii Number of finger probes used each year Numberg 12 4 3 iii Number of boxes of 50 patient plates used each year Number 12 0 25 48 iv Number of 100g tubes of gel used each year Numberp 12 0 5 24 ti Multiples according to the basic set Take into account the multiples in your basic set if applicable to allow for the way you work Then calculate the quantity required as follows Quantity of accessory Z required per year Quantityz Numberz x Multiple 7 From example ii above If your basic set of pulse oximeter finger probes is two one in use one being cleaned Multiple g 2 Thus quantity of finger probes required each year Quantityp 3x2 6 tii Totals according to the number of machines you own Consider the total number of similar machines you are buying accessories and consumables for N Then calculate the quantity required as follows Total quantity of accessory Z needed per year Total Quantity x N In example ii above Perhaps you have four pulse oximeters in use N 4 Thus total quantity of finger probes needed per year Total 6x4
138. d make decisions about the following issues see Box 27 overleaf for examples Which method to use What cleaning equipment to use The correct daily maintenance and sterilization of the cleaning equipment The frequency that different areas must be cleaned The appropriate cleaning agents and disinfectants to use and the correct concentrations The protective clothing required e Possible rationalization and standardization of cleaning materials in order to enable groups of health facilities to have common purchasing power Hygiene Practices in the Kitchen The regular cleaning of all the equipment in the kitchen has been discussed in other parts of this Guide Other equipment related issues to address and staff practices to introduce are Separate equipment such as knives chopping boards and slicing machines that are used for handling raw food from those used for cooked food so that microbes are not transferred to the cooked food causing food poisoning e Hand washing facilities with soap for kitchen staff so that they can wash their hands between handling different types of food between different activities and after going to the toilet e Adequate refrigeration through properly working refrigerators and cold store rooms Extraction hoods over cookers which are clean and working effectively 79 80 5 3 3 Ensuring the workplace is clean BOX 27 Strategies for General Cleani
139. d of them the skills required and possible ways to achieve promotion However it is important not to limit any individual to working at a specific level as this could seriously hamper the service A doctor must sometimes be prepared to help out with tasks such as nursing and cleaning activities To be able to recruit clinical and support staff with these skills there need to be sources of basic training in your country or geographical region Section 3 5 discusses the sorts of basic training required its availability and your ability to access such courses will depend on the country you live in It is important for there to be modules on the basic training courses which teach equipment specific skills however this will depend on the strategies that have been adopted by your training authorities Recurrent Funding Equipment only remains operational and safe if adequate recurrent budgets are planned and allocated by your health service provider These budgets need to cover all equipment related expenditure requirements including the supply of accessories consumables spare parts protective clothing test equipment e reference materials Guide 2 of this Series provides advice on how your health service provider can plan and budget for recurrent costs You will need to work within the financial resources allocated to you In addition you will have to follow the financial policies and procedures of your organization in order to ens
140. das laundry bird droppings and occasionally dead birds can foul the water supply if the roof to the water tank is broken use wire netting across openings to keep birds out of the health facility regularly maintain water tank covers and roofs Flies and mosquitoes flies breed in dustbins and garbage bags and contaminate food mosquitoes breed in any stagnant water and spread malaria seal rubbish in plastic or paper bags and put in bins with lids wash and dry rubbish bins do not let puddles and water that has collected in open containers stay standing for long Bees wasps and hornets make their nests in partially enclosed areas and the nest wraps around parts of equipment have made nests under the roof eaves around telephone and electricity cables in the wiring of distribution boards etc keep a watch out for insect nest building destroy the nests when they are in their early stages and are therefore still small make their nests in roofs especially in buildings of simple design where access is easy are carriers of disease and can foul areas of your health facility with their droppings cover openings with mosquito netting if an uninterrupted form of fixing can be found investigate chemical and ultrasound deterrents in the long term alter building designs to avoid admittance 81 5 3 3 Ensuring the workplace is clean Figure 9 Ways of Improving the Quality of Water T
141. dder Paper shredder Partitions movable office Photocopier Small Large Piano Projector Overhead Slide Video Recorder tape Safe Scale postal Screen projector Settee Table 7 Nursing Departments Nursing departments consist of cardiac care chemical dependency intensive care medical surgical care neonatal intensive care nursery pediatrics pediatric developmental disabilities and psychiatric units Item Bassinet Bath Sitz Whirlpool Bed Birthing Electric Flotation therapy Hydraulic Labor Manual Orthopedic Bench metal or wood Bin metal or wood Blood pressure device electronic Bookcase metal Years 5 10 10 8 10 5 5 10 20 10 10 20 10 10 12 Years 15 10 10 15 12 10 15 15 15 15 15 15 6 20 Item Shelving portable steel Sofa Stamp Machine Stapler electric or air Stencil machine Stereo equipment Table Folding Metal or wood Television receiver Time recording equipment Transcribing equipment Typewriter electric Valet office Video cassette recorder player Walkie talkie Water cooler bottle Word processor Large Small Work station Item Cabinet Bedside File Instrument Metal or wood Pharmacy Solution X ray Central supply furniture Chair Blood drawing Dental Executive Folding Geriatric Hydraulic surgeon s Years 20 12 10 10 Years 15 15 15 15 15 15 15 15 10 15 15 10 10 15 Continu
142. de for planners and implementors GTZ Eschborn Germany Health and Safety Executive 1989 Essentials of health and safety at work HMSO Books London UK ISBN 0 11 885494 1 Huys J 1996 A guide to power conditioning and power back up produced by FAKT Basler Mission and HEART Consultancy Stuttgart Germany Huys J 2003 Sterilization of medical supplies by steam volume 1 General theory 2 edition HEART Consultancy Renkum The Netherlands ISBN 90 75829 04 3 International Electrotechnical Commission IEC medical electrical safety standards IEC 60101 website www iec ch Annex 10 Source material bibliography Jantsch F and H Vest 1999 Management of solid and liquid waste at small healthcare facilities in developing countries GATE Information Service Division 44 Environmental Management Water Energy Transport GTZ Eschborn Germany Johnstone P and J Ranken 1994 Management support for primary health care A practical guide to management for health centres and local projects FSG Communications Ltd Cambridge UK ISBN 1 87118 02 4 Kaur M and S Hall 2001 Medical supplies and equipment for primary health care A practical resource for procurement and management ECHO International Health Services Limited Coulsdon UK ISBN 0 9541799 0 0 Kwankam Y et al 2001 Health care technology policy framework WHO Regional Publications Eastern Mediterranean Series 24 Health car
143. ded bodies such as professional associations which apply government sanctioned regulations Most governments would agree that the protection of health and the guarantee of safety of health services is vital However in many countries this regulatory function is underdeveloped with weak legal and regulatory frameworks To regulate health services the government should adopt suitable quality standards for all aspects of health services including acceptable international or national standards for healthcare technology drugs and supplies in order to ensure their efficacy quality and safety establish systems to ensure standards are met so that the bodies enforcing regulations have legal sanctions they can use if standards are infringed e establish wide ranging policies covering all aspects of the utilization effectiveness and safety of healthcare technology drugs and supplies establish systems to ensure these policies can be implemented 2 1 Framework requirements for quality health services For health services the Ministry of Health is the body most likely to develop these government regulations Other health service providers need to be guided by government laws and should look to the Ministry of Health for guidance or follow their direction if required to do so by law or regulation Establishing Standards for your Health System The government should agree on which quality standards have to be met by the health
144. dit new modules Health colleges who provide basic training for nurses doctors physiotherapists etc can introduce new modules aimed at developing equipment related skills for equipment users Provide opportunities for practical on the job experience Practical experience with or without supervision provides excellent training as long as it is targeted at the right skill level When a piece of equipment is not in use staff should be encouraged to familiarize themselves with the equipment and learn its principles and its different applications Continued overleaf 43 44 Strategy 3 5 Developing staff skills BOX 9 Strategies for Developing Equipment Skills continued Advantage Disadvantage Provide opportunities for studying and teaching Books manuals and articles from journals will answer many questions on principles of operation and care for different types of equipment see Annex 2 If staff are given opportunities to study with a little pressure and an expectation that they will lecture to colleagues afterwards the benefits for individuals can be great Let different types of staff nurse radiographer laboratory technician etc attend their peer group meetings This allows staff to share experiences regarding equipment to learn from their colleagues and to develop a professional approach to work The meetings will be available nationally and internationally Provide various traini
145. dried and aired for at least one hour Obtain 36 freshly laundered cotton cloths for example theatre or Mayo cloths Fold them to A4 size Stack 18 of the folded cloths one Criss cross four pieces of autoclave tape standard heat sensitive on top of the other autoclave tape from corner to corner and from side to side On the top of the 18th cloth place as shown autoclave tape in a special cross pattern see diagram Place the remaining 18 folded cloths on top Compress and wrap all 36 cloths into a pack and seal it with tape The pack should be about 25 cm high and weigh about 7 kg Autoclave the pack in the centre Always use the required temperature for the required length of of an empty autoclave time as per the instructions for the autoclave s normal cycle Do not place it on stainless steel as this will cause condensation to gather at the base of the pack unless the stainless steel surface is covered first Allow the pack to cool on an acceptable surface If the autoclave tape has evenly changed there is no problem with the autoclave Open the cooled pack and However if there are differences in intensity in the tape changes assess the findings on the this indicates that there are air pockets in the autoclave criss cross tape preventing total steam penetration This means that there is a problem and the vacuum is defective and not removing the air from the chamb
146. ducts ECRI Plymouth Meeting USA Elford J 1992 How to look after a refrigerator Healthlink formerly AHRTAG ISBN 0 907320 07 4 Ellis J 1999 Human resources policy and procedure manual KANDO hospital management project Ministry of Health Zambia DFID Ziken International Consultants Ltd Lewes UK 225 226 Annex 10 Source material bibliography Eschmann 1975 Matburn GX series operation table instruction manual Eschmann Bros and Walsh Ltd Lancing UK Eschmann 1980 DV110 series portable high low vacuums surgical suction units User handbook Eschmann Bros and Walsh Ltd Lancing UK Eschmann 1989 Sterilization techniques and cross infection Eschmann Bros and Walsh Ltd Equipment Division Lancing UK Eschmann 1990 J4 operation table instruction manual Publication No T IM27A Eschmann Bros and Walsh Ltd Lancing UK Eschmann 1992 VP25 portable high vacuum suction unit User handbook Eschmann Bros and Walsh Ltd Lancing UK Eschmann 1996 SES 2000 autoclave service manual ST SM8 Eschmann Bros and Walsh Ltd Lancing UK European Committee for Electrotechnical Standardization CENELEC website www cenelec org European Committee for Standardization CEN website www cenorm be FAKT 1995 The equipment management cycle A new tool for planning health care technical services FOCUS No 12 June 1995 FAKT Stuttgart Germany Haddon B 1995 A
147. dures and waste disposal regulations local fire service authorities which develop fire regulations and guidelines the national body responsible for the regulations and standards for electricity supply and electrical installations Infection and hazard control committees are required in the health service at district level and at facility level depending on the size of the facility They need access to international data on hazards Feedback is available on hazards from international sources in the form of international Alert reports see Annex 2 The central level of your health service provider organization will need to subscribe to the sources of this literature and make it accessible to health facilities With guidance from government your health service provider needs to take overall responsibility for safety issues within its facilities from a management and legal viewpoint Section 2 1 since the health service provider is the body that people will make claims against if there are any adverse incidents Effectiveness of Equipment This Guide defines effectiveness as the appropriate use of equipment and its availability for use Section 3 3 It does not attempt to cover cost effective delivery of healthcare Measuring the cost benefits of effective healthcare delivery requires special monitoring techniques It is an enormous subject and is not the main scope or aim of this Guide Guide 2 however covers how to eff
148. e Vacuum cleaner Vegetable peeler electric Vending machine Vise large bench Warmer Dish Food Washing machine Commercial small Domestic Linen large Welder Wire tightener twister Years 10 12 10 10 10 10 20 10 10 10 10 15 10 10 Annex 8 Typical equipment lifetimes LIST 2 The GTZ German Government Technical Aid Agency Source Halbwachs H GTZ 2000 Maintenance and the Life Expectancy of Healthcare Equipment in Developing Economies in Health Estate Journal March 2000 pp 26 31 The GTZ list contains estimates for fewer equipment items but it more closely reflects the realities in developing countries The GTZ used a particular research method a Delphi survey see source paper to obtain and analyze feedback from 23 experts from 16 different country backgrounds The experts were made up of hospital engineers bio medical engineers a public health doctor manager health physicists and an health economist Rather than providing exact lifetimes this approach provides a range for the lifetime that depends on the quality of the initial equipment and how well it has been maintained Reproduced here is a table containing a summary of their findings Table Summarizing GTZ s Findings Equipment type Poor quality makes Good quality makes Poorly Well Poorly Well maintained maintained maintained maintained Air conditioner window type Anaesthetic machine Boyles Centrifuge G
149. e Echocardiograph system Echoview system Electrocardiograph Electrocardioscanner Holter monitor scanner Electroencephalograph Electrolyte analyzer Electromyograph Electrophoresis unit Electrosurgical unit Ergometer Evacuator Evoked potential unit Exercise apparatus Years 5 N OU WM W NNN UN N Item Years Exercise equipment outdoor 10 Exercise system computer assisted 5 Exerciser orthotron 10 Eye surgery equipment phacoemulsifier 7 Fibreoptic equipment 5 Fibrometer 7 Film changer 8 Film viewer 10 Flow cytometer 5 Fluid sample handler 5 Fluorimeter 10 Fluoroscope 8 Frame turning 15 Furnace laboratory 10 Gamma camera 5 Gamma counter 7 Gamma knife 10 Gamma well system 7 Gas analyzer 8 Gastroscope 3 Geiger counter 10 Generator 5 Gloves lead lined 3 Hand dynamometer 10 Heart lung system 8 Heat sealer 5 Hemodialysis unit 5 Hemoglobinometer 7 Hemophotometer 10 High density mobile film system 10 Holter Electrocardiograph 7 Electroencephalograph 7 Homogenizer 10 Hood exhaust or Bacti 10 Hydrocollator 10 Hydrotherapy equipment 15 Hyfrecator 10 Hyperbaric chamber 15 Hypothermia apparatus 10 Image analyzer 5 Continued overleaf 217 Annex 8 Typical equipment lifetimes Table 8 Diagnostic and Treatment Departments continued Item Image intensifier Immunodiffusion equipment IMX analyzer Incubator laboratory Inhalator Intraarterial shaver Iontophoresis unit Isodensitomet
150. e but not dripping wet cloths sponges scrubbing brushes buckets and mops wet vacuum pick ups scrubbing machines polishers etc Do not use brooms dusters dry mops etc as these dry cleaning methods whisk dust and microbes into the air and increase the risk of infection Care and cleaning of All cleaning equipment must be sterilized regularly and maintained because the equipment the equipment itself is a breeding ground for microbes e the equipment can spread the microbes further around the facility e the cleaning water must be regularly changed for fresh water otherwise you are simply moving dirt from one place to another and stagnant water breeds microbes redistribution of dirt is time consuming but it is not cleaning and therefore it might as well be left undone Controlling Infestations by Vermin There are a number of pests that are commonly found in health facilities All of them carry microbes on their bodies and their droppings are microbe laden In addition many of them get into and damage equipment Box 28 provides some examples and strategies for controlling them Cleaners must report signs of pests immediately If steps are not taken to remove the pests efforts to clean areas frequented by them are a waste of time The regular removal of litter is essential for reducing vermin Section 5 4 5 3 3 Ensuring the workplace is clean BOX 28 Strategies for Controlling Vermin Rats and mice are attracted to
151. e fitting lid Box 21 describes the safety issues that must be addressed when using boilers if disinfection 1s to be successful 5 3 1 Decontamination BOX 21 Safety Issues When Using Instrument Boilers DO DON T fill the boiler with clean water load the boiler with many items touching each other separate the items so that they are not 8 R as disinfection will not touching each other or the sides of the boiler be guaranteed and open hinged instruments 8 boi boil without enough water to cover the items completely with sufficient 8 cover the items as this will water that cannot boil dry damage the boiler and the items boil the items for the required time which will vary from 10 60 minutes depending on your add any items during the boiling cycle as this will contaminate the existing items and you will height above sea level 8 y lt a F need to start timing from the beginning again time the boiling period from when the water boils a thii i i time the boiling period from the time the water if boiling stops for any reason such as a i 8 Stop y starts to be heated otherwise the items will not ower cut you must restart the process again P y P 8 be disinfected from the beginning leave disinfected items in the water because it allow the boiler to cool down before draining can easily become re contaminated the hot water to avoid scalds disinfect by boili
152. e surface of the fluid Ingestion Do the following swallowing Ban mouth pipetting use pipetting devices instead Provide hand basins and encourage hand washing to break the hand to mouth route of infection Ban eating drinking and storing food in the laboratory as contamination is too easy Ban smoking and the application of cosmetics in the laboratory since they provide opportunities for organisms to transfer from contaminated fingers to the mouth Injection Do not use hypodermic needles and syringes in place of pipettes If necessary obtain instruments which remove septum caps so that pipettes can be used automated equipment which uses needle probes to take samples from septum capped bottles without fitting a shield glass pasteur pipettes as hands are easily stabbed use soft plastic ones instead poor quality culture tubes which may break when stoppered and inoculate staff buy better quality items instead chipped culture tubes the rims of which may be contaminated and inoculate the operator have a glassware inspection routine and regularly discard condemned glassware 5 5 3 Laboratory hazards Figure 12 Basic Microbiological Safety Strategies ee a eee e good laboratory practice which minimises the possibility of organisms escaping from their culture vessels even with the best methods accidents and escapes do occur disinfectants that deal immediately with accidents and escap
153. e technology management No 1 ISBN 92 9021 280 2 Lee P 1995 Get it right A guide to maintenance safety precautions and hygiene of medical equipment draft ECHO International Health Services Ltd UK unpublished Linden E van der 1996 MOHSS laundry services feasibility study First draft Namibia integrated health programme Trend Line Economic and Management Services Windhoek Namibia Maurer I 1990 Hospital hygiene 3rd Edition Edward Arnold London UK ISBN 0 7131 4443 2 McGloughlin B 1999 Finance and procurement policy and procedure manual KANDO hospital management project Ministry of Health Zambia DFID Ziken International Consultants Ltd Lewes UK Medicines and Healthcare Regulatory Agency of the UK MHRA website www mhra gov uk MHRA 2005 Medical device alerts series Medicines and Healthcare Regulatory Agency Products MHRA London UK Ministry of Health of Botswana 1991 Central medical stores ordering lists 1991 1992 MOH Gaborone Botswana Modi N 1986 A guide to phototherapy for neonatal hyperbilirubinaemia Air Shields Vickers Basingstoke UK Muis B Bruijn ACP de Drongelen AW van and J Huys 2001 Optimalisation of the process for manually operated jacket steam sterilizers RIVM report 318902011 RIVM Dutch Institute for Public Health and the Environment Bilthoven The Netherlands Neureiter J and A Tschank 1989 Technician s handbook for hos
154. e workshops This will create a network that supports the needs of all your health facilities Maintenance is of course only one of many HTM activities that need to be carried out However the fact that maintenance workshops usually already exist in most countries serves as a useful starting point for establishing a physical HTM Service across your health service provider organization and across your country For more details on how to organize an HTMS refer to Guide 1 2 1 Framework requirements for quality health services Finances To ensure that healthcare technology is utilized effectively and safely throughout its life your health service provider will need to plan and allocate adequate capital and recurrent budgets See Guide 2 for more advice on this In a government organized system these funds have to be provided by government budgets while private systems or mixed systems must generate the required funds from their customers or from benefactors and donors Depending on your health service provider and country your HTM Service may be able to generate income by charging for services provided Whether this income can be used to further improve the HTM Service depends on the policies of the responsible financing authority such as the treasury or central finance office Guide 6 provides advice on this The Importance of Introducing a Healthcare Technology Management Service We have established the importance of adopting
155. ealth SCIH Swiss Tropical Institute Socinstrasse 57 PO Box CH 4002 Basle Switzerland Tel 41 61 284 82 79 fax 41 61 271 86 54 email martin raab unibas ch website www sti ch francais scih scih htm Undertakes consultancies in healthcare technology management in developing countries and countries in transition TALC Teaching Aids at Low Cost PO Box 49 St Albans Herts AL1 5TX UK Tel 44 1727 853869 fax 44 1727 846852 email talc talcuk org website www talcuk org UK registered non profit charity specialising in supplying affordable books slides and teaching aids on health and community issues in developing countries with a particular focus on materials for PHC and district levels Third World Network Email twnet po jaring my website www twnside org sg The Third World Network is an independent non profit international network of organizations and individuals involved in development issues Its website offers articles and position papers on a variety of subjects related to developing countries including trade health biotechnology and bio safety Transaid Transport for Life 137 Euston Road London NW1 2AA UK Tel 44 20 7387 8136 fax 44 20 7287 2669 email info transaid org website www transaid org A charity working in the field of international transport management Thus unique organization works with many sectors including health to ensure that transport resources are efficiently and effectively used
156. ection 5 5 4 fire Section 5 5 5 accidents Section 5 5 6 gt There may well be other hazards that you will have to develop strategies for We suggest that the central HTM Working Group or its smaller safety sub groups Section 1 2 should be responsible for establishing policies and guidelines in all safety areas It will have to consult with the relevant national authorities that provide guidance in these areas Section 2 2 The facility level HTM Working Group or its smaller safety sub groups needs to develop and implement good safety practices Gases Health facilities often contain a variety of cylinders which may contain various fuels and gases under pressure such as oxygen medical air carbon dioxide propane LPG acetylene Various strategies are shown in Box 33 overleaf for the safety of gas cylinders because they can be hazardous for a number of reasons They contain a flammable substance Their contents are contained under pressure They are heavy 6 Their invisible contents may leak Some health facilities may have oxygen concentrators and or piped gas as well as cylinders They will require similar safety strategies to keep flammable sources away to prevent liquid getting into the equipment and to test for wasteful leaks In addition hazardous materials can give off fumes such as chemicals and solvents A number of strategies should be pursued such as f
157. ectively plan and budget for healthcare technology and will help you to deliver the healthcare that you wish to provide 2 2 Background conditions specific to this guide Healthcare technology represents a substantial asset for your health service provider that needs to be managed efficiently Health facilities need sufficient functioning items of equipment which support the efficient and effective delivery of patient care Under provision threatens the effective treatment of patients Equipment can involve risks to patients and staff particularly if it is not used properly Thus the quality of care delivered to patients is dependent upon how effectively you purchase manage and use your equipment Staffing and Skills Levels If your health service provider is to guarantee the correct and safe use of its equipment it needs to recruit enough staff with the necessary skills Section 3 5 Adequate training for equipment operators and managers is necessary if you are to fill the wide variety of health service posts and ensure specialists for many disciplines are available It will be very difficult to ensure effective and safe equipment operation without sufficiently skilled staff Thus your organization will need to offer adequate recruitment packages so that staff can be retained in employment Ideally your health service provider will be able to pursue strategies Section 8 2 to motivate staff evaluate staff performance use staff app
158. ectives each year in HTM Teams and order to improve their performance after reviewing the previous year s HTM Working Groups performance develop suitable measurement indicators for these goals and gather baseline data Setting Goals participate in the annual action planning seminar Health Service ensures the Health Management Information System is developed to include Provider factors which measure progress with equipment Heads of Department ensure progress against annual goals is monitored displayed and used to and Safety provide feedback to department group staff as well as to develop improved Sub Groups goals for the following year decide on suitable equipment related statistics which are informative and easy to gather use incident reports attendance figures and departmental records to gather and compile statistics enter them on Statistics Forms and file them in Statistics Folders use the statistics when reporting to management monitor staff s good and bad performance in relation to equipment and feed it into the staff appraisal system no p D O x a D cC O Cc O Health Management ensure that progress against any goals annual or regular is used to prompt the Teams correct response such as training better budgets different suppliers career progression etc analyze the information in the Accident Record Book or Incident Forms to develop a combination of strategies which will address
159. ed 57 5 How to ensure safe operation 5 HOW TO ENSURE SAFE OPERATION Why is This Important Every different type of equipment has its own safety requirements and it is necessary to make sure equipment does not become hazardous to you or your patients Equipment also has a role to play in various safety strategies around the health facility Thus Health Management Teams need to guarantee the safety of patients staff and visitors by introducing safety procedures for equipment relating to the use of equipment how to behave around equipment national health and safety at work legislation 5 1 GENERAL DISCUSSION ON SAFETY There are many different types of equipment safety issues that need to be addressed by your health service provider Although many of these safety areas are inter related for the purpose of this Section we have grouped them under the following headings Specific hazards when operating different equipment Section 5 2 Infection control issues which relate to equipment such as decontamination linen handling and ensuring the workplace is clean Section 5 3 Waste management issues relating to equipment such as separation of general and hazardous waste and the handling treatment and disposal of waste Section 5 4 Other equipment related hazards such as gases electricity radiation laboratories fire and accidents Section 5 5 The security of equipment and testing for its
160. ed with the cylinder valve open as the excessive pressure will Ensure the cylinders are colour coded and stamped correctly A i severely damage the thread according to the standard laid down by the national governing authority dismantle a cylinder valve or re adjust a pre set pressure regulator Ensure the valves are free from oil grease moisture and dust on if either of these develop a leak Ensure the correct key or spanner of similar length not more they must be replaced than 150mm is available for opening valves severe damage can ee P 8 8 check for leaks using oily soap as be caused if the wrong tool is used this can create an explosive Close the cylinder valve when the equipment is not in use mixture otherwise the life of the regulator will be shortened PE use jointing compounds or tape to Check regularly for leaks listen for a hissing noise and with a mend a leak toothbrush apply detergent solution e g 0 5 on the suspect area and look for small bubbles which appear at the leakage point 5 5 2 Electricity Electrical Installations and Earthing Human and animal bodies are electrical conductors The passage of electrical current through the body can cause burns or such severe muscle cramp that the victims are unable to free themselves from the point of contact If electricity flows through the human heart see Figure 10 overleaf it causes irregular heartbeats If it is not possible for s
161. ed on the wall beside the equipment e Laminated cards or paper in plastic pockets attached to hung from the equipment itself e Laminated cards showing User PPM schedules for the staff to carry around and refer to when carrying out User PPM Section 7 2 e Acetates for use with overhead projectors OHP so that the training courses can be run and rerun for refresher training purposes e PowerPoint presentations a developing computer tool and video computer projectors for larger institutions who often make presentations the modern OHP Videos can form a useful resource for re training as back up and for reference etc If the video is to be of use it is important that suitably experienced professionals undertake the filming Investigate the possibility of hiring a video camera and cameraman from persons who currently undertake the videoing of such technical activities Buy ready made training videos Keep copies of the training resources produced together in one place Obtain these from manufacturers and other sources or example electrical safety RS Components safe handling of medical gases BOC care and use of the microscope Olympus refer to Annex 2 Choose a suitable location for storing the various resources handouts posters laminated cards overhead acetates videos computer files Possibilities are the office of the n Service Training Coordinator HTM Manager or Human Resource Man
162. ed opposite Table 7 Nursing Departments continued Item Chair continued Kinetron Podiatric Shower bath Specialist s Chart rack Chart recorder Clothes locker Fibreglass or metal Laminate or wood Computer caridial output Credenza Crib Croupette Defibrillator Desk metal or wood Doppler Dresser Food service furniture Frame turning Housekeeping furniture ICU and CCU furniture Infant care center In service education furniture Insufflator Labor and delivery furniture Laboratory furniture Lamp Bilirubin Emergency Lawn and patio furniture Light Delivery Examining Portable emergency Natural childbirth backrest Nursing service furniture Operating room furniture Years 15 15 10 15 20 Item Operating stool Ophthalmoscope Osmometer Otoscope Ottoman Patient monitoring equipment Phototherapy unit Physicians in and out register portable Physiological monitor Pump breast Scale baby Settee Shelving portable steel Sofa Stall Bars Table Anaesthetic Autopsy Electrohydraulic tilt Examining Folding Food preparation Fracture Instrument Light Metal Obstetrical Operating Orthopedic Overbed Pool Refrigerated Therapy Traction Urological Wood Telemetry unit cardiac Thermometer electric Ultrasonic fetal heart monitor Work station Annex 8 Typical equipment lifetimes Years 15 10 10 10 10 10 10 15 12 20 12 15 15 20 10 15 10 15 15 1
163. effective healthcare technology management There are various framework requirements to help you do this These include legislation regulations standards and policies These framework requirements create the boundary conditions within which you undertake healthcare technology management They include central or national guiding principles policy issues and high level assumptions that can impede or assist you in your work It is very difficult to function effectively if these framework requirements do not exist and you should lobby your organization to develop them Depending on how autonomous your health facilities are you may be able to develop these framework requirements at facility region district or central level In most industrialized countries laws regulations policies and guidelines form an indispensable part of health service management For many developing countries however these regulatory procedures have yet to be developed Guide 1 provides a fuller analysis of how to develop these instruments and shows that effective healthcare technology management HTM is essential in order to deliver quality health services Section 2 1 summarizes these points and offers advice on the regulatory role of government establishing standards for your health system policy issues for HTM the importance of introducing an HTM Service o managing change Section 2 2 goes on to discuss the background conditions
164. efore it is treated on site or transported to centralized waste handling sites outside your facility Thus you will need a suitable storage place for the waste Waste type A should be kept in its usual type of container but protected from weather and scavengers The collection points should be fenced roofed and protected from the wind Waste types B C and D require special storage facilities lockable to prevent unauthorized access large enough to store the volume of waste gathered between collection dates with enough space for movement of the carts used to move the waste well lit well ventilated and as cool as possible protected from the sun or even air conditioned walls and floor to be waterproof smooth rustproof well drained easy to clean and disinfect located well away from fresh food stores and food preparation areas chemicals and radioactive agents should be kept separate from other infectious waste in a separate room or locked cupboard On site treatment Not necessary for waste type A The main treatment methods for waste of category B C or D are disinfection and incineration Radioactive waste should never be treated on site but should be collected and taken to an appropriate treatment site Some liquid chemicals may be neutralized or diluted Sewage and wastewater treatment systems include pit latrines septic tanks aeration ponds biogas plant seedbed purification etc
165. eger Stierle gtz de Website http www gtz de de 4030 htm Friedeger Stierle is the contact for the GTZ s healthcare technology management programme and any articles or documents on HTM Healthlink Worldwide Cityside 40 Adler Street London E1 1EE UK Tel 44 20 7539 1570 fax 44 20 7539 1580 email info healthlink org uk website www healthlink org uk Publishes a range of free and low cost newsletters resource lists briefing papers and manuals about health and disability Publications include HIV testing a practical approach which is a briefing paper on HIV counselling and laboratory testing HEART Consultancy Quadenoord 2 6871 NG Renkum The Netherlands Tel 31 317 450468 fax 31 317 450469 email jh heartware nl website http www heartware nl Consultancy firm working in all aspects of healthcare technology management in developing countries It also produces and supplies the PLAMAHS software package for managing the inventory model lists maintenance and procurement needs for your healthcare technology stock HEART also undertakes research and training and produces publications on many aspects of sterilization for developing countries It has developed a basic testkit for performance testing of sterilizers and can identify suppliers that still manufacture basic sterilizers manually operated fuel heated HMSO Her Majesty s Stationery Office Website www hmso gov uk Publishers of material produced by departments o
166. electrodes clean of lubricants and fluids Store accessories carefully in appropriate places pouches holders etc Store small items properly when they are not in use keep diagnostic sets in their cases for example Remove batteries when battery operated items are not in use in order to avoid corrosion for example ophthalmoscopes doppler heart rate detectors Take apart items that disassemble easily and clean internal parts for example unscrew stethoscope earpieces and remove aural wax detach and clean the valves on ambu bag resuscitators Store lenses such as microscope objectives and eye pieces with a desiccator such as silica gel sachets to prevent fungal growths In the case of items that need water to operate such as water stills and autoclaves always check that water is present before switching the item on Check that oxygen bottles are free from oil and grease which can cause explosions Each type of equipment will have specific care and cleaning instructions Box 16 provides an example of the type of instructions required when cleaning and caring for a microscope 55 56 4 3 Care and cleaning BOX 16 Example of Care and Cleaning Instructions for a Microscope S these may vary and require additions depending on the make and model WD Daily DO Dust optical surfaces condenser objectives eyepieces using a blower or soft camel hair brush Remove immersion oil from the objective at the
167. elop and implement good infection control practices Box 20 provides some important strategies 5 3 1 Decontamination BOX 20 Decontamination Strategies e Establish a definite policy for hand disinfection covering all staff being made aware of the method of washing hands between attending to patients using soap alcohol impregnated tissues or 70 alcohol spray all staff including maintenance staff being made aware of when and how to use surgical gloves and or rubber household gloves Equipment must be decontaminated by an appropriate method both after use and between uses for example between one patient and the next and before maintainers are expected to handle or repair it Decontamination of medical equipment such as suction pumps must be addressed by the user department as equipment operators know what the equipment has been used for in order to prevent cross contamination due to improper cleaning and improper disinfection General handling of infectious agents blood body fluids infectious organisms etc to be addressed by a Waste Management and Hygiene Plan Section 5 4 Decontamination of equipment should be controlled by a central department or group of people in the health facility to ensure that correct methods are followed and that sterility is achieved when required Such a department should be the Central Sterile Supplies Department CSSD with advice from the infection control committee All staff invo
