Modeled on Kit-N (Equipment for Neonatal Resuscitation ... · PDF fileAnnexure VII Neonatal Resuscitation Kit Modeled on Kit-N (Equipment for Neonatal Resuscitation) recommended by

Annexure VII

Neonatal Resuscitation Kit

Modeled on Kit-N (Equipment for Neonatal Resuscitation) recommended by Government of India as part of its CSSM programme.

Contents of Neonatal Resuscitation Kit

Item Quantity 1. Container box, hard-case type, with handle 1 2. Mucus sucker, plastic, disposable, capacity 20 mL 2

3. Laryngoscope, infant, with 3 blades 1 (3 blades)

4. Batteries for laryngoscope 2

5. Spare bulb for laryngoscope 1

6. Ventilatory (Ambu) bag, pediatric type 1

7. Face mask, transparent, with self-sealing rim, infant size 1

8. Endotracheal tube, neonatal 2

9. Stilette for endotracheal tube insertion 1

10. Catheter, nasal, rubber, open tip, funnel end, size 8F 2

11. Catheter, suction, rubber, size 8F 2

Laryngoscope should be checked periodically and the batteries replaced if required.

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Annexure VIII

Mercury containment kit

Mercury is a toxic metal and presents an acute health hazard. Every health facility must provide ready access to a mercury containment kit to deal with mercury spillages from healthcare equipment. The kit outlined below is intended to handle small spillages, such as from a broken thermometer or sphygmomanometer. Kits to deal with larger scale spillages will require additional personal protection equipment like face mask, goggles and gum boots.

Contents of basic Mercury Containment Kit

Item Quantity1. Container box, plastic hard case type, approx. 220 mm X 150 mm X 60 mm 1

2. Examination gloves, polythene, medium size 2 pairs

3. Boards for coalescing mercury globules, plastic, postcard size 2

4. Syringe, plastic, disposable, 2 mL 1

5. Syringe, plastic, disposable, 5 mL 2

6. Bottle with tightly fitting screw-cap, glass, capacity 15 mL 27. Pouch, polythene, self-sealing type, 150 mm X 100 mm, 80 micron thick 1

Annexure-IX WHO guidelines for prescription audit

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Annexure – X

Questionnaire on Prescriptions

The monitors will be expected to collect and carry with them at least 10 samples of prescriptions from the

clients during the exit interview. These will be audited at the state level. However the assessors will also

examine some of the prescriptions and look into the following aspects and allot score against each query in

Form A: “Providers’ availability and practices”. If they see any deviation from what is desirable, they will

brief the medical officer so that he/she takes corrective actions. This process will help the facility score

better marks during subsequent visits.

Suggested questions on prescriptions:

01. Information on patient identification avalable?

02. Are chief complaints and duration written?

03. Does the prescription have diagnosis/provisional diagnosis?

04. Are drugs prescribed in generic names?

05. Are the drugs from the eligible Essential Drug List (EDL)? Prepared based on STG, Referral Manual

and ESP supplied to them during the training on the use of STG. Attached in Operational Manual.

06. Are medicines prescribed outside the EDL, if so, is the ground for doing so is justified according to the

assessor?

07. Does the prescription have the doctor’s name and signature (stamp)?

08. Are the medicines written in capital letters/legibly?

09. Are investigations, if applicable, advised?

10. Are abbreviations OD/BD/TDS/AC/PC etc avoided?

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Annexure XI

IUD Insertion Kit

Modeled on Kit-G (IUD Insertion Kit) recommended by Government of India as part of its CSSM programme.

Contents of IUD Insertion Kit

Item Quantity 1. Tray, with lid and recessed cross-bar handle, size 300 X 220

X 70 mm 1

2. Lotion / Sponge bowl, capacity approximately 600 mL 1 3. Vaginal speculum, double-bladed (Sims’), size #3 1 4. Vaginal speculum, bivalve (Cusco’s), size medium 1 5. Sponge holding forceps, straight, multiple ratchet, box lock,

size 200 mm 2

6. Tissue forceps (Allis), size 200 mm 1 7. Uterine sound, graduated (Simpson’s), size 300 mm,

graduated in 20 mm 1

8. Surgical scissors, straight, blunt point, size 150 mm 1 9. Gloves (surgical), sterile, size 6½ 1 pair10. Gloves (surgical), sterile, size 7 1 pair11. Gauze swab, sterile, size approximately 76 mm X 76 mm Packet of 612. Recommended Intrauterine Contraceptive Device with

applicator 1

Tray and all instruments should be of high quality stainless steel.

