Chiquo Healthcare Systems Pvt. Ltd.,

INPLANT TRAINING REPORT

(During the vacations of II nd, III rd & IV th Semester 2014/2015)Submitted by,

S.Tarunkumar (1131310016)Under the supervision of,

Mr. Sathish KumarBiomedical department

Prashanth hospitalMr. Venkat

Biomedical DepartmentFortis malar hospital

Mr. M.S. RaviManaging director

Chiquo healthcare systems

DEPARTMENT OF BIOMEDICAL ENGINEERINGSCHOOL OF BIOENGINEERING

FACULTY OF ENGINEERING &TECHNOLOGYSRM UNIVERSITY

SRM Nagar, Kattankulathur-603203Kanchipuram District

October 2015

CONTENTS• Introduction• Departments visited• Physiotherapy• Dialysis• Blood transfusion• Radiology• Medical gas supply system• CSSD(Central Sterile Supply Department)• OT(operation theater)

INTRODUCTIONThe purpose of this implant training was to gain a hands on experience in the field of biomedical engineering Our main aim was to gain knowledge practically and thereby enhance our skill sets. This report is about the 4 weeks of industrial training done as part of curriculum. It includes the role of biomedical engineer in health care Organization. This report includes the various departments in a hospital and the various instrumentation used in respective departments. It also includes the design of Operation theatre,cssd,medical gas supply system.

Departments visited:-• Physiotherapy• Dialysis • Blood transfusion• Radiology• Medical Gas Supply System• Central Sterile Supply Department(CSSD)• Operation theatre

Physiotherapy

Diathermy equipment:-Three forms of diathermy are in wide use by physical therapists in hospitals and clinics: shortwave, ultrasound, and microwave. In shortwave diathermy, the part to be treated is placed between two condenser plates, and the highest temperature is concentrated in the subcutaneous tissues. Shortwave usually is prescribed as treatment for deep muscles and joints and is sometimes used to localize deep inflammatory disease. Ultrasound diathermy uses high-frequency acoustic vibrations; their heating effect increases circulation and metabolism and speeds up the rate of ion diffusion across cellular membranes. During treatment the apparatus is moved slowly across the surface of the area to be affected. Ultrasound is used to heat selected muscles that are too deep to be significantly affected by surface heating. Microwave diathermy uses radiation of very high frequency and short wavelength similar to that used in microwave ovens; all physiologic responses are due to its heating effect. Depending on the amount of heat generated, diathermy can be used to merely warm or to destroy tissue. In the first instance, it is particularly beneficial in relieving muscle soreness and sprain. In the second, as an adjunct to surgery, diathermy is used to coagulate, prevent excessive bleeding, and seal off traumatized tissues. It is particularly effective in eye surgery and neurosurgery. Diathermy therapy is also used effectively to treat back pain, to remove warts and moles, and to destroy or localize bacterial infection of tissues.

Dialysis Equipment

• Dialysis uses a special fluid that contains a mixture of pure water and chemicals to carefully pull waste, salt and extra water out of your blood without removing substances the body needs. In turn, you’ll be able to keep safer levels of certain chemicals in the bloodstream, including potassium. There are two main types of kidney dialysis—hemodialysis (HD) and peritoneal dialysis (PD). Take a closer look below to see how each type of treatment works. PD uses the lining of your abdominal cavity, called the peritoneal membrane, to naturally filter fluid and waste from the blood. HD uses a filter outside of your body called a dialyzer. With help from the dialysis machine, blood flows from the body, into the filter where waste and fluid are removed, and then back into your body. There are three common forms of HD: in the comfort of your own home, in a dialysis center with other people, and in a center that offer nocturnal dialysis which is performed while you sleep

Blood transfusion Lab

Blood Type % of Population Can Give Blood to Can Receive Blood from Chance of Finding a Compatible

Donor

A+ 34.3% A+, AB+ A+, A-, O+, O- 80% (4 out of 5)

A- 5.7% A+, A-,

AB+, AB-

A-, O- 13% (1 out of 8)

B+ 8.6% B+, AB+ B+, B-,

O+, O-

60% (3 out of 5)

B- 1.7% B+, B-,

AB+, AB-

B-, O- 9% (1 out of 12)

AB+ 4.3% AB+ Universal recipient (can receive all blood types)

100%

AB- 0.7% AB+, AB- AB-, A-,

B-, O-

14% (1 out of 7)

O+ 38.5% O+, A+,

B+, AB+

O+, O- 50% (1 out of 2)

O- 6.5% Universal donor (can donate to all types)

O- 7% (1 out of 15)

• Blood type is classified according to the presence or absence of substances inherited from one’s parents, called inherited antigenic substances.

