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What I have written about below are only my opinions and there may be things I have missed out.
Let us assume that you are starting in a country that has either nothing or very little in the way of maintenance facilities. If you are simply starting a workshop in one hospital all I will write below will simply be on a smaller scale but the same process.

You should always aim, in an ideal world, to be self-sufficient in maintenance services.
This means not only looking after the high-tech equipment but everything from the fabric of the buildings, electrical, plumbing, drains and so on though beds, wheelchairs to theatre equipment and surgical instruments. How much you do depends on finances, skills, staff numbers available to you and what your hospital management want you to do.

First a few thoughts on medical equipment.
Medical equipment is very expensive; in general terms an item labelled medical will be 10 times the price of a similar non-medical item.
For example. A pressure regulator used for powering an orthopaedic air drill will be ten times the price of an oxy/acetylene regulator used with a cutting torch in a car scrap yard, the only real difference is that the medical one will be chrome plated.
Spare parts are also very expensive, again the ten times rule will apply.
Servicing medical equipment by appointed agents is three times the prices of say car servicing and that is in Europe / North America. Once you get away from this area the more remote you are the more the price increases. The price may increase greatly to the point where it becomes uneconomical.
It is much cheaper to train your own technicians or even send them abroad to be trained than to buy in servicing.
There are advantages in doing it with your own staff.
•Cheaper.
•Far quicker response. (Minutes instead of weeks.)
•More reliable.
•You are giving jobs to local people.
•Local people will care more for the equipment because it belongs to ‘their’ hospital.

Donated equipment.
This may be a difficult subject but you must consider very carefully what equipment is being donated to you.
For example, if an American charity is going to donate money or equipment it is natural for them to donate American equipment. A French charity will donate French equipment and so on.
This may mean that the donated equipment may not be the most suitable for your circumstances or fit in with what you already have.
You should try to get equipment that you want and is most suitable for your hospital, the climate it has to work in, its requirement for maintenance and your ability to maintain it and afford the cost of maintenance.

Take an item like a blood gas analyzer. Incredibly useful to doctors, it has the ability to measure parameters like pH, Co2, O2, haemoglobin, metabolites and electrolytes plus many calculated values from a tiny quantity of blood and all within two minutes.
The problem is that it will need daily maintenance with parts and consumables that are very expensive, it could cost at least  € 11,000 a year to run. (2012)
Stop looking after it for three days and it will probably stop working.

When purchasing equipment, you must ask the makers or their agent some questions and insist on the correct answers, then make sure that they stick to what was agreed.
•Do they guarantee spares?
•Ask for prices of service kits, spares and consumables to give you an idea of maintenance / running costs.
•Will they provide service information? (You may have to get your technicians trained by them to get it).
•Can they provide Internet-based / email technical support. Some companies like Diamedica in the UK, for example, actively encourage you to email them for advice.
•Will they provide free training. This is always worth asking for if there is competition for a sale. (You may have to agree to pay the travel for your technicians to go to the makers factory, or to the agents training establishment).
•What is the warranty and use it if things go wrong.
•Check that it is suitable for your climate. Get it in writing.

All this may be difficult and you will have to be diplomatic if a charity is offering to pay for it.
In the long run you will be better off considering your equipment requirements very carefully.
Most equipment is designed to work in well-regulated hospitals in advanced countries.
They often do not work so well or last for so long in tropical climates with high humidity, dusty conditions and the threat of insect attack.
For example, oxygen concentrators. There are many different makes but only a few are WHO approved for developing countries use.

It comes down to the phrase ‘appropriate equipment’.

Anaesthetic equipment.
Your anaesthetist will tell you that there are (to the best of my knowledge) two directions you can go in the provision of anaesthetics, the conventional route of developed countries with anaesthetic machines or draw over anaesthetics used in many developing countries.
Your anaesthetist will know which is better from their point of view, my only comments from a technicians and a financial point of view is that the draw over system will be much cheaper to set up and maintain.


Setting up a workshop or maintenance facilities in a country or a hospital.

Start as follows.
Do a survey.
1. Decide on the scope of your maintenance ambitions.
2. How many hospitals do you have to look after?
3. Cost your ambitions.
4. Can you afford to set up and run the workshops required?
5. Do you have the staff, suitably trained, to realise your maintenance ambitions?
6. If not can you recruit and train them?

Once you know what you can do;
1.Find existing rooms or build a workshop to suit your ambitions.