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Annexure XII

Suturing kit

Contents of Suturing Kit

Item Quantity 1. Tray, with lid and recessed cross-bar handle, size 250 X 200

X 70 mm 1

2. Lotion / Sponge bowl, capacity approximately 500 mL 1 3. Sponge holding forceps, straight, multiple ratchet, box lock, size 200 mm 1

4. Dressing scissors, straight, blunt points, size 150 mm 1 5. Dressing scissors, curved, blunt points, size 175 mm 1 6. Dissecting forceps, plain, size 200 mm 1 7. Dissecting forceps, plain, fine, size 150 mm 1 8. Needle-holder, straight, narrow jaw (Mayo-Hegar), 130 mm 1 9. Needle, suture, straight, cutting, 73 mm 610. Needle, suture, curved, 3/8 circle, cutting, No. 12 611. Suture materials (e.g. 1 reel of black braided silk) As required12. Gloves (surgical), sterile, size 6½ 3 pairs13. Gloves (surgical), sterile, size 7 3 pairs14. Gauze swab, sterile, size approximately 76 mm X 76 mm Packet of 615. Cotton wool, sterile, 25 g packet 616. Roller bandage, 10 cm wide 4 rolls17. Roller bandage, 15 cm wide 2 rolls18. Adhesive tape, 10 cm wide 1 roll

Tray and all instruments should be of high quality stainless steel. For suture removal, 1 Bandage cutting scissors, angled (Lister’s) size 175 mm, 1 Stitch cutting scissors (Heath’s) size 175 mm and 1 Dissecting forceps, plain size 150 mm may be maintained in a separate non-sterile tray.

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Annexure XIII Guideline to Standard Surgical Set

Abdominal operations require about 40 common instruments plus instruments specific to the type of surgery being conducted. In a primary healthcare facility equipped with an OT such a common set of instruments may be collected and called a Standard Surgical Set. For a specific operation, the common set can be expanded in one of three ways: By maintaining special instruments in an instrument locker, and sterilizing them when needed. Making incomplete special sets of the specific instruments and adding them to the standard set when necessary. Making complete special sets. This is the most convenient method, but it requires many more instruments,

particularly hemostats.

An occasional emergency operation can be done with only one standard set, but if there is a list of patients to operate on, multiple standard sets will be required if the waiting time between operations is to be reasonable. Sterilization of instruments by boiling will take at least 30 minutes turnaround time, and the same by autoclaving will require at least 45 minutes. Therefore, if instruments are limited, it is a good idea to start by collecting two standard sets adapted for laparotomy and cesarean section. Once these are in place, additional sets like a second cesarean set, vasectomy set, tubal ligation set, tracheostomy set, and minor sets for procedures like abscess drainage and circumcisions, may be built up. A cesarean section is a special kind of laparotomy and a set for it differs from a laparotomy set mainly in that it includes Green-Armytage forceps and Doyen's retractor. The latter is specially designed for pelvic operations and replaces a general abdominal wall retractor. If the facility does many uterine evacuations, two or more sets for D&E would be useful.

It is important to remember that it is pointless to try to build up surgical sets without adequate disinfection and sterilization arrangements. Hence, a facility acquiring surgical instruments must also acquire electrically operated instrument sterilizers or autoclaves and adequate supporting equipment like sterilizable instrument trays, aerosol disinfectors, dressing drums, catheter trays and instrument lockers. In addition it must set up a clear protocol, outlining designated personnel, procedures and timeframes for storing, sterilizing, utilizing and maintaining the equipment and carrying out OT room disinfection procedures.

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Annexure XIVContents of Standard Surgical Set for laparotomy

Item Quantity1. Tray, with lid and recessed cross-bar handle, size 400 mm X 250

mm X 70 mm 2

2. Towel forceps (Backhaus), size 125 mm (can also hold sucker tube) 1

3. Towel clips, cross-action type 64. Kidney dish, capacity medium 15. Lotion / sponge bowl, capacity small and medium 26. Gallipot, with cap, 500 mL 27. Sponge holding forceps, straight, multiple ratchet, box lock, size

250 mm 6

8. Scalpel handle, No. 3 19. Scalpel handle, No. 4 110.Scalpel blade, No. 11 511.Scalpel blade, No. 15 512.Scalpel blade, No. 22 513.Dissecting forceps, plain, size 180 mm 114.Dissecting forceps, toothed, size 180 mm 115.Dissecting scissors (Mayo or Metzenbaum), straight, size 165 mm 116.Dissecting scissors (Mayo or Metzenbaum), straight, size 215 mm 117.Dissecting scissors (Mayo or Metzenbaum), curved, size 165 mm 118.Dissecting scissors (Mayo or Metzenbaum), curved, size 215 mm 119.Tissue forceps (Allis’), 4 X 5 teeth, size 150 mm 220.Tissue forceps (Babcock’s), 4 X 5 teeth, size 200 mm 221.Artery forceps (Spencer-Wells), straight, 150 mm 622.Artery forceps (Spencer-Wells), curved, 200 mm 623.Artery forceps (Kocher’s), straight, 140 mm 224.Mosquito forceps (Halstead’s), straight, 125 mm 625.Mosquito forceps (Halstead’s), curved, 125 mm 626.Needle-holder, straight, narrow jaw (Mayo-Hegar), 130 mm 127.Needle-holder, straight, narrow jaw (Mayo-Hegar), 175 mm 128.Needle, suture, straight, cutting, 73 mm 629.Needle, suture, curved, 3/8 circle, cutting, No. 12 630.Needle, suture, curved, 3/8 circle, round bodied, No. 12 631.Needle, suture, curved 1/2 circle, round bodied, No. 6 632. Retractor (Langenbeck), blade size 90 mm X 25 mm 133. Retractor (Langenbeck), blade size 75 mm X 25 mm 134. Retractor (Morris’s) blade size 50 mm 135. Retractor (Morris’s) blade size 75 mm 136. Retractor, abdominal, self-retaining type (e.g. Kirschner’s frame with set of 4 blades) 137.Suction nozzle (Yankauer), 280 mm with Suction tube 23F, 225