• Blood types are classified according to the ABO system:• A: contains antigen-A and anti-B antibodies.• B: contains antigen-B and anti-A antibodies.• AB: contains both A and B antigens but no antibodies.• O: contains no antigens, but contains both anti-A and anti-B antibodies• If a person of Blood group A is given Blood from a donor from Blood group B, the

anti B antibodies will stick to the B antigens on the donated red Blood cells entering their body. This makes a reaction that can be fatal. Therefore, exact matching is critical; possibly the difference between life and death

Radiology Department

• Ionizing radiation like x-rays are used to get the image of a particular area or organ. The x-ray utilizes ionizing radiation to capture the images and thereby getting the 2D image of the object. Advanced X rays include CT scan where high intensive X-rays are used to capture the image of the object. There would be an array of detector between the source and the receiver. MRI does not use ionizing radiation to capture the image but uses magnetic field to capture soft tissues. Another X-ray equipment is the cath-lab where they insert a catheter into the femoral vein to find the cross sectional view of the artery or vein

MEDICAL GAS MANIFOLD:• 1) Oxygen is used primarily for respiratory therapy and anesthesia. Constant supply and immediate availability throughout the

hospital is essential. The system is designed to be maintained at 4 Barr pressure at the outlets. • 2) Nitrous oxide is used primarily used in OT area. Pressure required at each outlet is 4 Barr. Medical air (compressed air) is

primarily used for respiratory therapy in areas like emergency rooms, intensive care areas, etc. It is also widely used in OT area.

• 3) Medical air is used in administering breathing treatments and as a mixing component for other respiratory gases. The air used for medical purpose must be free from oil, moisture and contaminants. The system is designed to provide an outlet pressure of 4 Barr.

• 4) Vacuum is an essential part of medical gas system. Vacuum is widely used throughout hospital facilities in patient treatment and in laboratory. In surgical recovery and intensive care areas, it is used to remove fluids from incisions and assists vital post- operative drainage. Vacuum systems are normally designed to provide15-20”mm of Hg at the furthest point from the central vacuum system.

• 5) Nitrogen, carbon dioxide, helium and argon are also used other than the above mentioned gases for cutting, laparoscopy and calibration respectively.

• For ensuring this, the entire system need to be designed, installed and commissioned with high degree of technical expertise skill and experience. The design and planning of a medical gas distribution system may be divided under the following:

• 1. Location where it is required and the number of outlets • 2. System pipeline routing and determination of size of pipes • 3. Medical gas supply source.• 4. Intermediate pipeline controls • 5. Gas service outlets • 6. Critical care area equipment• 7. Alarm monitoring equipment

• Location:• -The location of the medical gas manifold/plant room should be outside the hospital for safety purpose as well as to prevent

noise from plant disturbing patients in hospital. • -The area should have accessible to road in order to bring in medical gas cylinders and to take back the empty cylinders.• -In case of liquid storage the tanks should be mounted in a fenced isolated location.• Design:• The manifold room and the plant room should be isolated with a divider to prevent any form of accidents. The design of both

the manifold and plant room are defined separately• MANIFOLD ROOM:• - Access to manifold rooms should be from the open air, not from corridors or other rooms• -There should be a redundant stand-by supply source to meet breakdown situations--like a dual system for gas supply and

alternate bottled gas supply source• -The manifold room will contain the manifolds as well as cylinder racks holding sufficient spare cylinders to replace one bank

of each manifold and the emergency/reserve manifold• -Adequate space should also be allowed for cylinder handling• -Two doors should preferably be provided in a manifold room. One should be large enough to facilitate cylinder handling and

must be in an outside wall• -The internal walls, including any internal doors of the manifold room, should be suitable non-combustible two-hour fire-

resistant material• -The cylinders must be placed over the Rubber mats and chain guard should be provided to prevent any accidental fall of

cylinders.• -The empty and filled cylinders should be stored separately to avoid any confusions while installation.