168. end of each day using a small amount of mild soap solution Clean grease from lenses only using lens paper or medical cotton wool For stubborn dirt absolute alcohol ethyl alcohol or methyl alcohol can be used but handle carefully as it is flammable Dust the body of the microscope and then clean with a small amount of mild soapy water and dry thoroughly Store the microscope under a dust cover at night and when not in use In humid environments store the microscope in an air tight plastic cover with blue silica to absorb moisture This prevents the growth of fungus If the silica turns pink the item is moist and should be dried out in a hot air oven General care DON T e Use your fingers as they are greasy Use other materials tissue paper rags etc on lenses as they may scratch the surface Use ethanol acetone or xylene to clean lenses as they can dissolve the cement holding the lenses in place Use alcohol as it will damage painted or plastic surfaces Store the microscope in a wooden box in humid environments unless the box is heated by a 15W bulb Never remove the eyepieces from the microscope and leave the openings unplugged e Never dismantle the optical components as they can become misaligned e Never clean with a dripping wet cloth always use a damp cloth instead e Always switch off the light and unplug the microscope when not in use Monthly e The microscope s mechanical p
169. endar Format PPM Wall Calendar Timetable Months Week Water Still Microscope Refrigerator Key q 3 monthly quarterly m monthly w weekly 7 3 TESTING FOR ELECTRICAL AND MECHANICAL TRUSTWORTHINESS Equipment should be kept in an acceptable physical and working condition at all times so that it can perform competently and safely Equipment should not be allowed to deteriorate to such an extent that it becomes untrustworthy or hazardous Section 5 For example frayed mains leads disconnected earth metal with stress fractures leaking gas valves cracked glass failing brakes gt gt perished rubber materials 7 3 Testing for electrical and mechanical trustworthiness One strategy is for staff to regularly check equipment visually for such disintegration However to reduce the risk of such problems regular testing for electrical and mechanical trustworthiness using test instruments is required Such testing ensures the safety of equipment and calibrates its performance and so requires safety testing and calibration instruments Safety and calibration testing usually takes place regularly throughout the life of the equipment During the acceptance process when equipment first arrives see Guide 3 on procurement and commissioning Whenever staff suspect that there may be a problem or the equipment may not be performing properly Regularly as pa
170. enerator diesel Generator petrol Microscope Oven hot air laboratory Refrigerator electrical Refrigerator kerosene Sphygmomanometer aneroid Sphygmomanometer mercury Sterilizer bench top horizontal Sterilizer floor standing vertical Suction pump electrical Truck pick up Washing machine electrical 223 Form for registering written off equipment Annex 9 FORM FOR REGISTERING WRITTEN OFF EQUIPMENT Figure 25 shows a form that can be used to register when equipment is condemned and written off ANNEX 9 It acts as both a record for the health facility to take the item off their inventory and a record for the Board of Survey to organize the destruction or disposal of the item in an appropriate way Example List of Expendables to be Written Off Form Figure 25 Aanung Jo peog BETTER aeq ae EO EE Eoo la PAE T E eee e a E nantes OC A 1500 Je 0L OL 6 8 Z 9 G v L uononys p uonipuoo ysoo jeulBuo jesodsip Bulpyebas uo e6yeuo ul pause jqe oru sun juswyedeq pes soueuayulewW uolyeue dx3 JO UMOUY J JEquUINN 10 peBbewep ueyolg aje Jo uoNduoseq JO pe H Jo uols o9q jo uoluIdO ysoo jeuIBUO Qog yeay hennen ensenennnsen nnevennnenenenennmuunnnmmmnnnn Js qwnu jenas siea OUTS 000 To e s bia a aaa aa jo aBueyo u swa jqepu dx Jo 4S7 u L Woy ponad y Buunp 1e pue
171. ent has reached the end of its life and condemning it ii physically disposing of the equipment safely and promptly ili taking it off the health service records iv triggering its replacement so that the service it provided can continue Currently equipment in the health service is seen as the property of the controlling body of the health service provider organization In other words Ministry of Health equipment is the property of the national government and equipment in a private hospital is the property of the business firm that runs the health service These controlling bodies require the equipment to be officially written off by a relevant authority for example in the government sector the Ministry of Finance will have some form of Board of Survey These decommissioning authorities may be based nationally at the district region or even at the health facility level These authorities must be told when equipment reaches the end of its life They will then officially condemn it and arrange for its disposal and any auctioning of viable items or scrap to recover money for the controlling body the treasury in the government sector for example This process can take a long time but should occur regularly in order to avoid large and dangerous graveyards of old equipment dotted around the facility site Health facilities must be able to cope with the stocks of condemned equipment in the meantime and must create special storage sites w
172. ent internal components as well as an external housing which is insulated because it is made of plastic Such equipment can be recognized by the box within a box symbol on it E and no earth connection is required iii Earthing This means that all metal parts of your electrical installation are linked within a system that has an earth lead This earth lead must be connected to the general mass of earth via an earth electrode a metal rod or mat The system is designed to ensure the immediate electrical discharge of stray currents to earth without danger Box 34 describes some common problems with the electrical installations at health facilities all of which can present safety hazards to any humans and animals wandering around the site Experience in West Africa At one hospital the electrical installation for a ward block had much too small an earth cable similar to lamp flex This was mounted on the external wall of the building and had erroneously been intended to provide an earth by being buried in the ground However goats had nibbled through this wire leaving no earth protection for the building At another hospital the main incoming electricity supply cable for the facility came in at floor level into the waiting room of the out patients department There it had been stripped of all insulation to connect into the main distribution board This left bare metal at 380 Volts within easy reach of the children playing
173. ents sufficient resources to undertake user PPM Teams materials funds training etc Heads of Department liaise with the HTM Service to develop the user PPM system e plan these activities and implement them according to the written guidelines and timetables e monitor to ensure that their staff are adhering to correct PPM techniques and timetables for equipment report any problems to the Health Management Team so that training needs can be addressed User Staff e only undertake the sorts of procedures that do not require the intervention of the maintenance department e undertake the user PPM activities regularly according to a timetable and the training received e refer to the training resources and posters provided Section 3 5 and manufacturers manuals Section 3 4 for guidance HTM Team report any problems identified with user PPM to the Head of Section and Health Management Team so that training needs can be addressed or disciplinary action can take place e plan and implement the more technical PPM tasks see Guide 5 on maintenance management Health Service Providers ensure the HTM Service has sufficient safety testers see Annex 6 All Staff e undertake visual checks to monitor whether equipment is electrically and mechanically trustworthy HTM Teams e undertake regular safety tests with the necessary test instruments Equipment Users report any faults to their Section Head immediately they occur Section Heads r
174. eport any faults to their HTM Team immediately using the correct Work Request Job Form see Guide 5 on maintenance management e use the User Department Maintenance File to review progress on maintenance work see Guide 5 gt Z ro 5 O 6b o A A pu N O c 7 O c _ O Q o 5 LL Continued overleaf 153 Section 7 summary BOX 58 Summary of Procedures in Section 7 on Ensuring Continuous Operation continued HTM Service undertakes the technical judging activities to identify when equipment should be decommissioned undertakes the necessary reporting dismantling cannibalizing and storage activities to ensure equipment is taken out of service and does not return to use Purchase and Supplies administer the official communication with the Board of Survey and the Officers finance head office of the health service provider Health Management chase the Board of Survey to act so that large graveyards of scrapped Teams equipment do not gather on health facility grounds ensure that disposal of equipment and parts is undertaken according to the Waste Management and Hygiene Plan Section 5 4 ensure that decommissioning of equipment triggers the purchase of a O 2 7 2 E O O QO replacement item when applicable Boards of Survey officially write off equipment promptly organize the auction of only those pieces of equipment which are safe for reuse and a
175. equipment 118 6 1 General discussion on accessories and consumables In your country there may be other supply routes which could help your health service provider to obtain high quality supplies For example e Your country may have a booming photographic industry which could help with the sourcing import distribution and storage of good quality X ray film Sometimes church or mining health sectors can be more flexible than government ones in their procurement practices Thus it will be useful for different health service providers to collaborate and do business with each other Quantities to Buy Many accessories and consumables have a shelf life Items with an expiry date Items affected by heat Items which rust or collect condensation Items which deteriorate such as batteries Shelf lives will affect your ability to buy in bulk affect your ability to buy well in advance require you to provide good quality storage facilities Section 6 2 require you to have an effective stock control system to ensure that you conform to the rules for stocks with shelf lives SLFO shortest life first out and FIFO first in first out principles Section 6 2 Thus where possible use centralized storage and bulk purchasing arrangements as these are more economical and ensure a good turnover of stock The quantities that you decide to buy Section 6 3 also depend on the lead time for eac
176. er Isolation chamber Isotope equipment Isotope scanner Kiln K pads Kymograph Lamp Deep therapy Infrared Mercury quartz Slit Laparoscope Laryngoscope Laser coronary Laser surgical Laser positioner Laser smoke evacuator Lifter patient Linac scalpel Linear accelerator Lithotripter extracorporeal shock wave ESWL Mammography unit Fixed Mobile van Marograph Mass spectrophotometer Microbiology analyzer Microscope Microtome Microtron power system Mirror therapy Muscle stimulator 218 Magnetic resonance imaging MRI equipment Years 5 10 7 10 10 10 8 7 12 d 7 10 5 10 10 10 10 10 nnn NOW W mn um NI Ww NN N ON N DO Ww C Ur Item Nebulizer Pneumatic Ultrasonic Nephroscope Neurological surgical table headrest Neutron beam accelerator Noninvasive CO2 monitor Optical readers Orthotron system Orthourological instruments Oscilloscope Oven Paraffin Sterilizing Oximeter Oxygen analyzer Oxygen tank motor and truck Pacemaker cardiac external Pacing system analyzer Panendoscope Parallel bars Pelviscope Percussor Perforator Peripheral analyzer pH gas analyzer pH meter Phonocardiograph Photocoagulator Photography apparatus gross pathology Photometer Physioscope Pipette automatic Plasma freezer Platelet rotator Positron emission tomography PET scanner Proctoscope Prothrombin timer automated Proton beam accelerator Pulmonary function
177. er Therefore the autoclave requires adjustment e Maintenance staff can create the process profile for each machine They must make up a typical most difficult test load for use in your autoclave have thermocouples an electronic thermometer and a pressure gauge place the thermocouples at various points in the sterilizer and the load and connect them to the thermometer these will show that correct temperatures were reached at correct points in the cycle use the pressure gauge to verify that correct readings were obtained on the pressure gauges of your autoclave put your autoclave through its various different cycles record all the parameters during each cycle to create a process profile as long as the readings are what they would expect sterilization will have been achieved and the profile will be a correct one 73 5 3 1 Decontamination The official standard validation test uses eight thermocouples to measure temperatures but a basic validation kit is available which uses just two one in the chamber the other in the load see Annex 2 The idea is that CSSD staff only release the load from the sterilizer to the users if all the process parameters were met For every cycle ideally registration would take place and a Bowie amp Dick test would be performed then only if the results are validated is the sterility of the load or pack confirmed However this method requires CSSD staff to have time and a
178. er 15 Central data processing unit 10 Blanket dryer 15 Clock 10 Blanket warmer 15 Coffee maker 5 Bottle washer 10 Compactor waste 10 Broiler 10 Compressor air 12 Burnisher silverware 15 f Conveyor tray 10 Cage animal 10 Cooker pressure for food 10 Camera identification 5 Cooler walk in freestanding 15 Camera surgical 5 A w a Cutter cloth electric 10 Camera television monitoring c Dod j color or black and white 5 ETEN 109 0 Camera videotape color or black and white 5 Dish sterilizer 10 Dishwasher 10 Can opener electric 10 Capsule machine 10 Disinfector 15 Continued opposite 220 Table 9 Support Departments continued Item Dispenser Butter refrigerated Milk or cream Drill press Dryer Clothes Hair Drying oven paint shop Enlarger Extractor laundry Floor buffing and polishing machine Floor scrubbing machine Floor waxing machine Folder flatwork Food chopper Freezer ultracold Fryer deep fat Garbage disposal commercial Glassware washer Griddle Grinder food waste Helicopter Hoist chain or cable Hot food box Hotplate Humidifier Ice cream freezer Ice cream soft machine Ice cream storage cabinet Ice cube making equipment Indicator remote Intercom Ironer flatwork Kettle steam jacketed Key machine Laminator Lathe Lawn mower power Linen press Linen table Linen washer Years 10 10 20 Item Lint collector Loom Lowerator Manne
179. er of New Stocks form and the remaining unissued items to the Stores Controller so that they can be entered into the stores system according to the standard procedure Section 6 2 The Stores Controller sets up the correct stock cards bin cards so that the stores reordering system can come into effect automatically The Stores Controller enters the stores code for each item on the Register of New Stocks form and provides the relevant user departments and the HTM Manager with lists of the new items received and their stores codes for ordering purposes The HTM Manager files the Register of New Stocks form with the stores codes in the relevant equipment files see Guide 5 on maintenance management and provides this information to the Specification Writing Group if they need assistance with updating specifications and detailing future purchase contracts see Guide 3 on procurement and commissioning The stocks of equipment accessories consumables and spare parts should be issued and reordered according to the procedures given in Sections 6 2 and 6 3 tems into the stock control system Entering i Annex 5 Example of a Register of New Stocks Form Figure 23 0 w9 8c801Z n w Jad p wugg g susidosu Bulqn 0 v 9O0SEEL NLA Oj Ieqqnu yeas NLA 0 g 68SEEZ Ajquiasse aed ane yeo 4 0 tA cvoerl ZS X QW M S 0 Z L9 SbL w6eiydeip 19m0 eld 0 G 8S SrZ JSNEYX9 J9 U JOJOOULOD 0 id evoerZ wbesyde
180. erse incidents should be submitted to the HTM Working Group or its safety sub groups who can monitor and act on the incidents Section 8 2 and report to the Health Management Team It will be necessary for Health Management Teams to ensure that their staff have the necessary safety gear required to do their jobs such as gloves goggles masks overalls and boots SAFETY DURING EQUIPMENT OPERATION Staff need to understand the hazards that equipment can pose to the patient operator maintainer and visitor while it is in use Box 18 contains some examples of common safety issues that arise when operating healthcare technology Therefore safety procedures for each type of equipment should be included in equipment operation training It should be requested as part of the package of inputs purchased with the equipment see Guide 3 on procurement and commissioning The best information regarding equipment safety during operation is usually contained in the manufacturer s user manual and or service manual A wide range of reference material is also available see Annex 2 The HTM Working Group should provide written guidance and in some cases posters can be displayed for staff which summarize the guidance and experience of their colleagues Section 3 5 If staff do not have personal copies of these resources they should be available in the library for reference Section 3 4 5 2 Safety during equipment operation B
181. es that contaminate benches and equipment safety cabinets which prevent the inhalation of organisms if they escape into the air autoclaves and incinerators that kill the organisms when investigations are finished Primary barriers around organisms protective clothing including gowns gloves safety spectacles Secondary barriers and rarely masks around the worker personal hygiene such as hand washing immunization and medical care safe disposal of infectious waste Section 5 4 security and limited access of the public care of invited visitors Tertiary barriers around the laboratory Chemical and Physical Risks There are other hazards in laboratories due to faulty use of certain equipment such as centrifuges risk of flying objects autoclaves risk of bursting bottles etc see Box 18 explosion risks from gases faulty use of gas burners and sparking centrifuges because of worn brushes from lack of maintenance incorrect storage and handling of flammable chemicals such as ether nitric acid and hydrogen peroxide incorrect handling storage and spillage of chemicals and reagents acids alkalis ammonia etc Advice on all these issues should be available from your country s National Laboratory Service and reference materials see Annex 2 Quality Control In addition the National Laboratory should provide a system of quality control procedures to monitor the performance of the work undertake
182. ese leakage currents are too high Reticulation of the earth It is the responsibility of the health service provider to run cables from the main around the site earth at the incoming supply point to the distribution board for each building and to run cables within each building to every socket outlet and light point The size cross sectional area in mm sq of the earth conductor in any circuit should relate to the size of the main phase line conductor s For example e Phase conductors greater than 35mm sq require earth conductors at least half the size and rounded up to the next nearest size of cable for example an incoming supply cable of 95mm sq requires a main earth conductor of 50mm sq Phase conductors of between 16 and 35mm sq require earth conductors of 16mm sq Phase conductors of less than 16mm sq require earth conductors of the same size so a 2 5mm sq ring main circuit requires an earth conductor also of 2 5mm sq Continued overleaf 97 98 5 5 2 Electricity BOX 35 Strategies for Providing Good Quality Electrical Installations continued Distribution boards Any electrician or electrical contractor that you employ or hire must connect up the electrical installation to the distribution boards It is essential that they e file off the sharp metal edges of the cut outs made in the distribution board e calculate the loading of the various circuits and design the circuits cable sizes and circuit breakers
183. ess to the items they need whenever they need them without abuse of the system the people running the stores are familiar with the items they order and issue Do not forget that you also have a responsibility for other equipment related items such as the spare parts and maintenance materials A similar discussion for these items is provided in Guide 5 on maintenance management The HTMS storage system may end up being responsible for all equipment related items 121 122 6 2 Storage system and procedures Whether you decide to turn departmental staff into stores persons or use the professional skills of existing stores personnel depends on the knowledge of the staff their recognition of the range of equipment related supplies whether the stores are holding bulk quantities or only those for daily weekly use whether you need access to the supplies for out of hours emergencies It is common for general stores staff to have a problem with recognizing the wide range of equipment related supplies in stores and this can lead to a number of problems such as non issue loss and incorrect ordering It is vital to train stores staff and procurement officers to recognize equipment related items There needs to be some mechanism to control when accessories are replaced and consumables used to avoid abuse of the system For example this needs to avoid batteries being replaced early and the old ones being used at home printer i
184. expense It is full of good advice to help you start planning for safety and contains checklists diagrams and case studies covering a wide range of workplace hazards Available from HMSO Books UK Annex 2 Reference materials and contacts Gas safe with medical gases training video BOC Medical Code 888859 This video includes information on the storage and handling of cylinders identification and procedures in the event of fire etc Available from BOC Medical Infusion systems Medicines and Healthcare Regulatory Authority 1995 MDA Device Bulletin No DB 9503 May 1995 This publication addresses many aspects of the use and selection of infusion systems Its purpose is to raise awareness of the nature of infusion systems their advantages and their potential risks with a view to reducing the number of adverse incidents that arise from their use It describes the different types of infusion devices risks and applications training programmes safety recommendations purchasing and management responsibilities Available from MHRA Maintenance and repair of laboratory diagnostic imaging and hospital equipment WHO 1994 ISBN 92 4 154463 5 Medical administration for frontline doctors A practical guide to the management of district level hospitals in the public service or in the private sector 2 edition Pearson C 1990 FSG Communications Ltd Cambridge UK ISBN 1 871188 03 2 Medical equipment in Botswana A framew
185. f the UK government Humanitarian Information for All c o Human Info NGO vzw and Humanity CD Ltd Oosterveldlaan 196 B 2610 Antwerp Belgium Fax 32 3 449 75 74 email humanity humaninfo org website www humaninfo org The goal of this organization is to disseminate health care information free of charge in developing countries Thus their Medical and Health Library makes publications available on the internet Refer to their homepage to find the large list of publications available Annex 2 Reference materials and contacts Institute of Decontamination Services UK Website www idsc uk org Formerly the Institute of Sterile Services Management Publishes the ISSM Journal Intermediate Technology Development Group ITDG and ITDG Publishing The Schumacher Centre for Technology and Development Bourton Hall Bourton on Dunsmore Rugby CV23 9QZ UK Tel 44 1926 634400 fax 44 1926 634401 email enquiries itdg org uk website www itdg org The Development Group is a charity concerned with the research and development of appropriate technologies for application in developing countries It has worked on topics such as alternative electrical supplies access to water disability aids medical supplies It also undertake consultancies The Publication Division produces and disseminates books and journals covering aspects of health development and appropriate technology It can be contacted at Tel 44 1926 634501 fax 44 1926 634502
186. ference buyer s guides and equipment data specification sheets provide easy reference for equipment buyers The framework can be adapted to guide general equipment purchasing Available from WHO Surgery at the district hospital Obstetrics gynaecology orthopaedics and traumatology Cook J Sabkaran B and A Wasunna eds 1991 Dept of Surgery Eastern General Hospital Edinburgh Scotland ISBN 92 4 1544139 An illustrated guide to essential surgical procedures in small hospitals for treating the major complications of pregnancy and childbirth common gynaecological procedures and managing traumatic injuries including fractures and burns Emphasis is placed on standard surgical protocols that represent the safest line of action in hospital settings where equipment may be primitive drugs limited and specialist services sparse these requirements are discussed Available from WHO 183 184 Annex 2 Reference materials and contacts Surgical instruments A pocket guide 2 4 edition Papanier Wells M and M Bradley 1998 ISBN 00721678017 A pocket guide listing and describing surgical instruments sharps dissectors forceps clamps retractors suction tips dilators endoscopic instruments internal stapling devices and most commonly used instrument sets for a variety of surgical procedures Includes a picture of the instrument with a brief description explaining the uses varieties and alternative names Available from major
187. fety Statistics should be gathered regularly for example on a monthly or quarterly basis Box 61 shows the sort of statistics that can be gathered You will need to decide which are the most useful ones for your health service BOX 61 Examples of Statistics Which Can be Gathered Regularly Type of statistics Examples Statistics obtained by counting numbers The workload and performance of different types of equipment such as e how many times the equipment is used e how many times patients or samples etc are sent away because the equipment was unavailable The number of times work with equipment is cancelled due to different causes such as e consumables not being available e no money to buy cleaning materials e low staffing levels e equipment broken specific accessories unavailable The number of adverse incidents due to different causes such as poor safety procedures no cleaning taking place no user PPM untrained staff Statistics obtained by doing calculations Use of internal resources for example the cost of running equipment Statistics obtained by doing analysis This method is used for things that are more difficult to measure or assess and refers to the quality of performance and user satisfaction rather than quantities The compilation of these statistics is made easier if you design relevant and useful Statistics Forms to enter the data into We suggest that you file these Statis
188. ffice HMSO Medical equipment in sub saharan Africa A framework for policy formulation Bloom G and C Temple Bird 1988 IDS Research Report Rr19 and WHO publication WHO SHS NHP 90 7 ISBN 0 903354 79 9 This book provides a good overview of the situation of medical equipment in Africa Its approach to the analysis is to unpackage medical equipment technology into its component activities such as planning allocating resources procurement commissioning operation maintenance training etc It provides good general policy formulation strategies to address the problems discussed Available from WHO Practical steps for developing health care technology policy A manual for policy makers and health service managers in developing countries Temple Bird C 2000 Institute of Development Studies University of Sussex UK ISBN 1 85864 291 4 This book is a practical step by step guide for developing health care technology policy It can be used by health service providers regional and district health authorities health facility managers and external support agencies It describes a process for developing health care technology policy which is collaborative participatory iterative and involves community stakeholders Guidance is provided on underlying management concepts undertaking a situation analysis running a ideas workshop formulating policy developing an implementation plan and procedures manual as well as the resources req
189. for development and operation WHO Regional Publications Western Pacific Series No 22 1998 ISBN 92 9061 121 9 Estimated useful lives of depreciable hospital assets revised 2004 edition American Society for Hospital Engineering 2004 American Hospital Association ISBN 1 55648 319 8 One of the organizations which have tried to estimate typical equipment lifetimes for healthcare technology The AHA s extensive list reflects how equipment lasts within the United States health care system whether it was manufactured in the US or abroad It covers buildings estate fixed equipment and individual items of movable equipment The list was compiled after discussions with manufacturers of healthcare equipment discussions with various hospital department managers and analysis of actual retirement practices for actual hospital assets Available from AHA Maintenance and repair of laboratory diagnostic imaging and hospital equipment WHO 1994 ISBN 92 4 154463 5 Maintenance and the life expectancy of healthcare equipment in developing economies Hans Halbwachs GTZ In Health Estate Journal March 2000 pp 26 31 This article comes from one of the organizations that have tried to estimate typical equipment lifetimes for healthcare technology The GTZ estimates are for 16 types of medical equipment and plant and tries to more closely reflect the realities in developing countries The article describes the Delphi survey used to obtain feedb
190. ges can indicate seven different types of problem Ready made Bowie amp Dick test sheets arrow check indicators These are individual A4 size sheets of special paper that you place inside your own Bowie amp Dick test pack made of cloths see Figure 8 instead of strips of autoclave tape They contain lines of chemical finish that change from light to dark evenly across the whole sheet if the autoclave cycle has been successful Although they are sensitive they only tell you that the cycle failed they don t tell you what type of problem you may have Ready made small Bowie amp Dick test TST strip indicators These are individual strips of special paper with a large circle dot of chemical finish which changes colour if the autoclave cycle has been successful They should be placed in the most difficult location in the load such as inside packs or drums Although they are sensitive they only tell you that the cycle failed they don t tell you what type of problem you may have Using standard heat sensitive autoclave tape in order to make up your own Bowie amp Dick test pack see Figure 8 and Annex 2 This requires knowledge of the correct method of making a pack The tape will change from light to dark during the autoclave cycle and will show if there are parts of the tape which did not change colour and therefore did not receive sufficient TST Although cheaper it is a more complicated method and does not give you diagnostic inform
191. gnostic imaging and hospital equipment WHO 1994 ISBN 92 4 154463 5 A practical manual for maintenance and repair of basic laboratory and diagnostic equipment as well as anaesthetic machines operation room equipment and ultrasound and X ray generators Intended for use in settings that do not have technicians or engineers with specialist expertise The manual uses line drawings and numerous checklists for inspection and cleaning good working practices routine operation and maintenance It is also useful as a training aid It includes advice on many topics relating to safety and testing such as disinfection gas cylinders laboratory hazards radiation hazards and hazards from other types of equipment Available from WHO Manual of darkroom technique Palmer P 1985 WHO Basic Radiological System ISBN 92 4 154178 4 This manual is intended for use by operators working with the WHO Basic Radiological System WHO BRS but the principles and methods described can be used in the processing of X ray films taken with any type of X ray equipment The manual provides a step by step illustrated guide to darkroom technique and outlines all the basic requirements for the storage and handling of X ray films and processing equipment It contains sections covering the maintenance of the processing tank non electric and the cassettes and screens This is in the form of schedules of cleaning to be undertaken daily weekly and monthly Available fro
192. gov hiv pubs brochure care6 htm Laundry Deliver website www deliver jsi com USAID funded project focusing on supply chain logistics for health products in developing countries from estimating demand for supplies and maintaining optimal supply levels to proper storage guidelines Eurasia health knowledge network EHKN website www curasiahealth org Specialises in the health information needs of the Former Soviet Union FSU and Central and Eastern Europe CEE Site links to clinical practical guidelines medical textbooks and other educational materials many in Russian and other regional languages European forum for hospital sterile supply website www efhss com The forum runs a website hosting most European associations related to sterile supply It is a useful resource with a question and answer page discussion forum training and other useful information on sterilization 191 192 Annex 2 Reference materials and contacts FIN Free international newsletters www healthlink org uk Healthlink produces this publication that lists over 130 print and electronic health related newsletters and magazines which are available free to readers in developing countries Free medical journals website www freemedicaljournals com This site is a comprehensive up to date list of medical journals available free on the internet GATE German Appropriate Technology Exchange www5 gtz de gate The GATE Information Service seeks to improve the te
193. h item the time taken for goods to arrive once ordered When purchasing new equipment and funds are available it is a good idea to purchase a supply of consumables accessories and spare parts at the same time Consider purchasing enough for a set period such as a two year supply see Guide 3 on procurement and commissioning Manufacturers manuals their local representatives and suppliers can often provide information and advice about the likely consumption rates of the items you require and this may help you decide on the quantity to order 119 6 1 General discussion on accessories and consumables Responsibilities Equipment related supplies are often forgotten among all other general and medical supplies such as food stationery linen bandages syringes and catheters If you are told that there is not enough money in the recurrent budget to cover equipment related needs many clinical activities will stop because there are no rolls of recorder paper tubes of ultrasound gel replacement bulbs and the like Therefore staff need to see the management of these materials as a collective responsibility Box 47 shows the many people who have a role to play BOX 47 Responsibilities for Recurrent Materials Health Management ensures that adequate quantities of equipment consumables and accessories are Team available at all times through the work undertaken by the Purchasing Department and the Finance Section Purchas
194. he incoming water supply may e Treat it using methods such as sand filtration boiling chlorine not be safe to drink and may UV light although this will not sterilise it contain bacteria e Do not allow puddles of water to remain anywhere on the health facility premises for long e Cleaning equipment such as buckets and other water containers should always be stored dry and clean e Water for drinking and cleaning should always be drawn fresh Any microbes in water will multiply if the water is left standing for any length of time or is stagnant Water which has collected in soap dishes usually holds high numbers of bacteria e Soap dishes and soap bays on wash basins should always be dried by the cleaners Pure water may be required for some clinical purposes for example laboratory tasks but is expensive e Water stills and de ionizing units are available for water purification although this will not produce sterile water e Only use pure water for purposes that need it e Soften it using resin and salt filters chemicals or small electronic descaling units for pipes e The softening plant can be placed at the main water supply Hard water supplies can point or at the location of sensitive equipment such as damage equipment and cause boilers washing machines autoclaves stills etc safety hazards e Collect rain water which is soft from the roof using guttering down pipes
195. he ineffectual practice of soaking and boiling at other locations around the health facility Reorganize the packing system see below in order to facilitate the sterile pack service and to be more effective in achieving sterility Reorganize the packing system to Prepare smaller individual packets of each item cotton provide smaller sets and packets dressings mayo cloths etc and only sterilize them on of items demand based on order lists from the user departments This will eliminate the practice of sterilizing large drums containing a volume of items which will not be used in one day which in turn leads to the drum standing around for a day or two and becoming contaminated as the lid is continually opened for items to be removed This will also eliminate the need for continual resterilization of the items which is more costly and leads to the contents deteriorating Continued overleaf 69 70 5 3 1 Decontamination BOX 23 Strategies for Ensuring Sterility continued Reorganize the packing system to Reorganize instrument sets into basic sets and specialized provide smaller sets and packets additional instruments sets for specific types of operation of items continued for example caesarian extras laparotomy extras orthopaedic extras Then pack these sets separately This avoids the practice of packing all instruments bowls and towels for a certain type of operation on one tray creating
196. he problem and would have been able to prepare hot food for the mothers and staff 4 3 Care and cleaning BOX 15 Common Care and Cleaning Strategies Keep all items clean and dry Dust equipment such as large free standing items regularly Where applicable replace the dust cover at the end of the shift if there is no dust cover make one Keep equipment such as laundry and kitchen equipment clear of debris such as fluff food threads grease paper waste etc Switch off and unplug items when they are not in use except for items which have a battery back up that must keep charging such as defibrillators or items which need a continuous supply refrigerators etc When cleaning never flood the machine with fluid or a dripping wet cloth use a damp cloth instead Clean with the appropriate chemicals solutions and materials at the end of the shift equipment which comes into contact with patients uses gels etc The operator manual will contain guidance on the correct chemicals to use Section 5 3 Disinfect equipment such as theatre equipment after each patient Check the operator manual for guidance on the correct disinfection method Section 5 3 Unknot tangled leads on ECG recorders interferential units and the like When moving equipment unplug the power cord and wind it up starting from the machine end and working to the plug in order to avoid twists Wipe accessories such as ultrasound probes and reusable
197. he staff graduate they then find that they lack the necessary knowledge or techniques for the clinical procedures required They are therefore incapable of applying particular machines and cannot deliver the necessary healthcare 4 2 The correct application BOX 14 Common Examples of Application Training Requirements Ophthalmoscopes in diagnostic sets Eye doctors can train operators on the correct clinical application diagnosis and use of the different features offered Electrosurgical diathermy units Surgeons need to practise with the many different features offered by newer models making use of pieces of meat from the kitchen or bars of soap and definitely not patients Defibrillators Management committees and surgeons need to clarify when these can be used users need to refresh their memories on the correct application for different sizes of patient as well as familiarizing themselves with the defibrillator s controls and how to operate it Resuscitators ambu bags Doppler foetal heart rate detectors Operators need training from doctors concerning the correct clinical application and use of the different features offered as well as a policy on who is authorized to use the oxygen facility Users need to familiarize themselves with these units and get some practice in their use with assistance from an ultrasound radiographer Infant warmers Paediatricians need to control the programming of
198. head of department group leader officer in charge senior operator Buildings where healthcare is delivered ranging from small units clinics health centres and small hospitals rural district diocesan to large hospitals regional referral Furniture with a specific clinical use in health facilities such as beds cots trolleys infusion stands Health management body such as facility management committee district regional diocesan central health management team Board A provider of health services such as Ministry of Health or Defence non governmental organization private institution employer organization or corporation for example mine faith organization Comprises all organizations institutions and resources devoted to health actions defined as any effort in personal or public health services or through intersectoral action whose primary purpose is to improve people s health Source WHO Head of the HTM Team ranging from a general member of health staff with some management skills in the smallest HTM Teams to an engineering manager in the highest level of HTM Team Healthcare technology management service made up of a network of HTM Teams and HTM Working Groups A body responsible for the management of equipment such as equipment management team maintenance management team physical assets management team Part of the HTM Service A working group or standing committee responsible for making