mm 1 set


This standard laparotomy set can be readily converted to a Caesar set by addition of 6 Green Armytage forceps, 1 Doyen’s retractor and 1 Tenaculum forceps (Schroeder or Braun).

Annexure XV

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Dilatation and Evacuation Instrument SetModeled on Kit-L (Standard Surgical Set VI) recommended by Government of India as part of its CSSM programme.

Contents of D&E Instrument SetItem Quantity1. Tray, with lid and recessed cross-bar handle, size 300 X 250 X

70 mm 1

2. Lotion / Sponge bowl, size small 100 mm dia 13. Towel clips, cross action type 44. Sponge holding forceps, straight, multiple ratchet, box lock,

size 200 mm 4

5. Artery forceps (Spencer-Well’s), size 140 mm 26. Dissecting forceps, toothed, size 180 mm 17. Dissecting scissors (Mayo or Metzenbaum), straight, size 165

mm 1

8. Ovum forceps (McClintock), curved, size 290 mm 19. Tissue forceps (Allis), size 160 mm 210.Uterine curette, blunt (Sims’ blunt), size 260 mm X 11 mm

(No. 4) 2

11.Uterine curette, sharp (Sims’ sharp), size 260 mm X 9 mm (No. 3) 2

12.Uterine dilator (Hegar’s), length 220 mm, double-ended, set of 8 sizes 8 (set)

13.Uterine sound, graduated (Simpson’s), size 300 mm, graduated in 2 cm 1

14.Vaginal speculum, self-retaining (Graves’), size medium 115.Vaginal speculum, double-bladed (Sims’), sizes small,

medium, large3

(different sizes)

16.Vulsellum forceps, curved, multiple teeth, size 230 mm 1


Annexure XVI

No Scalpel Vasectomy Instrument Set8

Procedure reference: Li S, Goldstein M, Zhu J, Huber D. The no scalpel vasectomy. Journal of Urology 1991; 145: 341-4.

Contents of No Scalpel Vasectomy (NSV) Instrument Set

Item Quantity 1. Tray, with lid and recessed cross-bar handle, size 10” X 8” X 3” 1

2. Lotion / Sponge bowl, small, 4” dia 1 3. NSV ring clamp, 5½”, 3.5 mm ID 1 4. NSV hemostat, sharp point, smooth jaws, curved, 5½” 1 5. Scissor, dissecting, straight, sharp point, 5½” 1


Annexure XVIITrained Birth Attendant Kit

A large number of deliveries in India, particularly in the rural areas, continue to be domiciliary events rather than institutional deliveries. Deliveries at home have traditionally been attended by women who have ritualistically performed the duties of 'dais' or birth attendants. The Reproductive and Child Health Programme currently in operation in our country lays due emphasis on simple yet evidence based interventions to make the goal of safe motherhood a reality. One of the measures advocated is training of these dais to make them trained birth attendants (TBA) and equip them with simple provisions to enable a safe delivery at home when no complications are anticipated. The TBA kit will help in ensuring the '5 cleans' during delivery – clean hands, clean surface, clean cut, clean cord tie and clean stump.

Contents of Trained Birth Attendant Kit

Item Quantity

1. Container box, plastic hard-case type, preferably with handle 1

2. Disinfectant soap (e.g. Chloroxylenol soap) 1 cake

3. Plastic sheet (size approximately 5' X 3') 1

4. Surgical gloves (disposable, size 7) 1 pair

5. Scalpel blade (sterile, No. 10) 1

6. Thread (strong twine) 1

7. Umbilical cord clamp (disposable)* 1

8. Cotton wool, sterile – 25 g pack 1

9. Cotton wool, non-sterile – 100 g pack 1

10. Sterile gauze packet (6 pcs) 1

11. Towel for wrapping newborn (soft, hand towel size) 1

12. Mucus sucker for newborn (disposable)* 1

The items marked with an asterisk are optional.

Current practice does not require application of any disinfectant to the umbilical cord stump.

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An enamel or stainless steel tray with lid, size about 30 cm X 15 cm, can substitute for the carry case if the kit need not be carried over a distance.

Annexure XVIII

LABORATORY REAGENT LIST - PATHOLOGY

Annexure XIX

Sl. No.