• PLANT ROOM:• -Ventilation should be provided at both high and low levels for all manifold rooms, to allow circulation of air.• -Plant rooms should be designed and constructed to ensure the satisfactory control of noise emission• -Two compressors are required in order to share their load of working (i.e. when one compressor blows off the other switch the

role).• -The compressor should be provided with a pressure switch that automatically switches on and off the compressors according to

the pressure within the storage tanks.• -The pressure inside the storage tanks should be set according to the size and volume of the hospital• -The air from the storage tanks should be dried before supplying into the hospital, for these special drying units are installed along

the pipeline. • -There should be two pipelines, one with 4 Barr pressure (normal uses) and the other with 7 Barr pressure (orthopedic surgeries).• -Both the above mentioned pipelines should be bypassed in order to use during service in the main supply lines.• -Water cooling system has to be set up if the compressor used is of oil consuming and crank shaft mechanism.• -Two vacuum pumps are required in order to share their load of working (i.e. when one pump blows off the other switch the role).• -Pressure switch is connected along the pipelines connecting the vacuum pump and the storage tanks which switch on and off the

vacuum pump according to the pressure within the storage tanks.• -Since the vacuum is a negative pressure it requires special raisers in the supply lines.• -Bacteria filters are installed along the pipelines to prevent bacterial entry into the storage tanks.• -The size of the supply lines depends upon the size of the hospital• Colour Coding:• -There are various systems of colour but the German standard is the most used since it is easy to follow:• The table below shows the German colour system of the gas pipeline

GAS PIPELINE COLOUR CODING

Oxygen White

Nitrous oxide French blue

Carbon dioxide Grey

Air Black and white

Vacuum Yellow

Dry nitrogen Black and grey

CENTRAL STERILE SUPPLY DEPARTMENT

• The zones of the CSSD are classified for unidirectional flow as well as for proper handling of the instruments and equipments to be sterilized.

• The CSSD should have four zones for a smooth work flow, they are as mentioned below

1. The unclean and wash disinfection zone2. The assembly and packing zone3. The sterilization zone4. The sterile and the distribution zone

• The unclean and wash disinfection zone• This zone is where the materials to be sterilized is received and cleaning of the used

equipment’s/materials, rubber and plastic goods either manually or by machines.• -The equipment’s used in this zone are ultrasonic cleaner, washer disinfector with built in dryer and

distilled water tank Ultrasonic cleaner - The units should be a compact free-standing bench model, with a built-in tank manufactured from high-quality (316) stainless steel and a solid-state generator that sends ultrasonic (approx. 42,000 cycles per second) impulses through wash water containing detergent and electrical heating; microprocessor controlled display with memory time and temperature functions. The electrical energy should be transformed into sound waves by transducers, fixed to the bottom of the tank. The tank should be made of solid stainless steel (316).

• Washer disinfector with built in dryers - The washer should perform pre-rinsing, cleaning, post-rinsing, thermal disinfection, final rinsing and drying phases. Validated programs are secured by access code. Detergents and rinse agents should be automatically dispensed during the cycle

The assembly and packing zone

• Clean and dry instruments are packed before sterilization so that they are not contaminated while handling after they are sterilized. Working counters are required in this area.

• - Most of the instruments are packed in trays (tray assembly) that are wrapped with double layer of cotton cloth.

• -Paper envelopes are also available for packing the instruments. These are equally effective but expansive.

• -Plastic bags (ETO bags) are used for packing the items for ETO sterilization. The packs are labeled indicating date of sterilization and date of expiry (wherever possible).

• -It includes checking of glass items for breakages, needles and instruments for sharpness and breakages, assembling of the equipment after washing and drying, making appropriate sets for use by various departments and packaging along with sealing either manually or using a machine before sterilization.

• - Adequate documentation and labelling of each pack should be done and records should be maintained.

• -The major equipment’s used in this zone are gauze cutting machine and the sealing machine

• A brief description of each equipment used in this zone is given separately:

• Sealing machine: It is used for the sealing the plastic bags in which instruments are packed. After packing and SEALING, the instruments are shifted for sterilization

• Gauze cutting machine: A large quantity of cotton balls and gauge pieces are used in various patient care areas and are required to be sterilized before using them. Traditionally these are prepared in the CSSD. Cutting the gauge is very arduous job and is done with the help of Gauze cutting machine. During the process of gauge CUTTING, the cotton fibers ARE dispersed in the air and may get settled on the sterilized items spoiling them. Therefore, a separate room is required for cutting the gauge and preparing cotton balls adjacent to the packing area.