199. his An incident report is submitted Section 8 2 Skill shortages are discovered during the staff appraisal process Section 8 2 The HTM Working Group or its safety sub groups decides if extra training is the appropriate solution Managers agree with the individual which training would be the best development strategy and request it from the Human Resource Department training sub group 3 5 Developing staff skills BOX 9 Strategies for Developing Equipment Skills Strategy Advantage Disadvantage Send staff to factories that manufacture equipment This can be good training but may be expensive as it often entails going abroad and paying in foreign currency However the equipment manufacturer may have a local representative that has the skills to provide the necessary training Although this is a more affordable option the danger is that the company will offer a course which is either too simple not much more than a factory tour or alternatively is very theoretical Good communication is required to ensure that this equipment specific training is effective and appropriate Invite engineers from manufacturers to visit your facility to conduct training on their equipment This option may not be the most affordable and therefore may not be ideal if you are facing financial constraints If the company s local representative has sufficient skills to undertake the training this may be more affordable
200. hnology BCT Department WHO Geneva Switzerland Reinhold Werlein Biomedical Engineer Swiss Centre for International Health of the Swiss Tropical Institute Basle Switzerland reviewed by Dr E Aniteye Consultant Lecturer in Anaesthesia ICU Korle Bu Central Hospital Kumasi Ghana Dr P Asman Head of the Bio engineering Unit Ministry of Health Accra Ghana Tsibu J Bbuku Medical Equipment Specialist Central Board of Health Lusaka Zambia Peter Cook Biomedical Engineer ECHO International Health Services Coulsdon UK Freedom Dellosa Chief of Hospital Equipment Maintenance Service Division Region 9 Mindanao Peninsula Department of Health Zambonga City Philippines Pieter de Ruijter HTM Consultant HEART Consultancy Renkum The Netherlands Acknowledgements Roland Fritz HCTS Coordinator Christian Social Services Commission Dar es Salaam Tanzania Andrew Gammie Project Director International Nepal Fellowship Pokhara Nepal Jan Huys HTM Consultant HEART Consultancy Renkum The Netherlands Pramod Joshi Medical Equipment Engineer Technical Assistance Programme International Nepal Fellowship Nepalgunj Nepal Godfrey Katabaro Biomedical Engineering Technologist Kagera Medical Technical Services church health sector Kagera Tanzania Derrick Mayungo Deputy Head of Biomedical Engineering University leaching Hospital Lusaka Zambia Jenny Poulter Nursing Consultant Green Pastures Ho
201. hs H and C Temple Bird eds 1991 GTZ Eschborn Germany This book mainly aimed at maintenance technicians covers the maintenance requirements for common items used at district level anaesthesia equipment infant incubators X ray equipment suction pumps autoclaves and laundry equipment including some advice on safety testing and test instruments It also includes information on workshops and stock control of parts Available from GTZ Stock control software Stock control of items in stores is an area where simple computer software programs can be of assistance once you have mastered a manual paper system have a large enough store for example at central level and can obtain sufficient training of staff The following products can be viewed on the internet and should provide either a full demonstration CD of the software to study or use of a shareware program free of charge for a set period of time e Website www easy4you net EN stock htm Low cost stock control and invoicing package for small to medium size businesses provided as shareware software e Website www microsoft com BusinessSolutions Navision supplychain aspx Navision sales and stock management software is suitable for medium to large scale businesses and is available in various building blocks Navision is used by several central national medical stores in Africa but requires a lot of training Website www requisoft com stock stock html Requisoft Stock software cont
202. ials contact details are on the website UNICEF s Supply Catalogue formerly the UNIPAC catalogue lists products with their specifications under categories such as immunization and cold chain medical devices and kits water environment sanitation and engineering education communication etc View it online at www supply unicef dk Catalogue The goods are supplied by the UNICEF Supply Division UNICEF Plads Freeport 2100 Copenhagen OE Denmark Tel 45 3527 3527 fax 45 3526 9421 email supply unicef org Voluntary Service Overseas VSO and VSO Books 317 Putney Bridge Road London SW15 2PN UK Tel 44 20 8780 2266 email webteam vso org uk website www vso org uk A Uk based charity with worldwide experience of providing skilled volunteers for work overseas including workers in the fields of medicine hospital engineering and associated technical services VSO Books publishes practical books about specific areas of development using the professional experience of volunteers World Bank WB www worldbank org One of the world s largest sources of development assistance including health nutrition and population projects World Council of Churches WCC PO Box 2100 1211 Geneva Switzerland Tel 41 22 791 6111 fax 41 22 791 0361 email info wcc coe org website www wcc coe org International fellowship of churches that produces publications and newsletters Recent publications include Guidelines on medical equipment d
203. ide 4 The healthcare technology management cycle Sample organizational chart for the HTM service Examples of prompts showing that training is required Strategies for developing training materials How to make up your own Bowie amp Dick test pack Ways of improving the quality of water Routes for electricity to flow through the heart to earth IEC symbols on equipment labels showing the level of safety protection Basic microbiological safety strategies Sample stock card bin card Sample layouts for the stock control ledger Strategies for making user staff undertake maintenance and repair Strategies for expanding user PPM Example timetable of PPM for users in wall calendar format Strategies for safety testing Steps in a typical decommissioning process The planning and review cycle Example of a process profile common to many sterilizers Annex 3 Sample store requisition and issue voucher Annex 4 Example of a register of new stocks form Annex 5 Maintenance work request job form Annex 7 Example list of expendables to be written off form Annex 9 166 168 173 206 11 18 23 42 46 73 82 94 100 105 126 135 143 144 146 148 152 155 202 203 205 208 224 1 Introduction 1 INTRODUCTION Why is This Important This introduction explains the importance of healthcare technology management HTM and its place in the health system It also describes the purpose of the
204. ieve Timetable Actions agreed Names of How progress will Resources Time frame for listed in order persons who will be determined required start and of priority be responsible see indicators completion below 8 1 Setting goals annually for equipment operation and safety ii Recommendations You will discover that some important problems cannot be overcome or improvements achieved unless extra supplies staff or funds are provided or unless assistance is obtained from outside In such cases recommendations are required These should be Specifically addressed to the person official department organization etc that is able to carry out the recommendation Reasonable there is no point in asking for the impossible such as 10 times more staff Essential there should be no easy way for the user department to achieve the same results on their own iii Longer term objectives You will also discover some problems which cannot be solved in one year Maybe they need large amounts of money longer preparation or plenty of time to achieve Or maybe it is simply not possible to do everything at once In such cases longer term objectives are required which will be carried forward to the next year or for implementation later on How to Measure the Goals Each goal must be easily measured so that you can see if it has been achieved or if progress is being made You need a way of determining if you are moving
205. if necessary and to ensure that HTM policies are implemented provides sufficient inputs to ensure the HTMS is effective uses strategies to manage the changes involved carefully so that they can o 2 gt _ D o C D L gt ino O be successful conform to regulations and guidelines provided by government All Health conform to the standards set by government Service Providers follow the policies of the Ministry of Health MOH if regulated to do so in general develop their own internal Healthcare Technology Policy and expand strategies develop their own HTM Service made up of a network of teams and working groups with sufficient inputs to ensure it is effective in order to ensure that HTM policies are implemented follow MOH regulations on the HTMS if regulated to do so implement strategies to develop skills in managing change staff motivation effective communication encouragement and supportive training with demonstrations introduce rules and procedures using discussion working groups training workshops etc with the staff that will implement them include all parties involved in the network of HTM teams and working groups in the development of the HTMS introduce changes to HTM step by step with a careful review process Continued overleaf 29 30 gt fa ep xe Cc fa Cc O pur _ Q O Section 2 summary BOX 4 Summary of Issues in Section 2 on F
206. imple and logical way so that items can be found quickly and easily Organize the stock into different sections for different categories of supplies in other words cluster items by their application Code each row block shelf and bin in order to identify the location of each part Clearly label each section of the store allocate each item to a specific place and label the position of the item on the shelf so that it is easy to read Provide every bin and shelf partition with a stock card Monitoring Monitor stock movements either through a paper record system or using a computer program Rotate stocks according to their expiry date Use the SLFO shortest life first out and FIFO first in first out rules and store items that have the latest expiry date at the back and items with the earliest expiry date at the front Use the FIFO rules for items without an expiry date and mark these with the date of receipt Put a red star or a similar mark on the labels of all items that have an expiry date within the current year Remove expired damaged or obsolete items from the shelves and dispose of them according to approved waste management procedures Section 5 3 Experience in El Salvador The Maintenance Department of the Public Health Service in El Salvador established their central store and regional and local sub stores with support from German Technical Aid All their equipment related supplies are given codes which are
207. in Part i Resource and Information Centres For the following institutions we have included the name address contact details a brief description of the various services they offer and additional contact details for further relevant activities AfriAfya AMREF Building PO Box 30125 Nairobi Kenya Tel 254 2 609520 fax 254 2 609518 email info afriafya org website www afriafya org Established by Kenya based health agencies AfriAfya provides community access to relevant and appropriate health knowledge and information in an interactive manner As well as a section on HIV AIDS there is a news centre message board and discussion forum on their website AFTH African Federation of Technology in Healthcare PO Box 19070 Tyberg 7505 South Africa Email contacts ykwankam cht uninet cm and pheimann mweb co za For information use website http ifmbe news iee org ifmbe news may1998 mre html and look up the South African Medical Research Council SA MRC Albert Browne International Ltd Chancery House 190 Waterside Road Hamilton Industrial Park Leicester LE5 1QZ UK Tel 44 116 276 8636 fax 44 116 276 8639 website www thebrownegroup co uk This company manufactures sterilization monitoring systems and is a source for a wide range of ready made Bowie amp Dick tests in different forms using TST technology Amazon Bookshop PO Box 81226 Seattle Washington 98108 1226 USA Website www amazon com or www amazon co uk Inter
208. in types of sterilizers those for naked instruments and utensils those for wrapped or porous fabric loads and those for fluids the correct method for each job is followed the sterile chain is maintained There must be quality control at each stage of the process cleaning set assembly wrapping loading sterilizing and sterile storage asystem of monitoring for sterility is implemented It is advisable to have a centralized sterilizing system this ensures that sterile supplies are available for all sections in the health facility that bad practices are eliminated and that the most effective use is made of available and appropriate equipment Box 23 provides some strategies that may require you to make changes to your existing system in order to achieve these ends The main advantage of these proposals is to ensure the sterility of items It is also likely that these proposals will save money Some additional linen bowls trays and instruments may need to be purchased to help the introduction of this alternative system but the theatre and CSSD functions will improve resulting in a quicker more efficient service for the theatre and wards If necessary a specialist could be contracted to set up the new system to ensure it is functioning correctly and to train staff 68 5 3 1 Decontamination BOX 23 Strategies for Ensuring Sterility Choose methods that End the use of instrument boilers disinfectors as they do ens
209. including endoscope disinfection Available from major internet bookshops Hygiene promotion A practical manual for relief and development Ferron S Morgan J and M OReilly 2000 ISBN 1853395056 This manual has been written for fieldworkers aiming to reduce the incidence of water and sanitation related diseases in relief and rehabilitation programmes Also useful for other development workers particularly those working in the fields of community development health and engineering Available from TALC Hospital hygiene 34 Edition Maurer I 1990 Edward Arnold London ISBN 0 7131 4443 2 This book makes an important contribution to the understanding of infection and methods of infection control worldwide It deals with the subject in an entertaining and stimulating manner and provides direct advice and guidance in a difficult area of hospital administration It provides any health service worker who deals with hospital hygiene with information and illustrations so that informed decisions can be made priorities assessed and training programmes organized It covers hospital infection sterilization disinfection dust control cleaning with water chemical disinfection and hygiene policies Available from major internet bookshops Immunisation in practice A guide for health workers who give vaccines WHO 1996 MacMillan ISBN 0 333 63095 5 A guide for health workers giving immunisations Explains about vaccinations and provides p
210. ing keeping an eye out for hazards using equipment properly accessing and handling equipment what to do in an emergency and recognizing the signs Available from RS Components Ltd Safety in clinical and biomedical laboratories Collins C ed 1988 Chapman and Hall Medical ISBN 0 412 28370 0 This book is a concise guide to proper practice in a clinical environment to achieve safety at work It covers chemical electrical mechanical microbiological and radiation hazards laboratory first aid and safety checklists Available from major internet bookshops 185 186 Annex 2 Reference materials and contacts Equipment related infection control A handbook for managers Insecticide treated net projects Chavasse D Reed C and K Attawell 1999 Malaria Consortium Designed to be a practical decision making tool for project managers the handbook covers planning implementing and monitoring treated net projects illustrated with examples from more than 30 projects in 16 countries Available from http woww liv ac uk stm malaria mepubns htm Chemical disinfection in hospitals 2 edition G Ayliffe D Coates and PN Hoffmann 1993 ISBN 0901144347 This book is a guide to disinfection in hospitals and laboratories It covers the principles properties and safety of chemical disinfection and disinfectants There are chapters on disinfection policy and cleaning and disinfection of the environment skin and medical equipment
211. ing User Staff Undertake Maintenance and Repair Strategies People Responsible Managers maintainers and users meet together to agree on responsibilities for measures and actions that are acceptable to all according to staff accountability strategies see Box 5 Promote a sense of ownership among users The Health Management Team ensures that adequate maintenance and repair resources personnel materials Provide resources money are available for the continuous functioning of the equipment stock during its life through the work of the HTM Service and external contractors Heads of Section should be responsible for planning user PPM tasks and timetables as advised by the HTM Service giving the tasks to appropriate operators and monitoring that the work is done Plan the work Operators should take personal responsibility for ensuring that Implement the plans they undertake the user PPM tasks that they have been trained for and allocated by their Head of Section To preserve the safety of the patient operators should assume that all medical equipment present in clinical areas is operational at all times therefore any faulty equipment will have been removed Guarantee safety As soon as a fault appears on equipment which is used by the patients bed side the operator should remove it from the clinical area When equipment breaks down or is not functioning correctly the Respond to faults user sh
212. ing and purchases the correct items of good quality from reliable suppliers Supplies Officer Stores Controller correctly and efficiently stores issues and controls equipment consumables accessories and spare parts as well as cleaning materials monitors the stock levels of equipment materials in the main stores and ensures that they reorder the materials in time Equipment Users correctly handle and store equipment accessories before after and during use ensure that consumable items are not used in a wasteful manner HTM Teams correctly handle and store equipment spare parts and tools ensure that maintenance materials are not used in a wasteful manner Section Heads monitor the use of equipment materials in their section monitor the stock levels of equipment materials in their sub stores and sections and ensure that they reorder from the main stores in time Experience in Botswana Health staff were having problems describing which equipment accessories and consumables they wanted to order and stores staff had difficulty identifying the items requested Thus the government s Central Medical Stores decided to develop an order catalogue that described each item together with an illustration 120 6 2 Storage system and procedures 6 2 STORAGE SYSTEM AND PROCEDURES Elements of the Storage System Your health service provider will need to decide where equipment accessories and consumables are stored There a
213. ing instruments ANNEX 6 SAFETY AND CALIBRATION TESTING INSTRUMENTS Some instruments provide basic tests while others are designed for more complex procedures Box 64 provides some advice on the types of test instruments required which are bench top instruments Not every HTM Team or workshop needs all of them it will depend on the skill levels of the staff However anyone maintaining or repairing medical equipment needs some form of medical equipment safety tester either a basic one made from common bench tools or a commercially available product for comprehensive testing Other smaller hand tools used for testing purposes are included in the regular tool kits for maintenance staff see Guide 5 on maintenance management BOX 64 Example of Safety and Calibration Testing Instruments by Type of Work and Skill Level Electrical insulation tester megger meter mains socket wiring tester phase tester continuity tester Specialist three phase tester Electronic multimeter Basic bench top power supply Specialist counter timer function generator oscilloscope Medical equipment ammeter and earth break box instead of MES tester electronic thermometer standard mercury BP apparatus defibrillator analyzer tester Specialist ECG simulator electro surgical unit ESU analyzer medical electrical safety MES tester analyzer non invasive BP monitor tester oxygen analyzer oxygen flow meter mon
214. ing material Source Huys J 2003 Sterilization of medical supplies by steam volume 1 General theory and edition HEART Consultancy Renkum The Netherlands ISBN 90 75829 04 Annex 4 Example of a supplies order form ANNEX 4 EXAMPLE OF A SUPPLIES ORDER FORM Figure 22 shows a form that can be used when ordering supplies It acts as both a requisition voucher for goods from stores and a record of the items issued If the voucher is produced as a standard duplicate order book then the information can be used both by the user department as a record of the goods ordered and by stores staff for stock management purposes Figure 22 Sample Store Requisition and Issue Voucher rn 5 a i G O ep i g O Sc 3 0 3 2 5 5 3 5 7 a T a 7 n ja 2 2 5 4 o no D 2 o D 9 O 2 0 O 3 HB Qn 3 2 e ys gt O i g g E P 3 oe H is Pet DoD 5 z a p 5 ION b P S s l 2 S 5 5 n q o f o z 5 as A 2 5 fe e gt zo a 2 ae ze O 9 3 2 8 ls B 8 2 2 O n A ja 3 i x i S is 7 0 a i E o 5 S icv Q o E o S D gt oO 2 E 0 E aol 2 2 ov g g go Q n 555 E 8 8 58 3 on 8 g eu S g 3 N 2 8 gt
215. inked to regulations then other health service providers must also follow them Each health service provider can expand them internally and must establish systems to ensure they are implemented One key framework requirement for this Series of Guides is that your health service provider should have started work on a Healthcare Technology Policy for guidance on this process see Annex 2 Such a policy usually addresses all the healthcare technology management HIM activities involved in the life cycle of equipment as shown in Figure 4 Figure 4 The Healthcare Technology Management Cycle Planning and Assessment Decommissioning Budgeting and and Disposal Financing Maintenance RN Technology Assessment and Repair and Selection e Monitor O and f evaluate D Operation d gt A Procurement and Safety U and Logistics Training and Skill Installation and Development Commissioning 2 1 Framework requirements for quality health services Here we will consider just four issues that provide key background conditions Finances Standardization A vision for health services The provision of maintenance A Vision for Health Services Every health service provider needs a realistic vision of the service it can offer This should include a clear understanding of its role in relation to other health service providers in the national health service Only when this vision is known can the health service provider
216. internet bookshops Training manual for central service technicians 4th edition American Society for Healthcare Central Service Professionals 2001 ASHCSP USA ISBN 0 7879 5947 2 This manual is an introductory text developed to acquaint entry level aides and technicians with the scope of the central service central sterile supply department profession and with the scientific principles that underlie their daily work Updated materials include easy to read graphs new photographs and updated information on regulation governing agencies and web links Other publications are available linked to this manual such as a workbook an instructor s guide a manager s manual and so on see ASHCSP website Available from ASHCSP Where there is no technician A practical guide for users of medical equipment Remmelzwaal B and E de Villiers eds 2002 MOHSS Namibia This manual aims to cover situations where the nearest knowledgeable maintenance technician or private company is hundreds of kilometres away and health workers must develop basic skills related to maintenance calibration and safe operation of equipment In a modular style it covers 10 pieces of medical equipment commonly found in district health facilities The manual intends to serve both as a training manual and as a practical reference guide for individual health workers Available from Ministry of Health and Social Services Namibia Safety Issues Tip Thi
217. ion it is important to allow the load to dry after sterilization before it is stored otherwise the moisture will provide a breeding ground for micro organisms You must regularly monitor the performance of autoclaves in order to ensure that the items are sterile by the end of the autoclave s cycle in other words to ensure that sufficient time steam under pressure and temperature were received The common cycles depending on the material to be sterilized are steam at 134 C for three minutes or 121 C for 15 minutes and 115 C for 30 minutes for fluids 5 3 1 Decontamination Sterilization performance can only be guaranteed if you register the physical conditions pressure temperature time Registration and steam penetration during each sterilization cycle means that the process parameters are recorded during each sterilization process validate verify these results against a known similar correct test process profile and ensure such results are consistent and reproducible The process parameters fall into two categories The first pressure temperature and time can be easily recorded but the second steam penetration is more difficult to monitor For the first category advanced automatic sterilizers usually have a recorder that prints the basic parameters pressure temperature time on special sheets of paper and or stores them in a computer database For manually operated sterilizers the
218. ion and safety The main purpose is to establish an annual planning cycle which reviews past performance problems and needs identifies solutions and sets specific goals for the year prepares an annual action plan for delivering improvements in the coming year monitors implementation starts back at the beginning again with another review the following year Setting Goals Three types of goals are required targets recommendations and longer term objectives i Targets Targets guide the work of the user department HTM Working Group or its sub groups and HTM Team during the following year They help to improve services and make sure that the most important work gets done Targets are one of the best tools for judging progress and work performance We suggest that each department group should have between five and 10 targets following the SMART target setting process Specific state what should be done and who will do it Measurable easy to measure or easy to decide that the target has been achieved or if progress is being made Achievable possible to carry out with existing staff equipment and money Relevant cover a priority problem or improvement Time bound state when the activity should be completed by It will be clearer if targets are written down using the following headings which can be used when the final plans are produced Target By whom How to measure How to ach
219. ion on accessories and consumables It doesn t matter which way you purchase this safety gear as long as it is not forgotten The advice offered in this Section is just as relevant for safety gear and can assist you with its purchase storage and replenishment Availability Accessories are those items which connect the machine to the patient breathing circuits ECG leads probes transducers etc e assist with the use of the machine internal trays foot switches computer mouse etc e adapt its performance different sized adaptors objectives lenses etc Thus accessories are often the main link to the patient the part most handled by staff flexed bent twisted and even mis used subject to a great deal of wear and tear 4 the most vulnerable part of a piece of equipment Even if a piece of equipment lasts for years accessories may need to be replaced regularly therefore accessories must be available for the lifetime of the equipment Consumables are those items which are used up daily during the operation of the equipment such as X ray film disposable electrodes laboratory reagents ultrasound gel washing powder toner and solder will be needed throughout the lifetime of the equipment The availability of accessories and consumables will dictate how long staff can keep using a piece of equipment Once accessories and consumables are no longer available a piece of equipment cannot be
220. ip jaddn aye q 0 v 6S S Z A quiasse ALA 0 144024 wpeiydeig 0 Yv L9ZSYZ Buu 0 OL OL aqn 0 194 4 J0JD9UUOD Pe Hue jYyHIYy S 89 v v 60rrZ Jel jod 98 944 0 667969 ad mau u 16 Yoyms Ale Os S 09 LZLOEL a6neb wnnoe os 0 6r6clZ AJLA O4JUOD LUNNDe Or S L 9 9 94244 AELE Aquiasse 1414 G6 98 vS6clZ 8SrdA A quiasse do ser S8 L 9 9 99 969 Zve ve0 Aejep dwy z esn4 GLE 9 wg vl 626 28 n w Jad p wugg g u sdo u oyezs yue HBulgn UOHONS 6 6 s1 OIGoYdoupAy jqesods q syed aieds y Orzo OL L96 28 OL 40 xoq x p 194 feve oeq ajqesodsip pajees s jqewnsuo9 E 10 2 uuo9 p Bue y piy qn Bunosuuog Buluolssimwos 9 9 Jay euajoeq aiqesodsip psjees Bulinp siasn 0 U AJG 91 c9 LZSOErL Aiquiasse do Jef d yaqqny Apesije sajqewnsuoo S 89 E 60rrZ OJI OMy Suef UOJNS JOd pue saliossao0y Zz UON Jaljddns e207 Lv8Z9Z 06L vr 00 Xe4 ZZE SZ 064 vY 00 I9L YN r18 SLNG xessns s m HupueT peoy 19 9d SS21PpyY pr usjem pue sog uuewyosg ueunjoeynuey oOo SLZ Z0 ZS1 28 G2dA Jepow dund uonons ajyjoq a 6uls ada quawidinbg 1 sn PeAMaw paj oedxy pogd salo S aod yun Ayueno Jequinu ed uolndusseg yoo s jo adAL JB JOUOD S 10 OY Aq paadu aq oJ wea BUIUOISSIWILWOD 9y Aq pajadwoo aq Of w104 SYIO S M N 40 19 SIB8y 205 206 Annex 6 Safety and calibration test
221. ipment correctly Section 3 5 ensure they are familiar with equipment operation Section 4 1 provide adequate care and cleaning of equipment Section 4 3 follow correct safety procedures for themselves and patients Section 5 keep equipment secure Section 7 1 provide regular checks on the performance of equipment in use and carry out the planned preventive maintenance PPM tasks designated for users Section 7 2 ensure equipment is in a functional state Section 7 3 carry out basic repairs when suitably trained Section Heads are responsible and accountable for the equipment in their section ensure that equipment is used well in other words the equipment is cleaned cared for checked calibrated used correctly and safely and is kept securely report faults to the HTM Team promptly Section 7 4 Continued overleaf 13 _ oO C oO O O D Cc x _ z Section 1 summary BOX 3 The Collective Responsibility for Operation and Safety continued HTM Managers ensure technical staff carry out planned preventive maintenance and periodic user training see Guide 5 on maintenance management ensure that senior technical staff correctly write off and dispose of equipment at the end of its life Section 7 5 HTM Teams test equipment to ensure that it is in an acceptable and trustworthy condition Section 7 3 know the correct maintenance and repair routines follow good maintenance practice and have
222. ipment effectively it will be necessary to make decisions about and address the following issues eer The appropriate decontamination methods to follow Decontamination i SARE is a broad term covering Who will be responsible for decontamination of which processes which remove type of item inactivate or destroy Daily procedures contaminating infectious agents from items or surfaces and Decontamination processes are used to prevent contamination make items safe for handling and the spread of infection by medical instruments and disposal or reuse if this is equipment The three decontamination processes commonly possible and advisable see used are cleaning disinfection and sterilization Sections 5 4 and 6 1 It is important to understand how successful these processes are and to understand what the commonly used terms actually mean Brief definitions are provided here to show the difference between terms and help to show the least successful method cleaning through to the most successful sterilization 5 3 1 Decontamination Cleaning removes visible material dirt grease blood body fluids etc and reduces the number of some infectious micro organisms Disinfection reduces the population of harmful micro organisms on any surface but does not eliminate all viruses and bacterial spores Therefore it is important to realize that boiling and using chemical disinfectants do not produce sterility Sterilizatio
223. ips without fearing that the items you do not use will go off Thus with better coordination you can make more efficient use of your consumables Another strategy for ensuring the most effective use of equipment and materials is to train special equipment operators who will be responsible for running particular equipment during clinics or work sessions Section 3 5 The layout of buildings and departments can also contribute significantly to the effective use of equipment and staff Architects can advise on placing furniture and equipment in the available space in an orderly and effective way which ensures appropriate flow patterns suited to the function of the room see Guide 2 Is Your Equipment Economical to Run It is best to choose makes and models of equipment which are input efficient Just as some vehicles are more fuel efficient than others some makes of equipment are more economic in their use of consumables This should be considered during equipment planning and procurement see Guide 2 on planning and budgeting and Guide 3 on procurement and commissioning 3 4 3 3 Efficient use of equipment All equipment has a life cycle cost the recurrent cost required to keep it going throughout its life such as fuel consumables maintenance and training The cost of these factors can vary considerably between different manufacturers especially consumables For example the initial purchase price of infusion pump type A may
224. is planned and ordered on a country wide district wide or health service provider basis It is therefore important to combine forces with other facilities or health service providers and it may be wise to follow standardization strategies of the Ministry of Health It is important that these standardization efforts do not just apply to products purchased by health facilities but also to donations Standardizing your healthcare technology may be difficult for a number of reasons Your country and local businesses may have their own trade practices and interests National donors may have tied aid practices while the procurement procedures of international funding agencies health service institutions and individuals may act against your standardization strategies see Guide 3 19 2 1 Framework requirements for quality health services You may need to hold discussions with organizations such as the Ministry of Industry and or Trade the chambers of commerce or specific business associations as well as external support agencies However it is well worth persevering as standardization offers many benefits both in terms of cost and efficiency Provision of Maintenance Proper maintenance is essential to ensure that the equipment you have purchased continues to meet the standards required throughout its entire working life Undertaking maintenance belongs to the service provision function of health systems and could therefore in
225. issioning it is vital to specify particular and exact requirements for your accessories and consumables For each item you will need to provide as much of the following information as possible The name of the manufacturer of the equipment Make model and year of manufacture of the equipment Serial number of the equipment o A full description of the item required try to use the description and names used in the manufacturer s manual or order catalogue Size type for infant child adult etc and material Quantity and pack size required e Manufacturer s order number for that part and quantity When buying new equipment you can try to rationalize your accessory and consumable stock You achieve this by buying equipment which makes use of the types of accessories and consumables which you already keep in stock This would be the most efficient use of your stock of supplies and is an important reason for standardizing the equipment you buy to a small number of makes and models Section 2 1 Also consumables and accessories bought in bulk are often much cheaper However for maximum safety there are situations where you actually want non interchangeable accessories and consumables For example you will want gas connectors with different threads so that you cannot connect carbon dioxide to the oxygen inlet transducers for measuring different parameters which are colour coded to prevent confusio
226. istrict health facilities Guidelines for development and operation WHO Regional Publications Western Pacific Series No 22 1998 ISBN 92 9061 121 9 This revised and expanded book presents detailed richly illustrated guidelines for the planning and design of district hospitals including the efficient utilization of space and easy movement of people equipment and supplies It also provides extensive information on the selection and maintenance of medical and laboratory equipment Additional material covers sanitation and waste management emergencies and disasters the procurement of essential drugs and safety testing and calibration instruments Available from WHO Medical equipment in developing countries Two neglected issues planning and financing Berg H 1992 WHO Document WHO SHS CC 92 2 This document is aimed primarily at health planners It describes planning problems and outlines the procedures that should occur before equipment is purchased in order to ensure that the implications of ownership are known It looks at the recurrent cost implications of equipment and presents a method for unit costing and shows the consequences through examples Available from WHO See Guide 2 on planning and budgeting for more material on planning and designing health facilities and their equipment as well as the life cycle costs of equipment Operation Care and User Maintenance This material covers issues in Section 3 2 on equipment
227. ital management project Ministry of Health Zambia DFID Ziken International Consultants Lewes UK Temple Bird C and H Halbwachs eds 1991 Spare parts and working materials for the maintenance and repair of health care equipment Report of workshop held in L beck August 1991 GTZ Eschborn Germany Temple Bird C and B Kidger 1997 Technical assessment of medical equipment supplied under DFID assistance Report of the May June 1997 consultancy mission for the Ghana health sector aid programme Ziken International Consultants Ltd Lewes UK Visser P 1995 Infection control Paper 501 in Making hospitals work better volume I Working papers on hospital management and organisation KANDO hospital management project Ministry of Health Zambia DFID Ziken International Consultants Lewes UK Visser P 1995 Sterile packing in the CSSD Paper 502 in Making hospitals work better volume I Working papers on hospital management and organisation KANDO hospital management project Ministry of Health Zambia DFID Ziken International Consultants Lewes UK Ward C S 1985 Anaesthetic equipment Physical principles and maintenance 2 4 Edition Bailli re Tindall London UK ISBN 0 7020 1008 1 West of Scotland Health Boards 1985 Acceptance and routine testing of medical electrical equipment Test and Check Procedures Book 5 Physicare Glasgow UK WHO 1987 Interregional meeting on the m
228. ithin their grounds The Condemning Disposing and Replacement Process Figure 19 shows the likely steps in a typical decommissioning process The Health Management Team might have to chase the Board of Survey to visit the health facility promptly in order to officially condemn the equipment and arrange for it to be auctioned off Ideally condemned equipment is only disposed of once the official condemning process has occurred However if this does not happen regularly the health facility cannot afford to become choked with old and scrap items and should start a process of cannibalizing the equipment in order to reduce the impact of the stockpile and to gain as much use as possible from the old items Hazardous components should be properly disposed of as described in Section 5 4 The Health Management Team should pursue with the health service provider the possibility of establishing their own facility level Board of Survey as soon as possible if one does not already exist being able to sell off metal items for scrap returning any money raised from the sale of condemned items to the budget of the health facility 151 152 7 5 Decommissioning disposal and replacement of equipment Figure 19 Steps in a Typical Decommissioning Process Technical action Administration Official response Technical action Record keeping Official action Senior maintenance staff
229. itor patient simulator multi parameter two channel pH meter standards phosphorescent strip pressure vacuum meter spectrophotometer standards X ray line resistance meter X ray mAs meter X ray phantoms Continued opposite Annex 6 Safety and calibration testing instruments BOX 64 Example of Safety and Calibration Testing Instruments by Type of Work and Skill Level continued Medical equipment gas analyzer Advanced specialist very expensive and only required in the largest workshops ultrasound therapy unit output precision test balance ventilator tester Note 1 The medical electrical safety MES tester analyzer should include an IEC 60101 1 test load 2 A portable appliance tester PAT could possibly be used instead of an MES something is better than nothing However it cannot necessarily go down to the correct sensitivity for medical equipment or check for patient probe leakage Use of a PAT requires specialist advice in order to be aware of its limitations 207 208 Annex 7 Maintenance work request job form ANNEX 7 MAINTENANCE WORK REQUEST JOB FORM Figure 24 shows an example of a form that can be used both to request maintenance work by the user department or the HTM Manager and to record the work undertaken by the maintenance staff Thus it keeps together the records of the request and the response made Its multiple copies are filed by the user department and the HTM Team so