Pathological Tests

Reagent Required

Instrument Required

PHC(OPD only)

BPHC/PHC(Bedded)

RH

1. Hemoglobin Estimation

DRABKIN’S SOLUTION

COLORIMETER DO DO DO

2. Total Leukocyte Count & Differential Count

WBC Dilution fluidLeishman StainEDTA Vial

Microscope Glass Slides.Neubauer Hemocytometer

DO DO DO

3. Malaria Parasite

Leishman Stain Glass Slides. DO DO DO

4. Estimation of ESR

3.8% Sodium Citrate

Westergreen Pipette DO DO DO

5. Blood Grouping & Rh-Typing

Anti-A, Anti-B, Anti-D, Monoctonal 1gM antibody

Glass Slides.Testube – 75x10mm

DO DO DO

6. Routine examination of Urine

Benedict’s SolutionAcetic Acid

Centrifuge Machine.Testubes.

DO DO DO

7. Routine examination of Stool

Lugol’s Iodine.Normal Saline

Microscope.Glass Slides.Cover Slips

DO DO DO

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LABORATORY REAGENT LIST - MICROBIOLOGY

Sl. No.

Microbiological Tests

Reagent Required

Instrument Required

PHC(OPD only)

BPHC/PHC(Bedded)

RH

1. Malaria –-Blood Test-Dual Antigen

Leishman Stain.Kit

DO DO DO

2. Dengue Spot Kit DO DO DO

3. AFB Smear Carbol Fuschin20% H2SO4

Methylene blue

Microscope DO DO DO

4. Slit Skin Smear – For AFB

5% H2SO4 DO DO DO

5. Stool for OPC & OBT

Lugol’s Iodine.Spot Kit

DO DO DO DO

6. Urine for Pus Cell

Centrifuge DO DO DO

7. Smear for microfilouia

Leishman Stain Microscope DO DO DO

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Annexure XX

LABORATORY REAGENT LIST - BIOCHEMISTRYSl. No.

Group of Drugs

PHC(OPD ) only

BPHC/PHC(Bedded) RH

1. Laboratory Reagents

N/10 HCL, 3.8% Sodium Citrate, WBC Diluting Fluid, Leishman’s Stain, Distilled Water, EDTA, JSB-I&II (for Hb, TC, DC, ESR and Malarial Parasite).

Conc. Carbol Fuschin, Conc. (20%) Sulphuric Acid, Methylene Blue (for Sputum for AFB).

Benedict’s Solution, Glacial Acetic Acid (1%, 5%), Sulphur Powder, 10% Barium Chloride, Fouchet’s Reagent (for Urine for RE/ME).

Normal Saline, Lugol’s Iodine/Gram’s Iodine, Benzidine Powder, Hydrogen Peroxide (Stool for OPC and Occult Blood Test).

Reagent Kits :• Blood Sugar,• Blood Urea,• Pregnancy Test Kit,

Blood Grouping Reagents :• Anti-A,• Anti-B,• Anti-D.





Reagent Kits :• Blood Sugar,• Blood Urea,• Serum Creatinine,• Serum Uric Acid,• Serum Bilirubin,• Serum Total Protein,• Pregnancy Test Kit,• VDRL Test Kit.






Reagent Kits :• Blood Sugar,• Blood Urea,• Serum Creatinine,• Serum Uric Acid,• Serum Bilirubin,• Serum Total Protein,• Pregnancy Test Kit,• VDRL Test Kit.


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Annexure-XXI

Cleaning and infection control in primary healthcare facilities

Infection control is an important aspect of healthcare. A large number of pathogenic organisms can be found in any healthcare setting and they may get transmitted from one individual to another through person-to-person contact, airborne, food-water, or vector based transmission, or through contact with instruments, equipment or surfaces contaminated with blood or body fluids. Fortunately, recognizing the channels of transmission and taking routine preventive measures can greatly reduce the burden of infection. The following should be universally known and implemented in primary healthcare settings.

General cleaning and disinfection

Regular cleaning and maintenance is not only aesthetically pleasing but improves safety and reduces the risk of infection in healthcare settings. Cleaning is the removal of waste and foreign matter and generally reduces 90% of the environmental microbial load. Most of the remainder can be tackled by regular disinfection procedures. Although disinfection kills pathogenic microorganisms and mild disinfectants (e.g. phenolic disinfectants and detergents) may be used during cleaning, disinfection is not a substitute for cleaning. In fact, attempting disinfection without prior cleaning is generally ineffective because dirt and organic matter may prevent adequate action of the disinfectant. Large surfaces like floor and walls should be regularly cleaned but are usually only disinfected during gastroenteritis outbreaks. However, critical areas like OT rooms and tables need periodic disinfection as well.

Dusters and brooms should not be used much in healthcare facilities because they disperse dust. Wet mopping and swabbing are recommended. In wet mopping, disposable cloth is preferred to reusable cloth. Disposable swabs or wipes should routinely be used for cleaning clinical areas like trolleys, examination couches and patient beds.

