Standard Operating Procedures for Sterilization Services in Camps

Transcription

1 Sandard Operaing Procedures for Serilizaion Services in Camps Family Planning Division Minisry of Healh and Family Welfare Governmen of India March 2008

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3 Sandard Operaing Procedures for Serilizaion Services in Camps Family Planning Division Minisry of Healh and Family Welfare Governmen of India March 2008

4 2008 Minisry of Healh & Family Welfare Governmen of India, Nirman Bhawan, New Delhi Any par of his documen may be reproduced and excerps from i may be quoed wihou permission provided he maerial is disribued free of cos and he source is acknowledged. Prining of his ediion for Governmen of India is suppored by UNFPA, New Delhi

5 G.C. Chaurvedi Addl. Secreary & Mission Direcor Hkkjr ljdkj LokLF;,oa ifjokj dy;k.k ea=ky;] fuekz.k Hkou] ubz fnyyh & Governmen of India Minisry of Healh & Family Welfare Nirman Bhavan, New Delhi Foreword In a counry where he populaion has crossed he billion mark provision of assured qualiy Family Planning services for he people becomes he prioriy of he policy makers. Serilizaion is sill he mos popular FP mehod adoped by our people o limi heir family. As he demand for serilizaion services remains very high wih a large unme need he counry has coninued wih he camp mode o reach he services o people in under served and under reached areas. However, he camp approach hrows ou challenges in erms of qualiy in service. Under he recenly launched Naional Rural Healh Mission (NRHM) of Governmen of India he archiecural changes envisaged would also address o hese issues by ensuring assured, fixed day qualiy services a FRUs, CHCs and 24x7 PHCs. However, we need o coninue wih he camp mode for some more ime ill we achieve he NRHM goals. As India is winessing large changes in erms of developmen in he curren era of globalizaion, he focus is now shifing from mere provision of services o qualiy service provision. Ensuring qualiy services in camps becomes one of he essenial componens in Family Planning service provision. The Governmen of India has recenly revised he Manuals on Female and Male Serilizaion and Qualiy Assurance Manual on Serilisaion, which form he sandard guidelines for serilizaion service for service providers. This manual on Sandard Operaing Procedures (SOP) addresses imporan areas like planning for a camp, logisics and manpower provision, infecion prevenion measures and monioring qualiy of services provided. The manual has been prepared wih he experise and insighs received from Sae Program officers, service providers, specialiss like senior Obseric & Gynecologiss, Surgeons, Public Healh specialiss. I is sincerely hoped ha his manual would help in adhering wih serilisaion sandards in he camps organized in many pars of he counry. The effors pu in by he Family Planning Division in preparing his maiden manual on SOP for Serilisaion services and commimen o ensure qualiy services in Family Planning is ruly commendable and is deeply appreciaed. March 2008 Shri G.C. Chaurvedi Addl. Secreary & Mission Direcor

6 Dr. M.S. Jayalakshmi Depuy Commissioner (FP) Hkkjr ljdkj LokLF;,oa ifjokj dy;k.k ea=ky;] fuekz.k Hkou] ubz fnyyh & Governmen of India Minisry of Healh & Family Welfare Nirman Bhavan, New Delhi Acknowledgemen This manual eniled SOP for serilizaion services in Camps has been prepared as a supporing documen o he Sandards on Female and Male Serilisaion and Qualiy Assurance Manual on Serilizaions, for ensuring qualiy care in he Serilisaion camps. As he demand for serilizaion services remains high and sill here are gaps in organizing fixed day service provision a sub disric level in many Saes, dependence on camps for caering o unme need for limiing mehods will have o coninue for some more ime. This manual has been prepared based on he inensive inpus received from various service providers, program managers and expers providing FP services in camps. I has been aemped o make he manual pracical under he exising service condiions, a he same ime ensuring adherence o sandards, hallmark of service qualiy. I wish o acknowledge he conribuion of various expers who have helped he Family Planning division in preparing he manual afer exensive discussions and experience sharing. I singularly wish o appreciae he coninuous, uniring effors and valuable inpus received from Dr Alok Banerjee, Dr. B. P. Singh, Dr. Kaza and Dr. Mangal. A special word of appreciaion for Dr. Dinesh Agarwal, Naional Programme Officer, UNFPA for helping in he concepualizaion of he manual. I am also hankful o all he Sae officials whose experience in developing a sysem in qualiy care helped he exper group o prepare a need-based manual. I also acknowledge he suppor rendered by WHO especially Dr Sonia Trikha in faciliaing all he meeings. The suppor exended by UNFPA in publicaion of his manual is sincerely acknowledged. The rus and suppor of Shri Amarjee Sinha, Join Secreary in all our endeavors o esablish qualiy care in Family Planning is deeply cherished by he division. My special hanks o Dr. Jaya Lalmohan and Dr. Sonali, Consulans in Family Planning Division who have irelessly worked for compiling his manual. A special word of appreciaion for Dr. S.K. Sikdar, AC (FP) whose conribuion has been immeasurable. I acknowledge he secrearial assisance rendered by Shri. Chauhan and Shri Malhora from FP division o bring ou he manual in ime. I is hoped ha his manual would encourage disrics o ensure he highes qualiy of care in serilizaion service provision. March 2008 Dr. M.S. Jayalakshmi Depuy Commissioner (FP)

7 Inroducion and he scope of he manual Range of services in a camp Counselling Clinical Services Lab Tess Pre-requisies for serilizaion camps Sie Probable Clien Load Camp Timings Saff Equipmen/Insrumens and Supplies Roles and responsibiliies of programme managers and service providers... 9 I. Pre-camp Aciviies (beginning of he year)... 9 II. During Camp Conducion of camps Pre-camp Aciviies Camp Aciviies Pos-camp Aciviies Prevenion of infecion: asepsis and anisepsis Mainenance of Asepsis in OT Processing of Equipmen, Insrumens and oher Reusable Iems Serilizaion or High-Level Disinfecions (HLD) Disposal of Wase, Needles, and Oher Maerials Assurance of qualiy in camp seing Annexures Annexure 1: Equipmen for Male/Female Serilizaion: Annexure 2: Managemen of Emergencies in Serilizaion Services Annexure 3: Common Emergency Drugs Lis of expers for formulaing he Sandard Operaing Procedures on Family Planning Services... 40