230. itoring are useful for providing feedback to staff Health Management Teams and the Healthcare Technology Management Service Monitoring progress involves a number of different activities The following monitoring activities are described in this Section Monitoring progress against the annual goals as set in Section 8 1 e Monitoring progress in general using statistics incident reports and staff appraisal Monitoring Progress Against Annual Goals Monitoring progress against goals is one of the best ways that staff managers and the health service provider can judge their work performance Thus it is necessary to follow up the plans and goals set in order to ensure that they are put into practice If this is not done and goals sit on a shelf gathering dust then all the time spent planning will have been wasted Regular monitoring of progress against goals is essential throughout the year This should be done using the measuring and charting methods introduced in Section 8 1 Displaying annual goals and gt progress towards them can be helpful to staff At the end of each year it is essential to review and carefully analyze the results achieved on all the department goals before starting to develop the Annual Action Plan for the following year This step is the most important to review results on a regular basis with the people who are doing the work This is the time
231. ke these tasks and if they require further skill development put in a request to their Head of Section Section 3 5 take responsibility for conforming to the local security regulations for the facility and its site Section 7 1 Purchasing and Supplies Officers made responsible for purchasing the correct consumables and cleaning chemicals Stores Controllers made responsible for keeping track of stocks of consumables and materials in the various stores Section 6 Continued overleaf 33 3 1 Accountability BOX 5 Strategies for Making Staff More Accountable continued Type of Staff Strategies Health Management try to develop a suitable working environment where managers are seen to Teams be present and performing well themselves consider positive strategies with bonuses and rewards for good behaviour with equipment as incentives for making staff more responsible and accountable consider disciplinary mechanisms so that staff are charged for intentional loss of or damage to equipment and accessories to make them more accountable for their actions Typical issues to consider to make the system fair are Should someone who breaks equipment while working correctly be charged How do you ensure that charging doesn t result in people breaking nothing by doing nothing Should missing or wilfully damaged equipment be charged to the operator or the Section Head in order to deter theft and
232. l Services Windhoek Namibia R ttjes M 1995 If not in use switch off Guidelines and key recommendations for a sustainable and cost effective energy supply for health facilities in remote locations FAKT Stuttgart Germany Safe Injection Global Network SIGN website 2003 www SIGN who int Sages Engineering Consultants 1999 Electrical survey of health facilities Summary of report Ministry of Health Ghana DFID Sages Accra Ghana Skeet M and D Fear 1995 Care and safe use of hospital equipment VSO Books London UK ISBN 0 9509050 5 4 Temple Bird C L 1990 Equipment management course notes Postgraduate diploma in medical electronics and medical equipment management Department of Medical Electronics and Physics Medical College of St Bartholomew s Hospital London UK unpublished Temple Bird C 2000 Practical steps for developing health care technology policy Institute of Development Studies University of Sussex Ziken International Consultants Lewes UK ISBN 1 85864 291 4 Temple Bird C Bbuku T and the Equipment and Plant Sub Group 2000 Equipment management policies and procedures manual KANDO hospital management project Ministry of Health Zambia DFID Ziken International Lewes UK Temple Bird C Bbuku T and F Kamanga 1995 Proceedings of the planning workshop to develop maintenance systems Annex V of the October 1995 consultancy report KANDO hosp
233. l as any training materials Sections 3 4 and 3 5 follow good strategies when operating equipment as detailed in Box 12 report any problems to the Health Management Team in order to trigger training interventions Health Service ensures application training is planned for and given Provider Equipment Users ensure they know how the equipment they use should be applied and ask for Section Heads help and training if unsure and HTM Teams refer to operator manuals and reference books for guidance as well as any training materials Sections 3 4 and 3 5 report any problems to the Health Management Team so that any training needs can be addressed Health Management allocate the user departments with sufficient appropriate cleaning materials and Teams resources for the care and cleaning of equipment Section 5 3 HTM Service and prepare care and cleaning instructions and timetables HTMWGs Equipment Users ensure they know the care and cleaning techniques for the equipment they use Section Heads and ask for help and training if unsure and HTM Teams ensure care and cleaning of equipment takes place according to the given timetable and following good strategies as described in Box 15 for guidance on the correct method for care and cleaning refer to the manufacturer s manual as well as training resources and posters Section 3 5 report any problems to the Health Management Team so that any training needs can be address
234. lagged to prevent burns Do not spread linen on the ground or over bushes to dry but hang it from washing lines if spin and tumble driers are not available Always iron items that have hung in the open air if your country has insects such as the mango fly that lay eggs on linen drying outdoors The ironing process whether by hand or by machine kills the eggs and prevents the larvae from hatching and burrowing into skin 5 3 2 Linen handling BOX 26 Strategies for Linen Handling Staff protection All staff involved in handling contaminated linen should be provided with appropriate safety clothing The risk of infection is high when dirt blood and infectious agents are present Aprons strong rubber gloves facemasks working boots etc are recommended In each section Sections using linen such as wards OPD clinics treatment rooms and theatres must use two separate types of receptacle soiled linen containers of different colours with labels one for contaminated linen and the other for uncontaminated linen Uncontaminated linen may be collected in some form of cotton bag contaminated linen should always be placed in strong waterproof plastic bags Used linen should be handled as little as possible to avoid cross infection Nursing staff should place used linen into the correct collection bag either for contaminated or uncontaminated items at the bedside to avoid carrying dirty linen through the department Staff
235. lations which describes how to plan and implement electrical installations safely in accordance with international wiring rules Guidebooks for implementing the IEE wiring regulations are also available Available from RS Components Ltd If not in use switch off Guidelines and key recommendations for a sustainable and cost effective energy supply for health facilities in remote locations R ttjes M 1995 FAKT Stuttgart Germany This practical document aims to provide a variety of courses of action that medical and administrative staff can pursue when health facilities are hit by energy problems It covers sustainable and cost effective energy supplies the different energy requirements possible energy sources and suggestions for a hospital energy supply It includes PPM schedules for air cooled diesel power plants Available from FAKT International seminar for hospital technicians engineers February 1998 Moshi Tanzania Clauss J ed 1998 FAKT La maintenance dans les systemes de sant Maintenance for health systems 4th GTZ Workshop Dakar Senegal September 1993 Halbwachs H and R Schmitt eds 1994 GTZ Testing to the 16 edition training video RS Components Ltd This video describes how to test electrical installations according to the latest IEE wiring regulations 16 edition Available from RS Components Ltd Laboratory safety District laboratory practice in tropical countries part 1 Cheesbrough M
236. leaning system 15 Emergency generator 20 Water fountain 10 Controls 12 Water heater commercial 10 Energy management system computer based 10 Water purifier 10 Water softener 10 Escalator 20 W k 0 Fans ceiling mounted 10 See LAN 2 Water wells 25 212 Part Two Estimated Useful Lives of Major Movable Equipment Major movable equipment is defined as assets that are generally assigned to a specific department within the health care facility but with the capacity of being relocated The assets have a minimum useful life of at least three years and a unit cost sufficiently large to justify the expense of maintaining an equipment ledger Note Included within the departmental listings are assets that may be considered to be minor equipment for Annex 8 Typical equipment lifetimes example surgical instruments with a three year life assignment Minor equipment may be defined as assets that are relatively small in size and unit cost and have high usage They are generally found in the obstetrics surgery and dietary departments Table 6 Administrative Departments Administrative Departments consist of administration barber shop board room admitting business office communications data processing education facilities management finance foundation graphics home health human resources infection control library lobby marketing medical education medical records medical staff facilities nursing administration pastor
237. linked to their equipment inventory coding system Their storage space is divided according to the inventory codes and the shelves are divided and labelled accordingly In this way supplies common to individual pieces of equipment are kept next to each other In addition their inventory coding system included codes for families of equipment areas of use Such as radiographic equipment suction equipment heating and ventilation equipment in this way supplies for individual machines are stored in the same area as supplies for other machines in the same equipment family In order to make the stock control system faster and more efficient they developed a computerized system with support from Dutch Aid 124 6 2 Storage system and procedures What to Keep in Stock Most stores systems have what are known as stockable items these are items which are automatically replenished when stocks run low and are therefore always in stock This is acommon system for medical and general items but is rarely in place for equipment related supplies and this makes it very difficult to keep equipment functioning You should therefore aim to make equipment related items stockable too including equipment consumables commonly used accessories the spare parts and maintenance materials required for PPM those parts and materials which experience tells you will be required for common repairs Less commonly used equipment related ite
238. lizer see above and a true online type of uninterruptible power supply UPS see below may help Your equipment is affected by power surges peaks and ripples caused by electro magnetic interference from lightning switching operations of heavy machinery permanent electro magnetic fields from transmitters etc and electrostatic discharges Suppression of electro magnetic interferences There are various strategies see Annex 2 such as ensuring all equipment is connected to a good earth grounded ensuring all ground connections are at the same voltage providing metallic shielding of power lines and data lines twisting of cable pairs which are connected to equipment input terminals separating power circuits for sensitive electronic equipment from those for heavy loads using radio frequency interference RFI filters unplugging equipment during thunderstorms installing an effective external lightning arresting system using lightning conductors installing a transient absorption system for high energy peaks and spikes using various separate types of surge arresters at different points in the electrical installation You suffer from power failures or power flaws and want to ensure that the supply of power is transferred to a back up system Power back up systems using generators or banks of batteries either for the total installation parts of it or individual pieces of equipment These can involve
239. llowed during installation Medical Electrical Safety Another important area of safety is medical electrical safety Medical electrical equipment has stricter electrical safety requirements and considerations than non medical equipment because it comes into direct contact with patients for example ECG recorders monitors diathermy units and physiotherapy ultrasound All such equipment should conform to and be manufactured to the international safety standard IEC 60101 see Guide 3 on procurement and commissioning It describes electro medical equipment according to the type of protection provided against electric shock defined as Class I II or HI and the degree of protection provided against electric shock defined as Type B BE or CF You can tell which sort of equipment you have by studying the symbols on the manufacturer s label attached to your equipment as shown in Figure 11 Such equipment will require dedicated safety testing procedures and test instruments which go further than the standard electrical safety tests described above All electro medical equipment should be regularly inspected and tested by bio medical technicians using the correct test instruments Section 7 3 To guarantee safety they should perform a variety of tests on each piece of equipment depending on its Class and Type such as e self checks supply voltage check insulation resistance test earth bonding test earth leakage current test
240. local workshop e writes a technical report explaining why the equipment should be officially condemned e submits this report to the Health Management Team and relevant User Department for information and discussion at management meetings the Purchasing and Supplies Manager who starts the official process the HTMWG in order that the condemnation triggers a replacement in the annual Equipment Development Planning process see Guide 2 The Purchasing and Supplies Manager completes a form such as a List of Expendables to be Written Off form see Annex 9 and submits it to the relevant e financial head office of your organization for example the Ministry of Finance e local Board of Survey whether it is a facility or district branch Section 1 2 The Board of Survey scrutinizes the report visits the facility and condemns the equipment thereby providing the HTM Service with authority to remove the equipment from service The HTM Team from your local workshop cannibalizes the equipment by e removing any useful components and parts from the condemned equipment for use on other equipment e storing these components and parts in the facility stores and maintenance sub stores depending on their size and number ensuring that any hazardous components or parts such as radioactive sources asbestos mercury etc are disposed of in a safe manner according to the Waste Management amp Hygiene Plan Section 5
241. loping and implementing PPM work for priority equipment before expanding to cover further Set priorities equipment Undertake a risk analysis concentrate on implementing PPM on essential or frequently used equipment rather than non essential or rarely used equipment ake use of any existing written user PPM schedules which you have and implement them Start gradually using existing f necessary start with checks every three months then later on resources increase the frequency by gradually introducing monthly and hen weekly checks or the frequency recommended by the manufacturer for the most critical equipment As new equipment arrives write further user PPM schedules and timetables train staff in their use Section 3 5 and implement them in order to preserve the investment in your new stock Allow for new arrivals Expand the amount of items covered by extending this user PPM work e either to cover more of the same type of equipment in other words if you are doing PPM for newly purchased suction Expand slowly pumps then expand the PPM to cover the older existing pumps too e or to cover additional different items in other words if you are doing PPM for suction pumps then expand the PPM to also cover operating tables Ensure that the Purchasing and Supplies Officer buys all new equipment together with its maintenance schedules they are Allow for further purchases often contained in the oper
242. lved in decontamination should be provided with appropriate safety clothing especially for the cleaning of equipment before sterilization The risk of infection is high at this stage when dirt blood and tissue are being removed prior to sterilization Aprons strong rubber gloves facemasks etc are recommended Develop preventive medicine policies to provide staff with post exposure prophylaxis when contaminated with infectious agents Contaminated equipment and instruments must be transported in labelled sealed plastic bags or boxes to the point where they will be decontaminated Develop staff training and a refresher training plan on infection control strategies Decontamination Methods You should always use the appropriate method of decontamination according to the guidance provided in the equipment manufacturers manuals the national policies and the resources available to you As explained the most common methods available to you are cleaning disinfection and sterilization But it is important to realize when combating infection that only proper sterilizing equipment the most common being steam pressure autoclaves can sterilize products Thus each health facility needs to implement appropriate decontamination methods suited to its size and needs The CSSD or relevant group of staff must ensure that the correct equipment is used and the correct method for each job is implemented as follows 65 66 5 3 1 Decont
243. m WHO Annex 2 Reference materials and contacts Medical supplies and equipment for primary health care A practical resource for procurement and management Kaur M and S Hall 2001 ECHO International Health Services Ltd ISBN 0 9541799 0 0 This book is intended for health workers and those responsible for the procurement and management of medical supplies and equipment at primary healthcare level It covers guiding principles for selecting supplies and equipment provides guidelines for ordering and procurement storage and stock control care and maintenance and considers decontamination and safe disposal of medical waste The manual also discusses the use of standard lists as a tool for encouraging good procurement practice and includes model lists of medical supplies and equipment required for primary health care activities in both health facilities in the community and basic laboratory facilities Available from TALC Physical asset planning and management software PLAMAHS HEART Consultancy This software package holds information and supports analysis on the equipment inventory equipment models and standards existing and planned facilities procurement support and maintenance support The software holds various digital images standard lists and templates for forms etc and has a security system It has been designed especially with developing countries in mind is available at special rates for developing countries and HE
244. maintenance workshop etc e the Head of Section or person responsible should lock them at the end of the day e the Head of Section or person responsible should hand the keys into the In Charge s room where they will be kept in a locked cupboard one person from the night shift team should be allocated responsibility for accessing keys if they are required in an emergency during the night In the case of all departments or rooms used 24 hours a day dispensary in patients 24 hour OPD casualty maternity labour small laboratory staff room etc night team members should lock individual rooms when not in use While any department or room is in use at any time of day equipment not in continuous use for example sphygmomanometers diagnostic sets foetal dopplers should be locked in the Head of Section s office All staff should be responsible for showing continued vigilance for items in continuous use Monitoring Heads of Section should regularly check their inventory of equipment to see if all items are present Response to problems In accordance with the accountability strategies Section 3 1 the Health Management Team should consider e how good behaviour is to be rewarded e what penalties to introduce for non compliance and negligence if theft is to be a punishable offence Similar strategies should be pursued for all maintenance tools see Guide 5 on maintenance management 7 2 User pla
245. manually operated sterilizers Annex 2 Reference materials and contacts RS Components Ltd Birchington Road Corby Northants NN17 9RS UK Tel 44 1536 201234 fax 44 1536 405678 email general rs components com website rswww com Supplier of equipment supplies parts and components for a wide range of engineering professions such as electrical electronic mechanical heating ventilation air conditioning plumbing welding pneumatics computing automotive Also a source of textbooks technical data books technical literature and training videos for all these engineering fields Source International Information Support Centre The Wellcome Trust Building Institute of Child Health 30 Guildford Street London WC1N 1EH UK Tel 44 20 7242 9789 ext 8698 fax 44 20 7404 2062 email source ich ucl ac uk website www asksource info The Source Centre has a unique collection of over 20 000 health and disability related information resources These include books manuals reports posters videos and CD Roms Many materials are from developing countries and include both published and unpublished literature Swiss Centre for Development Cooperation in Technology and Management SKAT Website www skat ch dc publ publ htm SKAT works internationally in the areas of water and sanitation architecture and building transport infrastructure and urban development They also publish the SKAT newsletter Swiss Centre for International H
246. me equipment and the provision of some services 100 Tip 5 5 2 Electricity Thus for safety reasons the emergency generator should be connected to items such as the refrigeration unit controlling the mortuary body store the blood bank fridge the water pump any sewage pump an autoclave an operating theatre UM any intensive care facilities Some health facilities will not have a main electricity supply from a supply company but will have to rely on an electrical generator alone which will be used for only a few hours a day This will affect the type of equipment you can own Other facilities will use alternative sources of electricity such as solar panels Whatever your power source you need to protect against sudden changes in supply such as electrical surges spikes cut outs lightning strikes etc which can ruin your equipment and mean you lose your data The most sensitive equipment in health facilities is the advanced electronic equipment such as telecommunications equipment telephones fax machines radio transmitters and receivers data processing equipment computers printers plotters monitors electronic diagnostic equipment radiography ECG ultrasound monitoring machines electronic laboratory equipment any other equipment with electronic control circuits Box 36 describes several measures you can take to adapt the power supply to the requirements of you
247. ment used to its limit overworked or overloaded how the equipment is handled is it abused how well the equipment is cared for and cleaned how well the equipment is serviced and how often the initial quality of the equipment was it new or reconditioned 6O the physical environment and climate that the equipment is used in Any replacement must be undertaken in accordance with the replacement policy see Guide 2 on planning and budgeting Box 57 provides an example BOX 57 Example of a Replacement Policy Equipment will only be replaced when one of the following valid reasons have been fulfilled Itis worn out beyond repair has reached the end of its natural life It is damaged beyond repair It is unreliable faulty old or unsafe It is clinically or technically obsolete Spare parts are no longer available Itis no longer economical to repair And one of the following valid reasons have also been fulfilled g Utilization statistics are available to show that it is still required h A demonstrated clinical or operational need still exists Equipment will not be replaced simply because itisold staff do not like it anewer model has arrived on the market 7 5 Decommissioning disposal and replacement of equipment Maintenance technicians and engineers are required to judge these issues and procedures are required for the following steps i assessing whether equipm
248. mes and titles given to the people and teams involved will vary depending on the type of health service provider you work with For the sake of simplicity we have used a variety of labels to describe different types of staff and teams involved in HTM This Series describes how to introduce healthcare technology management into your organization The term Healthcare Technology Management Service HTMS is used to describe the delivery structure required to manage equipment within the health system This encompasses all levels of the health service from the central level through the regions districts to facility level There should be a referral network of workshops where maintenance staff with technical skills are based However equipment management should also take place where there are no workshops by involving general health facility staff We call these groups of people the HTM Team and we suggest that you have a team at every level whether a workshop exists or not Throughout this Series we have called the person who leads that team the HTM Manager At every level there should also be a committee which regularly considers all equipment related matters and ensures decisions are made that are appropriate to the health system as a whole We have used the term HTM Working Group HTMWG for this committee which will advise the Health Management Teams on all equipment issues 1 1 Introduction to this series of guides Due to i
249. micals see Annex 2 67 5 3 1 Decontamination Box 22 Some Common Chemical Disinfectants and Their Potential Applications Chemical Dilution Contact Inactivates Important characteristics Potential application disinfectant g litre time min 1 week Equipment amp surface viruses Broad spectrum Vegetative bacteria viruses Non lipid viruses Bacterial Shelflife gt Corrosive Inactivated by organic matter Skin irritant Eye irritant Respitory irritant Dirty glassware decontamination Liquids to be discarded Quaternary ammonium compounds Phenolic 10 50 NE compounds Hypochlorites 5 10 30 lodoform 0 075 16 30 Ethanol 700 850 NE lsopropanol 700 850 NE Formaldehyde 2 80 30 solution of gas Glutaral 20 0 30 jo Zz m 1 t 1 t Of the pure disinfectant stored under appropriate conditions Available halogen Variable results with different viruses Not effective Source WHO 1994 Maintenance and Repair of Laboratory Diagnostic Imaging and Hospital Equipment WHO Geneva Method 3 Sterilization To ensure that sterilization is achieved each health facility should consider which strategies are appropriate for its size and needs The CSSD or relevant group needs to ensure that the correct equipment is used there are three ma
250. moveable parts trolley wheels microtome slides etc Replace lost worn out cracked or broken parts stethoscope earpieces and diaphragms rubber seals in pressure cooker type steam sterilizers etc Sharpen blades scissors microtome knives etc Check and replace chart recorder paper blood bank refrigerators ECG recorders etc Ensure that programmable or manual settings are returned to normal after the work of the previous day or shift diathermy machines monitors etc Inspect for wear and damage and either inform technical staff in the case of cracks in bedframes poor condition of mains cable and connectors etc or replace the faulty article if it is a standard stock item chipped suction bottles torn screen material etc Replace batteries and bulbs when they reach the end of their lives Check battery charging level lights and warning lights and respond as necessary defibrillator patient monitor etc Check that dials gauges indicator lights etc are working properly Go through the machine s automatic functional check programme infant warmers etc Descale elements water distillers boilers etc Perform Bowie amp Dick tests for autoclaves according to the recommended scheme For each equipment type there will be specific user PPM instructions Box 55 provides an example of the type of instructions required for refrigerators 141 142 7 2 User planned preventive maintenance PPM BOX
251. ms may remain as non stockable items How the System Works Usually the Stores Controller monitors the stock levels of stockable items and when stocks are running low submits order forms to the Purchasing and Supplies Officer to automatically buy in another batch However if a stockable system has not yet been established for equipment related items perhaps because funding for the health service is unstable recurrent items are considered for purchase each month or quarter when cash is available In this case the user department submits its order for further supplies to the Purchasing and Supplies Officer as described in Guide 2 on planning and budgeting see Annex 4 In addition user departments submit their orders for non stockable items to the Purchasing and Supplies Officer as and when they are required Keeping Track of Stocks Whenever new equipment related supplies arrive they should be entered into the stores system Also when new equipment arrives the stocks of accessories and consumables that were purchased with it should be entered by the Commissioning Team into the Stock Control system as described in Guide 3 on procurement and commissioning see Annex 5 125 6 2 Storage system and procedures Stores staff should allocate code numbers to the different equipment accessories and consumables enter onto the stock cards bin cards the sorts of information that is shown in Figure 13 Guidance on the
252. n Hospital Association AHA Source American Hospital Association 1998 Estimated Useful Lives of Depreciable Hospital Assets American Hospital Association Chicago USA The AHA s extensive list reflects how equipment lasts within the United States healthcare system whether it was manufactured in the US or abroad Their list was compiled following e discussions with manufacturers of healthcare equipment e discussions with various hospital department managers e analysis of actual retirement practices for actual hospital assets Their list is made up of a series of tables of different categories of equipment determined by the equipment s role in the health facility Part One Estimated Useful Lives of Land Improvements Buildings and Table 1 Fixed Equipment Land Improvements Land improvements are assets of an above ground or below ground nature found in the land area contiguous to and designed for serving a health care facility The asset cost would include a proportionate share of architectural consulting and interest expense for newly constructed or renovated facilities Item Years Item Years Bumpers 5 Paving including roadways walks Culverts 18 and parking continued Brick 20 Fencing Concrete 15 Brick or stone 25 Gravel 5 Chain link 15 pa Wire 5 Retaining wall 20 Wood 8 Shrubs and lawns 5 Flagpole 20 Signs metal or electric 10 Guard rails 15 Snow melting system 5 Heated pavement 10 Trees 20
253. n Remmelzwaal 1997 FAKT Project Number 390 This document is aimed at the health workers administrators maintainers and overseas aid workers who are involved in medical equipment management in developing countries It examines the variation in performance with management of medical equipment in different countries with the objective of identifying successful approaches It addresses some of the managerial issues related to the conservation of equipment allocation of human financial and material resources and acquisition and use It looks at the structure for the HTM Service and the HTM cycle Available from FAKT See Guide 1 for more information on further relevant issues such as health service definitions the place of HTM in health systems regulations and standards Developing Skills Managing Change and Monitoring Progress This material covers issues in Section 2 1 on managing change Section 3 1 on accountability Section 3 5 on training and Section 8 on target setting and monitoring progress It is listed alphabetically by title A book for midwives Klein S 1996 Hesperian Foundation ISBN 0 942364 23 6 This book provides practical information on antenatal care labour birth and post partum care It also includes a section on making teaching materials and low cost equipment Available from TALC Diagnosis and treatment A training manual for primary health care workers Birrell K and G Birrell 2000 VSO ISBN
254. n in all laboratories There are a variety of methods that they can employ for double checking that test results and readings are consistent and accurate 105 106 5 5 4 Radiation hazards 5 5 4 Radiation Hazards X ray Equipment X ray machines are obvious sources of radiation and safety policies and procedures must be produced regarding lead lining of rooms leaded control booths or screens with leaded glass the use of mobile machines outside of lead lined rooms the direction and timing of firing exposure the use monitoring and follow up of exposure badges for operators the use of lead aprons by operators the use of gonad protectors for patients Methods are required for monitoring and recording exposures and any adverse incidents Procedures are required for getting exposure badges dosimeters checked and implementing any follow up actions needed Advice on all these issues should be available from the national body responsible for radiation control Section 2 2 and reference materials see Annex 2 Box 38 provides some strategies for the use of X ray machines Other Radioactive Sources In addition in larger facilities there may be radiation hazards from other radioactive substances such as radio opaque materials and radioisotopes used for imaging and radioisotopes and radionuclides used in laboratories for tagging and radio immunoassay Follow these guidelines for these substances
255. n removes or destroys all living organisms making any surface free of micro organisms viruses and bacterial spores Sterilization is absolute therefore an item cannot be nearly sterile In addition you should be aware that there are two other terms you may hear which are used in particular fields Sanitize a term used in connection with catering and food equipment that means to reduce the number of micro organisms to an acceptable level on these items Antisepsis a term used in connection with living tissues and wounds that means the destruction of micro organisms on these areas in order to prevent sepsis rot or decay We are going to concentrate on cleaning disinfection and sterilization in this Section Three different processes or a combination of them are required because equipment is made up of a variety of components plastics rubber metal electronics etc which react differently to each procedure The procedures available have different drawbacks for example Some cleaning chemicals leave a sticky residue or are corrosive ruining valves for example High temperatures can distort the shape of some items ruining face masks for example Some chemicals give off fumes that must be ventilated and therefore must not be used for breathing circuits Exposure to liquids over a long time can cause rusting of surgical instruments and the like Chemicals require the right concentration to be effective
256. n when you connect them to the equipment 117 6 1 General discussion on accessories and consumables For most countries the procurement of accessories and consumables from abroad is a lengthy and tedious process It takes time to obtain quotations secure foreign currency and ship goods If you want to retain stock levels and receive items on time you must plan ahead for items procured from abroad Items procured locally should not pose such problems as long as funds are available They can be obtained from local suppliers or from a body such as a Central Medical Stores The HTM Working Group may want to develop a policy to purchase equipment accessories and consumables locally where possible in preference to overseas to encourage the development of sustainable local markets The HTM Working Group or its smaller stock sub group Section 1 2 should develop procedures for comparing products and reviewing their cost and performance before reordering them to avoid the purchase of items known to be poor Purchasing should be a process without political or social influence to avoid possible allegations of bribery You should also have a policy of only accepting free gifts if they come with a stock of accessories and consumables to ensure the equipment can be used see Guide 3 on procurement and commissioning The quality and effectiveness of a machine is often jeopardized by the use of low quality accessories and consumables P
257. nagement Health and disease in developing countries Lankinen K et al eds 1994 MacMillan Press ISBN 0 333 58900 9 This comprehensive book covers health and disease from the wider perspective of development in general It is of particular interest to medical and other professionals working in developing countries or for international cooperation agencies It is a valuable resource for district medical officers and students taking courses in public health and tropical medicine Besides sections on society economy and health infectious diseases and challenges for health care there is a section on health services to meet the challenges This section contains chapters of particular relevance to equipment such as Medical equipment management Temple Bird C Chapter 52 Essential laboratory services Willcox W Chapter 51 Available from major internet bookshops Health in the commonwealth Challenges and solutions 1998 1999 Commonwealth Secretariat 1999 Kensington Publications Ltd London This digest of articles covers a wide range of health issues such as resources and planning equity of access medical technology and equipment health promotion mother and child health community health communicable and non communicable diseases etc The content is aimed at policy makers and planners There is a range of technology articles on equipment telemedicine hospital design sanitation vector control water and air supplies
258. nd of its life a decommissioning disposal and replacement process must take place Decommissioning is the process of condemning equipment when it is no longer safe or of use and taking it out of service This process is sometimes known as boarding because originally government bodies called Boards of Survey were responsible for carrying out this task for government property 149 150 7 5 Decommissioning disposal and replacement of equipment All equipment has a life expectancy which will be dependent on the type of equipment and the type of technology it contains For example five years might be the typical life for an ECG monitor 10 years for a suction pump 15 years for an operating table and 20 years for an electricity generator Reconditioned equipment has a shorter lifetime than equipment bought from new Once equipment reaches the end of its life no amount of intervention will help it just needs to be replaced if the service it provides is to continue In fact to keep on trying to maintain equipment which has reached the end of its life will be costly To understand how equipment depreciates it is necessary to know the likely life of your equipment Typical lifetimes for common equipment are given in Annex 8 though these may need to be modified depending on the rate of use of the equipment how many tests per day How many patients per month etc e how many back up units you have is the equip
259. net bookshop American Hospital Association Clinical Engineering Section 840 North Lake Shore Drive Chicago Illinois 60611 USA Website http aharc library net Their documents are published by HealthForum use website www ahaonlinestore com American Society for Healthcare Central Service Professionals ASHCSP One N Franklin Avenue Chicago Illinois 60606 3421 USA Tel 1 312 422 3700 fax 1 312 422 4577 website www ashesp org ashcsp education publications html This society is for healthcare workers working in the central service and sterile processing field central sterile supply departments They produce a wide range of publications covering the training of technicians advice for managers continuing education for central service staff different sterilization techniques reusables decontamination assembly and packaging administration and organization cost analysis and total quality management AMREF International African Medical and Research Foundation Resource Centre AMREF Headquarters Langata Road PO Box 00506 27691 Nairobi Kenya Tel 254 2 501301 2 3 fax 254 2 609518 e mail amref info amref org website www amref org Publishes practical books journals and other literature for health workers and provides advice on primary health care Runs training courses and seminars BMA British Medical Association and BMJ Bookshop British Medical Journal BMA House London WC1H 9JR UK Tel 44 0 20 7383 6244
260. ng materials for staff to refer to see Box 8 and Figure 7 The materials together with demonstrations help staff to learn as well as providing them with something that they can regularly refer to when they are unsure A variety of resources can help you when you decide to undertake training yourself These will vary depending on the training source and on which of the available skill development options described in Box 9 you use Box 10 details some of the resources you may require Information BOX 10 Resources Required When Running Training Courses Yourselves about the training required background and needs assessment and the training sources available Training materials appropriate to the piece of equipment to be studied Space suitable for carrying out the training in Equipment to be practised on during the training courses Test and calibration instruments in order to verify technical conditions and safety during training Spare parts appropriate for user PPM training Supplies for user training such as consumables medical supplies and cleaning materials Manuals to refer to such as the manufacturer s operator and service manuals Test method and certificate a formal way of testing trainees and issuing them with a certificate at the end of the training course as a quality control and motivating factor depending on the extent of