Ceilings, walls, floors, doors, windows and toilets should be kept in good condition. First attend to any repairs that contribute to safety such as peeling plaster, frayed electrical wires, lifting tiles, splintering wooden furniture, broken plumbing fixtures, etc. Sinks, drains and other water outlets should not remain blocked. Cleaners should, daily, mop floors, wet wipe surfaces/handles, clean toilets and dispose garbage. Surfaces should be kept dry to avoid biofilm developing. These are slimy films of organic material that bacteria can grow in. Daily emptying of bottles and tanks can also avoid biofilms. However, cleaners should not be made to handle clinical waste or clean instruments and equipment unless trained and given appropriate materials.

During cleaning, adequate attention should be paid to easily missed areas like window sills, almirah tops, OT lamps, etc. For cleaning surfaces in contact with bare skin (e.g. trolleys, examination couches, door handles) use paper towels and detergents. If there is visible blood, wipe that first, allow to dry. Apply a disinfectant for 10 minutes then wipe off. Then clean whole surface with new wipe. For surfaces in clinical areas not likely to be in contact with bare skin (e.g. chairs, benches, sinks, etc.) damp mop using paper or cloth towels and use detergents periodically. If there is visible blood, wipe off, allow to dry and clean using a new wipe.

For cleaning areas or items that may be heavily infected (e.g. patient toilets, spittoons, waste bins), cleaners should use disinfectants and adequate personal protection gear such as gloves, masks, plastic aprons, and gum boots.

Linen (bedsheets, pillow cases, blanket covers), blankets and curtains are rarely implicated in the spread of infection but scabies mite, lice, and Hepatitis B virus in blood spots are of concern. Linen should be aesthetically pleasing so reject linen that is marked, torn or patched. It should be changed regularly to avoid accumulated odor and always after soiling. During washing linen should be soaked in hot water for at least 10 minutes. Soiled wet linen should be placed in leak proof plastic bags for transport to laundry. If a spill seeps through to the bed then remove the linen and clean the bed with detergent. Blankets should be dry cleaned at regular intervals.

When using a disinfectant, attention to the following is essential:• Suitability of surface material for a particular disinfectant (e.g. alcohol affects plastic/vinyl surfaces) should be considered. Also

the disinfectant should not be left in prolonged contact with the surface, since no further action will occur and continued exposure to chemicals may damage surfaces.

• Removal of organic matter first by general cleaning.

• Correct concentration and contact time.

• After disinfection, removal of all disinfectant from the surface concerned by adequate wiping to prevent subsequent contact with skin.

Handling blood and body fluid spillsAll blood and body fluid (e.g. vomit) spills should be treated as contaminated and capable of transmitting blood borne viral infections:• Small volume spills: Clean a blood spot by wearing gloves and applying a detergent wipe to remove spot and allow to dry.

Small spills may safely be absorbed onto paper towels after wearing gloves. Then apply a disinfectant or detergent wipe until the site is visibly clean and finally dry with fresh paper towel.

• Large volume spills: Cordon off the area. Wear gloves, and if necessary, masks, aprons and boots. If there are glass shards (e.g. from a broken test tube), remove these first by forceps and dispose them into sharps disposal containers. Pour

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disinfectant or detergent fluid over the spill and leave for a contact time of 20-30 minutes. Then wet mop with disposable cloth or paper towels. Dispose these towels and mops in appropriate bins.

It is to be noted that hospital grade bleach (sodium hypochlorite) is an effective disinfectant but is a strong oxidizing agent and reacts with many substances it contacts to form potentially harmful compounds. Metal items may be pitted and fabric can be damaged by chlorine releasing compounds. Care is required to avoid contact with skin and inhalation should be minimized. It should therefore not be used for routine cleaning but reserved for large volume spills and use during gastroenteritis outbreaks.

Staff immunization

Healthcare workers have to come in close contact with patients, articles used by patients and blood and other body fluids. Staff who work with sharps may be at increased risk of blood borne viral infections. Some infections are vaccine preventable. Therefore, they should be adequately immunized against infections like tetanus, typhoid, tuberculosis and Hepatitis B at commencement of work.

Staff should keep their own immunization records and the health facility should maintain a record for immunizations and testing done while staff work there.

While the focus for immunization should be on direct healthcare providers at risk, it should also be considered for laboratory staff who handle clinical samples and contract cleaners involved in waste disposal.

Handwashing

This is one of the single most productive steps in infection control. Hands should be washed under running water using a disinfectant – preference should be for a specially formulated hand disinfectant, liquid soap, disinfectant containing bar soap and ordinary bath soap, in that order. Wet the hands before applying the disinfectant. Avoid combining soap with a disinfectant as this may inactivate the latter. Cover any break in the skin with a water resistant dressing before washing and retain that dressing while dealing with patients.

Washing should involve rubbing all areas of the hands, including finger tips and webs. The following six steps should be followed. A right hander has tendency to spend more time washing the left hand and vice versa. However, both hands must be consciously washed equally.