8 ANM BCC CHC CMO FRU HLD IEC IP IUCD LHV MO MPW MSMF NFHS NRHM NSV OCP OT PHC QAC RCH RTI STI Auxiliary Nurse Midwife Behaviour Change Communicaion Communiy Healh Cenre Chief Medical Officer Firs Referral Uni High Level Disinfecion Informaion Educaion Communicaion Infecion Prevenion Inrauerine Conracepive Device Lady Healh Visior Medical Officer Mulipurpose Worker Manual on Sandards for Male and Female Serilizaion, GOI-2007 Naional Family Healh Survey Naional Rural Healh Mission No Scalpel Vasecomy Oral Conracepive Pills Operaion Theare Primary Healh Cener Qualiy Assurance Commiee Reproducive Child Healh Reproducive Trac Infecion Sexually Transmied Infecion

9 Inroducion The recen NFHS III ( ) resuls show ha he oal unme need in conracepion for he counry sill remains high a 13%, ou of which 6% is for permanen mehods and 7% is for spacing mehods. Tradiionally he counry has been adoping he camp approach in serilizaion since he early 70s o address he issue of large need versus low service availabiliy. Under he NRHM and RCH II programmes of Governmen of India many sraegies are being operaionalized o reduce he unme need in RCH services including conracepion. However, we need o coninue wih he camp approach for some more years unil adequae insiuionalized services are made available as per he needs of he people a he mos peripheral level. Though his approach has he advanage and flexibiliy of reaching he needy a heir doorseps, qualiy of care becomes an area of concern in such seings. Hence i becomes essenial o have guidelines developed for ensuring qualiy care in camps, addressing o he large demand in difficul o reach/underserved areas which are no usually endowed wih rouine services. Camps are an alernae service delivery sraegy aiming for meeing unme demand for serilizaion services especially in underserved areas. Clearly here are challenges in ensuring adherence wih he sandards in he camp seing. Presen documen addresses hese barriers by spelling ou operaing procedures and hus empowers service providers and camp managers o deliver qualiy services under all circumsances. The formulaion of Sandard Operaing Procedures (SOPs) for Serilizaion Camps is an imporan sep in ensuring provision of qualiy services o he growing number of cliens coming for serilizaion services in he ou reach camps. I is envisaged ha programme managers and service providers would be encouraged o ake appropriae remedial measures for ensuring adherence o sandards in he camps as laid down in he Manual on Sandards for male and female serilizaion by Governmen of India. The scope of he manual The Sandard Operaing Procedures would serve as a guide for planning, implemening and monioring qualiy of services in serilizaion in a camp seing, for programme managers, camp managers and service providers a all levels. This documen may also be found useful by he service delivery organisaions engaged in organisaion of he camps, including NGOs.

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11 1. Range of services in a camp Wha is a camp? A serilizaion camp is defined as alernae service delivery mechanism, when operaing eam locaed a a remoe faciliy (Disric HQs/Medical colleges/frus) conducs serilizaion operaions a a sub disric healh faciliy, where hese services are no rouinely available. Service package for camp services should include following: 1. Counselling Counselling is he process of helping cliens make informed and volunary decisions abou heir feriliy. Mehod specific counselling should be done whenever a clien is unable o ake a decision or has a doub regarding he ype of conracepive mehod o be used. In he case of cliens found eligible for serilizaion he following seps should be aken before she/he signs he consen form for serilizaion: Cliens mus be informed of all he available mehods of family planning and should be made aware ha for all pracical purposes, serilizaion is a permanen one. Cliens mus make an informed decision for serilizaion volunarily. Cliens mus be counseled in he language ha hey clearly undersand. Cliens should be made o undersand wha will happen before, during, and afer he surgery, is side effecs, and poenial complicaions, including failure In siuaions where he camp is providing oher FP mehods, mehod specific counseling should also be provided 2. Clinical Services (a) Permanen mehods Vasecomy Screening and clinical assessmen and/or Procedure Tubecomy Follow-up Pre-procedure insrucions/preparaion Pos-operaive examinaion & insrucions

12 4 Sandard Operaing Procedures for Serilizaion Services in Camps Depending upon he availabiliy of human resources, service availabiliy a he camp sies, he disric programme managers can decide he ype of addiional services o be offered in Serilizaion Camps as given below. Addiional Services (b) Spacing mehods IUCD Counselling Screening and clinical assessmen Inserion Follow-up Managemen of complicaions Removal Combined Oral Pills Counselling Eligibiliy assessmen Provision Condoms Counselling (c) Emergency conracepion Provision Insrucions for proper use Counselling Eligibiliy assessmen Provision (d) Screening and managemen of RTIs/STIs Diagnosis and managemen as per naional guidelines 3. Lab Tess Hb Urine for sugar and albumin Urine for Pregnancy Tes (as indicaed in Sandards of Male and Female Serilizaion) In case of RTI/STI lab ess as per GOI Guidelines

13 2. Pre-requisies for serilizaion camps The camp should be organized exclusively for serilizaion services. Addiional services can also be offered depending on he exising service provision for addiional services. 1. Sie All Serilizaion Camps mus be organized only a esablished healh care faciliies as laid down in he Sandards by GOI. For IUCD inserion, a clean separae room wih adequae lighing arrangemen and privacy will be sufficien. Oral Pills, Emergency Conracepive Pills and Condoms can be dispensed a he counselling area. Under no circumsances should Serilizaion Camps be organized in a school building/panchaya Bhavan or any oher such se up. Camps should be always organised eiher a CHCs or PHCs. 2. Probable Clien Load Esimaion of likely number of cliens o urn up for accessing services will help in deermining number of eams. For mainaining qualiy service, each surgeon should resric o conducing a maximum of: 30 laparoscopic ubecomy (for 1 eam wih 3 laparoscopes) or 30 vasecomy (NSV or convenional) or 30 minilap ubecomy cases. * Wih addiional surgeons, suppor saff, insrumens, equipmen and supplies, he number of procedures per eam may increase proporionaely. However, he maximum number of procedures ha are performed by a eam in a day should no exceed 50. Depending upon he expeced clien load, requisie number of eams should be mobilized by he camp manager. 3. Camp Timings Camp imings should preferably be beween 9 a.m. and 4 p.m.