261. ng more than 24 hours before clean the boiler after each day s use you use the items as the items may become contaminated even if stored in a closed container b Chemical disinfection This can be achieved by making use of the wide range of chemical disinfectants that are available Each is best suited for a specific purpose and must be used in a particular way to be effective Because not all disinfectants will kill all organisms a single disinfectant will not fulfil all your requirements stocking two different disinfectants may be sufficient Choose disinfectants which offer a wide range of activity are not readily inactivated are non corrosive when diluted are non irritant to skin are low cost Proper chemical disinfection depends on using the appropriate disinfectant at the right concentration and for adequate contact time It is important to follow the manufacturer s instructions for disinfectant handling preparation use and storage Incorrect dilution poor storage and repeated use of the same working solution reduce the effectiveness of chemical disinfection Box 22 summarizes some common chemical disinfectants and their potential applications the columns show the various benefits and hazards of using each type The Health Management Team should refer to the manufacturer s manual national guidelines and expert advice in order to ensure that they purchase sufficient stocks of the correct che
262. ng of Health Facilities Where to use always use clean freshly drawn water cleaning agents damp dust in any area clean walls floors ceilings or furniture in most areas with a general purpose detergent an anionic liquid use scouring powders that are not so abrasive that they scratch the surface on sinks wash basins sluices slop hoppers baths showers and lavatories use washing soda for cleaning waste pipes and overflows in sinks baths showers wash basins drain grids and drain pipes e use a grease solvent paste for cleaning cookers e use anon foaming detergent in dishwashers Where to use Disinfect disinfectants e baths during or after cleaning e kitchen work surfaces after cleaning e floors and work surfaces in operating theatres renal dialysis units special care units and other high risk areas during or after cleaning on some occasions when areas are known to have been soiled with infected organic material e patches of floor soiled by incontinence or bedpan spillings during or after cleaning How frequently The frequency of cleaning varies for different areas of the health facility For example to clean operating theatre floors several times a day e baths showers basins and lavatories at least once a day e walls once a month but immediately after being splashed with organic material What cleaning All cleaning should be done using one of the following which must be wet equipment to us
263. ng schedules need to be written for the remaining six departments and you plan to write them all in the next three months Calculation required Percentage of available cleaning schedules implemented _ Number of equipment cleaning schedules carried out in a time period x 100 Number of equipment cleaning schedules should have been done in that time period and percentage of equipment cleaning schedules developed _ Number of equipment cleaning schedules written in a time period x 100 Number of equipment cleaning schedules planned to write in that time period After three months you find that in fact you only managed to get three out of the four departments to implement their equipment cleaning schedules that is 75 of your first target to write equipment cleaning schedules for three of the remaining departments that is 50 of your second target 8 1 Setting goals annually for equipment operation and safety It is necessary to choose suitable indicators that are specific to all your annual goals There are many possible indicators for user departments safety sub groups and the health service as a whole so staff and managers should decide upon the most important activities or statistics and results to measure Examples of the types of indicators which can be used for equipment operation and safety are those describing the existing situation numbers of user created faults and breakdowns key accessories and c
264. ngerous needles and other sharps waste from the environment 89 90 5 4 2 Managing different types of waste BOX 32 Safety Issues Relating to Incinerators DO Design issues Have an upper pre heating chamber where wet waste can dry out prior to combustion Ensure good ventilation using enough air inlets and a sufficiently high chimney greater than 4m made of stainless steel Generally require fuel wood charcoal coal paraffin oil gas coconut husks etc to be added only during the start up period Include a method for cleaning flue gases in other words a cross draught combustion system that requires all gases to pass through the hottest part of the chamber Ensuring proper combustion Use fuel to preheat the waste in the start up period Add waste in small amounts for example load with only a few plastic sacks and wait for these to burn away before adding more Load with a good mix of combustible and non combustible material Add additional fuel firewood oil or gas if the waste does not burn properly you can collect waste motor oil for this purpose and soak cloths paper sawdust etc to place in the incinerator Leave the cover closed until most of the waste has burned away Ensure regular maintenance Safety for the operators Use protective clothing boots and gloves Avoid direct skin contact with wastes at all times Avoid skin contact with or inhalation of the
265. nical staff from the HTM Service and for which they have been trained For examples see Box 54 The approach should be to teach staff using demonstrations to remember the basic motto and strategy of Check Replace Inform they need to know the correct methods for undertaking maintenance and repair of equipment Information is available from a variety of sources The best information on equipment PPM is usually contained in the manufacturer s user manual and or service manual A wide range of independent reference material is also available see Annex 2 Managers should write PPM schedules and timetables see below Resources from training sessions and in some cases posters provide the guidance and experience of colleagues Section 3 5 Staff without personal copies of these resources should find them in the library Section 3 4 7 2 User planned preventive maintenance PPM BOX 54 Typical Examples of the User s Role in the PPM of Equipment e Calibrate equipment to ensure it is operating within its required parameters scales photometer etc Check and tighten loose screws bed frames etc Change filters after their recommended duration of use suction pumps infant incubators etc Check for correct oil levels air compressor engine oil washing machine gear oil etc or water levels bench top autoclave reservoirs infant incubator humidifiers etc and refill as necessary Oil or grease
266. nk being ordered unnecessarily and sold off privately and light bulbs being used in people s homes Box 48 provides some strategies for all these issues The storage system at any level such as a hospital may have a main store which stocks the major bulk of all items but issues weekly regular requirements to smaller sub stores in user departments or the maintenance workshop The items issued to the sub stores depend on the value and frequency of use of each item A user department or workshop is allowed a sub store when they have a secure lockable storage room itis agreed which are the regular items required on a daily weekly basis for storage in the department the Stores Controller provides the department with the necessary stores forms to complete the Stores Controller trains a suitable staff member from the department to correctly fill in the necessary stores forms for the stocks held in their department the department has special storage requirements goods requiring refrigeration for example so the Stores Controller allows bulk stores to be held outside the main stores under agreed special conditions as long as they are secure Box 49 overleaf provides some strategies for creating a suitable secure and clean store which is organized in a simple and logical way 6 2 Storage system and procedures BOX 48 Strategies for Storing Equipment Related Items Strategy Suggestions If you decide to use a general health
267. nned preventive maintenance PPM 7 2 USER PLANNED PREVENTIVE MAINTENANCE PPM Equipment which is well looked after will last a long time The best way to look after equipment is to maintain it Maintenance 1s a collective responsibility with lots of people involved such as maintenance staff in workshops equipment manufacturers and your HTM Team see Guide 5 on maintenance management However general health staff and equipment users as part of the HTM Service Section 1 1 have a vital role to play see Box 3 They should report any faults promptly to the maintenance department but they should also undertake some daily basic level maintenance tasks themselves These activities are mainly aimed at ensuring that the performance and functioning of equipment is checked and corrected Planned preventive maintenance PPM is a series of activities carried out on equipment with the aim of preventing breakdowns and ensuring that equipment is operational and safe By following a specified schedule of activities according to a given timetable user PPM should reduce the amount of time the equipment is out of service PPM is important because it enables your department to catch any problems before they become crises prevent breakdowns save money as PPM is cheaper than repairs following breakdowns make sure that equipment is fully operational 6 guarantee accuracy and reliability the autoclave sterilizes the laborat
268. nnual work planning Paper 401 in Making hospitals work better volume II Working papers on hospital management and organisation KANDO hospital management project Ministry of Health Zambia DFID Ziken International Consultants Lewes UK Haddon B 1995 Monitoring targets and work performance Paper 402 in Making hospitals work better volume II Working papers on hospital management and organisation KANDO hospital management project Ministry of Health Zambia DFID Ziken International Consultants Lewes UK Halbwachs H 1992 Health care equipment for developing countries The conflict between needs and interests GTZ Eschborn Germany Halbwachs H 1993 Maintenance and the district health system Approach and perspectives in Maintenance for Health Systems Report of the 4th GTZ Workshop in Dakar Senegal September 1993 GTZ Eschborn Germany Halbwachs H 2000 Maintenance and the life expectancy of healthcare equipment in developing Economies pp 26 31 in Health Estate Journal March 2000 Halbwachs H 2001 Physical assets management and maintenance in district health management GTZ Eschborn Germany Halbwachs H and A Issakov eds 1994 Essential equipment for district health facilities in developing countries GTZ Eschborn Germany Halbwachs H and R Werlein 1993 Training health personnel to operate health care equipment How to plan prepare and conduct user training A gui
269. ns and longer term objectives They put forward questions advice and suggestions for amendments He or she ensures that agreement is reached for all goals After the seminar The Health Management Team reviews and finalizes the material from the seminar The Health Management Team distributes the Annual Action Plan Heads of Department Chairs of Sub Groups display their goals It reviews the materials generated at the seminar arranges them appropriately in order to produce the Annual Action Plan combines duplicated suggestions from different working groups writes any additional goals required makes revisions as necessary groups together all targets recommendations and longer term objectives by team department and subject It ensures that the Annual Action Plan is reproduced quickly and distributed widely around the service so that all staff have access to it They ensure the goals are displayed in suitable locations to ensure that staff are aware of them 163 8 2 Monitoring progress with equipment operation and safety 8 2 MONITORING PROGRESS WITH EQUIPMENT OPERATION AND SAFETY Part of the management of equipment related activities is the identification of problems and needs All equipment related activities should be monitored and evaluated and the performance of equipment staff and departments should be supervised this applies to all clinical technical and support departments The results of such mon
270. ns that help relate the information to health workers own experiences Topics include identifying health problems assigning priorities to their solution planning and implementing programmes and evaluating results Also serves both as a training and reference guide covering all aspects of primary health care management including equipment and drugs Available from WHO Physical assets management and maintenance in district health management Halbwachs H 2000 GTZ document Annex 2 Reference materials and contacts Setting up community health programmes A practical manual for use in developing countries 2 4 edition Lankester T 2000 ISBN 0333679334 A practical how to manual designed for a wide range of health workers working with community health programmes With revised and updated material on planning management and evaluation of health programmes ranging from choosing and training a team through the setting up of clinics and advising village health workers Includes new information on community based approaches to safe motherhood immunisation malaria and TB based on WHO guidelines Available from TALC Training health personnel to operate health care equipment How to plan prepare and conduct user training A guide for planners and implementors Halbwachs H and R Werlein 1993 GTZ Eschborn The aim of this book is to ensure that users are in a position to operate equipment and plant without causing failure o
271. nstitutions etc NICE National Institute of Clinical Excellence website www nice org uk Provides guidance to the UK National Health Service NHS on current best practice covering both health technologies from medicines to diagnostic techniques and the clinical management of specific conditions Programme for appropriate technology in health PATH website www path org PATH identifies develops and applies appropriate technologies to public health problems in developing countries Public health care laboratory website www phclab com Global forum of information exchange and resource centre for laboratory personnel and those concerned with PHC laboratory services in developing countries Safe injection global network SIGN alliance website www who int injection_safety sign en This is a network discussion group for safe injection issues from technical managerial and operational issues to policy development consensus formation and advocacy It covers a wide range of topics such as whether to use reusable or disposable items The alliance produces the electronic newsletter SIGNpost The site is hosted by WHO TechNet Technical network for strengthening immunisation services website www technet21 org Forum focusing on improving management and operational logistics for health service delivery in developing countries in particular immunisation services The manager s electronic resource center website http erc msh org The
272. nstructions Box 13 provides an example of the type of instructions required when using an electrical suction pump When operating equipment it is also essential to follow good strategies for using consumable materials Section 6 4 1 How to operate equipment BOX 13 Example of Operating Instructions for an Electrical Single Jar Suction Pump these may vary and require additions depending on the make and model How the equipment works e The suction pump is used to remove a body fluid such as blood mucus or vomit from a body cavity wound or respiratory tract There are several types of suction machine According to the design different flow rates and different pressures high low or dual can be attained Some machines can only be used intermittently and should not be used for several hours at a time The pump draws fluid from the patient through a flexible tube into a reservoir jar bottle When the jar has filled to a certain level the float valve prevents fluid entering the pump by cutting off the suction The machine must then be switched off and the jar emptied A bacterial filter between the jar and the pump reduces the risk of cross infection and potential damage to the pump To prepare for use check the following Think about You have the correct machine for the task Is the pressure kPa sufficient Is the pressure and flow rate too high for infants The state of the machine Is it clean and in good condition The ma
273. nsumables specific to a particular machine Section 6 place and store accessories carefully in the appropriate holder pouch or drawer to prevent them dropping on the floor or getting lost only use the correct chemicals and cleaning methods specific to a particular machine Section 4 3 DON T pull equipment around by its lead use equipment to prop open doors balance equipment on the edge of beds drop equipment tangle and create knots in the leads spill liquids over equipment use equipment surfaces as tables scratch equipment use equipment for private purposes without permission use hot equipment surfaces for heating food other than legitimate kitchen appliances store food in refrigerators designed for other purposes such as for storing vaccines or a blood bank leave cables or equipment in positions where people may trip or injure themselves leave windows open but unlatched as a strong wind could swing them against the wall and shatter the glass put rubbish down toilets this will block the drains 3 2 General good behaviour towards equipment There are also specific dos and don ts for each type of equipment Box 7 provides an example of the type of instructions for an hydraulic operating table BOX 7 Examples of Dos and Don ts for an Hydraulic Operating Table these may vary or require additions depending on the make and model DO check leg section is secure and apply brake on table base before using
274. ny materials for which a scrap value can be obtained 154 8 How to undertake action planning and monitoring of progress 8 HOW TO UNDERTAKE ACTION PLANNING AND MONITORING OF PROGRESS Why is This Important Managing the activities described in this Guide will involve a cycle of actions You need to monitor your performance and set yourself goals so that you can improve Then you monitor your progress revise your goals and review your progress again thus undertaking a continuous cycle of planning and review Such evaluation helps you to ensure the quality of your work This is one element of quality management an important goal for managers The planning and review activities are interlinked in a cycle as shown in Figure 20 but it is necessary to start the discussion at some point in the cycle This Section discusses the planning process setting goals in Section 8 1 the review process monitoring progress in Section 8 2 Figure 20 The Planning and Review Cycle pee action _ Kon Rey 7 LAN x aL Set Revise H Monitor i Goals l 1 Performance Progress l a feedback All staff involved in equipment operation and safety should be involved in planning and reviewing their progress with this work Thus this Section is relevant for all different types of staff in the user departments and committees HTM Teams HTM Working Groups their various safety sub groups
275. o now there will be little information currently on stores stock cards from which the Stores Controller can make these calculations Thus for existing equipment you may need to carry out a one off exercise to identify the type of accessories and consumables required the quantities used their sources and possible prices see Guide 2 on planning and budgeting The HTM Working Group can nominate a stock sub group Section 1 2 to undertake this one off exercise the findings of which will be based on the experience and identified needs of the user departments Guide 2 describes how the information collected can be used to calculate more realistic recurrent budgets The information should also be given to the Stores Controller for entry onto the stock cards so that there is sufficient data on usage rates reorder levels and reorder times for equipment accessories and consumables In the case of new equipment purchases a well documented list of the accessories and consumables supplied should be entered into the stores system automatically during the equipment acceptance process as described in Guide 3 on procurement and commissioning see Annex 5 You will need to decide What type of supplies do you need What do you commonly use What is worth holding in stock e What quantities of each item should you order How much do you need to have available for use Which items are the most important to keep in stock Is the ac
276. o za Contact for further information about the Medcin 400 Gas Incinerator a pre assembled incinerator designed for rural and small scale healthcare waste management Olympus Microscopes UK Scientific Divisions Great Western Industrial Park Dean Way Southall Middlesex UB2 4SB UK Tel 44 207 253 2772 fax 44 207 251 6330 email info olympus uk com website www olympus co uk Manufacturer of microscopes and other optical equipment with bases around the world Source of microscope training video PAHO Pan American Health Organization Pan American Sanitary Bureau Regional Office of the World Health Organization 525 Twenty third Street N W Washington D C 20037 USA Tel 1 202 974 3000 fax 1 202 974 3663 website www paho org The Pan American Health Organization PAHO is an international public health agency working to improve health and living standards of the countries of the Americas It also serves as the Regional Office for the Americas of the World Health Organization Antonio Hernandez is the contact for healthcare technology issues email 1hernana paho org RIVM Dutch Institute of Public Health and the Environment Laboratory for Medicines and Medical Devices Dept LGM Postbak 50 Postbus 1 3720 BA Bilthoven The Netherlands Tel 31 30 2749111 fax 31 30 2742971 email info rivm nl website www rivm nl sector4 lgm index html Amongst other topics this organization has undertaken research on the performance of
277. ocks run out Section 6 3 Human Resource Departments hire suitably skilled operators and maintenance staff and offer attractive packages in order to retain them in post Section 2 2 facilitate in service training to improve the skills required for equipment Section 3 5 ensure that staff performance with regards to good and bad practice when using equipment is reflected in appraisals Section 8 2 In Service Training Coordinators enable staff to express needs for equipment related skills development arrange the necessary relevant training in equipment related subjects for all staff develop training resources and train staff according to timetables Section 3 5 Infection and Hazard Control Officers and Safety Sub groups Boards of Survey monitor levels and incidence of infection hazards and accidents Section 8 2 develop policies and practices to control infection hazards and accidents Section 5 train staff and assist them to comply with safety procedures are authorized to condemn and board equipment at the end of its life Section 7 5 are authorized to officially dispose of the property and assets of your organization are authorized to officially auction off condemned equipment and provide the monies to the central financial body such as the treasury 2 Framework requirements 2 FRAMEWORK REQUIREMENTS Why is This Important In order to deliver quality health services it is essential to undertake
278. ollowing the instructions for use carefully wearing face masks providing appropriate ventilation open windows switch on fans etc using fume cupboards in laboratories 91 92 5 5 1 Gases BOX 33 Strategies for the Safety of Gas Cylinders DO DON T Personnel Take great care when handling the cylinders making sure that there are at least two people to lift and carry large cylinders Wear good foot protection when moving a cylinder in case it is inadvertently dropped Use a wheeled cylinder trolley to move cylinders regular dragging of cylinders will cause severe damage to the fabric of the health facility such as stairs carry a cylinder by its valve allow pressurized gas to come into contact with the skin allow flames or smoking anywhere near the cylinders as the contents promote combustion use grease or oil anywhere on the equipment as this can create an explosion risk Storage Keep cylinders dry clean and in a well ventilated area Keep cylinders away from flames lighted cigarettes flammable liquids and combustible material Use clear signs to warn of potential dangers Sort and store different gases separately Store E sized and smaller cylinders of medical gas only on their sides and larger cylinders in an upright position Store cylinders of liquefied petroleum gas LPG in an upright position Use chains and other methods to prevent cylinders from falling over
279. ologies to determine their efficacy and effectiveness and to help you make decisions for capital planning and acquisition Technology management using equipment equipment support equipment management asset Management technology assessment to manage technology in health care from conception to retirement Source Department of Health Service Provision World Health Organization 2000 173 174 Annex 2 Reference materials and contacts ANNEX 2 REFERENCE MATERIALS AND CONTACTS This Annex is in two parts and provides information about Part i Books guidelines databases and websites Part ii Organizations sources of publications in part i resource and information centres i Books Guidelines Databases and Websites The following books guidelines videos databases and websites are listed in subject categories according to the topics found in Sections of this Guide For each publication a brief description of the content and the main source s are included Contact details for the source organizations are included in Part ii Readers should note that many of the publications are available at low cost In some countries it may also be possible to obtain these publications from local bookstores as publishers and distributors increase efforts to ensure wider availability Published prices may be flexible depending on the order size discounts available and distribution method Tip Many books and documents cover
280. omeone to switch off the electrical source immediately the individual will be unable to breathe and the heart will soon stop beating The seriousness of the electrical accident will depend on the intensity of the current flowing through the body 93 5 5 2 Electricity Figure 10 Routes for Electricity to Flow Through the Heart to Earth Source Neureiter J amp Tschank A 1989 Technician s Handbook for Hospital Engineering Kenyan Austrian Development Cooperation Ministry of Foreign Affairs Austria Did you know gt Currents as small as 0 5 milliamperes 0 0005 Amps passing through humans can be felt as a tingling in the tongue or fingers If humans come into contact by hand with a live object currents of 10 milliamperes 0 01 Amps can make their muscles contract and their hand grasp the live object and not let go e Currents upwards of 50 milliamperes 0 05 Amps can be fatal if they pass through the heart e For comparison consider that such a current is 100 times less than that used by a single bar of a normal electric fire which ee 5 Amps P livestock Earth leakage currents exceeding 25 milliamperes can prove to be 94 Currents will always flow from a high source of volts the electricity supply to earth 0 volts through the easiest path the path of least resistance known as impedance and measured in Ohms Thus electrical installations and electrical equipment mu
281. on Avoid the following actions which create aerosols and infectious airborne particles breathing in Using inoculating loops larger than 3mm in diameter or incompletely closed as they will shed their contents Vigorous spreading of culture plates and slides with loops gentle movement is safer Flaming charged loops in ordinary bunsens use hooded bunsens or disposable plastic loops instead Blowing out pipettes causing bubbles to form and burst drain the pipettes instead Vigorous mixing of cultures such as sucking and blowing with pipettes use vortex and other mixers instead together with culture tubes or bottles that are stoppered Allowing drops to fall from the tips of pipettes onto hard surfaces use an absorbent bench covering preferably soaked in disinfectant Using unstoppered centrifuge tubes and misbalanced loads use screw capped tubes and sealed buckets instead see Box 18 Homogenization that creates aerosols that are released when the container is opened use stomachers instead Mixing in unstoppered containers use bottles and tubes with stoppers instead or vortex mixers Dropping cultures where possible plastic petri dishes release less aerosols than glass ones when dropped Allowing probes of automated equipment to move too abruptly fit guards and slow the movement down instead Pouring infected fluids straight into another fluid use a funnel with its tip beneath th
282. onations Annex 2 Reference materials and contacts World Health Organization WHO 20 Avenue Appia CH 1211 Geneva 27 Switzerland Tel 41 22 791 2476 or 2477 fax 41 22 791 4857 website www who int en WHO offers advice and undertakes programmes on all aspects of health care Contact your regional or field office for advice on all aspects of health care and WHO materials the addresses of the regional offices worldwide are available on the website i WHO has programmes and literature on many aspects of healthcare technology management Andrei Issakov Coordinator of Health Technology and Facilities Planning and Management is the contact and source of WHO literature on healthcare technology management that is not available as published documents email issakova who int ii WHO produces and distributes books manuals journals practical guidelines and technical documents several include aspects of healthcare technology management The Distribution and Sales Office is the contact point for information on WHO publications email publications who ch website www who int publications en To order WHO publications use email bookorders who int WHO has a comprehensive library and information service on international public health literature Contact email library who int The WHO library catalogue has electronic access to more than 4000 technical documents use website www who int library ili iv WHO produces many
283. ondemning boarding and auctioning of equipment at the end of its life Country Experience Many developing countries are short of staff who can monitor and regulate safety issues and suffer because of this For example Some have few safety inspectors nationally who can monitor the performance of boilers lifts electricity installations etc Some may only have one infection control officer for the whole country 25 2 2 Background conditions specific to this guide Authorities Responsible for Safety A great many bodies may exist in your country which produce guidance on the wide range of safety issues covered in Section 5 For example you will need to conform to e national Health and Safety at Work legislation the national body responsible for the regulations on radiation control and guidelines regarding dosimeters the National Laboratory which sets quality standards for laboratory tests bodies such as the Medical Council and General Nursing Council which have guidelines on infection control e the national body such as the Ministry of Labour which sends out inspectors who issue certificates of safety and workmanship on pressure vessels such as boilers and autoclaves and inspect lifts local government bodies or council authorities which produce building safety regulations and waste disposal systems any environmental and or public health authority which produces environmental policies and proce
284. onsumables available and used number of X rays taken numbers of equipment accidents hazardous incidents improved performance number of accident free driver days waiting time to receive results of laboratory tests numbers of equipment operators attending training courses increase in the number of user PPM interventions cost benefits number of patients seen per piece of equipment owned for certain departments efficiency and effectiveness equipment availability per year for different types of equipment The user departments safety sub groups HTM Working Group etc should meet to agree on a few suitable indicators that can be measured easily and quickly if possible Positive indicators are preferable as they motivate staff Sometimes it is useful to use common indicators for different teams groups and staff so that their progress can be compared Once the indicators have been agreed they need regular measuring and charting The relevant Health Management Team will need to decide how records of these indicators will be kept for example in a register with a form or on a chart Section 8 2 who will be responsible for keeping them how regularly the results will be summarized each month for example what form of charts and displays you will use to display the monthly summarized results so that it is easy for people to see how they are progressing The Annual Planning Process In prepara
285. oor accessories and consumables may break if they are not strong enough they may not perform as expected or they may rub corrode or in some way damage other parts of the machine Even if you have a first class piece of equipment poor paper gives you a poor recording for diagnostic purposes poor film or poor quality developer give you poor radiographs for diagnostic purposes poor breathing circuits which collapse easily compromise the functioning of a ventilator or anaesthetic machine poor quality drill bits break quickly poor quality engine oil reduces the life of the engine poor quality batteries affect the performance of the equipment have a short life and leak poor tyres compromise the safety of a vehicle Cost and quality often go together Equipment manufacturers own brand of accessories and consumables often produce better results than lookalikes Many companies are set up solely for the purpose of manufacturing lookalikes these products are often but not always cheaper but may be of inferior quality We recommend that as the items get more technically complex or critical you should try and buy better quality accessories and consumables A discussion on sourcing and obtaining good quality products can be found in Guide 3 on procurement and commissioning High technology equipment may introduce hidden consumable problems such as special miniature internal batteries that store the set up parameters of the
286. operator needs to read and write down the pressure and temperature at specified intervals for example every minute To monitor steam penetration in autoclaves you will also need some form of passage indicator a consumable that changes colour to indicate that steam penetrated your load pack and that it successfully passed a sterilization process The method to use is the Bowie amp Dick test the internationally accepted standard Box 24 shows different ways of carrying out the test depending on the resources you have available for buying the consumables required see Annex 2 Experience in Nigeria A mission hospital in Nigeria uses a small vertical electric autoclave run by two nurse aides under the supervision of a nursing sister With this arrangement they cover all the sterilizing needs of the theatre maternity department and wards Sterile instrument packs are prepared for all major operations and stored on shelves in a room adjacent to the operating theatre 71 5 3 1 Decontamination BOX 24 Different Types of Bowie amp Dick Tests Available Ready made Bowie amp Dick test packs These are square blocks that are placed inside the autoclave for a cycle Inside the block is a sheet containing lines of special chemical finish that change during the autoclave s cycle and display different colours to illustrate if there are any TST problems They are sensitive and diagnostic since the different colour chan
287. ories of items described as healthcare technology Benefits of healthcare technology management HTM The collective responsibility for operation and safety Summary of issues in Section 2 on framework requirements Strategies for making staff more accountable General good behaviour strategies when dealing with equipment Examples of dos and don ts for an hydraulic operating table Strategies for expanding your library Strategies for developing equipment skills Resources required when running training courses yourself Summary of procedures in Section 3 on utilizing equipment effectively General strategies when operating equipment Example of operating instructions for an electrical single jar suction pump Common examples of application training requirements Common care and cleaning strategies Example of care and cleaning instructions for a microscope Summary of procedures in Section 4 on correct operation Some examples of common safety hazards during equipment operation Use of different decontamination procedures Decontamination strategies Safety issues when using instrument boilers Some common chemical disinfectants and their potential applications Strategies for ensuring sterility Different Bowie amp Dick tests available Strategies for monitoring sterility Strategies for linen handling Strategies for general cleaning of health facilities Strategies for controlling vermin Strategies for waste management Page
288. ork for management development Temple Bird C L Mhiti R and G H Bloom 1995 WHO publication WHO SHS NHP 95 1 Medical supplies and equipment for primary health care A practical resource for procurement and management Kaur M and S Hall 2001 ECHO International Health Services Ltd ISBN 0 9541799 0 0 Medicines and Healthcare Regulatory Agency MHRA UK products This agency of the UK government formerly the Medical Device Agency ensures medical devices and equipment meet appropriate standards of safety quality performance and effectiveness are used safely and that they comply with relevant Directives of the European Union The MHRA provides a variety of publications such as e Medical device alerts replacing former hazard notices safety notices device alerts advice notices etc Device bulletins replacing former evaluation reports Device evaluations Advice on a wide variety of safety topics visit the website click on contacts then medical devices then search under a subject area such as decontamination or laundry for example Available from MHRA Safety at work training video and interactive CD RS Components Ltd 1994 Codes 446 2446 and 446 2452 catalogue page 1 196 Sept 2003 This video CD covers the important safety issues that every electrical apprentice needs to know It includes sections on the range of hazards and risks of working in the electrical industry health and safety law portable appliance test
289. orking in health facilities or within the decentralized health authorities many of the principles will also apply to staff in other organizations for example those managing health equipment in the Ministry of Works private maintenance workshops and head offices Depending on the country and organization some daily tasks will be undertaken by end users while others may be carried out by higher level personnel such as central level managers For this reason the Guides cover a range of tasks for different types of staff including equipment users all types maintenance staff managers administrative and support staff policy makers 6M external support agency personnel 1 1 Introduction to this series of guides They also describe activities at different operational levels including the health facility level the zonal administration level such as district regional diocesan the central national level by external support agencies Many activities require a multi disciplinary approach therefore it is important to form mixed teams which include representatives from the planning financial clinical technical and logistical areas Allocation of responsibilities will depend upon a number of factors including your health service provider e the size of the organization the number of decentralized levels of authority the size of your health facility e your level of autonomy The na
290. orrect temperatures for washing are used see Annex 2 To save energy some hospitals wash different types of linen at different temperatures but if you cannot be certain of the type of contamination involved it is safer just to use the higher temperature level as follows 65 C for 10 minutes for soiled linen 93 C for 10 minutes for fouled and infected linen These figures only work if detergent is used and additional time is allowed for the warming up and mixing of contents by the washing machine If you have no detergent you will have to boil the linen at 100 C for five minutes If you have no hot water use proper laundry detergents and chemicals suitable for cold washing as well as chlorine bleach Continued overleaf 7 78 5 3 2 Linen handling BOX 26 Strategies for Linen Handling continued In the laundry continued If you do not have washing machines wash linen by hand and hang it on lines to dry in fresh air and sunlight to assist with disinfection To save resources water from the laundry may be recycled for example for watering garden crops However water from the washing machines used for infected linen in other words blood stained or containing solids is unhygienic and should not be recycled Transporting linen Staff should ensure hygienic storage and rotation of linen always keeping dirty and clean linen apart Ideally laundries should be designed and built in such a
291. ory results are correct etc increase the availability of equipment and reduce down time extend the life span of equipment reduce equipment running costs ensure equipment is safe for patients users and maintenance staff Experience in West Africa A doctor handed over a stethoscope to a maintainer complaining about a muffled sound The diaphragm was in order What was the problem The doctor was not aware that even stethoscopes must be stored and taken care of properly and after removing the nest of a solitary bee from the flexi tube the device was working again 139 140 7 2 User planned preventive maintenance PPM Tip e PPM consists of a number of tasks of varying technical complexity Regardless of the complexity of the equipment there may be three levels of tasks that can be undertaken by different types of staff The simpler duties performed by the users of the equipment if they are adequately trained The bulk of the work performed by in house technicians with a basic training see Guide 5 on maintenance management More complex work has to be done by specialized maintenance personnel This can be in house maintainers or for some sophisticated equipment may involve staff from the manufacturer or service agent For details on managing such maintenance contracts see Guide 5 Users should only undertake the sorts of PPM tasks that do not require the intervention of tech