1) Palm to palm 2) Palm to palm with fingers interlaced

3) Palm over dorusm with fingers interlaced 4) Cupping palms together

5) Rotating thumb within palm of other hand 6) Rubbing tips of bunched fingers against palm

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Nails should be kept short to facilitate handwashing. Watches, rings and jewelry should be removed prior to washing. Rinse hands well under running water to remove traces of soap or disinfectant. Avoid touching the tap or basin after washing. When handwashing prior to surgery, hold hands higher than elbows during rinsing to prevent contamination by run-off from forearms.

Dry hands thoroughly by patting (rather than rubbing). Use paper napkins or clean cloth towels. Sterile towels or hand dryers may be used prior to surgery.

Use of alcohol handrubs as alternative to handwashingAlcohol based handrubs can be used where sinks and running water are not conveniently located or when patients have to be attended to in rapid succession. They may also be used before repetitive minor procedures such as intramuscular injections or venepuncture for blood sampling. Alcohol has the advantage that it acts rapidly against most microorganisms but evaporates quickly without residual effect. Alcohol handrubs should incorporate an emollient to reduce drying and damage to skin. A sufficient volume should be used so that the hands are still wet at 10 sec following application. With alcohol handrubs, note the following: Alcohol is inactivated by organic matter so hands must be visibly clean before use. Ensure hands are dry before recommencing activity to reduce defects in gloves and flammability. Alcohol is not placed near sink because water is not required and incorrect use may result. Alcohol and powder from gloves can interact so avoid contact by ensuring hands are dry first. Alcohol handrubs are not recommended during gastroenteritis outbreaks – handwashing is required.

Gloves use

Handwashing combined with gloves use greatly reduces the opportunity for microbes to spread from person-to-person during sterile procedures. Gloves should also be worn, as a personal protection measure, during any procedure that entails contact with body parts, articles or surfaces potentially contaminated with pathogens, particularly blood borne viruses. Therefore all healthcare providers must be aware of the importance and techniques of gloves use.

The following are general rules of gloves use• Gloves are to be worn during surgery and other sterile procedures. They are also to be used during genital examination and

when contact with sharps, non-intact body parts and other potentially contaminated articles and surfaces is anticipated. Only sterile gloves are to be used during sterile procedures. Sterile surgical gloves are made of latex. If there is a latex allergy then use nitrile gloves.

• Make sure that gloves are of good quality and so unlikely to tear or puncture easily during use. Double gloving may be appropriate in some circumstances, like orthopedic surgery.

• Handwashing is must before gloves use.• Hands are also to be washed after glove use since bacteria may proliferate in pooling sweat, and to remove traces of latex and

powder. Also tiny holes or tears may have contaminated hands with blood and other fluids.• Wear gloves of appropriate size as ill fitting gloves are more liable to tear or get punctured during use.• Change gloves in between procedures and patients. If they are used for more than one task or patient, they themselves can

become a source of contamination.

Wearing sterile gloves

Sterile gloves come packaged pre-cuffed (the wrist part of the glove turned inside-out). When putting on sterile gloves, remember that the first glove should be picked up by the cuff only and put on the non-dominant hand. The second glove is for the dominant hand should then be touched only by the other sterile glove. The following are the steps in putting on sterile gloves:

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1. Open the outer package of sterile gloves on a dry clean surface. Then wash your hands before opening the inner wrapper, exposing the cuffed gloves with the palms up. Place them in appropriate left-right position. Alternatively, request somebody else to open the package of gloves for you.

2. Pick up the glove for the non-dominant hand by the cuff, touching only the inside portion (that intended for contact with skin) of the cuff by the dominant hand.

3. Point the fingers of the glove toward the floor to keep them open nut be careful not to touch anything and to hold the gloves above waist level. Slip in the left hand. Do not attempt to reposition the fingers of the glove if not correctly placed (e.g. two fingers in the same slot), you can readjust the fit when both gloves are on

4. Pick up the second glove by sliding the fingers of the gloved hand under the cuff of the second glove. Be careful not to contaminate the gloved hand with the ungloved hand as the second glove is being put on.

5. Put the second glove on the ungloved hand by maintaining a steady pull through the cuff.

Finally adjust the fingers so that both gloves fit comfortably. If you are wearing long-sleeved aprons, carefully turn the cuffs back on the sleeves. If gloves are being put on for surgery or other sterile procedures, nothing must be touched with the gloved hands before the procedure begins. This is difficult in practice. Therefore keeping the gloved hands interlocked till the procedure begins is a good idea.

Removing gloves after useRemove used gloves before touching anything – taps, tabletops, pens, etc. are frequently contaminated because they are touched while wearing used gloves. As you remove the gloves, avoid allowing the outside surface of the gloves to come in contact with your skin, because this will have been contaminated with blood and other body fluids. Avoid letting the gloves snap, as this may cause splashes onto your skin or other people in the area. The steps in removal are as follows:

1. Grasp one of the gloves near the cuff and pull it partway off. The glove will turn inside out. Keep the first glove partially on before removing the second glove to avoid touching the outside surface of either glove with bare hands.