2. Recruit your technicians

3.Equip the workshop and technicians

4. Train your technicians.

Things to consider.
1. Your workshop might be able to take in paid work from other hospitals or you may be able to use skills and spare capacity to take in work from local non-medical sources, again for money. This income can help to fund the workshop.

2. Take care with technician training, if you train them to a very high standard and not pay them much, you risk them leaving and going to work in industry.

3. Autoclaves are a difficult one. While function checks and minor repairs should be possible with a little training, in the UK and no doubt in Europe and other developed countries, autoclaves have to have regular inspections as to the safety of the pressure vessel. This can only be done by people who are specially trained and certificated to do so.

Workshops.

What determines the size of a workshop? (Physical size and staffing)
1. Scope of your maintenance ambitions.
2. The number of theatres.
3. The number of high dependency wards.
4. The number of wards and clinics.
5. Age and range of equipment.
6. Distance from support, quality of roads. (May be cut off during rainy season)
7. Money.

What factors are we looking at?
1. Number of staff.
2. Physical size of the workshop.
3. Expertise of the staff.
4. Range of test equipment.
5. Range of tooling.

Technicians skill range required.
The range of skills will depend upon the size of the hospital, the equipment used and the scope of required maintenance.
It may include any or all of these.
1. Electrical.
2. Electronic.
3. Mechanical engineering.
4. Plumbing.
5. Carpentry.
6. Masonry.

What do we need in the workshop?
1. Staff numbers to suit the number of beds / theatres, amount of equipment and scope of maintenance.
2. Bench space and storage for each technician.
3. Full set of tools for each technician.

Some test equipment required for the workshop.
1. Artificial lung for testing ventilators.
2. Electrical safety checker.
3. Paramagnetic or ultrasonic oxygen analyser.

Other requirements.
1. Storage of spares
2. Engineering facilities.
3. Electricity and gas supply (Compressed air and if you can, oxygen for testing equipment)
4. Cleaning facilities.
5 Shelves for service books and other documentation.
6. Service records and cards.
7. A computer would be nice for keeping service records and internet access, but don’t discount good old pen and paper, cheaper and more reliable.

Organisation.
Make sure that the department has a regular budget available to it.
Appoint a chief technician in overall charge.
Make sure technicians are trained to service the equipment in the hospital.
Catalogue all the equipment you look after.
Start a planned maintenance scheme for the equipment you are responsible for. (Not only medical equipment but building maintenance as well, if you do it)

Planned maintenance
Even if your technicians are not trained to maintain an item of equipment, even if they do not have spare parts you should still do regular checks;
Electrical safety checks, (even if it only involves a good visual inspection, 80% of all faults are found visually)
Function checks.
Record on a record card every job you do on a piece of equipment, (planned maintenance or break-downs.). Record every other job you do so that you can justify your workshop to the hospital management.

Specific tasks
Workshop facilities
1. Find a room of suitable size with respect to the number of technicians, amount and type of work.

2. Try to have the workshop close to your main areas of equipment use.(You do not want to be wheeling anaesthetic machines around outside in the monsoon season.)

3. Make sure you have plenty of natural light.

4. Construct benches for each technician.
Each bench should be around 6 foot long and 3 foot deep in size, you will need to equip it with at least four power sockets, the sockets should be protected with earth leakage current circuit breakers for personal protection. Each should have an adjustable strip light for good work illumination (Each technician must have their own bench space).

5. Make sure you have good number of electrical outlets in the workshop generally and that gas for testing is available.

6. Ensure good storage facilities for spares and paperwork. Spares are very expensive and need protecting from humidity, dust and insect attack.

7. Provide each technician with a tool kit. (See end for ideal requirements.)

8. Facilities for welding and brazing.

9. Facilities for engineering, a pillar drill, bench grinder, bench buffer, band saw and, if you have suitably trained staff, use of a lathe and a mill.

10. Facilities for disinfecting / cleaning equipment.

Technician identification and training
1. Identify all your technicians.

2. Speak to them and get an understanding of their qualifications, abilities and aspirations.

3. With an idea of what maintenance you are going to cover, (buildings, electrical, plumbing, medical equipment, surgical instruments) allocate your technicians or recruit as money and requirements allow.

4. With regard to existing qualifications, plan a structured training program including language lessons for each technician. For those doing medical equipment maintenance and where English is not a spoken language, encourage them to learn it if possible. (A high proportion of medical equipment is made in English speaking countries).