14 6 Sandard Operaing Procedures for Serilizaion Services in Camps 4. Saff A. For Female Serilizaion (a) Local eam Serial No. Camp Service Sie/Couner Toal No. of Saff Caegory and No. of Saff 1. Regisraion 1 Male worker/clerk 1 2. Hisory & Clinical Assessmen 2 MO 1 Saff Nurse/LHV/ANM 1 3. Counselling Area 1 Healh supervisor/anm 1 4. Laboraory Examinaion Pre-operaive Preparaion/ Premedicaion preparaion room Insrumen & reusable iems processing/serilizaion area IP Room 7. Operaion heare 3 8. Pos-operaive room 2 9. Office-cum-sore 2 Lab Technician 1 Cleaner 1 1 Saff Nurse/LHV/ANM IUCD/Oher procedure room 2 ANM 2 2 OT Aendan 1 Ward Boy/Aya 1 Saff Nurse/ANM 1 (eiher from he sie area or if no here a he sie, hen o come wih he visiing eam) OT Aendan 1 Cleaner 1 MO 1 Saff Nurse/ANM 1 Accounan 1 Compounder/Pharmacis 1 (b) Visiing eam members Serial No. Saff Caegory No. of Saff for Tubecomy Laparoscopy Minilap 1. Empanelled ubecomy surgeon Anaesheis (preferable) OT Assisan 1 -

15 Sandard Operaing Procedures for Serilizaion Services in Camps 7 B. For Male Serilizaion (a) Local eam Serial No. Camp Service Sie/Couner Toal No. of Saff Caegory and No. of Saff 1. Regisraion 1 Healh worker (M)/clerk 1 2. Clinical Assessmen 2 MO 1, Male worker 1 3. Counselling Area 1 Male Supervisor/Male worker 1 4. Laboraory Examinaion 2 Lab Technician 1 Cleaner 1 5. Pre-operaive Preparaion Room 1 Healh worker-male Insrumen & reusable iems processing/serilizaion area Operaion heare 8. Pos-operaive room 2 9. Office-cum-sore OT Aendan 1 Ward Boy/Aya 1 Saff Nurse/ANM 1 Cleaner 1 MO 1 Saff Nurse/ANM 1 Accounan 1 Pharmacis 1 (b) Visiing eam members Serial No. Saff Caegory No. of Saff for Vasecomy 1. Empanelled Surgeon 1 The responsibiliy of provision of he addiional services is o be borne by he local eam as per he guidelines laid down by Governmen of India. 5. Equipmen/Insrumens and Supplies The Equipmen/Insrumens and supplies needed for ensuring qualiy services in serilizaion camps, is given in Annexure 1. In camps where oher services are offered, addiional supplies for hose services also need o be made available. The In-Charge of he faciliy where he camp is being organised is he CAMP MANAGER who has he overall responsibiliy for he effecive organisaion of he camp.

16 2. Pre-requisies for serilizaion camps The camp should be organized exclusively for serilizaion services. Addiional services can also be offered depending on he exising service provision for addiional services. 1. Sie All Serilizaion Camps mus be organized only a esablished healh care faciliies as laid down in he Sandards by GOI. For IUCD inserion, a clean separae room wih adequae lighing arrangemen and privacy will be sufficien. Oral Pills, Emergency Conracepive Pills and Condoms can be dispensed a he counselling area. Under no circumsances should Serilizaion Camps be organized in a school building/panchaya Bhavan or any oher such se up. Camps should be always organised eiher a CHCs or PHCs. 2. Probable Clien Load Esimaion of likely number of cliens o urn up for accessing services will help in deermining number of eams. For mainaining qualiy service, each surgeon should resric o conducing a maximum of: 30 laparoscopic ubecomy (for 1 eam wih 3 laparoscopes) or 30 vasecomy (NSV or convenional) or 30 minilap ubecomy cases. * Wih addiional surgeons, suppor saff, insrumens, equipmen and supplies, he number of procedures per eam may increase proporionaely. However, he maximum number of procedures ha are performed by a eam in a day should no exceed 50. Depending upon he expeced clien load, requisie number of eams should be mobilized by he camp manager. 3. Camp Timings Camp imings should preferably be beween 9 a.m. and 4 p.m.

17 Sandard Operaing Procedures for Serilizaion Services in Camps 4. Saff A. For Female Serilizaion (a) Local eam Serial No. Camp Service Sie/Couner Toal No. of Saff Caegory and No. of Saff 1. Regisraion 1 Male worker/clerk 1 2. Hisory & Clinical Assessmen 2 MO 1 Saff Nurse/LHV/ANM 1 3. Counselling Area 1 Healh supervisor/anm 1 4. Laboraory Examinaion Pre-operaive Preparaion/ Premedicaion preparaion room Insrumen & reusable iems processing/serilizaion area IP Room 7. Operaion heare 3 8. Pos-operaive room 2 9. Office-cum-sore 2 Lab Technician 1 Cleaner 1 1 Saff Nurse/LHV/ANM IUCD/Oher procedure room 2 ANM 2 2 OT Aendan 1 Ward Boy/Aya 1 Saff Nurse/ANM 1 (eiher from he sie area or if no here a he sie, hen o come wih he visiing eam) OT Aendan 1 Cleaner 1 MO 1 Saff Nurse/ANM 1 Accounan 1 Compounder/Pharmacis 1 (b) Visiing eam members Serial No. Saff Caegory No. of Saff for Tubecomy Laparoscopy Minilap 1. Empanelled ubecomy surgeon Anaesheis (preferable) OT Assisan 1 -

18 Sandard Operaing Procedures for Serilizaion Services in Camps B. For Male Serilizaion (a) Local eam Serial No. Camp Service Sie/Couner Toal No. of Saff Caegory and No. of Saff 1. Regisraion 1 Healh worker (M)/clerk 1 2. Clinical Assessmen 2 MO 1, Male worker 1 3. Counselling Area 1 Male Supervisor/Male worker 1 4. Laboraory Examinaion 2 Lab Technician 1 Cleaner 1 5. Pre-operaive Preparaion Room 1 Healh worker-male Insrumen & reusable iems processing/serilizaion area Operaion heare 8. Pos-operaive room 2 9. Office-cum-sore OT Aendan 1 Ward Boy/Aya 1 Saff Nurse/ANM 1 Cleaner 1 MO 1 Saff Nurse/ANM 1 Accounan 1 Pharmacis 1 (b) Visiing eam members Serial No. Saff Caegory No. of Saff for Vasecomy 1. Empanelled Surgeon 1 The responsibiliy of provision of he addiional services is o be borne by he local eam as per he guidelines laid down by Governmen of India. 5. Equipmen/Insrumens and Supplies The Equipmen/Insrumens and supplies needed for ensuring qualiy services in serilizaion camps, is given in Annexure 1. In camps where oher services are offered, addiional supplies for hose services also need o be made available. The In-Charge of he faciliy where he camp is being organised is he CAMP MANAGER who has he overall responsibiliy for he effecive organisaion of he camp.