292. ould report this to their Head of Section who completes a Work Request Job Form and sends it immediately to the HTM Team Section 7 4 Users should remove the equipment or disable it and clearly label it as faulty Maintainers should ensure that they respond as quickly as possible to any maintenance and repair requests The Health Management Team ensures the continuation of clinical services by promptly disposing of and replacing equipment when it is condemned by the HTMS at the end of its natural life Section 7 5 Ensure continuous services HTM Teams should ensure that the staff in their facility have sufficient skills to enable them to maintain repair and operate equipment effectively and safely by implementing a rolling programme of refresher training Provide career development If operators and maintainers require further skill development they should put in a request to their Head of Section The Human Resource Department includes the duties of cleaning basic care and maintenance of equipment in the job descriptions and contracts for health service staff 143 7 2 User planned preventive maintenance PPM You will need a strategy to slowly expand how much of your equipment stock receives user PPM User departments should consult with the HTM Service and follow strategies to build up PPM gradually over time as shown in Figure 16 Figure 16 Strategies for Expanding User PPM nitially concentrate on deve
293. oup Section 1 2 is responsible for establishing all training requirements This Section looks at some strategies which can be taken at the facility or district level to implement the Equipment Training Plan developed in Guide 2 on planning and budgeting You will need to consider the sources of training and professional support available and Box 9 provides a variety of strategies to help you with this When you begin to monitor how equipment is used you will notice a number of prompts that training is required These training requirements should be passed on to your Health Management Team Section 8 2 Figure 6 shows the likely prompts Figure 6 Example of Prompts Showing That Training is Required Staff newly arrived at a facility or transferred between departments Staff admit that they need any type of equipment related training Heads of Section see that staff are short of particular equipment related skills Maintenance staff identify user related problems with equipment New equipment arrives at the health facility according to the Equipment Development Plan Guide 2 Response In Service Training Co ordinator organizes induction training on equipment related skills They request it from their Head of Section They request the necessary training from the HTM Working Group or its training sub group They report this to the HTM Manager The training sub group Commissioning Team organizes t
294. p org uk ajol Offers free online access to tables of contents and abstracts of over 70 journals published in Africa Blood transfusion safety BTS website www who int bct Main_areas_of_work BTS BTS htm WHO site covering blood safety issues from access to safe blood and blood products to evaluations of HIV testing kits British medical journal website http bmj bmjjournals com Free worldwide access to BMJ and the student BMJ and wide range of specialist journals to users in low income countries CEN website www cenorm be The European Committee for Standardisation website lists the essential European Standards they publish regarding sterile supplies They include standards for different sorts of sterilizers and Bowie amp Dick tests e g EN285 EN13060 validating sterilization techniques e g EN554 chemical disinfection e g EN1499 testing systems e g EN866 EN877 packaging and labelling e g EN868 EN556 Centers for Disease Control and Prevention CDC website www cdc gov This agency of the US government is a leading centre for providing up to date information on disease prevention and control health promotion and education activities The website has a wide range of information For example discussions on the correct laundering of linen at www cdc gov ncidod hip STERILE laundry htm e how laundries should wash infected material at www cdc gov ncidod hip Blood worker htm laundering for patients with AIDS at www cdce
295. pital engineering Kenyan Austrian Development Cooperation Ministry of Foreign Affairs Austria Nikon 1991 Alphaphot 2 YS2 H binocular microscope User instruction manual Nikon Tokyo Japan Paton J Green B and J Nyamu 1996 The division for the supply of medical spare parts in the health system of Kenya Ministry of Health Nairobi GTZ Eschborn Germany Pearson A 1995 Medical administration for frontline doctors A practical guide to the management of district level hospitals in the public service or in the private sector 2 4 edition FSG Communications Ltd Cambridge UK ISBN 1 871188 03 2 Picken D and M Bennett 2002 De Montfort University design of very low cost incinerators for emergency situations in developing countries in Collected papers of the seminar on appropriate medical technology for developing countries 6 February 2002 IEE Healthcare Technologies Professional Network IEE London UK Ref No 2002 057 Pruss A Giroult E and P Rushbrook 1999 Safe management of wastes from health care activities WHO Geneva Switzerland Remmelzwaal B 1997 The effective management of medical equipment in developing countries A series of five papers FAKT Stuttgart Germany 227 228 Annex 10 Source material bibliography Remmelzwaal B and E de Villiers eds 2002 Where there is no technician A practical guide for users of medical equipment Ministry of Health and Socia
296. place iii Staff appraisal Another form of reporting and feedback is staff appraisal by managers Informal methods include activities such as sharing information support and supervision A formal method is a staff appraisal process which monitors the work performance of individuals and identifies areas for goal setting for both the individual and their manager The purpose of the interaction is to guide the individual in their job evaluate their performance take corrective action to improve job performance e agree required training development and other strategies by the employer which would assist the employee to become more effective in their job Regular monitoring of equipment related activities will also mean that instances of good or bad work performance in relation to equipment can be incorporated into the staff appraisal system For a fuller description of staff appraisal strategies see Guide 5 on maintenance management Box 62 contains a summary of the issues covered in this Section 167 Section 8 summary BOX 62 Summary of Procedures in Section 8 on Action Planning and Reviewing Progress Health Service ensures there is an annual action planning process whether across horizontal Provider levels within a health facility or district or within a vertical programme for example for the laboratory service as a whole Heads of Department set their targets recommendations and longer term obj
297. ples Or snc basie ser e two that have just come out of the autoclave full of newly of accessories ioe sterilized instruments e two inuse in the autoclave full of items being sterilized e two being filled with dirty instruments waiting to be sterilized Step 3 Consider the Lifetime of the Accessory or Consumable Consider Examples The next issue to consider is how long the accessory will last before it fails Some accessories have a long life some have a short life and some are disposable thrown away after one use Consumables are considered in the same way as disposables as follows a Accessories with a long life Baskets in pressure cooker type sterilizers These are not likely to wear out therefore you do not need any extra ones in stock When they break you can buy them as required as a spare part b Accessories with a short life that Jars of suction pumps diathermy probes patient lead sets are reusable The manufacturer s literature and your experience will tell you the likely life of the part so you can calculate how many you will need ina year c Disposable accessories Stick on ECG electrodes are disposable accessories and consumables they can be supplied in various quantities such as bags of These are used up as you operate the 50 or boxes of 1 000 equipment so you need to calculate the quip 2 y ro Rolls of recorder paper and tubes of ultrasound gel are consumption rate this is
298. pliers Annex 2 Reference materials and contacts A pocket book for safer IV therapy drugs giving sets and infusion pumps M Pickstone ed 1999 ISBN 094 867232 3 This pocket book has been written to help clinical staff deliver safe IV therapy It covers the calculation of drug dose the make up of drug solutions and the selection of infusion devices and associated equipment Available from major internet bookshops Basics of light microscopy training video Olympus Microscopes Code 30892 This video is both suitable for beginners or for those wishing to refresh existing knowledge It provides information about various objectives proper illumination magnification scales and imaging quality Based on combined technical know how and experience this video is an easily understandable and interesting teaching tool for microscopists and anyone who would like to become one Available from Olympus Microscopes Blood pressure measuring equipment Principles use maintenance repair Huys J 1992 TOOL Amsterdam ISBN 90 70857 26 X This book is for medical technicians in rural hospital and clinics It covers the principles of common BP equipment how to use BP measuring equipment advice about its use and instructions for maintenance and repair Available from Medical and Health Library free at http media payson tulane edu 8086 csi bin gw e tle11copyrigh mhl 1 T 1 B 21 1 500 50 00f amp q amp l e amp s 00 Care and safe
299. pment in Botswana A framework for management development Temple Bird C L Mhiti R and G H Bloom 1995 WHO publication WHO SHS NHP 95 1 This book reports on the results of a study of the healthcare technology sector in Botswana and the lessons learnt are of relevance to many other countries The study was undertaken by unpackaging the sector into its component activities such as planning allocating resources procurement commissioning operation maintenance training etc In this way the book provides good general healthcare technology management strategies to address the problems discussed This book discusses many of the common operation and safety problems found in health facilities Available from WHO Annex 2 Reference materials and contacts Physical assets management and maintenance in district health management Halbwachs H 2000 GTZ document This paper provides practical guidance to health workers involved in district health systems concerning health technology one of the critical areas in managing health service delivery at district level It presents the physical assets management approach and elaborates on key strategies for maintenance financing quality control monitoring indicators and a basic paper based maintenance information system It also has an example of a maintenance job card Available from GTZ The effective management of medical equipment in developing countries A series of five papers Bastiaa
300. posed on walls rather than inside conduit Connections and cable joints are left with the metal exposed without any insulation even those carrying a 380V three phase supply Strategies are required to obtain good quality electrical installations which provide a decent earth and prevent against electric shock hazards Advice should be sought from the electricity supply company and reputable electrical contractors who should work according to wiring regulations for example for anglophone countries the latest Institution of Electrical Engineers IEE Wiring Regulations see Annex 2 Box 35 provides examples of some of the strategies required and who ts responsible for them 5 5 2 Electricity BOX 35 Strategies for Providing Good Quality Electrical Installations and a Decent Earth Providing the earth at the It is usually the responsibility of the electricity supply body to provide an origin of the installation adequate earth at each site by one of the following methods e Protective Multiple Earthing PME incorporated into the design of the electricity distribution system around your country The cable sheath armouring of the electricity supply company s main incoming cable to your site is connected back to the earth at the supply company s sub station A driven earth system at each site either a metal rod or a mat buried several metres underground that provides an earth the quality of which is dependent on the lo
301. principle be carried out by the government the private sector or by a mixture of the two It is useful to organize the maintenance system along similar lines to the health service provision already existing in your country For instance if the health sector is predominantly run by the government it is probably simplest to let the government run the maintenance organization as well In contrast if private organizations run the health services it makes little sense for the maintenance activities to be carried out by a government body In the majority of cases a mixed system is most likely However the government may wish to take a regulatory role and establish regulations that guarantee that healthcare technology performs effectively accurately and safely The rules established are valid for all health service providers irrespective of their type of organization Specific maintenance requirements would not need to be prescribed by the regulatory body Instead it is up to individual health service providers to decide how these will be provided However the nature and the complexity of some maintenance services often call for partnerships between the public and private health service providers Partnerships may also exist between health service providers and private sector sources of maintenance support For more details refer to Guide 1 To provide maintenance services you will normally need to establish good links between maintenanc
302. ps Each working group is given different departments or areas of the health service to consider Each working group analyzes their department area under study No more than 10 people in each group with a mix of nurses doctors and other staff in order to improve participation They are given the material prepared by those departments as described earlier in this Section They review performance over the past year assess how well targets were implemented consider the lists of problems and solutions provided identify successes carefully examine problem areas Each working group prepares a list of e between five and 10 most important difficulties or problems for the department area their five to 10 targets recommendations and longer term objectives They take large sheets of paper with the name of the working group on top and from their analysis they clearly list the priority problems e the targets recommendations and longer term objectives The second half day to one full day The participants are brought together in a plenary session Each working group presents its findings in turn Participants from other groups provide input The Chair oversees an end result of the plenary session The purpose is to reach agreement on all proposed targets recommendations and longer term objectives by the end of the seminar They display and briefly explain their list of problems targets recommendatio
303. pue saw Hulepsoay a ejNdjeD 0 MOH 1S XO 134 6 3 Calculating usage rates and reorder levels Figure 14 Sample Layouts for the Stock Control Ledger Example 1 Stock Control Ledger Item description Item code no Unit pack size Order quantity Date Quantity received Quantity used Balance Quantity to order Signature Example 2 Stock Control Ledger Item description Item code no Unit pack size Order quantity Date Previous count Amount Amount Present count Quantity to Signature physical received used physical order The Head of Department and storesperson will routinely review the stock control ledger and will submit the information on accessory and consumable requirements and rates of use to the Finance Officer in order to improve budget allocations the Purchasing and Supplies Officer Specification Writing Group and Tender Committee see Guide 3 on procurement and commissioning in order to incorporate experience of the quality performance and cost of items into the next round of purchasing the Stores Controller in order to prompt the reordering process and timing of procurement Box 52 contains a summary of the issues covered in this Section 135 Section 6 summary BOX 52 Summary of Procedures in Section 6 on Accessories and Consumables Health Service ensures sufficient accessories and consumables are available fo
304. quin Marking machine Meat chopper Mixer commercial Nourishment ice station Oven Baking Microwave Roasting Packaging machine Platform Paint spray booth Paint spraying machine Paper baler Parking lot sweeper Pipe cutter threader Planer and shaper electric Plate bending press Platemaker Computerized Noncomputerized Popcorn machine Power supply Press laundry Printing press Range domestic Refrigerator Domestic Commercial Undercounter Remote control receiver Rotary tiller Sanitizer Saw Band Bench electric Meat cutting Scaffold Scale laundry Movable Platform 3 3 Planned Preventive Maintenance Years 15 15 10 10 10 10 10 10 5 10 10 12 15 10 15 5 10 10 10 5 10 8 10 15 10 10 8 10 10 10 10 10 10 10 10 10 10 15 Continued overleaf 221 222 Annex 8 Typical equipment lifetimes Table 9 Support Departments continued Item Sewing machine Shears squaring floor Shoulder wheel Simulator Slicer Bread Meat Snowblower Steamer vegetable Telephone cordless Telephone equipment for deaf Telephone monitors Telephone system Television monitor Television receiver Toaster commercial Tractor Truck automotive Forklift Multipurpose filling Pickup Van Years 15 12 20 5 10 10 10 10 10 10 10 10 D Item Truck hand Hot food Tray Ultrasonic cleaner Urn coffe
305. r back up It is aimed at health workers facing problems with ensuring power quality for any electrical equipment and ensuring power is available when you need it It deals with the problems which can occur in the mains supply and an explanation about the main measures which can be taken for power conditioning and power back up including advice on suppressing electro magnetic interferences and radio frequency interference and advice on different types of uninterruptible power supplies It is meant for anyone involved in the decision making process for the procurement and installation of such equipment Available from FAKT 187 188 Annex 2 Reference materials and contacts Electricity at work training video RS Components Ltd 1990 Code 446 2238 catalogue page 1 201 Sept 2003 This video examines electricity at work regulations It includes sections on the need for regulations the dangers of electricity safe construction and maintenance of electrical systems strength and capability of electrical equipment equipment exposed to adverse conditions prevention of danger earthing and protective devices electrical continuity joints and sockets excess current protection isolation of equipment live working access for work and suitable personnel and training Available from RS Components Ltd IEE wiring regulations 16th edition William Ernest amended 2004 RS Components Ltd This is the latest edition of the EE wiring regu
306. r different purposes the different procedures to pursue for different disorders or treatments They will also need to understand the safety precautions they must take Section 5 Traditionally colleges offering basic training for health are responsible for teaching clinical procedures Thus they must have access to the necessary equipment for this purpose both in their teaching rooms and at suitable clinical locations such as hospitals There will be many areas where staff need to brush up their application skills and it will be an ongoing requirement to identify these training needs Box 14 provides some common examples Equipment users will need to admit their need for application training and ask for help The HTM Working Group must consider application training when purchasing new equipment and the possibility of incorporating such information and training into the package of inputs purchased with the equipment see Guide 3 on procurement and commissioning Equipment users should only operate equipment for which they are suitably qualified Clinical meetings committee meetings departmental meetings or specifically organized training sessions can all be used to provide application training as appropriate Country Experience Often in developing countries clinical procedures are taught in health training schools using obsolete equipment or with insufficient units to give students adequate exposure When t
307. r equipment and protect it These measures assume that your generators and the mains supply grid are in a good condition or cannot be influenced in the case of the public mains supply If they can be improved solve these problems first if possible 101 5 5 2 Electricity Box 36 Power Conditioning Strategies Problem Solution Your power supply An over or under voltage cut out device voltage may become This automatically switches off the power supply when it is too high or too too high or too low low but your equipment may be cut off frequently Your supply voltage A step up or step down transformer is stable but always too This provides a fixed increase or decrease of voltage but it cannot cope high or too low by a with voltage fluctuations constant amount Your power supply suffers Voltage stabilizers from voltage fluctuations These stabilize smooth the variations in the voltage without cutting off the power supply to your equipment There are various manual and automatic types of stabilizer Your power supply suffers from Frequency stabilization frequency fluctuations If the problem lies with your own generator you can improve the situation measured in Hertz through maintenance strategies see Annex 2 If the problem lies with the electricity authority s supply there is little you can do In the case of 102 expensive equipment using an electronic inverter type of voltage stabi
308. r health facilities Provider considers the use of a revolving fund to help finance the needs for accessories and consumables Section Heads decide on the accessories and consumables required for different types of equipment Health Management buy good quality accessories and consumables Teams Health Service decides whether equipment accessories and consumables will be stored ina Provider separate section of the health service storage system or a separate network of HTMS stores provides the resources necessary for a full stock control system decides whether to employ stores personnel throughout the system or to train other staff to be storespersons provides training to ensure stores staff recognize equipment related supplies develops an illustrated stores catalogue of equipment related supplies Section Heads or create suitable stores and sub stores for equipment related items HTM Managers follow rules for keeping a store provide advice authority for the issuing of stocks to ensure the correct parts are E he dp gt op D x O op used for the correct application Stores Staff implement a stores code numbering system for equipment related items enter new equipment related stocks onto stock bin cards make equipment related items stockable items whenever possible issue regular requirements to smaller sub stores Health Management undertake a one off exercise to discover the usage rates and
309. r malfunction Part one addresses the planner administrator developing user courses and gives information about methods course organization finances etc Part two discusses interesting issues for the implementers i e how to design a course teaching methods and teaching aids conducting a course etc This practical guide provides sample checklists questionnaires worksheets tests certificates etc Available from GTZ Transfer of learning A guide for strengthening the performance of health care workers Intrah PRIME H JHPIEGO March 2002 This book is for health care workers involved in training and learning interventions and enables them to transfer their newly acquired knowledge and skills to their jobs resulting in a higher level of performance and sustained improvement in the quality of services at their facilities Available from free online at http A2ww prime2 org prime2 section 70 html Efficient Use of Equipment This material covers issues in Section 3 3 such as equipment utilization building design and cost effectiveness It is listed alphabetically by title Approaches to planning and design of health care facilities in developing areas Vol 3 Kleczkowski B and R Pibouleau eds 1979 WHO Offset Publication No 45 ISBN 92 4 170045 9 This volume addresses the issue of hospital design in terms of the building structure itself It discusses inpatient areas outpatient department surgery radiology department equipping
310. r the HTM Servi yo N D O uoddns 2 jeoluyoo E Pa wee Figure 5 l oO Jeoruyoa b 1949 Ayioe4 J AQ 2UOZ 1 A pesuaD 23 24 2 2 Background conditions specific to this guide It is possible to write down all the correct procedures and yet still fail to improve the performance of staff To ensure that your HTM procedures are effective it is important for there to be good managers who can find ways to motivate staff Sections 2 2 and 8 Simply ordering staff to implement new procedures doesn t usually work It is much better to discuss and develop the procedures with the staff who will implement them This could take the form of discussion working groups or training workshops People who are involved in developing ideas about their own work methods are more likely to e understand the objectives understand the reasons why processes are necessary be encouraged to change their way of working be more interested in making changes which result in improvement see that the aim of the HTM procedures 1s to improve their delivery of healthcare We recognize that many readers will face difficulties such as staff shortages poor finances lack of materials a lack of influence and time and possibly even corruption Introducing new rules and procedures into a system or institution that has no real work ethic or which possibly employs dishonest workers will not have
311. ractical information on how to carry out immunisation look after vaccines and on methods of sterilisation and boiling Available from TALC WHO Optimalization of the process for manually operated jacket steam sterilizers Muis B Bruijn ACP de Drongelen AW van and J Huys 2001 RIVM report 318902011 This report describes research to find the optimal process for manually operated jacketed steam sterilizers that are mainly used in developing countries It looks at various test packs the use of thermocouples and test cycles to find the optimal process profile Available from RIVM Dutch Institute for Public Health and the Environment 2 edition Sterilization of medical supplies by steam volume 1 General theory Huys J 2003 HEART Consultancy ISBN 90 75829 04 3 This book focuses on the most common and most safe method used for sterilization in the Central Sterile Supplies Department in healthcare institutions sterilization by pressurised high temperature steam Originally intended to educate technical service personnel in remote health institutions it has grown into a textbook that can be used by anyone interested in sterilization Contains information on steam pulsing monitoring sterility self made test packs use of thermocouple testing kits and process profiles Available in several languages Available from HEART Consultancy Annex 2 Reference materials and contacts Vector control Methods for use by individuals and
312. raisal as a positive tool to develop staff skills and enable career progression discipline staff when necessary However their ability to achieve these goals will depend on the type of human resource policies and procedures they have in place In addition the central level of your organization usually plays a significant role in among other things developing training plans organizing and providing training scholarships approaching external support agencies to finance training programmes Staff training needs should be addressed at every level by an overall Equipment Training Plan This is an ongoing programme of in service training The development of such a plan is described in Guide 2 on planning and budgeting and should be financed by your health service provider It will also need to develop a clear policy on what form of bonding you will use to ensure that a member of staff sent for training remains within the health service on their return 27 2 2 Background conditions specific to this guide To be able to hire staff your health service provider needs an adequate structure of suitable posts Job descriptions are valuable tools for managers as they enable you to e identify suitable candidates for each post make the best use of the staff available plan for further training recruit suitable people Job descriptions are equally important for each worker they are a guideline for the work expecte
313. ramework Requirements continued All Health Staff and Managers conform to regulations and guidelines provided by relevant bodies on equipment operation and safety clinical practice laboratory practice condemning boarding and auctioning of equipment at the end of its life health and safety at work radiation control and dosimeters quality standards for laboratory tests infection control safety inspections building safety waste disposal the environment fire electricity supply and electrical installations Health Service Providers set up infection and hazard control committees and a variety of safety groups to cover all safety areas subscribe to relevant sources of operation and safety literature such as international data on hazards develop human resource policies and procedures to ensure staff career development and help to motivate staff establish an Equipment Training Plan see Guide 2 and job descriptions liaise with training authorities to provide suitable equipment specific modules on basic training courses develop financial policies and procedures which will ensure adequate funds for equipment operation and safety and effective stock management 3 How to ensure equipment is utilized effectively 3 HOW TO ENSURE EQUIPMENT IS UTILIZED EFFECTIVELY Why is This Important Equipment plays an essential role in the provision of healthcare services Staff must therefore be
314. rams Deutsche Gesellschaft fiir Technische Zusammenarbeit German government technical aid agency human immuno deficiency virus healthcare technology management healthcare technology management service healthcare technology management working group Hertz intensive care unit International Electrotechnical Commission Institution of Electrical Engineers International Organization for Standardization kilo Pascals liquefied petroleum gas lead time maximum level medical electrical safety tester minimum level Ministry of Health non governmental organization out patients department OQ PAT PME PPM PVC RCD RFI RS SMART SLFO TB TBO TST UPS WHO Abbreviations order quantity portable appliance tester protective multiple earthing planned preventive maintenance polyvinyl chloride residual current device radio frequency interference reserve stock specific measurable achievable relevant time bound targets shortest life first out tuberculosis time between orders time steam under pressure and temperature uninterruptible power supply Volts visual display unit World Health Organization vi vii List of boxes and figures List of Boxes and Figures Box 1 Box 2 Box 3 Box 4 Box 5 Box 6 Box 7 Box 8 Box 9 Box 10 Box 11 Box 12 Box 13 Box 14 Box 15 Box 16 Box 17 Box 18 Box 19 Box 20 Box 21 Box 22 Box 23 Box 24 Box 25 Box 26 Box 27 Box 28 Box 29 Categ
315. re now all members of the Elsevier Science Health Sciences Division European Union EU http europa eu int comm development index_en htm EU site for international development and aid FAKT Consultancy for Management Training and Technologies Gansheidestrasse 43 D 70184 Stuttgart Germany Tel 49 711 21095 0 fax 49 711 21095 55 email fakt fakt consult de website www fakt consult de Non profit consultancy firm that provides information on appropriate hospital and medical equipment and training in healthcare technologies FAKT is not a supply organisation 195 196 Annex 2 Reference materials and contacts Global Directory of Health Information Resource Centres Health Information for Development HID Project PO Box 40 Petersfield Hants GU32 2YH UK Tel 44 1730 301297 fax 44 1730 265398 email iwsp payson tulane edu website www iwsp org directory htm This is a directory of health information resource centres that is arranged alphabetically by country Between January 2000 and May 2001 Health Information for Development HID compiled a Global Directory of Health Information Resource Centres HIRCs This is available from their website The Directory is updated on an ongoing basis GTZ Deutsche Gesellschaft fiir Technische Zusammenarbeit German government technical aid agency Division of Health and Education PO Box 5180 D 6236 Eschborn Germany Tel 49 6196 791265 fax 49 6196 797104 email Fried
316. re a number of options depending on the size of your organization the different levels of healthcare delivery the supply and distribution system the storage system used by the health service for other types of supplies the structure of your Healthcare Technology Management Service H TMS the skills and trustworthiness of your staff It is important that someone takes responsibility for these equipment related items so that they do not get forgotten Options are First decide whether to include them with all other general and medical supplies in the health service storage system or separate them out and place them in the HTMS storage system Then use your normal distribution system and store different quantities at the central level the district regional level the health facility store or maintenance workshop store Finally decide whether the people looking after the stocks are going to be either trained stores personnel or departmental staff equipment users or maintainers Whatever you decide the individuals responsible should be given training on how to run the stock control system Different countries and health service providers find different solutions to this dilemma The most important issue is that you choose a flexible system which ensures that the person in charge of the stores at every level is trustworthy there is a proper stock control system equipment users and maintainers have easy acc
317. re today that it cannot easily be ignored It has a very wide application for example equipment is used to help diagnose whether a patient has malaria treat a patient by removing their gall stones monitor the condition of a patient s heart provide therapy in order to get a patient moving about again control the environment by supplying heat and light provide necessities such as running water transport patients and staff feed patients and staff gt gt gt 2 provide clean surroundings Every different type of equipment has its own way of functioning and its own safety requirements Thus it is very important to know how to make the best use of all types of equipment so that they can last as long as possible provide you with maximum benefits and not become hazardous to you or your patients a Did you know gt A number of investigations have shown that of the equipment problems reported approximately one third arise from operator problems one third arise from minor easy to solve technical problems such as a blown bulb or fuse or a loose power cord only one third require more serious fault finding procedures and special knowledge of the equipment So at least two thirds and maybe as much as 80 of the problems could be corrected by properly trained equipment users Leaving at most one third of the problems which require Gare trained maintenance personnel d 1 2 Introduction to this
318. re trade exhibition The reports of the papers presented at these congresses are sources of information on many topics such as sterilization air flow control waste management equipment safety etc The IFHE also publishes a newsletter International Federation of Infection Control IFIC North Manchester General Hospital Delaunays Road Crumpsall Manchester M8 6RB UK Website www ific narod ru International Federation of Sterile Supply IFSS 7 Kendal Drive Beeston Fields NG9 3AW UK Tel 44 115 9256364 fax 44 115 9256364 email GillianSills aol com website www ifssonline com Isopharm Sentry Ltd The Validation Centre Millindale Rotherham South Yorkshire S66 7LE UK Tel 44 1709 811460 fax 44 1709 813535 email sales isopharm sentry com website www sentry products co uk Supplier of a wide range of validation testing and commissioning equipment used with items such as sterilizers washer disinfectors and medical gas pipelines 197 198 Annex 2 Reference materials and contacts Malaria Consortium The original Malaria Consortium the joint partnership between the Liverpool School of Tropical Medicine and the London School of Hygiene and Tropical Medicine is no longer operating under that name However the report of its programme its publications and continuing projects can be accessed on website www liv ac uk lstm malaria There is anew NGO called the Malaria Consortium which is pursuing similar issues
319. related items the Stores Controller prompts the user department to complete an order form requesting further supplies in the case of stockable equipment related items the Stores Controller writes a purchase order for approval by the Health Management Team and submits it to the Finance Officer for payment 6 3 6 2 Storage system and procedures The stores stock control system can be either a manual paper system or a computerized system It doesn t matter which you use because the sort of data that you must record 1s the same whether you are designing the layout of a card or the fields on your computer screen Also any computer system involves an element of paperwork as standard forms can be printed out for stores staff and departments to fill in The rest of this Section covers paper forms and various manual ways to summarize the data If your health service provider has a computerized stores stock control system this can automatically generate purchase orders when reorder levels are reached Stock management is an area in which simple computer systems have proved to be quite valuable see Annex 2 CALCULATING USAGE RATES AND REORDER LEVELS When stocks of equipment accessories and consumables decrease levels must be replenished Thus it is necessary to monitor and control the stock of accessories and consumables in order to ensure that you always have the required items in stock on the shelves when they are needed To
320. rent collection vessels or bins must be available for the various types of waste They must be marked so that they are not mixed up Various types of waste should be segregated and held in colour coded containers To prevent waste being mixed up the colour coding should be agreed at national level General waste type A use plastic bags containers or bins 50 to 150 litre which are black for example Infectious waste type B use puncture proof containers 5 to 20 litre which are red for example Pathological waste type C use strong plastic bags or containers 10 to 30 litre which are green for example Toxic waste type D use puncture proof containers such as sealed drums or lead boxes labelled with the respective symbol 5 to 10 litre which are yellow for example Transport The transport of waste inside the health facility human handcart Waste type A Waste type A amp B transport trolley with a lid or hood or 180 litre tote bin with wheels Waste type C either of the above as long as in sealed plastic bags or containers Waste type D either of the above as long as in its sealed container Continued opposite 5 4 2 Managing different types of waste BOX 30 Strategies for Handling Waste continued Issues Strategies Intermediate storage General waste type A is normally dumped immediately while waste from the other categories sometimes needs to be stored b
321. report any incidents Section 8 2 ensure that staff are trained in the correct procedures to reduce risks when handling treating and disposing of waste monitor implementation of the correct procedures Equipment Users and HTM Teams Section Heads Safety Sub groups In Service Training Coordinator carry out the correct waste reduction segregation storage transport treatment disposal report any incidents Section 8 2 ensure that staff are trained in the correct procedures to reduce risks from other hazards monitor implementation of the correct procedures Equipment Users and HTM Teams carry out the correct procedures to reduce risks from gas electricity laboratories radiation fire accidents report any incidents Section 8 2 6 How to ensure the availability of accessories and consumables 6 HOW TO ENSURE THE AVAILABILITY OF ACCESSORIES AND CONSUMABLES Why is This Important Equipment accessories and consumables are essential because without them equipment simply will not function Ensuring that suitable equipment accessories and consumables are always available is a vital management issue 6 1 This Section looks at assessing the need for equipment accessories and consumables through the following issues e A general discussion on accessories and consumables Section 6 1 The storage system and procedures Section 6 2 Calculating usage r
322. requirements of Teams or HTMWG equipment related supplies for which there is no current information available see Guide 2 on planning and budgeting Section Heads calculate annual requirements see Box 50 provide the stores staff with the results for the stock control system Stores Staff calculate the reorder levels and order quantities see Box 51 enter the data on the stock cards keep a stock control ledger use the prompts from the stock control system to reorder more stocks when they are required so that stocks are always on the shelves Usage Rates and Reordering 136 7 How to ensure continuous operation 7 HOW TO ENSURE CONTINUOUS OPERATION Why is This Important You wish to get the most out of your equipment and for it to be available for use most of the time Thus it is necessary to make it secure Also if you take good care of your equipment it will last longer To ensure the continuation of the health service that your equipment supports it is necessary to replace the equipment at the end of its life For example if you want to continue offering dental services to patients you must replace your dental drill at the end of its life In this Section we offer advice on how to ensure the continuous operation of your equipment by covering the following issues e Security Section 7 1 User planned preventive maintenance PPM Section 7 2 Testing for electrical and mechanical trustworthiness Se