5. What has to be taught depends on the type of equipment you have or are expecting to get and the ability of the technicians.
•For technical and language training beyond your ability ask advice from cultural sections of foreign embassies, British council offices and similar. Speak with groups like the British VSO, the American Peace Corps and similar organisations from your own country.

6. If you are a visiting doctor trying to set up maintenance facilities speak to maintenance technicians in your hometown hospital for advice and assistance.

7. Rotate your technicians into the theatres and intensive care areas of the hospital for on going weekly sessions working with, in the case of theatres, the anaesthetist. Help the anaesthetist to understand how the equipment works and what problems you have with it. In turn you can see their problems and the consequences of equipment failure.

Equipment management.
1. Examine all the equipment you are responsible for and check it using the equipment classification system below.

2. Items you want to keep to use, number and create a record card for.

Equipment numbering system.
As part of a planned maintenance system it is important that all equipment is numbered so that a track can be kept of its life, servicing and repairs.

These allocated numbers should be kept on a record card for each item along with the details of what it is, which hospital and ward the equipment is in. Then on the reverse a date and brief description of work carried out. the number should also be put on the item of equipment.
If you have a computer, Start a spreadsheet running and add the details to it.
Use it to remind yourself of due service dates.

3. Broken items you think you are able to repair put to one side and over a period repair them.

4. Items with a 17 classification (see below) strip down and store spare parts (wheels, nuts, washers, pressure gauges, springs and so on. Label machine specific spares so they can be identified later)

5. Look around the hospital for service/user information for all equipment you are going to keep and file it.

If you are unable to find service/user information search the Internet, email the manufacturers or contact ebme.co.uk. EBME
This is a web site used by medical technicians mostly in the UK, free to join so sign up and ask for help not only with service information but also if you have problems with a machine.

6. For equipment, you are going to keep, decide on a service regime.
Ventilators, anaesthetic machines and defibrillators, for example, service twice a year. Prepare a check sheet as in the example below for technicians to follow.
All electrical items should be safety checked once a year.
Even if the equipment does not need regular servicing it should be at least function checked and cleaned once a year.
Some items such as oxygen concentrators will need regular, as in weekly, filter cleaning

Publicity
1. Keep the hospital management up to date with your work; wait till you have something worthwhile to say.

2. Keep the anaesthetists and surgeons happy.

3. Be prepared to allow technicians to do private work to earn money for the hospital. (Hospital work must come before money-making). Do little jobs for the staff for nothing (particularly senior staff (it raises your profile and wins you influential support)).

4. Offer to do work for other hospitals or business in the area to earn extra money to re-invest in your department. For example, if you have an electrical safety checker you may offer (for a small fee) to safety check equipment for outside businesses.

Equipment condition classification.

All items should be given a number from the list below.

17. Not working, not repairable, good for spare parts.

16. Not working, repairable with spares from scrap machines, spares not available from abroad or local suppliers.

15. Not working, repairable with spares from scrap machines, spares available from
local supplies.

14. Not working, repairable with spares from scrap machines, spares available from
abroad and local supplies.

13. Not working, new spares available on site, and locally.

12. Not working, new spares available on site, locally and abroad.

11. Working, spares available from scrap machines, new spares not available.

10. Working, spares available from scrap machines, spares available from abroad.

9.Working, spares available from scrap machines, spares available from abroad and locally.

8. Working, spares not available from scrap machines, spares available from abroad.

7. Working, spares not available from scrap machines, spares available from abroad and locally.

6. Working, new spares on site and available from abroad.

5. Working, new spares on site and available from abroad and locally.

4. Working, new and under guarantee, no spares ordered or on site, spares available abroad.

3. Working, new and under guarantee, no spares ordered or on site, spares available abroad and locally.

2. Working, new and under guarantee, spares ordered or on site, spares available from abroad.

1. Working, new and under guarantee, spares available on site, spares available from abroad or locally.

Total up the numbers recorded and divide by the number of items to arrive at an average condition figure.
This can be done for all items and / or for items of one classification.
This can be repeated a number of years later for a comparative study.

Tools.
Consider this. Tools are very cheap in comparison with medical equipment.
Do not be afraid to buy tools they can save you a great deal of money. List below.