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20 3. Roles and responsibiliies of programme managers and service providers All funcionaries in a camp mus work ogeher as a eam owards successful and smooh conducion of he camp. The roles and responsibiliies given here are only suggesive and hey can be inerchanged as per need/requiremen of a paricular siuaion. The organizaion of a camp has 2 sages- 1. Planning for he camp 2. Conducion of he camp This chaper specifies he roles and responsibiliies of officials for boh he sages. I. Pre-camp Aciviies (beginning of he year) A. Disric chief medical officer To updae he lis of empanelled surgeons and circulae o all camp managers To noify/designae camp managers a he faciliies likely o organize serilizaion camps during he year To organize availabiliy of funds from RCH 2 programme a he faciliy level To consiue eams for camps in consulaion wih I/C Disric hospial/ FRUs from where he providers are going o be sen o camps. B. Disric nodal officer for FP (ADHO, Dy CMHO, DPM or ohers) Develop block-wise quarerly camp calendar specifying dae and sie in consulaion wih camp in-charge To ensure communicaion o he operaing eams in advance To keep ready a lis of sandby saff so as o mee any coningency requiremens To keep a sock of equipmen such as laparoscopes/nsv equipmen ready and also arrange for AMC/repairs To ensure ha all necessary supplies required for he camps are made available in adequae quaniies before he commencemen of he camp To ensure ha adequae funds are available wih he camp manager for disbursemen as incenives.

21 10 Sandard Operaing Procedures for Serilizaion Services in Camps C. Camp manager/sub-disric hospial/fru/chc/phc (camp sie) To coordinae he eam aciviies wih he disric nodal officer To arrange for he required funds for organizing he camps To ensure availabiliy of he local eam members To ensure availabiliy of equipmen, insrumens and oher supplies for each camp To ensure inense IEC aciviies regarding he camp in his area in coordinaion wih he Disric auhoriies. II. During Camp For he delivery of services in he camps, wo eams are required o work in close coordinaion, i.e. he local eam a he camp sie and he visiing eam. Local Team Camp manager The responsibiliies of he Camp Manager are: To ensure all members of visiing eam reach in ime To assign responsibiliies for he faciliy saff for saffing differen saions To check ha OT has been disinfeced in advance To ensure ha emergency medicines and oher supplies are available a designaed places Sie medical officer To ensure ha all cliens are counselled properly To conduc full clinical assessmen of he cliens and documen he same as specified in he GOIs Sandards manual. To provide pre-procedure insrucions o cliens (MSMF, pg 54-58) To provide pos-procedure check-up and give insrucions, boh verbal and wrien before discharge for each operaed clien (MSMFl pg 62,63,69,70) To ake care of pos-procedure follow-up of cliens for any problem inclusive of sich removal for serilizaion cliens. To counsel and provide oher conracepive services o cliens found no eligible for serilizaion. Saff nurse/anm She will be overall in-charge of preparaion and mainenance of Operaion Theare (OT) complex and infecion prevenion measures. To provide counselling for all he cliens coming for serilizaion

22 Sandard Operaing Procedures for Serilizaion Services in Camps 11 To assis MO in performing pre-procedure clinical assessmen. To ensure documenaion of wrien informed consen To ensure sufficien maerial including serilized linen, insrumens and oher supplies To ensure proper IP pracices a all levels,before and during all procedures To ensure ha all he emergency equipmen is in funcional order and available To confirm he pre-procedure check-up of cliens by empanelled surgeon/gynaecologis and anaesheis and ensure compleion of records before he procedure To assis empanelled surgeon/gynaecologis and anaesheis during procedures To monior he cliens during he procedure and assis in pos-operaive care Laboraory echnician To ensure availabiliy of all he laboraory equipmen and reagens for he camp To perform pre-procedure invesigaions like Hb, urine, ec. To documen he findings of invesigaions on he clien s char To mainain he record of all invesigaions done To ensure qualiy of all laboraory invesigaions Pharmacis To ensure sufficien medicines and oher supplies for all he cliens To disribue medicines o he cliens as per guidance of medical officers/surgical eam To perform any oher duy assigned by he camp manager Healh supervisor/worker To assis in filling up chars and consen forms of cliens To give pre- and pos-procedure insrucions o cliens/aendans To guide he cliens for differen services In he absence of a Saff Nurse, should perform her duies To be in charge of he regisraion couner To perform any oher duy assigned by he camp manager Class IV (OT aendan/ward boy/ayah, ec.) To prepare faciliy for he camp under guidance of supervisors To shif cliens o and from OT To carry equipmen/aricles from and o he vehicle To assis OT Assisan and saff nurse in OT

23 12 Sandard Operaing Procedures for Serilizaion Services in Camps To deconaminae aricles To clean insrumens and linen To perform any oher job assigned by he camp manager Safai karmchari Visiing Team To clean he premises including lab, procedure room and OT To rim hair in vasecomy cliens To disinfec procedure room and OT under guidance of OT Saff To help he oher Class IV workers o shif equipmen and linen from one place o anoher and also o shif he cliens, if necessary To perform any oher job assigned by he camp manager Surgeon/gynaecologis To ensure ha each clien has been adequaely counselled and screened as per laid down Sandards in he prescribed forma including ensuring/confirming pre-procedure finess and informed consen of clien for he procedure To fill he checklis before conducing he procedure To ensure requisie equipmen/insrumens and supplies for he procedure as well as hose needed for emergency preparedness are as per he Sandards. To perform serilizaions of screened cliens as per he laid down procedures To ensure emergency and surgical procedure preparedness To pracice and ensure adherence o universal IP pracices in all procedures To documen procedural deails and pos-operaive insrucions on he records of all operaed cases as given in he Sandards To do pos-operaive check-up wherever required as per Sandards. To deal wih emergencies and ensure appropriae referral o higher cenre in case of complicaions Anaesheis (if available) To verify he availabiliy and funcionaliy of anaesheic insrumens and drugs a he camp sie To ensure pre-operaive check-up and finess for anaeshesia whenever required. To supervise local and adminiser regional or general anaeshesia according o he siuaion To deal wih any emergency/complicaion relaed o procedures

24 Sandard Operaing Procedures for Serilizaion Services in Camps 13 To documen anaeshesia noes in he char of each clien To do immediae pos-operaive follow-up of cases operaed under aneshesia Operaion heare assisan (OTA) To work in coordinaion wih saff nurse/anm/lhv To verify he availabiliy of all he equipmen and insrumens and ensure ha hey are in funcional condiion in he operaion heare To ensure HLD/serilizaion of equipmen, insrumens, linen, ec. To ensure cleanliness and disinfecion of OT In case of female serilizaion, o make sure ha he laparoscopes are processed afer each procedure and a he end of he camp session, as laid down in he Sandards. To assis he empanelled surgeon and anaesheis during procedures To perform any oher job assigned by he visiing eam