323. resources produced by other organizations see Annex 2 Training can also incorporate the experience of existing staff Figure 7 overleaf shows a number of strategies to follow when developing training materials Training Trainers The trainers who run the equipment training sessions are usually one or more of the following Staff from the equipment manufacturer Staff from the manufacturer s representative Clinical or maintenance staff from other teams workshops health facilities and health service providers who are knowledgeable about the equipment Senior clinical or maintenance staff within your team workshop or health facility who were previously trained on the equipment or who have the necessary skills e Partners in technical cooperation projects or staff from non governmental organizations and charities If you don t currently have enough trainers you can nominate staff who can be trained to become trainers When users and maintainers are being trained at the time of commissioning new equipment it may be useful to select staff from among the trainees who you would like to become trainers These individuals can then go on to train staff who could not attend the initial training sessions for example a matron could be trained to teach other nurses 45 46 3 5 Developing staff skills The trainers will need to be taught sufficient skills to train their colleagues They should be capable of
324. rols and manages an organization s stock and allows you to browse through your stock records It can be used on its own or as a module of the Requisoft Procurement system e Website www artisan co uk products index php p Stock Artisan stock management and control software is comprehensive and includes complex assembly component and works order systems Technician s handbook for compression refrigerators Part D How to keep stocks of spare parts WHO Expanded Programme on Immunization 1984 EPI TECH HB D Document EPI LOG 84 20 in Refrigerators use maintenance and repair series WHO Geneva This booklet contains a series of case studies to help the reader learn about spare parts management Although designed for vaccine refrigerators it can be applied to any spare parts It has sections covering how to choose and order spare parts how to keep track of stocks of spare parts how to decide who should keep the stocks and how many parts should be kept at each level of the health service It contains exercises and case studies for each topic Available from WHO 189 190 Annex 2 Reference materials and contacts Testing and Decommissioning This material covers issues in Section 7 3 on safety testing and test instruments and Section 7 5 on decommissioning It is listed alphabetically by title Care and safe use of hospital equipment Skeet M and Fear M 1995 VSO ISBN 0 9509050 5 4 District health facilities Guidelines
325. ronic newsletter dedicated to sharing knowledge regarding the latest technical developments in the fields of health nutrition population and reproductive health ID21 health website www id21 org health An internet based development research reporting service for health policy makers and development practitioners on global health issues Latest research summaries are provided on a searchable website by email and in a quarterly publication IEC website www iec ch International Electrotechnical Committee which sets standards for the safe manufacture of electrical healthcare technology There is a wide range of specific standards for medical electrical equipment falling under the standard numbers IEC 60101 1 2 and 3 IEE healthcare technologies professional network website www ice org pn healthtech The Institution of Electrical Engineers of the UK provides internet sites for a wide variety of engineering professions with the aim of enabling people to communicate with their peers around the world and access the latest global industry news and key information sources One of their professional networks focuses on healthcare technologies It has also hosted a series of seminars on Appropriate medical technology for developing countries and their reports can be obtained from the IEE INFRATECH discussion group WHO forum for global exchange of information on infrastructure and healthcare technology issues To subscribe send an email to listser
326. rt of the usual planned preventive maintenance tasks Section 7 2 At the end of every repair process whenever equipment breaks down see Guide 5 on maintenance management Safety and calibration testing should be encouraged even though some of the instruments required are expensive Section 5 5 2 discussed some tests required for electrical installations and for medical equipment Most test instruments are used for electrical electronic or medical equipment purposes Medical equipment has stricter electrical safety requirements and considerations than non medical equipment because it comes into direct contact with patients Such equipment will require dedicated safety test instruments which go further than simple electrical safety testers Thus the HTM Team will require adequate test instruments Annex 6 provides a list of the types of basic and more complex testers that an HTM Service will need Not all workshops health facilities at every level will need all of the instruments listed The type of test instruments you own will depend on the skills of your HTM Team it may be more economical and effective if the complex items are placed at regional or central levels where specialist staff are based and provide maintenance support by outreach Figure 18 offers some suggestions for increasing safety testing We recognize that following these suggestions will require a lot of resources money people time 147 7 3 Testing for
327. running both formal and informal training sessions in order to pass on their skills in the operation care and maintenance of equipment They will require training on the specific equipment concerned and can receive this either from the manufacturer from other facilities where the equipment is in use or from colleagues with the necessary experience Figure 7 Strategies for Developing Training Materials The HTM Working Group or its training sub group eet regularly To develop training resources for existing equipment as an ongoing exercise to develop a library of written resources Hold special meetings when new equipment arrives Study the operator and service manuals and develop suitable training resources from them otify manufacturers or their representatives of your raining needs Observe staff training carried out by equipment manufacturers or their representatives Convert the written guidelines into a range of resources visual aids Video the training activities If manufacturers are going to carry out training on equipment notify them in advance of the range of training and resources you require from them Attend the training sessions record the training given obtain copies of any handouts or overheads used and compile written resources in the usual format to add to the stock of training guidelines e Handouts for the trainees e Posters which can be plac
328. s Another strategy is to nominate and train certain members of staff to be some form of special equipment operative These individuals can be trained to set up operate apply and take care of specific items of equipment in order to ensure that it is used consistently and that it provides a reliable service Examples are given in the country experience box above Such a strategy has additional benefits For example nomination as a special equipment operative can be an incentive to motivate staff and lead on to them becoming trainers Box 11 contains a summary of the issues covered in this Section BOX 11 Summary of Procedures in Section 3 on Utilizing Equipment Effectively Equipment Users follow good practice when handling equipment and make themselves aware of general dos and don ts see Box 6 HTM Teams report any poor behaviour by equipment users that they observe through the HTM Manager to the Health Management Team Section Heads ensure their staff follow good practice with equipment and report any problems to the Health Management Team so that any training needs can be addressed 5 gt 14 ta m xe O O Continued overleaf 47 48 Section 3 summary BOX 11 Summary of Procedures in Section 3 on Utilizing Equipment Effectively continued Health Service Provider ensures that sufficient numbers of suitably skilled staff are recruited to operate its equipment and implements strategies to enco
329. s and assure ii Ensure sufficient quantities of clean injection equipment are available in safe injection practices each healthcare facility by implementing iii Establish procedures so that sharps are disposed of in such a way that multidisciplinary dirty injection equipment is not reused and the risk of accidental strategies comprising needle stick injuries is minimized three elements Choose between the i Reusable syringes and needles These can be effectively sterilized with three different types steam however evidence indicates that the result is difficult to ensure and of injection that breakdown in such systems leads to lack of sterilization equipment available ii Disposable injection equipment High rates of consumption mean high costs Potentially the safest method but the quality of such equipment must be regulated by national authorities so that unsafe reuse of disposables is actively prevented iii Auto disable syringes These are inactivated automatically after one use and prevent dangerous reuse of injection equipment This product is new so may not be available in your country in all sizes Implement a system Either use sharps containers which are puncture resistant of collecting used leak proof shatter proof containers into which sharps sharps in a secure way and syringes are placed In house solutions include Sig top or some form of rigid closable cardboard box using a plastic bottle
330. s in another department Therefore we use the term healthcare technology to refer to the various equipment and technologies found within health facilities as shown in Box 1 BOX 1 Categories of Equipment and Technologies Described as Healthcare Technology medical equipment walking aids health facility furniture communications equipment training equipment office equipment office furniture fixtures built into the building plant for cooling heating etc service supply installations equipment specific supplies fire fighting equipment workshop equipment fabric of the building vehicles laundry and kitchen equipment waste treatment plant energy sources For examples of these different categories see the Glossary in Annex 1 1 1 Introduction to this series of guides Often different types of equipment and technologies are the responsibility of different organizations For example in the government sector different ministries may be involved such as Health Works and Supplies and in the non government sector different agencies may be involved such as Health and Logistics The range of healthcare technology which falls under the responsibility of the health service provider varies from country to country and organization to organization Therefore each country s definition of healthcare technology will vary depending on the range of equipment and technology types that they actually manage For simplicity we of
331. s material covers issues in Section 5 such as operator safety decontamination issues waste management electrical safety medical equipment safety and accidents The material is listed alphabetically by title in each sub section Some sources cover many topics and are listed in the first sub section Sources that cover a single topic are listed in the sub sections dedicated to that topic When looking for a specific topic always check the first sub section to see if any sources also cover the subject matter you are interested in Sources covering many safety topics Care and safe use of hospital equipment Skeet M and Fear M 1995 VSO ISBN 0 9509050 5 4 Emergency Care Research Institute ECRI USA products ECRI Enhancing patient safety The role of clinical engineering American College of Clinical Engineering 2001 ACCE White Paper ACCE Plymouth Meeting USA This paper discusses the problem in the USA of the level of adverse incidents occurring in healthcare due to user error and the important role clinical engineers need to play in patient safety It contains information on other papers websites and organizations that deal with patient safety issues Available from ACCE website www accenet org Essentials of health and safety at work Health and Safety Executive HSE 1989 ISBN 0 11 885494 1 This practical easy to use guide helps you to prevent workplace accidents and comply with UK HSE law without major disruption or
332. s treatment such as monitoring the use of the incinerator e the methods for disposing of different types of waste and the documentation required to monitor its regular occurrence To help you to achieve all of this we suggest that the central HTM Working Group develops the policies on waste management and a Waste Management Hygiene Plan see reference material in Annex 2 with advice from national and municipal experts The facility level HTM Working Group or its smaller sub group the infection control committee Section 1 2 needs to develop and implement good waste management practices Box 29 discusses the idea that waste management strategies should follow the waste management hierarchy of avoidance utilization and disposal 83 84 5 4 1 Waste management philosophy BOX 29 Strategies for Waste Management Hierarchy Avoidance Avoidance and reduction of waste generation minimizes the necessary effort for waste treatment and disposal at health facilities Strategies e Waste reduction at source through product selection In practice it will not always be easy to decide what material is environmentally friendly or which chemical is less harmful The relevant expertise must be developed or advice sought Segregation of waste If waste is properly segregated at source before it gets mixed up special precautions in waste handling are only necessary for the hazardous portion of the waste see Box 30
333. s with appropriate national bodies for guidance on the various safety issues Group and its e consults Section Heads to identify safety issues relevant to their sections Safety Sub groups develops appropriate safety procedures to address hazards when operating equipment c O N 2 5 O wn Q equipment related infection control waste management control of all other hazards acts on incident reports Continued overleaf 111 Section 5 summary Operating Equipment Infection Control Cc E O c dp z Hazard Control BOX 44 Summary of Procedures in Section 5 on Ensuring Safe Operation continued Section Heads Safety Sub groups In Service Training Coordinator ensure that staff are trained in the correct procedures to reduce risks when operating equipment monitor implementation of the correct procedures Equipment Users and HTM Teams Section Heads Safety Sub groups In Service Training Coordinator carry out the correct safety procedures when operating equipment report any incidents Section 8 2 ensure that staff are trained in the correct procedures for infection control monitor implementation of the correct procedures Equipment Users and HTM Teams Section Heads Safety Sub groups In Service Training Coordinator carry out correct methods for decontamination and monitoring of sterility linen handling keeping the workplace clean
334. scope microlens 10 Telescopic shoulder wheel 15 Telethermometer 10 Tent Aerosol 8 Oxygen 8 Thyroid uptake system 5 Tissue embedding center 8 Tissue processor 7 Titrator automatic 10 Tonometer 10 Totalap 10 Tourniquet automatic 10 Tourniquet system 7 Traction unit 10 Transcutaneous nerve stimulator system 5 Transesophageal transducer 5 Continued overleaf 219 Annex 8 Typical equipment lifetimes Table 8 Diagnostic and Treatment Departments continued Item Years Item Years Treadmill electric 8 Wheelchair 5 Tube dryer 10 X ray equipment Tube tester 10 Developing tank 10 Ultrasound diagnostic 5 ri on Ultrasound unit therapeutic 7 Fu itur 15 Vacuvette 10 Image intensifier 5 Ventilator respiratory 10 Intensifying screens 5 Vial filler 10 Silver recovery unit 7 Vibrator 10 X ray unit l Fluoroscopic 5 Video Mobile 5 samer 5 Radiographic 5 Migut SOUE 5 Superficial therapy 5 Monitor Tomographic 5 Printer 5 Wiig 5 Table 9 Support Departments Support departments consist of biomedical engineering central sterile supply dietary engineering maintenance housekeeping environmental services laundry materials management security and staff facilities departments Item Years Item Years Air conditioner window 5 Cart Ambulance 4 Food tray heated refrigerated 10 Automobile Pe y Delivery 4 an i Passenger 4 HPP y Utility 10 Battery charger 5 Cash register 5 Bedpan wash
335. seam ie yBnoy ajqeaouasun pusuewad woovaq JO pabewep uayoig useq 3ALyY YOIUM Aaains jo pueog HO U PHM 3q 0 Sa qepuadxy Jo S17 224 Annex 10 Source material bibliography ANNEX 10 SOURCE MATERIAL BIBLIOGRAPHY Albert Browne International Ltd 1996 TST technology data sheets assorted Browne sterilisation monitoring systems Albert Browne International Ltd Cowfold UK Albert Browne International Ltd 1997 Browne sterilisation monitoring systems Albert Browne International Ltd Cowfold UK American College of Clinical Engineering 2000 The role of health care technology in enhancing patient safety by reducing medical errors in medicine ACCE White Paper Draft 2 ACCE Plymouth Meeting USA American Society for Hospital Engineering 1998 Estimated useful lives of depreciable hospital assets gnd edition American Hospital Association Chicago USA Amonoo Larston R Ebrahim G Lovel H and J Rankeen 1996 District health care Challenges for planning organization and evaluation in developing countries 2 edition Macmillan ISBN 0 333 57349 8 Berg H 1992 Medical equipment in developing countries Two neglected issues planning and financing WHO Document WHO SHS CC 92 2 WHO Geneva Bloom G H and C L Temple Bird 1988 Medical equipment in sub saharan Africa A framework for policy formulation IDS Research Report Rr19 and WHO publication WHO S
336. should avoid sorting contaminated linen before washing as much as possible No sluicing rinsing under a stream of water of contaminated linen should take place within the section for example at ward level Instead this will be done in the laundry with cold water Depending on the frequency of collection by laundry staff and the availability of pre wash facilities in the laundry it may be necessary to soak contaminated linen in the sections using linen Soaking is required to prevent stains from becoming engrained and spoiling the linen as follows e Sections which use linen should be provided with rubber garbage bins in which staff can soak contaminated linen in a freshly prepared sodium hypochlorite solution such as a 0 5 concentration of bleach in water for at least one hour Section staff send the soaked material to the laundry on a regular basis to be processed quickly so that the damp linen does not go mouldy In the laundry Refer to the manufacturer s manual national guidelines and expert advice in order to ensure that sufficient stocks of the correct industrial cleaning agents and chemicals are purchased for the laundry see Annex 2 Laundry staff must understand the proper use of appropriate chemicals to kill bacteria and the correct amount of cleaning agent which is effective not wasteful and does not cause foaming Refer to the manufacturer s manual national guidelines and expert advice to ensure that the c
337. specific guide Staff may feel that the use of equipment is something they already know about intuitively But as the statistics above show it is vital to address how operators use their equipment in order to ensure the correct care and handling of equipment Thus it is necessary to formalize and write down procedures ensure staff are properly trained about the procedures monitor the implementation of the procedures Equipment operation and safety is based on a series of commonly accepted ideas and standards which should be used to develop guidelines for staff Who is this Guide Aimed at This Guide is particularly suitable for the following Equipment operators and their department and facility managers within your organization e Technical maintenance staff in their capacity both as operators and as equipment maintainers e Equipment managers in your Healthcare Technology Management Service H TMS Other types of staff who have various responsibilities relating to operation and safety work such as administrators safety inspectors infection control staff trainers and finance purchasing human resource supplies and stores personnel All of these staff should have a good understanding of equipment operation and safety in their common effort to provide an effective and safe health service The recommendations and procedures outlined are primarily aimed at facility and district level personnel Howe
338. specific to this Guide and provides advice on authorities responsible for guidance on equipment operation and safety the aims staffing requirements and funding issues for operation and safety 15 2 1 Framework requirements for quality health services 2 1 FRAMEWORK REQUIREMENTS FOR QUALITY HEALTH SERVICES Regulatory Role of Government The World Health Organization WHO identifies four distinct functions for health systems e The provision of health services The financing of health services The creation of health resources investment in facilities equipment and training e The stewardship of health services regulation and enforcement Health service provision and financing as well as resource creation may be taken on by both the government and the private sector Thus there are various options for organizing health systems e Mainly public e Mainly private for profit for example run by a commercial organization and private not for profit for example run by faith organizations NGOs A mixture of government and private organizations However in all these systems the government is solely responsible for the regulation of health services The reason for this is that the government has a duty to ensure the quality of healthcare delivered in order to protect the safety of the population These regulations may then be enforced directly by government bodies or they may be enforced by publicly fun
339. spital International Nepal Fellowship Pokhara Nepal Dr S Samnakey Clinical Director of Surgery Aga Khan Foundation Private Hospital Nairobi Kenya Sulaiman Shahabuddin Director Patient Services Aga Khan Foundation Private Hospital Nairobi Kenya Dr Sok Srun Hospital Services Bureau Chief Ministry of Health Phnom Penh Cambodia Birgit Thiede Physical Assets Management PAM Advisor Ministry of Health Phnom Penh Cambodia using source material described in Annex 10 Source Material Bibliography with financial assistance from the Knowledge and Research Programme on Disability and Healthcare Technology DFID government of the United Kingdom with administrative support from all the staff at Ziken International Consultants Ltd UK especially Garth Singleton Rob Parsons and Lou Korda as well as Thomas Rebohle from FAKT Germany iv Abbreviations Abbreviations AAP AHA AMC Amps BP CD Rom CSSD DB DVD ECG EDP ELCB FIFO GTZ HIV HTM HTMS HTMWG ICU IEC IEE ISO kPa LPG LT Max MES Min MOH NGO OPD annual action plan American Hospital Association average monthly consumption Amperes blood pressure compact disc read only memory central sterile supplies department central sterile services department in the USA distribution board digital versatile disc electrocardiograph equipment development plan earth leakage circuit breaker first in first out g
340. st be designed to ensure that humans and animals are protected from access to high voltages above 50V cannot touch bare metal which is live connected to a voltage supply donot offer the best path of least resistance for currents to earth therefore a better earthing route with an impedance of 0 3 Ohms or less must be provided Earth leakage protection is therefore required to minimize the risk of electric shock to humans and dangerous and soon become fatal Therefore to prevent dangerous earth leakage currents attention is required to ensure that the electrical installation is carried out carefully the installation is examined and overhauled regularly one of the methods available for earth leakage protection is used 5 5 2 Electricity There are three methods of protection which can be used to prevent the occurrence of earth leakage currents i Using extra low voltages as your power supply Extra low voltage below 50 volts prevents the occurrence of dangerous earth leakage currents and can be provided by using batteries or transformers the secondary winding isolated from earth as your power source ii Using all insulated or double insulated systems The first requires the complete insulation of all parts of an electrical installation The second requires the use of double insulated equipment Such equipment a hand held electric drill for example has insulation around differ
341. standards for healthcare technology developing healthcare technology policies establishing systems to ensure the policy is implemented All these aims could be achieved if each health service provider practised healthcare technology management HIM as part of the everyday life of their health service The best way to do this is to have an HTM Service incorporated into each health service provider organization Box 2 Section 1 1 shows that HTM provides a wide range of benefits Guide 1 attempts to express this in terms of the sorts of savings that can be made if HTM is effectively carried out Taking maintenance as an example we can see that it has not only a positive impact on the safety and effectiveness of healthcare technology but that it also has two important economic benefits it increases the life span of the equipment it enhances the demand for health services since demand for services is crucially dependent upon the availability of functioning healthcare technology Healthcare technology that is out of order quickly leads to a decline in demand which will in turn reduce the income and quality of services of the health facilities You will lose clients if for example it becomes known that malfunctioning of sterilization equipment may endanger the health of the patients Similarly patients will avoid visiting health facilities that do not possess functioning diagnostic equipment 21 2 1 Framework requirements for q
342. stock levels required can be sought from the Head of Department or HTM Manager and information generated from a one off exercise as described in Section 6 3 store the new supplies on labelled shelves with their stock cards bin cards e issue a list of the codes for specific items to the user departments and HTM Teams so that they can easily identify and order items for example a spare bottle for suction pump Type A may have code number EA 07 050 Figure 13 Sample Stock Card Bin Card Stock Card Bin Card Card no Item description Unit pack size Cost Item code no Maximum level Minimum Reorder level Location Reserve stock level Order quantity Lead time Date Received from No No New Remarks Signature issued to received issued balance 126 If user departments have sub stores the staff in the main store can consult with the Head of Department and issue the short term requirements to the sub stores every week or month The Stores Controller then monitors the usage rate of stocks in the sub stores to ensure that the user department doesn t request too much for its regular issues and ensures that the department is only issued with what it really needs As goods are issued and marked off on the stock card the record system tells the Stores Controller when the stocks are low and the reorder level has been reached Then inthe case of non stockable equipment
343. sues which should normally be discussed before you buy the equipment in the planning phase see Guide 2 on planning and budgeting 37 3 3 Efficient use of equipment However if you already have a machine that is not used a great deal you can either choose to operate the machine on just one day a week and call patients in on that day This way the machine has a chance to warm up and can be used effectively for the day rather than being switched on and off throughout the week or plan when the equipment will be used during the day For example arrange for the majority of blood tests to be sent to the laboratory immediately after doctors rounds in the morning This would give you a large number of samples available before using your centrifuge and batch chemistry analyzer Do You Use Your Equipment and Materials Effectively How often you plan to use your equipment will have an impact on how effectively you utilize the consumables and materials required For example if you are running an antenatal clinic it is a good idea to ensure that the laboratory technician is available at the same time Then he or she can do the haemoglobin screening test while the clinical appointment takes place and it will not be necessary to ask the patient to return to the clinic another day for the laboratory test By concentrating equipment use to specific times you can open a multi pack of consumables such as stick on electrodes or reagent str
344. t explains each step in detail Although written for maintenance staff its advice is just as useful for any other types of staff Available from FAKT 177 178 Annex 2 Reference materials and contacts Hospital technology Communication a vital skill for successful healthcare technical service management FAKT 1999 FAKT Technical Library Data Sheet This paper discusses the importance of communication for both working in a team and working in an organization network It provides advice on how to communicate effectively its importance the barriers that exist how to promote effective communication the role of the head of department methods to use and related reading Although written for maintenance staff its advice is just as useful for any other types of staff Available from FAKT How to make and use visual aids Harford N and N Baird 1997 VSO ISBN 043592317X This booklet describes a number of useful and practical methods for making visual aids quickly and easily using low cost materials Available from TALC VSO Management support for primary health care A practical guide to management for health centres and local projects Johnstone P and J Ranken 1994 FSG Communications Ltd Cambridge UK ISBN 1 87118 02 4 This practical user friendly book gives support and guidance to leaders in health centres and other local projects to help stimulate and maintain primary health care PHC in their surrounding comm
345. t time or by cold water if the correct disinfectant is used at the correct concentration for the correct time The word linen is used to cover all items to be laundered It is recommended that in health facilities linen is divided into two categories Soiled linen which has been used and is no longer fresh but is uncontaminated by infectious agents Fouled and infected linen which is obviously fouled with urine faeces blood vomit pus etc or is known to have been in contact with an infection this 1s contaminated linen It is necessary to have appropriate linen handling procedures in place in order to avoid cross contamination and to avoid the transmission of infectious diseases to the linen handlers Many linen handling strategies are dependent on the use of the correct equipment To prevent contamination through exposure to contaminated linen HTM Working Groups or infection control committees need to develop and implement good infection control practices Box 26 provides some important strategies Other equipment related safety issues in the laundry are as follows Do not overload the washing spinning or drying machines as this strains the bearings Do not under load washing machines as this wastes cleaning chemicals and increases the friction in the linen making it wear out more quickly Avoid accidents Section 5 5 laundry floors must be well drained to avoid slippage and pipes must be
346. t which matches your socket outlets for example a three pin plug for a three pin socket makeshift modifications are dangerous the correct cable colours are identified and correctly connected inside the plug Exposed metal Metalwork which is not part of an installation could become live and would be dangerous under faulty conditions gas and water pipes radiators water taps sinks bathtubs etc The electrician electrical contractor should either bond all such pieces of metalwork that is connect them to the earth or completely insulate them Lightning protection Overhead distribution lines can attract lightning and therefore may provide a natural route for earthing Thus the electricity supply body or an electrical contractor should be asked to fit lightning arresters to the overhead poles at the ends of the main distribution lines or at a point where the distribution lines change direction 5 5 2 Electricity Once a good electrical installation has been provided it should be regularly inspected and tested by reputable electricians using the correct test instruments Section 7 3 To guarantee the safety of the installation they need to test for earth leakage test for circuit continuity test for loose connections perform insulation tests test switch leakages test for power check for the correct rating gt gt gt gt 2 check whether wiring regulations were fo
347. ten use the term equipment in place of the longer phrase healthcare technology throughout this Series of Guides What is Healthcare Technology Management First of all healthcare technology management HTM involves the organization and coordination of all of the following activities which ensure the successful management of physical pieces of hardware Gathering reliable information about your equipment Planning your technology needs and allocating sufficient funds for them Purchasing suitable models and installing them effectively Providing sufficient resources for their use Operating them effectively and safely Maintaining and repairing the equipment Decommissioning disposing and replacing unsafe and obsolete items gt UM Ensuring staff have the right skills to get the best use out of your equipment This will require you to have broad skills in the management of a number of areas including technical problems finances purchasing procedures stores supply and control workshops o staff development 1 1 Introduction to this series of guides However you also need skills to manage the place of healthcare technology in the health system Therefore HTM means managing how healthcare technology should interact and balance with your e medical and surgical procedures support services consumable supplies and e facilities so that the complex
348. that each can monitor progress with requests see Guide 5 on maintenance management Figure 24 Example of a Work Request Job Form Work Request Job Form Note this is a triplicate form 1st sheet is the User File copy 2nd sheet is the Maintenance Progress File copy 3rd sheet is the Equipment Section History File copy For User Department Only Facility Date Location Person making request lIn charge Full name Position Contact Equipment task Inventory no Fault description Equipment Work order received by Equipment returned to Full name For HTM Team Only Allocated to Section Type of service Repair Serial no Work undertaken Reasons for failure wear and tear mains unstable dirt contamination water oil user error handling faulty installation other specify Materials used Quantity Cost Test results Work time Travel time Why not completed Completed by Maintainer s signature Annex 8 Typical equipment lifetimes ANNEX 8 TYPICAL EQUIPMENT LIFETIMES LIST 1 Different organizations have tried to estimate typical equipment lifetimes for healthcare technology This annex contains the results from two different sources the American Hospital Association and the GTZ German Government Technical Aid Agency The America
349. that the PPM work is undertaken at the required frequency Some tasks need to be carried out after every use every shift daily or weekly and so on If your Healthcare Technology Management Service has a computerized maintenance management system see Guide 5 on maintenance management this can automatically generate work orders when PPM is required 145 146 7 2 User planned preventive maintenance PPM The simplest form of timetable is to have a monthly duty list Alternatively it is useful to display the planned work on wall calendars indicating when PPM should be carried out The calendar should incorporate space where staff can sign off and date when they finish the task to show that each timetabled PPM activity has taken place This method provides you with a visual record for managers to monitor An example is shown in Figure 17 It is also important to keep a record of any pieces of equipment that are substituted If your equipment has been labelled with some form of inventory code number see Guide 2 on planning and budgeting it will be easier to tell which particular piece of equipment you have been maintaining User PPM charts calendars and instructions should be displayed on the equipment or as near to it as possible to remind staff of their duties and for ease of completion Wall calendars can also be used to display daily care and cleaning schedules Figure 17 Example Timetable of PPM for Users in Wall Cal
350. the level of fluid in the jar reaches the 34 full mark if you let the jar overfill the float valve will close and the vacuum will stop 4 When your first jar is 3 4 full switch the machine off and either empty the jar reconnect the lid firmly and continue sucking or reposition both the patient and inlet tubing from your first jar lid to the lid of a replacement empty jar so that sucking can continue Then empty the full jar 5 If the jar overfills and the filter gets wet the machine will be damaged fluid in the pump and risk of cross infection and a replacement machine must be used Disinfect the full machine and send it to the HTM Team to be repaired 6 When finished with the machine unplug it from the electrical socket 4 2 The correct application 4 2 THE CORRECT APPLICATION Staff may feel confident about how to operate equipment but it is imperative that they also know the correct application for the equipment Staff need to be able to apply their taught clinical procedures correctly and to employ the correct methods of application so that equipment is used to its fullest capacity Staff will need to be trained in order to fully appreciate when and how to use equipment They will need to know when different features will be employed for different patients or uses the range of assistance a machine can offer them how to alter the relationship between the machine and the patient or sample fo
351. the settings on these units and must closely monitor their appropriate use to ensure that no harm comes to any infants Radiographic equipment Radiographers need to know the settings for various diagnostic examinations by X ray and fluoroscopy of the skeleton fractures head trauma infection chest TB infections tumours trauma abdomen trauma intestinal obstructions soft tissue foreign bodies calcification Ultrasound machines 4 3 Users should not perform pathological diagnosis of liver kidney and other internal organs unless they have received the required specialist training CARE AND CLEANING To maximize the life of equipment it is necessary that equipment users and maintainers know how to look after the equipment and clean it Users must care for and clean equipment regularly to a given timetable It is beneficial to do this because itis easier to see faults such as damaged suction pump tubing when the equipment is clean it prolongs the life of equipment for example protecting electronic parts from damage by dust protecting metal from corrosion by liquids or chemicals protecting rubber seals from degradation by greases it protects the operator and patient from infections from microscope eyepieces for example it improves the performance of equipment clean probes for ultrasound clean seals on fridge doors etc 53 54 4 3 Care and cleaning
352. the sewage pipelines and the kitchen grease trap drains move from there through holes in floors and walls which admit service pipes like to eat materials available in the kitchen food mortuary corpses and the pharmacy glycerine tablets thus are very effective at spreading microbes from one place to another climb inside equipment and chew through wires rats have been found in X ray machines and electricity distribution boards mice in infant incubators and operating theatre lights Strategies block any likely entrance holes use poison or traps either purchase equipment with vermin grills and guards or make your own from metal mesh or plastic keep rooms in regular use consider keeping cats for vermin control Ants and cockroaches like warmth and food so are common in kitchens and autoclaving units have trails that run for long distances they visit drains and sluices for moisture feverish patients for sweat open wounds for the discharge and commonly spread infections have even been found in sterile packs resuscitation equipment and drip tubes cover served food and stored food store food in air tight containers keep gifts of food for patients covered inside lockers tightly close bags containing soiled and fouled linen fill crevices in walls use poison and control chalk Birds such as pigeons bird droppings foul areas of the health facility they have access to such as veran
353. the skin or enter sterile body areas contaminated with readily transmittable organisms of medium to high infection risk Metal tongue depressors work surfaces washing bowls soiled items contaminated items thermometers infectious spills such as blood or urine on mattresses Surgical instruments dressings reusable items such as sterilizable syringes and needles reusable patient hoses bellows and other plastic metal and rubber components which do not distort at high temperatures e Hot air sterilizers can be used but are only effective if the instructions are followed exactly and they gee o oe reach the sterilizing temperature 160 C and remain there for a minimum of one hour Their disadvantages are long cycle time up to two hours high running costs high operating temperatures can damage sensitive items possibility of low temperature pockets which affect sterilization operator interference may interrupt the cycle meaning sterilization is not guaranteed For materials that cannot bear the high temperature of steam there are other methods using ethylene oxide gas plasma low temperature steam formaldehyde or radiation These require specialized equipment and many of them are very expensive and require daily microbiological checks To prevent contamination through exposure to blood body fluids and other infectious agents the HTM Working Groups or infection control committees need to dev