An IDEAL tool list.
Multimeter
Soldering Iron 25 watts approx.
6 in insulated snipe nosed pliers
6 in side cutters
7 in combination pliers
small slip joint pliers
trimming knife.
wire strippers 1 internal circlip pliers
external circlip pliers
straight point tweezers
flat blade screwdriver 3 inch
flat blade screwdriver 6 inch
flat blade screwdriver 8 inch
flat blade screwdriver 10 in
cross head screwdriver 3 inch no 0
cross head screwdriver 3 inch no 2
cross head screwdriver 6 inch no 0
cross head screwdriver 6 inch no 2
cross head screwdriver 10 inch no 2
mains testing screwdriver
set watchmakers screwdrivers flat blade
set watchmakers screwdrivers cross head
set metric hexagon keys
set imperial hexagon keys
set nut spinners 0, 2, 4, 6, 8, B.A
set nut spinners M2, M2.5, M3, M3.5, M4, M5, M6,
set B.A spanners open-ended and ring
set metric miniature spanners open-ended and ring.
4-inch adjustable spanner.
8-inch adjustable spanner.
set Swiss files.
engineers file 6 in flat.
engineers file 6 in round.
engineers file 6 in half round.
junior hacksaw.
spare pack of blades.
standard hacksaw.
spare pack of blades.
4 oz ball pein hammer.
set parallel pin punches.
flexible measuring tape.
6-inch rule.
vernier, dual scale.
pocket magnifying glass.
stopwatch.
torch.
Toolbox.

Additional workshop tools.
Which if these you need with depend upon the scope and range of maintenance undertaken.

general duty electric pistol drill.
6 in engineers square.
dial indicator.
set `v’ blocks and clamp.
surface plate, granite. (granite is better than cast iron for these)
spirit level.
surface gauge.
0-25 mm micrometer.
protractor.
inside calipers.
outside calipers.
dividers.
12-inch rule.
1 lb hammer.
2 lb hammer.
soft face hammer.
hand drill.
pr tin snips.
inch drive socket set.
torque wrench
pr stilson wrench 250 mm.
pr stilson wrench 350 mm.
pr self-gripping pliers 10 inch.
set combination spanners, metric.
set combination spanners, imperial.
G cramps 3-inch capacity.
G cramps 10-inch capacity.
tool makers clamps 2-inch capacity.
tool makers clamps 4-inch capacity.
mechanics vice 150 mm jaw width.
per technician, mechanics vice 75 mm jaw width.
London pattern anvil, 84 pounds.
riveting set.
propane torch, nozzles and large cylinder.
set metric drills. (high-speed steel)
set masonry drills.
set BA taps and dies. (high-speed steel).
set metric taps and dies. (high-speed steel).
set BSF taps and dies. (high-speed steel).
set BSW taps and dies. (high-speed steel).
set UNF taps and dies. (high-speed steel).
bench grinder.
bench polisher.
pillar drill.
lathe, ((about 1 meter between centres, (If you have a trained person to use it)).
universal milling machine. (If you have a trained person to use it)
Electric welding equipment.
Oxygen/Acetylene welding set.
Welding mask.
brazing goggles.
pair of safety glasses for each member of your workshop.

There are other tools that you will need if you are to do carpentry, plumbing or masonry work.

For electrical maintenance you will also need the following to begin with, and getting more as you find a need for it and can afford it.
Oscilloscope.
Bench power supply.
Signal generator.
‘MEGGA’ type insulation tester.
Electrical safety checker.

An example of a service sheet for a ventilator.

TRIBHUVAN UNIVERSITY TEACHING HOSPITAL
INSTRUMENT MAINTENANCE UNIT
KATHMANDU

SIEMENS 900 B SERVICE SHEET
1. Fit the parts as supplied in the service kit
2. Check working pressure manometer
3. Check zero of airway pressure meter
4. Check zero of the expired minute volume meter
5. Check calibration of pre-amplifier as per book
6. Check for leaks
7. Check patient tubes
8. Check alarm operation
9. Check plug for tightness of wires, and fuse
10. Check high-pressure hoses
11. Run and check all functions
12. Note the number of hours on the clock
13. Check the output of the mixer and note the results below.
14. Electrical safety check

Check the oxygen mixer.

30 %. . . . .
40 %. . . . .
50 %. . . . .
60 %. . . . .
70 %. . . . .
80 %. . . . .
90 %. . . . .
100 %. . . .

Comments. . . . . .

Technician’s signature. . . . .

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