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26 4. Conducion of camp In he following paragraphs, an aemp has been made o lis differen aciviies which are criical o deliver qualiy services in a camp seing. 1. Pre-camp Aciviies 1.1 Communicaion Aciviies i. Inform ANMs, ASHAs, AWWs, VHSC members in advance during monhly meeings abou he camp daes and venue ii. Organise wall painings a busy sies i.e. bus sands, display banners iii. Use local cable TV nework if possible 1.2 Planning for he Camp Orienaion of sie saff on previous day by camp manager Review of infrasrucure and availabiliy of equipmen and supplies including case shees, consen forms, follow up cards, ec. Mobilizaion of saff from periphery/addiional PHC/oher sies if required Preparaion of duy lis and inimaion of he saff Ensuring elecriciy and running waer supplies Ensuring availabiliy of compensaion money Confirming availabiliy of surgical eam a scheduled ime Ensuring availabiliy of ranspor faciliy for referrals Puing up display boards in healh insiuions, one monh prior o he camp, which shall inimae he dae of camp wih ime and services o be provided on ha day Providing adequae siing and waiing arrangemens wih proeced space (from sun and rain) provided for boh cliens and aendans. Making adequae arrangemens for drinking waer, saniaion and oile faciliies for he healh personnel as well as he cliens and heir aendans. One oile should be earmarked for women 2. Camp Aciviies Primary responsibiliy for organizing he camp lies wih he designaed camp manager

27 16 Sandard Operaing Procedures for Serilizaion Services in Camps All insrumens, drugs and supplies for he camps should be made available in advance and pu in heir righ places. Sie faciliy should ensure enough serilized linen and oher maerial including saionery and forms as per expeced clien load. The normal funcioning of he CHC/PHC should no be disruped. Adequae safey arrangemens in coordinaion wih he local police auhoriies should also be provided for, o preven any unoward incidens If large number of clien s are expeced There should be clear signages for he differen service areas as specified below o faciliae he smooh flow of cliens. GENERAL AREAS: Waiing area Regisraion area Counselling Area Clinical Examinaion Laboraory Examinaion Office-cum-sore PROCEDURE AREAS: Pre-procedure preparaion area Insrumen processing area Scrub area Operaion heare - if boh ubecomy and vasecomy services are provided, here should be separae operaion heares Pos-operaive or recovery room/ward

28 Sandard Operaing Procedures for Serilizaion Services in Camps 17 Flow Char for Camp Services Regisraion Counselling Clinical Assessmen for Cliens Agreeable for Serilizaion Fi for Serilizaion Unfi for Serilizaion Informed Wrien Consen RTI/STI Spacing Mehods Lab Tess Pre-procedure Assessmen Managemen and Counselling Counselling Mehod Provision Surgical Procedures If Services No Available, Refer IUCD Oher Spacing Mehods Pos-operaive Care Pos-procedure Counselling Pos-procedure Counselling and Medicaions 3. Pos-camp Aciviies Provide follow-up care as laid down in he Sandards Manual Aend o complicaions of procedures, if any, ha were performed in he camp (Refer o Sandards for Female and Male Serilizaion) All saff of he healh care faciliy should preferably be rained in emergency managemen. Guidelines for emergency managemen should be followed as given in Annexure 2

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30 5. Prevenion of infecion: asepsis and anisepsis I is mandaory o pracice appropriae infecion prevenion (IP) procedures a all imes wih all cliens o decrease he risk of ransmission of infecion, including he Human Immunodeficiency virus (HIV), Hepaiis C (HCV), and Hepaiis B (HBV). Sandard universal precauions of infecion prevenion include: Washing hands Ensuring self-proecion by wearing aires, gloves and employing oher physical barriers Adoping safe work pracices (o preven injuries from sharp insrumens) Mainaining proper mehods of environmenal cleanliness Ensuring he proper processing of insrumens and oher iems Following proper wase-disposal pracices and handling, ransporing, and processing used and/or soiled linen in he recommended and prescribed manner. Deailed guidelines for IP pracices are given in he Sandards for Male and Female Serilizaion. However, some of he imporan seps are highlighed in his chaper. 1. Mainenance of Asepsis in OT Before Surgery Clean he floor wih a mop soaked in 0.5% chlorine soluion. Clean he able/couner op wih a cloh soaked in 0.5% chlorine soluion Afer Surgery Deconaminae all operaing room surfaces ha come ino conac wih he paien (such as able) beween procedures by scrubbing and wiping hem wih 0.5% chlorine soluion The operaing able, couners/able ops and ligh handles should be wiped wih a deergen and 0.5% chlorine soluion Chlorine soluion should be prepared fresh daily When No in Use The OT should be locked when no in use Daily cleaning: Scrub and wipe he room wih he recommended disinfecan i.e. 0.5% chlorine soluion

31 20 Sandard Operaing Procedures for Serilizaion Services in Camps Movemen in and around he OT The enry of people and heir movemen inside he OT should be minimal as he inroducion of a number of micro-organisms is relaed direcly o he number of people and heir movemen During surgery, he door of he OT should be kep closed Only he personnel performing or assising should ener he OT Personnel who have any infecion should no ener he OT a all Recovery Room (RR) The enry of people and heir movemen inside he RR should be minimal as he inroducion of a number of microorganisms is relaed direcly o he number of people and heir movemen During pos-operaive care he door of he RR should be kep closed Only he personnel involved in pos-operaive care like he aending surgeon/anaesheis should ener Personnel who have any infecion should no ener he RR a all Only one relaive should be allowed 2. Processing of Equipmen, Insrumens and Oher Reusable Iems Seps involved are: 1. Deconaminaion of Equipmen, Insrumens, and Oher Reusable Iems Surgical insrumens, reusable gloves, and oher iems ha have been in conac wih blood or oher body fluids should be deconaminaed prior o cleaning Immediaely afer use, hese iems should be placed in a plasic bucke conaining a soluion of 0.5% chlorine for 10 minues Afer 10 minues, he iems should be removed from he chlorine soluion and rinsed wih waer or cleaned immediaely Uiliy gloves and clohes should be worn during his and subsequen seps A new chlorine soluion should be prepared a he beginning of each day 2. Cleaning of Equipmen, Insrumens, and Oher Reusable Iems Cleaning reduces he number of micro-organisms and endospores on insrumens and equipmen The insrumens and oher iems should be scrubbed vigorously wih a brush (a ooh brush is a good opion) in lukewarm waer wih deergen o remove all blood, issue, and oher residue Deergen should be used as waer alone will no remove proeins or oil

