Care of instruments and equipment: a success story
“When a person is hungry and you give him a fish, his hunger is satisfied for that

occasion. If you teach him how to catch a fish, it can take care of his hunger for the

rest of his life.” This is a teaching principle that is often repeated, and one that is

also very useful in the maintenance of medical equipment.
The nasal

instruments and equipment used in modern eye care have become very sophisticated and

expensive. Keeping them in good working condition can become a nightmare, especially if

hospitals are located in places where there is little service support from manufacturers

or suppliers. These items can fail to work unexpectedly and the resultant downtime can

compromise outcomes and patient safety.
An important fact about instruments and equipment is that, when manufactured by well-

established firms and supplied by reliable dealers, they seldom fail, provided they are

maintained as described in the user manual.
A machine is more likely to fail when it is first set up, often due to shortcomings in

its installation, use, or handling. For this reason, most manufacturers usually offer a

free warranty contract for the first year. Machines should be used often during that

period; any malfunction, however trivial, should be brought to the attention of the

supplier and rectified immediately. If this is done, the machine will usually work well

for the rest of its lifespan.
It is generally believed that doctors and/ or paramedical staff who use an instrument

or machine will take care of it, but this cannot always be expected. The patient is the

primary concern of doctors or paramedical staff. If there is a conflict, patient care will

take precedence – so nasal suction forceps care is bound to suffer. Also, some equipment is

too complex to maintain for a person who is not technically trained.
At Aravind Eye Hospital, we took these factors into account and devised a scheme

whereby a technically trained person is responsible for a sophisticated

pediatric

nasal instrument or piece of equipment. This person's responsibility is to take

care of it: to turn it on or off, and to go meticulously through all the stipulated steps

before it is ready to be handed over for use by doctors and paramedical staff. This

considerably lightens the workload of doctors – they can devote their full attention to

the procedure and the patient. When a procedure is over, doctors and paramedical staff may

be tired. Shutting the machine off in the sequence suggested by the manufacturer is then

the responsibility of the technically trained person.
There is no need for a fully fledged biomedical engineer to do this job, as it is

always possible to train a person with some engineering background on the various aspects

of a particular instrument or machine. That person can in turn train others to keep

equipment running in good condition. We find that graduates of our polytechnics (technical

colleges) do such jobs well.
We use such trained persons to maintain our phacoemulsification (phaco) machines, ERG

machine, fundus cameras, and expensive surgical instruments used in operations. We have

had great success with our LASIK machines: they are being used regularly and have

functioned, without any hitch, for the last seven years, which has surprised the supplier!
It is difficult to train many people within an organisation to look after

sophisticated nasal opertion forceps and equipment. Not all will have the competence

or the aptitude required to understand the technical details. Training one or two persons

with the right aptitude and making them responsible for looking after instruments and

equipment will ensure better maintenance and performance in the long term.
Medical equipment maintenance and use of personnel, is crucial. Used properly and

rational division of engineering and technical personnel, strict management, to train

engineering technical personnel with professional spirit, all-round for clinical medical

services; To strengthen the training of equipment use of personnel, highlight the

preventive maintenance and maximize or prolonged trouble-free of medical instrument

equipment, ensure the effective operation of the clinical diagnosis and treatment work.
The complexity of medical devices has increased over the past 10 years, and outbreaks

of infections due to contaminated devices have focused attention on the need to adequately

clean medical devices in order to ensure the adequacy of disinfection and sterilization.

There has been a paradigm shift in reprocessing of medical devices, with increased

emphasis on a quality management systems approach that requires validated cleaning

instructions from manufacturers and ongoing monitoring by reprocessing personnel to ensure

adequacy of cleaning. This article reviews the current issues related to medical device

reprocessing and summarizes the approaches used for monitoring cleaning efficacy for

surgical instruments and flexible endoscope system&accessory.
Forty to 70 % of medical devices and equipment in low- and middle-income countries are

broken, unused or unfit for purpose; this impairs service delivery to patients and results

in lost resources. Undiscerning procurement processes are at the heart of this issue.
We conducted a systematic review of the literature to August 2013 with no time or

language restrictions to identify what product selection or prioritization methods are