2. Similarly, leaving the first glove over your fingers, grasp the second glove near the cuff and pull it part of the way off. The glove will turn inside out.

3. Pull off the two gloves at the same time, being careful to touch only the inside surfaces of the gloves with your bare hands.4. If the gloves are disposable or are not intact, dispose of them properly. If they are to be processed for reuse, place them in a

container of disinfecting solution.

Remember to wash hands immediately after gloves are removed

Biomedical waste segregation at source and disposal

Biomedical waste refers to clinical and allied waste materials such as cytotoxic and other pharmaceutical waste. Clinical waste refers to waste material generated as a result of diagnostic, prophylactic or therapeutic procedures, and also those resulting from research or production activities with clinical materials.

Waste generated at a health facility includes both general waste (e.g. discarded stationery, glass plastic and other types of containers, kitchen refuse, etc.) and biomedical waste. Human excreta (feces and stools) are not normally regarded as biomedical waste unless they are obviously contaminated with blood. Sanitary napkins from patient treatment areas of a health facility (e.g. maternity wards) are classified as clinical waste. Since clinical and other biomedical waste materials pose the danger of transmitting infections or toxic chemicals they are not to be handled like general waste. Guidelines have evolved for segregation of clinical and other biomedical waste at source and their subsequent disposal in a manner safe to human beings and the environment.

General waste generated at primary healthcare facilities should be segregated from biomedical waste and disposed off as per municipal waste disposal norms. Black bags and bins can be used to segregate general waste and care must be taken to ensure that these are not contaminated with clinical material.

Biomedical waste generated at primary healthcare facilities need to be segregated as follows:

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Sharps: A sharp is an item that can pierce skin. It includes needles, lancets, scalpel blades, discarded sharp instruments, glass (including unbroken glass) items, metal pull caps from injection vials, etc. Consider any item that can pierce a waste bag as a sharp for disposal purposes to avoid bags leaking contents but adopt a practical approach – large non-contaminated IV fluid bottles may be recycled. Used plastic syringes are not sharp items per se, but since it is not recommended that used needles are removed from their syringes, the latter are also disposed off as sharps. Sharps should be placed in clearly labeled puncture proof containers that are relatively small. Such sharps disposal containers should not be filled beyond a reasonable limit, nor should their contents be compressed or emptied. Ensure the opening is visible so one can see any protruding sharps. Once the container fills up, seal it and give it for disposal.

Anatomical waste (e.g. placenta, body parts, tissue specimens) and obviously contaminated materials, such as used bandages, dressings, sanitary napkins, etc., are to be placed in sufficiently thick leak-proof yellow bags which should be tied off when filled up and carried to yellow storage bins. Tying small volumes of waste off reduces odor especially if the storage bin is only emptied monthly or less. If many bags are being emptied at one time, it will be easier to either bring the storage bin to the smaller bins bags or use a dedicated trolley with a lip to take bags to the storage area. Discarded cytotoxic drugs and other medicines are also to be disposed off in yellow containers.

All other non-contaminated non-sharp items generated as a result of clinical activities should be disposed off in leak-proof blue bags and bins. While occasional bloodied gloves, swabs may inadvertently be disposed to such a bin, sharps must never be disposed into it.

Mercury is widely used in healthcare equipment but is considered to be a highly toxic metal that must never be allowed to escape into the environment. All primary healthcare facilities must maintain a small mercury containment kit to tackle accidental mercury spillages from thermometers, sphygmomanometers and other devices.

Clinical waste is unsafe and its treatment and disposal is expensive. Auditing shows that clinical waste often contains misplaced waste such as packaging, stationery, paper napkins from hand-drying etc. Therefore placement of waste disposal bags and bins must be carefully considered. For instance, they should never be placed in areas accessible to the public such as waiting rooms and corridors. Clinical waste bins should never be placed next to sinks as they may soon fill up with paper towels. Sharps disposal containers should never be on the floor or on low benches where they can be accidentally stepped on sat upon. It may be a good idea to place clinical waste bins and general waste bins close by but not immediately side by side.

Once biomedical waste has been segregated at source at the primary healthcare facility, they should be disposed off as per applicable mechanisms and regulations. The facility head should ensure that accumulated waste, both general and biomedical, is regularly removed from the premises and necessary clearances from the pollution control board are in place.

Annexure XXII.Guidelines on Prescription quality assessment

A prescription, by definition, is a written order from a registered medical practitioner to a pharmacist instructing the latter to compound and dispense medicines as per the instructions provided and explain their use to the patient. In our out-patient department (OPD) set-up, the OPD / Emergency ticket, in addition to fulfilling the defined role of a prescription, also serves as a medium of communication between the physician and patient, and provides a summary record of the patient’s clinical condition since there is little scope of generating an additional case record document. Improving prescription quality, along with implementation of standard treatment, is one of the important goals of the STG monitoring project.