32 Sandard Operaing Procedures for Serilizaion Services in Camps 21 Soap is no recommended as i can leave a residue Ho waer should no be used because i can coagulae proein such as blood, making i harder o remove The iems should hen be rinsed horoughly wih waer and allowed o air-dry. Iems ha require HLD by boiling can be placed direcly in a po of waer afer cleaning Preparaion of 0.5% Chlorine Soluion Mix 150 gm of commercially available bleaching powder (abou 10 ablespoonful/30 easpoonful) in en lires of ap waer. Before mixing, make a pase in small quaniy of pre-measured waer and mix ino he remaining measured waer. The prepared chlorine soluion can be used for 24 hours. Prepare fresh chlorine soluion a he beginning of camp. 3. Serilizaion or High-Level Disinfecions (HLD) HLD by Boiling Insrumens for HLD mus be deconaminaed and cleaned wih deergen and waer prior o boiling Once he waer sars boiling, boil for 20 minues in a po wih a lid. Aricles mus be compleely immersed in he waer Do no add anyhing o he po afer boiling begins Afer boiling, remove objecs wih a serile or previously HLD forceps Use objecs immediaely or sore hem in a covered, airigh, dry HLD conainer for up o seven days If sored in an ordinary covered conainer, he objecs can be used for up o 24 hours HLD by Chemical Mehod Afer deconaminaing, cleaning, and drying he used objecs, soak for 20 minues in a soluion conaining 2% gluaraldehyde. Thoroughly rinse he objecs wih waer boiled for 20 minues before use Use objecs immediaely or place hem in a covered, dry HLD conainer Iems should never be kep soaked in waer or soluions such as Ceavalone, spiri, carbolic acid, gluareldehyde, ec. Always sore HLD iems dry. Seam Serilizaion (Auoclaving) Always consul he specific operaing insrucions supplied by he manufacurer Deconaminae, clean, and dry all insrumens ha are allowed o be auoclaved

33 22 Sandard Operaing Procedures for Serilizaion Services in Camps Wrap cleaned insrumens in cloh or newspaper, or place unwrapped insrumens in a meal conainer Arrange wrapped packs in he chamber or drum o allow free circulaion of hea or seam among he surfaces of all iems. Iems such as scissors and forceps should be serilized in an open posiion Serilize insrumens for he recommended ime as shown below: ** Serile waer can be prepared by auoclaving a 15 lbs. pressure Time necessary o auoclave liquids like waer depends on many facors and he mos imporan of which is he volume of waer being auoclaved. In general imings are: ml 20 minues ml 25 minues ml 30 minues ml 35 minues ml 40 minues Serilizaion by Chemical Mehod Deconaminaed, cleaned, and dried iems are pu in 2% gluaraldehyde soluion for a leas 8 o 10 hours. Iems such as scissors and forceps should be pu ino he soluion in an open posiion. Do no add or remove any iems once he imer sars. Iems should be rinsed well wih serile waer** (no boiled waer), air-dried, and sored in a covered serile conainer for up o 7 days. This mehod is mos suiable for endoscopes and plasic cannulae. Processing Laparoscopes Laparoscopes and accessories should be serilized or should undergo HLD using he chemical mehod by soaking in 2% gluaraldehyde soluion. All seps of he deconaminaion and cleaning process mus be followed before he laparoscopes and accessories are pu in he chemical soluion. Deconaminaion: Immediaely afer use, genly wipe he laparoscope, fibroic ligh source, and cable and plasic ubing wih lure lock using a cloh soaked in 60 90% ehyl or isopropyl alcohol o remove all blood and organic maerial. Cleaning: Place he dissembled pars of he laparoscope in a basin of clean waer. Wash all ouer surfaces using a sof cloh. Clean he inner channels wih a clean brush supplied wih he laparoscopic ki. Dry wih clean sof cloh.

34 Sandard Operaing Procedures for Serilizaion Services in Camps 23 High-level disinfecion: Pu clean and dried dissembled equipmen in a basin conaining 2% gluaraldehyde soluion for 20 minues. For he disinfecion o be effecive, all pars of he laparoscope mus be fully immersed and he disinfecan mus ouch all he surfaces of he insrumen. Rinse wice wih HlD waer (waer boiled for 20 minues and cooled) o remove all races of he disinfecan. Serilizaion: To serilize, soak he clean and dried dissembled laparoscope in 2% gluaraldehyde soluion for 8 o 10 hours. Rinse a leas hree imes wih serile waer o compleely remove all races of he disinfecan and sore in a serile covered conainer. 4. Disposal of Wase, Needles, and Oher Maerials Conaminaed wase is a poenial source of infecion for he saff as well as he local communiy. Therefore, wase should be disposed of properly. Wase should be buried or burn. Burning should preferably be done in an incineraor or seel drum as opposed o open burning. If burning is no possible, hen he wase should be pu in a pi and buried, bu i should never be hrown ouside or lef in open pis. For wase ha is o be picked by he municipal auhoriies, hese should be placed in closed dumpsers prior o removal. Solid wase, including dressings and oher iems conaminaed wih blood and organic maerial, should be disposed of in leak-proof washable conainers convenienly locaed in he OT/ procedure house. Liquid wase should be poured down a uiliy drain or ino a oile or larine wih a flush; or else i should be buried. Avoid splashing when disposing of liquid wase. Sharp objecs (hypodermic needles, scalpel blades, suure needles) should be disposed of in a puncure-resisan conainer wih a lid made of eiher meal or heavy rigid plasic or cardboard. Conainers wih needles and sharp objecs should be disposed of by burning or burying on sie.