The sterilization zoneIt renders materials sterile for quality patient care. It is achieved by steam sterilizers working at specified cycles of temperature and duration to attain adequate sterility assurance level (SAL). Advantage of steam sterilizers are rapid heating & penetration of loads, destruction of all forms of microbial life and no residual toxicity.Sterilization is done by either of the two methods in CSSD: • Steam sterilization by autoclaves • Gas sterilization by ETO (ethylene oxide) machines • Autoclave: “Autoclave” is the name of the machine that generates steam at a temperature of 121 degree centigrade under 15

pounds of pressure. An exposure of 20 minutes is required for sterilization. Before feeding the steam, vacuum is generated in the chamber of the autoclave so that no air pocket remains in the folds of linen and the steam IS distributed uniformly in the chamber.

• Autoclave is available with single door or double doors. Double door autoclaves have two doors on two opposite sides and have the advantage of maintaining uni-directional movement of materials. The unsterile items are fed into the chamber through one door and the sterilized items are taken out from the other door of the autoclave.

• ETO Sterilizer (for non-metallic materials): The items like cardiac catheters are thermo sensitive (damaged by heat) and therefore cannot be sterilized by steam. Such items are sterilized by ethylene oxide (ETO) gas sterilization. The ETO is an expansive and toxic gas. The items that are to be sterilized are placed in a chamber that is filled with ETO. As a result of the exposure to the gas all organisms attached to the item get killed but the item gets coated with gas molecules. It is absolutely necessary to ensure that these items are made free of gas molecules before using them on a patient. This is achieved by subjecting the items to forced ventilation. The entire cycle of sterilization and ventilation is long and may take about 8- 12 hrs. For each cycle of gas sterilization one ETO cartridge is required that is fixed with the machine before starting the cycle.

• Flash sterilizer: This is a special type of autoclave that has a very short sterilization cycle of about 3 - 5 minutes because of its ability to raise the temperature to 132 degree centigrade. The machine is generally kept in the OT. During the operations if there is urgent a requirement of sterilizing an instrument, it is done on flash sterilizer.

Double door Autoclave ETO Sterilizer

• The sterile and the distribution zone• This zone is where the sterilized materials are quality checked using colour bands and after sterilization, the

items are temporarily stored in a clean store (on racks) from where they are distributed to user departments • -In spite of the process instruments fitted on autoclaves which give a graphic record of temperature and

pressure, routine methods of check for sterilization must be incorporated.• -The sterilized materials from the sterilization zone are transferred into this sterile zone through special

pathway called the pass boxes.• -The pass box scans the materials passing through it using the ultraviolet radiation.• -Distribution area should be away from the receiving area and may comprise of a window with counter. • -In modern hospitals, there may be a separate lift for transporting the sterile materials to user departments. • Sterility Indicators• Three modes of sterility indicators are most often used and they have specific roles as mentioned below:• Mechanical indicators: These are monitoring instruments that record time, temperature, humidity and

pressure during the sterilization cycle.• Chemical indicators: These are devices with a sensitive chemical or dye to monitor one or more parameters of

a sterilization cycle.• Biological indicators: They employ the principle of inhibition of growth of microorganism of high resistance to

the mode of sterilization. Subsequent failure

Operation theatre

• In an operating department for which the most integrated function is required, cleanliness must be kept and the safety of facilities, equipments and devices must be maintained any times. Satisfying those conditions consists of wall, ceiling and slanted panels, and is capable of incorporating not only electrical equipment, medical gas system and lighting gears but all the necessary functions and equipment's at need. In addition, the modular theater has a high availability of extension providing for the introduction of new facility in the future, establishing as well an operating environment with high work ability and enough function. The most complex and challenging area of hospital construction is the operating department. An OT is of Class 10000 which means there should be only a 0.3 micron particle per cubic centimeter. The prefabricated Operating theatre offer the advantage of speedy construction combined with design, future expansion and development in surgical technique whilst simultaneously providing a structure of the highest quality and standards. Normally a modular Operating theatre consists of the Following Equipments and articles:

• A plenum Unit ( Laminar air flow)