While a full-scale prescription audit is beyond the scope of STG monitoring visits, the following key areas should be assessed. A score of 2 should be awarded if the practice is being satisfactorily implemented by all or majority of the doctors in the facility most of the time. If it is being followed by only some of the doctors, or only part of the time, the facility scores 1 on that item. The assessment time frame should include new prescriptions generated on the day of the monitoring visit plus old prescriptions generated for 2-3 months period preceding the visit.

Patient identification particulars being notedThe importance of this is obvious. The registration, demographic and contact details noted here must tally with those on the OPD / Emergency Register. Complete details will help in contact tracing if needed.

Stamp on prescriber’s name being usedThe prescriber’s identity must be clear for any prescription. The most convenient way to record this is to use a rubber stamp specifying the prescriber’s name and designation.

Chief complaints with duration notedDiagnosis / Provisional diagnosis / Injury notedThese should be entered in brief as the patient’s chief complaints and/or important symptoms and signs along with their duration. It is very helpful if a provisional diagnosis can be stated as well. The appropriateness / rationality of the prescription cannot be judged by subsequent prescribers and evaluators without this information.

Investigations, if applicable, being advisedMany therapeutic decisions need to be supported by appropriate investigations. Monitors should note that such investigations are being advised, even though medicines may already have been prescribed empirically.

Medicines are being prescribed as per STG (from essential medicines list)

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Prescriber can justify use of medicines outside essential medicines listAs far as practical, the medicines that are being prescribed should conform to those listed in the STG document. If alternative or additional medicines are being used, the prescriber should be able to justify the choice.

Generic drug names being usedIn general, medicines are to be prescribed in generic name – the advantages of this practice outweigh the disadvantages. ONLY GENERIC NAME should be used if the medicines are dispensed from the health facility itself. Brand names may be used if medicines are to be procured from outside (in this case the generic name may be followed by the preferred brand name in BLOCK letters) or if medicines with multiple active ingredients are being prescribed (the scope for using such medicines is very limited).

Dosing regimens specified are completeDosing regimen should be complete for every medicine prescribed. Complete dosing regimen includes the dosage form (or route of administration), individual dose, frequency of dosing and duration of treatment. Specify timing in relation to meals where relevant. Dose titration instructions should be written carefully. Potentially confusing instructions like ‘continue’, ‘repeat all’ should be used sparingly, if at all.

Latinizations and non-standard abbreviations are being avoidedThe disadvantages of this practice are obvious and prescribers should avoid non-standard abbreviations that are not evident to other prescribers and healthcare providers.

Prescriptions are legibleLegibility of the prescription will prevent many mistakes and medication errors. To be considered legible, a prescription should be read easily by all the monitors.

Annexure XXIIIInformation on Establishing Diagnostic Services in Primary Level Health Facilities through PPP

Establishing Diagnostic Services in Primary Level Health Care Facilities Through PPP.Information for the facility heads being trained under “Utilization and implementation of STG” in the IHFWList of Diagnostic Services to be introduced in Block Primary Health Centers and Rural Hospitals through Public Private Partnerships (PPP).

Mandatory tests/investigations that must be conducted at the diagnostic centre established under PPP I. Bio-chemistry

1. Blood Sugar (Fasting/PP/Random)2. Urea3. Uric Acid4. Creatinine5. Serum Triglycerides6. Serum cholesterol7. Liver Function Test8. Urine Albumin/Sugar9. Sugar, Urea and Creatinine (Combined)10. Lipid Profile11. CSF-Sugar, Micro Protein, Chloride (each)

II. Haematology1. Hb, TC,DC,ESR2. Platelet Count3. Reticulocyte count4. Foetal Hb %5. Blood Grouping and Rh factor

III. Pathology1. PAP stain2. Peritoneal/Pleural /Ascitic Fluid/Other body Fluids for Cytology(each)3. FNAC with slide

IV. Micro-Biology1. Blood Culture2. Urine Culture3. Pus Culture4. Sputum Culture other than TB5. Sputum/other smears for AFB or Gram Stain

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6. Throat Swab Culture7. Conjunctival Culture

V. Serology1. Australia Ag2. VDRL3. Mantoux Test4. ASO Titre5. Widal Test6. Pregnancy Test

VI. Clinical Pathology1. Stool/Urine for Routine Examination2. Stool for Occult Blood3. CSF Cell Type and Cell Count, Gram Stain, AFB Cell Type

VII. Radiological Investigations1. X-Ray (If not installed by the DoHW)2. U.S.G. (If not installed by the DoHW)

VIII. Cardiological investigation1. E.C.G. (If not installed by the DoHW)

Establishment of Sample Collection Centres at PHC s.The Private Sector Providers (PSP) will also be allowed to set up Sample Collection Centers at PHCs in the draining areas of the BPHCs/RHs.

For details on the guideline please consult Memorandum bearing no.HF/PPP/11/2009/17 dated February 8, 2010 from Sri A.K.Das, Special Secretary.

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Documents

Modeled on Kit-N (Equipment for Neonatal Resuscitation ... · PDF fileAnnexure VII Neonatal Resuscitation Kit Modeled on Kit-N (Equipment for Neonatal Resuscitation) recommended by