35 24 Sandard Operaing Procedures for Serilizaion Services in Camps Summary of Mehods of Serilizaion and High-Level Disinfecion for Various Reusable Maerials Maerials Linen (Drapes, sponges, scrub suis, operaing packs, ec.) Rubber goods (gloves, caheers, and rubber ubing) and Surgical Insrumens HLD Mehod Serilizaion No recommended Auoclaving: 121 C a 15 lb./sq. inch pressure for 30 minues. Should be used wihin one week. If drum is opened, hen use wihin 24 hours. By boiling: 20 minues By immersing in chemical: a. Gluaraldehyde 20 minues or b. Parasiic acid 10 minues By auoclaving: A 15 lb./sq. inch pressure for 30 minues Always wrap iems in paper/newspaper before auoclaving. Gloves should always be serilized for 30 minues a 15 lb./sq inch pressure by wrapping in paper/newspaper and should be used hours afer serilizaion so ha hey regain heir elasiciy By immersing in chemical: a. Gluaraldehyde 10 hours or b. Parasiic acid 30 minues

36 6. Assurance of qualiy in camp seing The qualiy of serilizaion services provided can be assessed hrough he already exising documenaion ools available a he faciliies and insrumen/ools specifically designed for his purpose. The areas requiring improvemen should be idenified using hese ools and his will ulimaely be beneficial in improving he qualiy of he services delivered. The following need o be moniored for assuring qualiy care in a camp: Faciliy inpus Procedures adoped Mainenance of records and regisers Clien care and saisfacion The Disric Qualiy Assurance Commiee (DQAC) as well as he Qualiy Improvemen Commiee (QIC) a he faciliy level are responsible for monioring qualiy. Role of DQAC The DQAC should monior a leas 10% of he camps held in he disric o ensure qualiy of care as per he checkliss for Clien case record, Faciliy Audi, Observaion of Asepsis and surgical procedure, and Clien Exi inerview laid down in he Qualiy Assurance Manual for Serilizaion Services by Governmen of India. Role of Qualiy Improvemen Commiee A each service delivery sie serilizaion service needs o be moniored and reviewed. This ask can be performed by service providers from he faciliy iself hrough a process of selfassessmen ha will idenify issues relaed o qualiy improvemen, help in resolving he idenified problems, recommend soluions, and ensure ha high-qualiy services are provided. The suggesed composiion of he QIC a Disric Hospials/Civil Hospials/Sub-divisions/Referral Hospials is as follows: I/C Hospial/Medical Superinenden: Chairperson I/C Operaion Theare/Anaeshesia I/C, Surgeon I/C Obserics and Gynaecology I/C Nursing I/C Ancillary Services (ward boys)

37 26 Sandard Operaing Procedures for Serilizaion Services in Camps I/C Transpor I/C Sores I/C Records A he level of CHC, a smaller commiee of 4 o 5 members comprising he Medical Superinenden, I/C Surgery, I/C Obserics and Gynaecology, I/C OT, Nursing I/C and oher key members of saff should be consiued. The scope of work of his QIC will include all he processes involved in he serilizaion services being provided a he camp. The responsibiliies of he QIC will be as follows: Idenifying criical qualiy processes in ligh of he sandards for serilizaion Reviewing he processes wih he help of he checkliss on clien case audi/ faciliy audi/ observaion of sepsis and surgical procedure Developing a work plan lising aciviies for improvemen and puing his ino acion The QIC should mee once a monh o review, analyze and recommend soluions o he problems experienced in holding FW Camps and assess he qualiy of care. This is essenial for aking remedial acions for fuure camps, as camps are o be organized as a regular, fixed day monhly aciviy a faciliies like CHCs and PHCs where regular weekly services are no being provided.

38 Annexures

39

40 30 Sandard Operaing Procedures for Serilizaion Services in Camps C. Anaeshesia Drugs Serial No. Drugs No. Required Female Serilizaion Male Serilizaion 1. Inj. Diazepam 30 amps 5 2. Inj. Promehazine 30 amps 5 3. Inj. Penazocine 30 amps 5 4. Inj. Aropine 30 amps 5 5. Inj. Pehidine 30 amps - 6. Inj. Xylocaine 2% 25 vials 15 vials 7. Inj. Keamine 50mg/ml* 1 vials - 8. Inj. Scoline* 1 vials - 9. Inj. Penohal 1 gm vial* 1 vials - (*as per requiremen, if anaesheis is available) D. Emergency Drugs; *for Boh Tubecomy & Vasecomy Camps Serial No. Name No. Required 1. Inj. Andrenalin 10 amps 2. Inj. Hydrocorisone 10 vials of 100 ml each 3. Inj. Chlorpheneramine Maleae 10 amps 4. Inj. Frusamide 5 amps 5. Inj. Aropine 10 amps 6. Inj. Mephenine 2 vial 7. Inj. Aminophylline 5 amps 8. Inj. Deriphylline 5 amps 9. Inj. Soda Bicarb. 12 amps 10. Inj. Diazepam 5 amps 11. I/V fluids 5% dexrose 5 vacs 12. Normal Saline 5 vacs 13. Ringer Lacae 5 vacs * Anaphylaxis rays and emergency rays should be mainained and boh rays should be readily available in operaion heare and injecion room

41 Sandard Operaing Procedures for Serilizaion Services in Camps 31 E. Pos-Operaive Drugs Serial No. Name No. Required Tubecomy Vasecomy 1. Cap. Amoxycillin-cloxacillin 500 mg 500 capsules 600 capsules 2. Tab. Ciprofloxacin 500 capsules 600 capsules 3. Tab. Ibuprofen 400 mgs 500 ables 600 ables 4. Tab. B Complex 200 ables 200 ables 200 ables 5. Tab. Iron 200 ables - F. Disinfecans/Anisepics, ec. Serial No. Name No. Required Tubecomy Vasecomy 1. Glueraldehyde * 10 lire 5 lire 2. Povidine Iodine 5% 1.5 lire 1.5 lire 3. Spiri 2 lire 1 lire 4. Bleaching Powder 150 gms packes 15 packes 15 packes 5. Surgical Hand scrub 500 ml 500 ml 6. Deergen powder 250 gms. 250 gms. * Should be available wih he eam, if sie does no provide regular serilizaion services. G. Dressing Maerial Serial No. Name No. Required Tubecomy Vasecomy 1. Medicaed ape large size Adhesive plaser-10 cm wide 2 rolls - 3. Bandages 6 3 dozen 4 dozen 4. Coon ½ kg. roll Gauze Thin 4 4

42 Annexure 1 Equipmen for Male/Female Serilizaion Equipmen/insrumens and supplies are given for a clien load of 30 for one surgical eam A. Serilizaion Equipmen for Male/Female Serilizaion Serial No. Iem No. Required Female Serilizaion Male Serilizaion 1. Laprocaor/laparoscope ses 3-2. Minilap ses 5-3. NSV Kis 5 4. Convenional Vas Ki Volage sabilizer 1 6. Falope-rings 40 pairs - 7. CO2 cylinder (if available) 2-8. Insufflaors 1 - B. Anaeshesia Equipmen Serial No. Iem No. Required 1. Porable Boyle s apparaus* 1 2. Oxygen cylinders wih mask (adul) and wrench 2 3. Nirous oxide cylinders* 2 4. Laryngoscope 1 5. Ambu bag adul size 1 6. Endoracheal ubes 1 of each size * If anaesheis available

43 32 Sandard Operaing Procedures for Serilizaion Services in Camps H. Oher Equipmen and Aricles Serial No. Name No. Required Tubecomy Vasecomy 1. Cidex ray Female Urehral Caheer 2 (meal) Enema cans Sponge holding forceps Vaginal Speculum (Sims) Volsellum Serilized surgical gloves 6.5 Nos. 7 & 7.5 Nos. 40 pairs 40 pairs 40 pairs 30 pairs 30 pairs 40 pairs 8. Uiliy Gloves 7, 8 and 9 Nos. 6 pairs 6 pairs 9. BP apparaus Sehoscope Torch 4 cell Hea convecors Serilizaion drums Auoclave Boilers for HLD Seel bowls Chile s forceps Sharp scissors for gauze cuing Serilized Syringes 10 ml ml ml Surgical blades No. 11, pieces each 10 pieces each * 21. Cagu chromic foils Silk hread roll 2 roll burner sove Anerior vaginal wall reracor Uerine sound 2 -- * If convenional vasecomy done Cond...