• OT Lights

• Wall and ceiling

• OT Door

• X ray Viewer

• OT Table

• Equipment storage unit

• Surgical and anesthetic pendants

• Required Equipments

• Exhaust

• Control Panel

• Scrub Sink

1) Plenum Unit (laminar air flow):Bacteria cause infection within operating Theatre. Ceilings should be selected according to the surgical application. Supplied with optional air-conditioning and control systems, or as part of an existing mechanical services systems, the range of specialist ceilings reduce the risk of post-operative infection, whilst providing optimum comfort through the use of conditioned, filtered clean air. The ceilings consist of a plenum box supplied with conditioned air from the central system via HEPA filters mounted on the inlet to the supply ceiling. HEPA filters the supplied air to a level of 0.3 micron so as to ensure that the air supply does not cause any infection or further complications to the patient. Nowadays there are HEPA filters which consist of half carbon and half HEPA filter which is used to eliminate the smell during the Operating procedures. We use vertical laminar flow so that the air directly falls on the patient and also due to the gravitational force there is a proper supply.2) OT LIGHTSThey should have the quality of not forming shadows so that the surgeon operates effectively without any disturbance. The lights inside the plenum unit consist of air diffusers which filters the air and supplies light.In general the luminance of OT lights should be a minimum of 750 lux and with reference to AKASH hospital we found an OT light Polaris 200100 which had a luminance of 120-165 lux. There were also brightness controllers since laparoscopic surgeries are performed at low light luminance. Even UV lights are used whose control is outside the OT room. 3) WALL AND CEILINGThe fabricated operation room will be a free standing structure. With reference to CMH, galvanized iron sheets were used for the wall and ceiling. A special anti-bacterial paint was used for the walls. In general all the four corners have return air duct outlets and grill for the same made of steel duly powder coated with the colour choice to suit the hospital. Distance between the walls and panels to be around 100 mm. It has full support to provide straight by using clamps near the columns. Additional space can be utilized for making storage area/hatch box (pass box). Anti-bacterial paint does not leach out so that its anti-microbial system remains active throughout the life of the product. When Stainless steel wall is not provided GI sheet antibacterial paint is used which is of lesser cost.

4) OT DOORThe door used is either a stainless steel sliding door or push pull door which immediately closes after movement. A sensor might also be kept which can be controlled to open and close the door. The main OT doors mainly suitable for stretcher movement.5) X RAY VIEWERX -Ray Viewer is used in modular operating theatre to ease the operating staff during operation stage. X-Ray viewing screens are built by using the high efficiency electronics regulating ballast with dimming PCB for Controlling the light dimming, ranging from 100%-10%.X-Ray film could be clip securely onto the viewer for the best viewing result.6) OT TABLEElectro Operation Theatre Table Developed in close association with leading surgeons, they manufacture electric OT tables which operate with electricity but Consumes less power. The height of the operating table must be adjustable so that a surgeon can adapt it to their height. In addition it must be possible to tilt the table to the left and to the right to ensure a better overview into body cavities or to use gravity to move organs (e.g. laparoscopy). In addition, the individual operating table segments must also be adjustable.7) PENDANTSIn an Operating Theatre, the two most important Personnel are the anesthetists and the surgeon. With their handy uses next to them, they form a group of specialized people who strive to heal and save lives. 8) REQUIRED EQUIPMENTS In General A patient monitoring system , an Anesthesia machine for assisting the administration of anesthesia which is used to regulate and control the amount of gases (anesthesia) into the patient. There is also a defibrillator to handle the patient in case of a cardiac arrest.

9) SURGICAL CONTROL PANELAll the controls for a modular OT are provided on a membrane type, micro controller based electronic control panel mounted in the theatre wall. Control panel meet the electrical safety codes for high and low voltage systems. The control panel is user friendly. The fascia is made with superior quality UV resistance membrane with sterilization feature. The control panel may consist 6 tiles or 9 tiles. The product can be developed as per requirement of the hospital.• The tiles are as below.• Time of Days Clock• 1Elapsed Time Clock• Temperature Display/Control• Humidity Display/Control Lighting Control/ Dimming• Medical Gas Alarm Systems• Hands Free Telephone• HEPA Filter Status Indicator• Pressure IndicatorAll high voltage equipment will be installed in a separate enclosure can be positioned up to 250 meter away, allowing maintenance to be carried out with minimum disturbance. The remote cabinet consists of Operating lamp transformers, remote relay card, electrical distribution equipment and circuit protection equipment for all circuits within the operating theatre.

ConclusionSumming up I got a hands on experience in our field of bio medical engineering. I could learn the current trends in the healthcare industry and gain more knowledge. Thus we could upgrade our skill sets my clarity towards subject came only through the practical approach that I acquired in the training. I not only had an experience on equipments, but also designing aspects of rooms, especially Operation theatre, CSSD, Gas supply systems. I like to thank the Academic department of the hospital who granted permission and the freedom of learning think. I also thank our guide who have been a great support during my period of training.

Thank You