recommended or used for medical device and equipment procurement planning within low- and

middle-income countries. We explore the factors/evidence-base proposed for consideration

within such methods and identify prioritization criteria.
Results
We included 217 documents (corresponding to 250 texts) in the narrative synthesis. Of

these 111 featured in the meta-summary. We identify experience and needs-based methods

used to reach procurement decisions. Equipment costs (including maintenance) and health

needs are the dominant issues considered. Extracted data suggest that procurement

officials should prioritize devices with low- and middle-income country appropriate

technical specifications – i.e. devices and equipment that can be used given available

human resources, infrastructure and maintenance capacity.
Conclusion
Suboptimal device use is directly linked to incomplete costing and inadequate

consideration of maintenance services and user training during procurement planning.

Accurate estimation of life-cycle costing and careful consideration of device servicing

are of crucial importance.
The absence of safe, effective and well-functioning medical devices and equipment

(MDEs) impairs health service provision, leads to poor patient outcomes and poses

substantial health system and national security risks [1,2,3]. Nowhere has this been more

evident than the recent Ebola Virus Disease outbreak in West Africa [4,5,6]. The absence

of laboratory equipment to enable quick and accurate diagnosis, and personal protective

equipment to ensure effective infection prevention and control measures and health worker

safety, directly resulted in delays to emergency response, difficulties in care delivery

and lost patient and health worker lives [6].
The absence of appropriate technologies impairs more than emergency care, however:

routine services in maternal, child and reproductive care (e.g. immunizations or

reproductive control), interventions for non-communicable (e.g. diabetes management) and

communicable diseases (e.g. HIV/AIDS diagnosis) all require suitable infrastructure and

functioning technologies. From basic products such as weighing scales and condoms, to

glucometers and flow-cytometers, health service delivery is predicated upon the

availability, appropriateness, affordability and acceptability of MDEs [1].
Estimates suggest that between 40 and 70% of MDEs in resource poor settings are

broken, unused or unfit for purpose [7]. Indiscriminate procurement methods, a mismatch in

technology design and demand, high costs as well as deployment, maintenance and human

resource training challenges all contribute towards this issue [1]. Low- and middle-income

countries (LMICs) particularly lack the regulatory authorities, or biomedical engineering

capacity, to advise on what MDEs are suitable for use in harsh deployment settings: i.e.

facilities with high temperature, fluctuating electricity or no clean water supply. The

problem is compounded by a mismatch in MDE supply: manufacturers are located and attuned

to users in lucrative high-income markets [8]. Installation, preventive and corrective

maintenance services and user training programs are also traditionally absent in LMICs,

leading to unsafe device handling practices with potentially harmful consequences for

patients (e.g. in cases of misdiagnosis due to mis-calibration or infection propagation

due to device re-use).
This paper targets one aspect of the above problem: MDE procurement and resource

allocation in LMICs. To assist decision-makers in conducting informed and evidence-based

product selection decisions, we have conducted a systematic review of internationally

recommended methods for procurement planning and prioritization in settings experiencing

severe resource constraints, describing the context for these activities and summarising

normative recommendations. Little is known about how MDE procurement takes place within

resource-constrained settings; the WHO Baseline Surveys on Medical Devices are recent

attempts to explore this [9, 10]. The survey’s findings suggest that LMICs predominantly

conduct procurement at central ministry level within the public sector [9]; however, the

surveys do not provide further granular information on how LMIC conduct or plan MDE

procurement. For the purposes of this paper, we adopt the MDE definition laid out by the

Global Harmonization Task Force and WHO [11, 12].
The identification of best practices and common pitfalls in MDE procurement may lead

to improvements in MDE management and use. This would not only ensure improved use of

scarce financial resources, but also translate to devices being operational and used

competently for improved patient care. The systematic review is particularly timely given

global efforts for health system strengthening in LMICs: MDEs are recognized as critical

components in ensuring health system resilience to shocks and in achieving universal

health coverage. Substantial increases in MDE utilization have already been noted in

middle-income countries in Europe in line with expanding provision of health care

services; similar trends will undoubtedly follow in LMICs globally [13].