44 Sandard Operaing Procedures for Serilizaion Services in Camps 33 Serial No. Name No. Required Tubecomy Vasecomy 26. Powder for gloves * * 500 gms 500 gms 27. Wash basin Kidney rays, sainless seel Hypodermic needles numbers 23,24,26 4 dozen each 4 dozen each 30. I/V Ses Scalp vein ses size Venflon 20G Plasic Cconainers for deconaminaion Plasic ubs for cleaning insrumens Plasic linen conainer (for used linen), wih cover Wase conainers Wall clock 1 1 ** If auoclaved gloves are used I. Linen Serial No. Name No. Required Tubecomy Vasecomy 1. Surgical Gowns Plasic aprons Caps Masks Eye cover / shield * Covered plasic shoes sizes 8 & 9 or shoe cover 12 pairs 12 pairs 7. Serilized surgical shees (Cu shees) Mackinosh shee 15 meers 15 meers 9. Surgeon suis Paien suis 30 * If service provider uses own power glasses, hen no required, oher wise plain glasses/eye shield required

45 Annexure 2 Managemen of Emergencies in Serilizaion Services I is essenial ha when an emergency occurs he docors, nurses and oher saff should respond compeenly in order o save he life of he clien. Members of he saff mus be rained o handle specific complicaions. The person monioring he clien in he operaing operaion room heare and in he recovery room mus be aware of early signs of complicaions, and be able o ake iniial emergency acion. A leas one member of he eam mus know how o adminiser cardiopulmonary resusciaion. Knowing wha o do in an emergency requires knowledge of: Clinical siuaions, heir diagnosis and he reamen Drugs, heir use, adminisraion and side effecs Emergency equipmen and how i funcions and The role of each eam member in an emergency A. Approach o an Emergency When some one collapses or becomes suddenly ill: Try o keep calm and hink logically: you probably do know wha o do. Make sure ha some one wih medical knowledge says wih he clien Call for help. Delegae someone o call oher assisans and ge he oxygen cylinder, Ambu bag and emergency drugs. Talk o he clien; ask quesions. Sop any procedures ha are in progress on he clien and Proceed wih he following - Lower he head of he able Give oxygen Sar an IV if no in place Noe he ime Coninue o monior vial signs Assess he clien s ABC : Airways, Breahing and Circulaion

46 Sandard Operaing Procedures for Serilizaion Services in Camps 35 B. Assess he Clien s ABCs Airway: Is here anyhing blocking he mouh or hroa? Has he ongue fallen back? Try o exend he neck and pull he jaw forward. Breahing: Is he clien breahing? Pu your cheek down o he clien s mouh o look, lisen and feel for he passage of air. Circulaion: Check for pulse, preferably caroid. Use 5 seconds o check he pulse in he neck. C. Cardio-pulmonary Rescusciaion (CPR) Sep A: Airways 1. Open air ways, use head il chin lif posiion o correc obsrucion by ongue. 2. Look, lisen and feel for breahing for 3-5 seconds 3. Keep air way open 4. Clear air way by sucioning any secreions or vomius Head Til Chin Lif If clien is no breahing, follow Sep B Sep B: Breahing 1. Inser oral airway. Inser airway up side down (curved ip poining o roof of he mouh) and roae he air way 180 degrees during inserion unil he flange is agains eeh. If oral air way canno be passed, inser a nasopharyngeal air way. 2. Venilae paien using eiher an Ambu bag wih 100% oxygen or manual resusciaor wih room air. Place mask over mouh and nose. Apply pressure o keep sealed. Compress bag o deliver air. If he above is no available perform mouh- o- mouh resusciaion.

47 36 Sandard Operaing Procedures for Serilizaion Services in Camps 3. Give wo slow breahs. Mainain head il chin lif posiion Ensure breahs go in by waching ches rise and by lisening for breah sounds wih sehoscope on side of paien s ches If breahs do no go in, reposiion head and ry again o give breahs. Allow all air o escape beween breahs Avoid overly large volumes of breahs 4. Check caroid pulse. If paien has no pulse, follow Sep C. 5. Coninue breahing a he rae of breahs per minues unil he paien breahes sponaneously. Avoid more rapid breahs. 6. Place Endo-racheal ube ( if rained and skilled personnel available). Sep C: Circulaion Perform exernal cardiac compression (1) Ches compression echnique 1. Place your fingers on he lower margin of he clien s rib cage on he side nearer you (Shown in Figure). 2. Slide your fingers up he rib cage o he noch where he ribs mee he lower sernum in he cenre of he lower par of he ches. 3. Place he base of one hand on he lower half of he sernum (Shown in Figure) and he oher hand on op of he firs, so ha he hands are parallel (Shown in Figure). 4. Keep hands in conac wih he ches a all imes. 5. Compress sernum down 4 o 5 cm. smoohly.

48 Sandard Operaing Procedures for Serilizaion Services in Camps 37 Posiion he rescuer s hand on he lower half of he sernum A B C D Two person rescue: Give 5 compressions in approximaely 3 seconds Give 1 full breah. Afer every 5 compressions pause o allow second medical aendan o give 1 breah. Give breahs as in Sep B. One person rescue: Give 15 compressions in approximaely 10 seconds Give 2 full breahs. Afer every 15 compressions give wo breahs. Give breahs as in Sep B. 6. Sop CPR afer one minue o deermine if he paien has resumed sponaneously breahing or circulaion; oherwise do no sop CPR for more han 5 seconds. 7. Coninue CPR unil clien responds or for a minimum of 30 minues 8. Apply ECG leads if available. Coninue CPR and ransfer he paien o a higher cenre if needed.