354. the training Recognition a formal way of ensuring that the additional skills attained by staff are reflected in their promotion chances and job grades by the Human Resource Department Additional expenses possible room hire overnight accommodation travel and subsistence trainers fees visual aids teaching equipment etc Records a system for keeping a record of the specific training that a staff member has received 3 5 Developing staff skills Developing Training Materials We suggest you develop simple guidelines for each type of training required for every type of equipment based on good principles and procedures This Series includes the following examples Guide 2 covers equipment planning and budgeting e Guide 3 covers procurement adjudication of tenders and quotes installation and commissioning e Guide 5 covers PPM and repair for maintainers and spare parts management Guide 6 covers financial management for HTM Teams Finally this Guide Guide 4 covers good practice when handling equipment basic dos and don ts how to operate equipment the correct application of equipment care and cleaning safety procedures planned preventive maintenance for users and stores management The specific guidelines for different equipment types should be modelled on the advice in the equipment manufacturers operator and service manuals e the manufacturers PPM schedules written
355. this Series of Guides are to be congratulated for what is a comprehensive and timely addition to the global HTM toolkit Andrei Issakov Coordinator Health Technology and Facilities Planning and Management World Health Organization Geneva Switzerland Mladen Poluta Director UCT WHO HTM Programme University of Cape Town South Africa Acknowledgements Acknowledgements This Guide was written e with specialist support from Juliette Cook Biomedical Engineer Advisor to Ministries of Health of Mozambique and Vanuatu e with assistance from an Advisory Group of Hans Halbwachs Healthcare Technology Management Deutsche Gesellschaft fiir Technische Zusammenarbeit GU Z GmbH Eschborn Germany Peter Heimann Director WHO Collaborating Centre for Essential Health Technologies Medical Research Council of South Africa Tygerberg South Africa Antonio Hernandez Regional Advisor Health Services Engineering and Maintenance PAHO WHO Washington DC USA Andrei Issakov Coordinator Health Technology and Facilities Planning and Management Department of Health System Policies and Operations WHO Geneva Switzerland Yunkap Kwankam Scientist Department of Health Service Provision WHO Geneva Switzerland Martin Raab Biomedical Engineer Swiss Centre for International Health of the Swiss Tropical Institute Basle Switzerland Gerald Verollet Technical Officer Medical Devices Blood Safety and Clinical Tec
356. tics Forms in Statistics Folders and that you use them for creating reports for management Staff such as the In Service Training Coordinator and the Infection Control Officer can also play a role in monitoring equipment skills and issues across the health facility as a whole This helps them to identify where problems are occurring which they could follow up with in service training or other measures Section 3 5 In addition Department Heads should regularly report to the Purchasing and Supplies Officer regarding the quality of materials purchased Section 6 3 166 8 2 Monitoring progress with equipment operation and safety ii Incident reports Each health facility should have some formal method of reporting problems accidents and adverse incidents in all equipment related safety areas Section 5 Some type of Accident Record Book or Incident Form can be used so that staff can report whenever any type of incident occurs These should be submitted to the HTM Working Group or its safety sub groups The HTMWG should monitor the incidents and discuss the most appropriate solution in each case It will need to report to the Health Management Team and address the problems using a combination of strategies such as changing operating procedures introducing further safety measures training staff penalizing or rewarding the behaviour of staff redistributing equipment until such time as the necessary human skills are in
357. ties Summary of procedures in Section 6 on accessories and consumables Possible security strategies to consider Typical examples of the user s role in the PPM of equipment Examples of user PPM instructions for any types of refrigerators Strategies for developing PPM schedules Example of a replacement policy Summary of procedures in Section 7 on ensuring continuous operation Example of how to measure a goal Strategies for running an annual action planning seminar in the health service 86 88 90 92 96 97 102 103 107 108 108 109 110 111 111 115 116 120 123 124 129 133 136 138 141 142 145 150 153 160 163 viii List of boxes and figures Box 61 Box 62 Box 63 Box 64 Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Figure 21 Figure 22 Figure 23 Figure 24 Figure 25 Examples of statistics which can be gathered regularly Summary of procedures in Section 8 on action planning and reviewing progress WHO s definition of technology management hierarchy Annex 1 Example of safety and calibration testing instruments by type of work and skill level Annex 6 The place of healthcare technology management in the health system The relationship between the Guides in this Series The structure of Gu
358. ties at certificate level accredited with known bodies such as BTEC City and Guilds specific equipment courses such as sterilization technology courses ECHO International Health Services Ltd ECHO International Health Services is no longer trading as it used to Its services can be accessed as follows i the charitable foundation can be contacted at ECHO Ullswater Crescent Coulsdon Surrey CR5 2HR UK Tel 44 208 6602220 fax 44 208 6680751 website www echohealth org uk intro2 html ii the trading branch of the business wholesale providers of medical supplies and equipment is now Durbin PLC 180 Northholt Road South Harrow Middlesex HA2 OLT UK Tel 44 208 8696500 fax 44 208 8696565 email cataloguesales durbin co uk website www durbin co uk iii ECHO publications are still available from TALC see below ECRI Emergency Care Research Institute 5200 Butler Pike Plymouth Meeting Pennsylvania 19462 1298 USA Tel 1 610 825 6000 ext 5368 fax 1 610 834 1275 website www ecri org Offers guidance and advice on healthcare technology planning procurement and management and health technology assessment and assistance Elsevier Health Science Elsevier Books Customer Services Linacre House Jordan Hill Oxford OX2 8DP UK Tel 44 1865 474110 fax 44 1865 474111 email eurobkinfo elsevier com website www us elsevierhealth com Books published by WB Saunders Mosby Churchill Livingstone and Butterworth Heinemann a
359. tion 3 4 or Kee DIRECT SUNLIGHT a A ich x MAGNETS NO Da tas C TO DUST SMOKE STEAM NO NO NO Source Lee P 1995 Get it Right A Guide to Maintenance Safety Precautions amp Hygiene of Medical Equipment ECHO International Health Services Ltd UK unpublished 35 36 3 2 General good behaviour towards equipment Box 6 provides some examples of dos and don ts that apply to equipment in general BOX 6 General Good Behaviour Strategies When Dealing With Equipment DO only use equipment for the purpose it was designed for only use portable equipment while it is safely positioned on a suitable flat surface such as a worktop trolley or the floor ensure moveable parts such as lids wheels and extensions are securely locked in place before the equipment is used only use equipment if you know the correct operating technique and are competent and trained to use it Section 4 1 keep loose clothes away from moving parts Section 5 5 only use equipment when you have the proper safety gear for example lead aprons gloves goggles Section 5 1 only use equipment with patients when you are sure it is functioning correctly and safely Section 5 always make sure the correct service supplies are available such as electricity water gas before switching the machine on only use the correct accessories specific to a particular machine Section 6 only use the correct co
360. tion for the annual action planning process every user department HTM Team and safety sub group should be involved in carrying out a review of their performance and progress in the previous year their targets plans and needs for the coming year 161 162 8 1 Setting goals annually for equipment operation and safety Department Heads or Chairs of Sub Groups should involve their staff through regular meetings Alternatively if the team is large they can nominate a small review group to prepare material for the action planning process It is useful for each group to undertake an exercise which involves asking a selection of their clients about the department s work Thus a user department or sub group will ask their clients what they think are the five most important problems regarding equipment operation and safety These clients should be a mixture of staff in the health facility served by the user department or sub group members of the Health Management Team at their facility or district the HIM Team e patients If targets were prepared the previous year they should be assessed to see how well they were implemented This helps the user department or sub group to identify and study the successes and problem areas for the team and agree on which problems are priorities for tackling in the coming year The user department or sub group should now have prepared sufficient information to take to the annual
361. tions Technology generation acquisition and utilization require massive investment and related decisions must be made carefully to ensure the best match between the supply of technology and health system needs the appropriate balance between capital and recurrent costs and the capacity to manage technology throughout its life Healthcare technology has become an increasingly visible policy issue and healthcare technology management HTM strategies have repeatedly come under the spotlight in recent years While the need for improved HTM practice has long been recognized and addressed at numerous international forums health facilities in many countries are still burdened with many problems including non functioning medical equipment as a result of factors such as inadequate planning inappropriate procurement poorly organized and managed healthcare technical services and a shortage of skilled personnel The situation is similar for other health system physical assets such as buildings plant and machinery furniture and fixtures communication and information systems catering and laundry equipment waste disposal and vehicles Preface Preface continued The mis management of physical assets impacts on the quality efficiency and sustainability of health services at all levels be it in a tertiary hospital setting with sophisticated life support equipment or at the primary healthcare level where simple equipment is needed for effec
362. tious and pathological waste incineration is the most appropriate method or possibly burning Chemical waste may need chemical treatment such as neutralization or denaturing Radioactive substances have to be packed and sealed for final disposal General waste non infectious healthcare waste incinerator ash and neutralized denatured chemical waste can be landfilled with ordinary municipal solid waste Hazardous waste radioactive carcinogenic mutagenic or infectious waste must be disposed of separately in specially designed landfill sites waste pits or guarded underground places Type A General waste and non infectious healthcare waste which requires handling similar to that of municipal solid waste For example newspapers magazines books packaging material food residue Type B Infectious waste which require special precautions during handling and disposal For example sharps syringes needles scalpels blood soaked bandages cultures and stocks of infectious agents Type C Pathological waste which requires special treatment for reasons of hygiene and particularly for cultural and ethical reasons For example body tissue body parts human foetuses organs Type D Toxic waste which needs individual disposal methods For example drugs chemicals diesel oil formaldehyde acids solvents mercury developer reagents etc radioactive substances batteries X ray film Most waste
363. tive diagnosis and safe treatment of patients What is vital at all levels and at all times is a critical mass of affordable appropriate and properly functioning equipment used and applied correctly by competent personnel with minimal risk to their patients and to themselves Clear policy technical guidance and practical tools are needed for effective and efficient management of healthcare technology for it to impact on priority health problems and the health system s capacity to adequately respond to health needs and expectations This Series of Guides aims to promote better management of healthcare technology and to provide practical advice on all aspects of its acquisition and utilization as well as on the organization and financing of healthcare technical services that can deliver effective HTM The Guides individually and collectively have been written in a way that makes them generally applicable at all levels of health service delivery for all types of healthcare provider organizations and encompassing the roles of health workers and all relevant support personnel It is hoped that these Guides will be widely used in collaboration with all appropriate stakeholders and as part of broader HTM capacity building initiatives being developed promoted and implemented by WHO and its partners and will therefore contribute to the growing body of evidence based HTM best practice The sponsors authors and reviewers of
364. toe Do you need temperature probes for use on the skin or rectally The different types of patient or sample and therefore the size of accessories you may need If the accessory should be a reusable or a disposable type Do you need BP cuffs for adults children infants and neonates Do you need centrifuge rotors that can take 50ml test tubes or 15ml test tubes Do you want reusable ECG plate electrodes and fixing straps or disposable stick on ECG electrodes The associated and connecting parts for the accessories you need Don t forget that the patient leg supports poles for your operating table will also need sleeves straps and clamps Continued overleaf 129 6 3 Calculating usage rates and reorder levels BOX 50 Steps for Calculating Annual Requirements of Accessories and Consumables continued Step 2 Calculate the Basic Set Calculation Examples Once you know the type of Although you only use one monopolar diathermy electrode at a time accessories you require you need you may need to own a basic set of three monopolar electrodes to decide on the quantities of e one in use each accessory required for the e one being cleaned way you work this will make up one asa spare your basic set Once this has Although your small bench top autoclave may only have two shelves Dect established you rar aier you may need to own a basic set of six trays three for each shelf multi
365. towards your goal this is called an indicator There will always be several possible indicators for each goal and more than one way of measuring them You need to know where you are starting from in other words what the situation is now this is called the baseline data The data chosen must be relevant to the indicator Box 59 provides an example of different ways of measuring a goal using indicators and baseline data 159 160 8 1 Setting goals annually for equipment operation and safety BOX 59 Example of How to Measure a Goal Goal Let s make the health facility a cleaner place An indicator Increase the number of equipment cleaning schedules implemented One way of measuring this Calculation required Percentage of available cleaning schedules implemented per month _ Number of equipment cleaning schedules carried out x 100 Number of equipment cleaning schedules should have been done Baseline data All 10 departments have been given equipment cleaning schedules but in July only two were found to be following them Therefore your baseline data is 20 Your aim is to improve this situation and increase this percentage Alternative way of measuring this Baseline data In a study of the current situation you find that equipment cleaning schedules have only been written for four departments and you plan to help them to start implementing these over the next three months Additional equipment cleani
366. ts the most common causes of fires BOX 42 The Most Common Causes of Fires Common electrical faults responsible for fires e Overloading of circuits too may appliances plugged into one socket outlet e Long and badly positioned electrical cables too near hotplates or similar equipment or where they are in contact with water Equipment left switched on unnecessarily overnight or left unattended Equipment that uses flammable liquids or gas placed too near to naked flames Common naked flame faults associated with fires Gas heated appliances cookers bunsen burners etc whose flame full flame or pilot is left unattended Containers of flammable liquids oil petrol ether etc or flammable materials cotton wool paper etc left too close to the flames of gas heated appliances or other naked flames such as cigarettes Gas heated appliances including those using propane and acetylene connected with perished incorrect or poor quality tubing Use of matches instead of mechanical lighters matches are not always extinguished when discarded 5 5 6 Accidents Equipment should be in an acceptable condition at all times so that it cannot cause harm to patients staff or visitors To avoid accidents buildings need to be structurally sound service supplies should be dependable and trustworthy equipment should perform competently and safely There are a number of issues to consider regarding the prevention of
367. ts role the HT MWG must be multi disciplinary Depending on the operational level of the HTMWG its members could include the following Head of medical clinical services Head of support services Purchasing and supplies officer Finance officer Representatives from both medical equipment and plant maintenance Representatives of equipment users from a variety of areas medical clinical nursing paramedical support services etc Co opted members if specific equipment areas are discussed or specific interest or need is shown The HTM Working Group prepares the annual plans for equipment purchases rehabilitation and funding and prioritizes expenditure across the facility district as a whole see Guide 2 on planning and budgeting It may have various sub groups to help consider specific aspects of equipment management such as pricing commissioning safety etc How to Use These Guides Each Guide has been designed to stand alone and has been aimed at different types of readers depending on its content Section 1 2 However since some elements are shared between them you may need to refer to the other Guides from time to time Also if you own the full Series a set of six Guides you will find that some sections of the text are repeated We appreciate that different countries use different terms For example a purchasing officer in one country may be a supplies manager in another some
368. tten organizational procedures in line with the strategies laid out in the policy which staff will follow on a daily basis The titles in this Series provide a straightforward and practical approach to healthcare technology management procedures Guide 1 covers the framework in which Healthcare Technology Management HTM can take place It also provides information on how to organize a network of HTM Teams throughout your health service provider organization Guides 2 to 5 are resource materials which will help health staff with the daily management of healthcare technology They cover the chain of activities involved in managing healthcare technology from planning and budgeting to procurement daily operation and safety and maintenance management Guide 6 looks at how to ensure your HTM Teams carry out their work in an economical way by giving advice on financial management How the Guides are coordinated is set out in Figure 2 1 1 Introduction to this series of guides Figure 2 The Relationship Between the Guides in This Series Framework structure Organizing a network of HTM Teams Guide 1 Chain of activities in the equipment life cycle Ensuring efficiency Financial management of HTM Teams Guide 6 Who are These Guides Aimed at These Guides are aimed at people who work for or assist health service provider organizations in developing countries Though targeted primarily at those w
369. uality health services Thus the justification for introducing an HTM Service is that it will benefit you economically and clinically by ensuring that healthcare technology continues to meet the standards required throughout its working lifetime The activities of an HTM Service belong to the service provision function of health systems However the government may wish to take a regulatory role and establish regulations that guarantee that HTM occurs To achieve this it will be necessary to have agovernment body to provide regulations that will ensure the continued performance and safety of healthcare technology throughout its life acontrol mechanism to check that all health service providers pursue these healthcare technology management activities effectively legal or other sanctions that are enforceable if the rules are infringed The government body responsible for providing regulations could be the central level of the national HTM Service Each health service provider could then develop its own HTM Service It should involve a network of teams and committees that enable HTM to be practised in all facilities In order to establish an effective HTM Service you will need to provide sufficient inputs such as finance staff workshops equipment and materials Only in this way will you get the outputs and benefits that you require For details of how to develop such an HTM Service see Guide 1 The organizational
370. uired to complete these tasks Available from Ziken International Consultants Ltd See Guide 1 for further resources on and examples of developing healthcare technology policy Regulating relationships with external support agencies that provide equipment Guidelines for health care equipment donations WHO 1997 WHO document WHO ARA 97 3 This document presents guidelines that aim to improve the quality of equipment donations not to hinder them They are not an international regulation but intended to serve as a basis for national or institutional guidelines to be reviewed adapted and implemented by governments and organizations dealing with health care equipment donations They provide detailed guidance and checklists for both the potential donor and recipient The guidelines are based on extensive field experience and consultations with many experts internationally They also merge together several earlier documents including the one listed below Available from WHO Guidelines on medical equipment donations Churches Action for Health 1994 World Council of Churches publication This paper is a guide for those accepting and making donations and is also useful for those planning to buy equipment It clearly lays out in point form the responsibilities of the recipient and the responsibilities of the donor Available from WCC 175 176 Annex 2 Reference materials and contacts Understanding healthcare technology ma
371. understand the issues involved 31 32 3 1 Accountability 3 1 ACCOUNTABILITY Users are the custodians of the equipment they operate It is their responsibility to ensure that equipment is in a good functional state at all times In other words that it is working giving reliable results being operated correctly and safely It is common for health service staff to feel that they do not own the equipment therefore it is not their responsibility and it must be somebody else s problem It will be necessary to introduce the following new ideas to all staff and incorporate such responsibilities into their job descriptions Collective responsibility for health service property Their new role of being accountable for equipment Their performance with regard to equipment being registered as part of their appraisals Section 8 2 Not only must users be responsible for the equipment in their care they must also be responsible for using consumables correctly For example placing the wrong type of overhead transparencies into photocopiers or printers will result in the plastic melting and the equipment being damaged It is inevitable that equipment will be lost or damaged from time to time Equipment security should be addressed seriously see Section 7 1 for guidelines Damaged equipment that has not been subjected to abuse should not be charged to the operator But your organization has to consider what action will
372. unities Aid workers and others unfamiliar with PHC and basic management techniques may also benefit Includes sections which will assist with staff motivation such as teamwork and team effectiveness managing oneself others and tasks and managing change as well as sections on planning and monitoring progress Available from TALC Medical administration for frontline doctors A practical guide to the management of district level hospitals in the public service or in the private sector 2 4 edition Pearson C 1990 FSG Communications Ltd Cambridge UK ISBN 1 871188 03 2 This book provides information for doctors who combine wide clinical responsibilities with administration and support for primary health care services It covers a wide range of topics with country examples including management structures infrastructure and maintenance buildings support services and equipment hospital supplies training outreach programmes and wider responsibilities in the district and above It includes advice on many safety topics such as cleaning procedures linen handling earthing lightning protection and fire prevention Available from TALC On being in charge A guide to management in primary health care 24 edition McMahon R Barton E and M Piot 1992 ISBN 9241544260 This practical guide aims to improve the managerial skills of middle level health workers The text is reinforced with practical examples questionnaires and illustratio
373. urage retention of staff in service develops the mechanisms for making staff accountable for the equipment they work with see Box 5 agrees the action to be taken by the Human Resource Department if persistent loss or abuse of equipment is discovered agrees incentives for good performance with the Human Resource Department Equipment Users and Section Heads Accountability Health Service Providers and Health Management Teams ensure they understand their responsibility for equipment and act in such a way as to protect it ensure they understand how accountability for equipment will affect them plan the location of equipment so that it can be used efficiently consider sharing resources between facilities see Guide 2 on planning and budgeting plan when to use equipment and how to link appointments and services for patients in order to use equipment efficiently when purchasing equipment choose products which make efficient use of resources such as consumables fuel finances and maintenance support see Guide 2 on planning and budgeting and Guide 3 on procurement and commissioning dp D _ Cc 2 O LL Equipment Users and Section Heads Health Management Teams Resources Health Service Provider use consumables efficiently without wastage plan when to use consumables so that once a pack is opened its contents do not go off develop a reference library see Box S to contain all resource materi
374. ure sterility not sterilize Do not try leaving instruments in the sun as this practice does not work End the practice of soaking dropped instruments for a period of time in chemical disinfectants liquids or creams This does not sterilize the instruments in fact if the chemicals are not renewed regularly they have proven to be a good culture medium Choose the right equipment in In small health facilities such as clinics the right place in order to establish e Use the simple pressure cooker type autoclave a sterile pack supply service or bench top autoclave for small volume and low quantity of unwrapped non porous non fabric items For porous or fabric items use the hot air sterilizer larger autoclave supply of sealed sterile products from a district source or learn a steam pulsing method for the pressure cooker type autoclave see Annex 2 In larger health facilities Only use bench top autoclaves where specialist small volume and low quantity unwrapped non porous non fabric items are involved such as in the dentist clinic or eye theatre Ensure all the remaining instruments and supplies are sterilized centrally in the large autoclaves in the Central Sterile Supplies Department CSSD to cover normal working needs and dropped items Ensure the CSSD supplies sterile packs to all relevant sections in the health facility as a whole the sooner this can be introduced the easier it will be to stop t
375. ure that stock management and expenditure accounting are carried out according to the regulations Box 4 contains a summary of the issues covered in this Section Section 2 summary BOX 4 Summary of Issues in Section 2 on Framework Requirements Government actively regulates health services whether they are delivered by public providers private providers or a mixture of the two develops checking systems and legal sanctions for infringement of health regulations adopts suitable standards for quality health services in general specifically for healthcare technology adopts standards for design development and manufacturing performance and safety use and training waste disposal develops donor regulations to ensure all equipment received through foreign aid and donations also complies with the standards establishes public or quasi public supervisory bodies to enforce regulations and standards Ministry of Health develops national policies for health services specifically develops a Healthcare Technology Policy to cover all healthcare technology management activities including a vision an element of standardization the provision of maintenance provision of finances for all HTM activities the organizational structure for an HTM Service regulates on these issues if required develops an HTM Service made up of a network of teams and working groups uses the central level of the HTMS as the national regulatory body
376. used even if it is in perfect working condition Disposable or Reusable Some accessories and consumables such as diathermy plates probes breathing circuits electrodes and filters are available as disposable and as reusable products and you may need to decide which type to buy Both types have advantages and disadvantages in terms of convenience and cost as shown in Box 45 114 6 1 General discussion on accessories and consumables BOX 45 Advantages and Disadvantages of Disposables and Reusables Disposables are items designed for single use reduce the risk of cross infection are more convenient to use than reusables should only be used once and should not be reused cost more than reusables since they need to be replaced more often and must be bought in bulk regularly require you to have a regular and reliable recurrent budget require a regular and reliable supply of replacements from a reputable source are not designed to be sterilized Reusables are designed to be used more than once should only be reused after proper cleaning and sterilization and or disinfection are cheaper to buy but you will have the additional cost of sterilizing them require you to have the necessary equipment required for sterilization put staff and patients at risk of diseases such as hepatitis B and HIV if the items are not properly sterilized between uses may be more reliable if supply problems are likely for disposables can be kept
377. v listserv paho org Enter in text subscribe infratech your full name International health exchange website www ihe org uk Provides training information and advice to health workers in emergency aid and development situations This site also provides information about jobs and health development issues Annex 2 Reference materials and contacts Joint Commission on Accreditation of Healthcare Organizations JCAHO website www jcaho org This American body has published new patient safety standards that cut across disciplinary boundaries in an attempt to make safety a fundamental principle of patient care These standards cover infection control the environment of care and other disciplines KAR Knowledge and research programme on disability and healthcare technology website www kar dht org and for the latest projects being funded use website www disabilitykar net This is the Knowledge and Research Programme on disability and healthcare technology of the UK government s Department for International Development DFID It supports a range of projects on development and use of appropriate disability and healthcare technologies in developing countries The website also provides links to i Disability and healthcare technology newsletter produced every six months describing the progress and findings of the projects funded ii KaR global database on healthcare technology publications organizations manufacturers training i
378. ver the Guide also explains what the responsibilities are at all levels of the system to help you to see the bigger picture What Topics are Covered The Guide outlines a number of practical steps for equipment operation safety care of equipment disposal of equipment supplies management These will help you to use and look after your equipment without coming to harm and to continue to deliver health services to patients 1 2 Introduction to this specific guide The system introduced in this Guide provides a solid approach to managing equipment operation and safety However we recognize that there are other ways of organizing these issues which may be more appropriate for your administrative system The important thing is to implement a well functioning system As you read through the recommendations in this Guide you may find it useful to refer to advice in other Guides in the Series as indicated in the text Additional useful reference materials and contacts are given in Annex 2 How is This Guide Structured The structure of Guide 4 highlights the different activities which you must manage in order to achieve safe and correct use of equipment as shown in Figure 3 mu Q i o ie gt o W a c O r o e h Q a o A Section 1 Introducing the Series and this particular Guide Understanding the central framework for HTM and PEENE
379. way that there is a physical barrier between the dirty and clean linen areas If not there must be sufficient physical separation between e the routes used by dirty laundry and clean linen trolleys the trolleys designated and labelled for use with dirty or clean linen the storage locations for clean linen and piles of dirty or condemned linen If your linen is transported for many miles to reach the nearest laundry or it is laundered by a private contractor great care must be taken to address all hygiene and infection control risks so that you protect members of the public from your infectious agents 5 3 3 Ensuring the Workplace is Clean It is necessary to have procedures that ensure you keep the workplace clean in order to maintain general levels of hygiene Many of the issues involved are dependent on the correct use and care of equipment such as cleaning the health facility in general 6 hygiene practices in the kitchen controlling infestations by vermin guaranteeing a safe water supply general waste and sewage management this will be discussed in Section 5 4 To guarantee the general cleanliness of the health facility the HTM Working Groups or infection control committees need to develop and implement good infection control practices for these areas Cleaning the Health Facility in General The regular cleaning of rooms service installations fixed equipment furniture etc 1s
380. wer concrete 20 Heating ventilating and air conditioning Wood 10 composite system 15 Duct work 20 Heat pump system 10 Fan air handling and ventilating 20 Humidifier 15 yir al 20 Incinerator indoor 10 Piping 20 aan i E Precipitator 10 Da PIBE Pump 10 Intercom system 10 Air conditioning system Laboratory plumbing piping 20 Large over 20 tons 10 Magnetic door holders 10 Medium 5 20 tons 10 Medical gas system composite system 15 Small under 5 tons 5 Nurse call system 10 Air curtain 15 Oil storage tank 20 Antenna system 10 Oxygen gas and air piping 20 Boiler 20 Paging system 20 Deaerator system 15 Physicians in and out register built in 10 Boiler smokestack metal 20 Plumbing composite 20 Clean air equipment 15 Fixtures 20 Piping 25 Clock system central 15 Pump 15 Co generation plant generator powered 15 Pneumatic tube system 15 Door alarm 10 Radi tot Door closing devices for fire alarm system 15 Cast iron 25 Electric lighting and power Finned tube 15 Composite 18 Sewerage composite 25 Conduit and wiring 20 Piping l 20 Emergency lighting system 15 Sump pump and sewerage ejector 10 Feed wiring 20 Solar heating equipment 10 Fixtures 10 Surge suppression system 15 Switch gear 15 Telephone system 10 Tameiomae 3 Television antenna system 10 Elevator Television satellite dish 10 Dumbwaiter 20 Temperature controls computerised 10 Freight 20 Passenger high speed automatic 20 Unit heater 10 Passenger other 20 Vacuum c
381. while they waited 95 96 5 5 2 Electricity BOX 34 Common Problems With Electrical Installations Poor or no earthing arrangement Earthing is by far the most important factor determining safety of equipment and installations No earth is provided at all Ineffectual attempts are made to provide an earth and the impedance is much too high gt 0 3 Ohms because tiny earth wires are used the earth wire is broken the earth rod is too short the earth rod is only buried shallowly Poor circuit design with little or no attention paid to circuit loading and cable sizing Many installations are fed from already overloaded supplies and are subject to large voltage drops indicated by dimming of the lights Undersized cables are used and if the supply voltage is low equipment stops functioning The circuit loading between the three phases is not balanced and this causes voltage and frequency fluctuations Unsatisfactory cable joints Proper connectors that give a mechanically and electrically sound connection are not used Bare metal is left exposed People erroneously simply twist cables together to join them even main overhead incoming supply line conductors up to 25mm sq Poor workmanship Colour coding of cables for different parts of the circuit is ignored Sharp metal edges are left on the cut outs in distribution boards which cables can catch on Single insulated cables are run ex
382. will encourage a sense of ownership of the Service and its responsibilities and will lead to greater acceptance and motivation among staff If you are short of skilled staff such as technicians managers planners or policy makers you may need to obtain specialist support to assist with some of these tasks BACKGROUND CONDITIONS SPECIFIC TO THIS GUIDE Your country and health service provider may have existing regulating principles and conditions which will affect or can inform aspects of your operation and safe use of equipment You will need to see if the regulations and policies discussed in this Section exist in your country organization If they do then follow them If not you will need to flag these issues at the central level of your organization and continue to follow the advice provided in this Guide at your level Responsible Management Authorities If you work for a health service provider organization you will need to conform to any regulations and guidelines concerning equipment operation and safety produced by the central management body In addition there may be professional bodies which provide guidance for their area of expertise Section 4 For example Bodies such as the Medical Council and General Nursing Council which have guidelines on clinical practices The National Laboratory which provides guidance on laboratory practices The National Board of Survey which has regulations and procedures on the c
383. with a small opening and a screw g i otherwise commercial products are available use an encapsulated mechanical destruction device that destroys the needle only This should be designed to have a sealed collection compartment which ensures any aerosol of contaminated fluids created is not exposed to the air The syringes should be collected like all other infectious waste Implement an Use incineration or burning for all sharps containers and for the sealed effective and safe collection compartments of the mechanical destruction devices system of disposing of sharps containers Source WHO 2003 Safe Injection Global Network SIGN website 5 4 2 Managing different types of waste One method of waste treatment is burning incineration Open burning by adding petrol diesel or oil to a heap of waste in a pit or in the open should be avoided By this method combustion is often incomplete leading to scavenging the residue may still be infectious and the air pollution due to emission of particles and bad smells are unacceptable A better method is to use an incinerator There are specific safety issues relating to these pieces of equipment Many health facilities in developing countries cannot afford the expensive investment and subsequent running costs of the sophisticated incinerators used in modern hospitals in industrialized countries which meet all hygiene and environmental protection requirements However there
384. working environment otherwise petty tyranny may prevail The most important thing 1s for staff to be in an environment where their managers are present involved expect the correct results and are seen to perform well themselves 3 2 3 2 General good behaviour towards equipment Box 5 provides some strategies for making staff more accountable by clearly setting out their responsibilities towards equipment GENERAL GOOD BEHAVIOUR TOWARDS EQUIPMENT It is very important to instil in health staff good practice concerning their interaction with equipment Some staff will intuitively know how to treat equipment others will need to be guided and taught Some staff may not have regularly come into contact with equipment before starting their job in the health service This Section looks at the general behaviour of staff in relation to any type of equipment The approach should be to teach staff using demonstrations to remember the basic motto and strategy of Safety Care Maintenance they need to understand the basic dos and don ts when dealing with equipment A list of dos and don ts is often given in the equipment manufacturer s literature Staff should also have written resources from their training sessions and in some cases posters which display the guidance and experience of their colleagues on good behaviour towards equipment Section 3 5 Copies of this advice should be made available in the library for reference Sec

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