We are partnering with World Health Immaging Alliance to rapidly and effectively implement digital x-ray services in Achham. We would like to implement this machine quickly, because we have the clinical capacity and the HIV epidemic is spiraling out of control.  We are seeing an increasing number of HIV+ patients who require X-Ray for evaluation of acute pneumonic processes like tuberculosis, community-acquired pneumonia, and PCP. We would like this to be a model for other organizations in ramping up effective, responsible X-Ray services in a timely manner. We should all work together to demonstrate not only the "how" of the model but also the "when" of the model-- and our measure for success on that end will be how many days it takes us from identifying the need and your organization to successful deployment. Our workplan is available for download here:

http://www.nyayahealth.org/Library/WHIA_nyaya_xray.pdf

Our accompanying fundraising campaign:

http://www.nyayahealth.org/Library/xray_campaign.pdf

 

Below is are some planning notes. 

 

 

Capacity, Demand, and Strategy to Utilize X-Ray Timeline for Implementation Layout of the Site Legal Requirements Security Patient Demand Human Resources Power Technician Support Training and Maintenance Manuals Communications Computing Dell D800 Specifications IBM/Lenovo 8932A17

  

Capacity, Demand, and Strategy to Utilize X-Ray

Nyaya Health presently has a cadre of 20 professional paid Nepali staff members and 60 volunteers. We are ready to expeditiously implement effective and efficient X-Ray services. The primary emergent reason for the need for X-Ray services is that they are critical for providing comprehensive HIV/AIDS services. Our district of Achham suffers from the highest prevalence of HIV in Nepal. The HIV epidemic, fueled by mass migration to India, is growing.  The government is providing us with antiretroviral medicines that they have procured through the Global Fund and other sources, and they are cooperative with all aspects of our diagnostic radiology program.

 

Presently, Nyaya Health is moving our operations from a health center to a government hospital that the Ministry of Health is turning over to Nyaya for managing.  The hospital is the site of the X-Ray deployment.  Currently, the nearest X-Ray facility is 3 hours away in a neighboring district.  Achham itself has no X-Ray capacity.

 

Timeline for Implementation

Gain government approval for Bayalpata Hospital.  Goal: April 1.

Siting of the hospital and identification of the room for x-ray.  Goal: April 10.

Fundraising with Rotary, WHIA, and Nyaya for the $67,000 required for implementation.  Goal: May 1.

Develop training and maintenance manuals/materials. Goal: May 1.

Identification of necessary personnel for installation and maintenance.  Goal: June 1.

Develop clinical protocols and electronic medical record forms.  Goal: May 15.

Undertake initial renovations of the spaces.  Goal: May 1.

Transport the x-ray and deploy it.  Ideally Swati on-site.  Goal: July 1. 

 

Layout of the Site

The x-ray will be deployed at our new hospital site in Bayalpata.  There are several rooms available in this 7-building facility for diagnostic radiology purposes.  We will be formalizing the renovations and siting process for the new radiology suite over the next few months.  We will need to communicate to the Achham team exactly what it is that we are requiring of space-wise, and identify the optimal location for the diagnostic radiology facility.  Consideration should be made for possible rapid expansion to include CT services as well.

 

We would need one workstation for viewing X-Rays.  

 

Legal Requirements

The requirements on the part of the Ministry of Health of Nepal are: 

• In order to install one x-ray machine, a room with a minimum area of 225sq.ft must be available.

• The wall thickness of the X-ray room must be (i) 9 inch with plaster of Paris or (ii) 6 inches with 0.2mm of lead barrier or (iii) 2.0mm of lead. In addition necessary steps must be taken in order to prevent radiation leakage due to cracks in windows, doors or the walls.

• Arrangements must be made such that the individual who will be exposing the x-ray must wear a 0.5mm Lead Apron or use an equivalent radiation protective material inside the x-ray room.

• A monitor should be made available in order to monitor the radiation dose for all radiology technicians. Radiation survey monitoring must be conducted from time to time.

• Lead glass/gloves and lead apron must be available in order to protect the eyes, thyroid and gonadal glands.

• X-ray exposure room, the dark room and the waiting room must all be separate.

• A poster detailing the potential harm and dangers of X-ray radiation must be displayed for public view in the radiology department. This must also encourage the prevention of unnecessary radiation exposure to pregnant women and young children.

• Second hand x-ray machines cannot be brought into Nepal without permission from the Ministry of Health.

   

Security

At the current clinic, we have a 24-hour security guard posting and are located directly across from a police baracks. We have the support of all local and national political parties through connections of various executives and staff members.  At Bayalpata, we will aim to have ideally two 24-hour post staffed by district of Achham police force.  At the current clinic, we have housed a 40,000USD ultrasound, a 8,700USD i-stat, a 1,200USD oxygen concentrator, our laptops, our 1,100USD VSAT satellite, and several thousdands of dollars worth of pharmaceuticals and medical equipment without any security problems.  

   

Patient Demand

We currently see 80-100 general primary care patients per day. Once we have the X-Ray capacity, we will become an authorized antiretroviral treatment provider and we expect to treat approximately 400 HIV+ patients per year. Screening for tuberculosis among HIV+ patients is in fact the single most emergent need for X-Ray services.  We currently have ad-hoc inpatient services with a daily census of approximately 1-2 patients per day.  When we move up to the hospital, we expect a daily census of 6-8 patients per day inpatient.  In our planning document, we project a demand of approximately 10 patients per day for X-Ray.

 

Patients would be directed to the X-Ray facility by the prescribing physician.

 

Human Resources

Our professional all-Nepali staff consists of a physician, 5 nurse midwives, 3 health assistants, 4 administration and auxiliary staff members, 2 laboratory technicians, 1 pharmacist, and 4 health workers. These are long-term, multi-year postings. They are assisted by rotating volunteer public health specialists, physicians, and business managers. These volunteers work at the clinic typically from one to eight months at a time.

 

Power

We are connected to grid electrical power with a backup 5 kW generator, a 4.6 kW inverter/rectifier, an 80 W capacity photovoltaics, and a battery system capable of storing approximately 660 AH. The overall layout of the system is shown on our Energy Issues page.  This system will be deployed at Bayalpata.  We are currently exploring obtaining a larger battery system, larger rectifier, and solar panels, but the current system is capable of supplying the WHIS-RAD.

 

Technician Support

We have strong contacts in Kathmandu for technical support and will hire a trained X-Ray technician who will oversee the operation of the X-Ray machine. We have secured funding for 3 years' worth of salary for this technician at the going rate of 10,000 Nepali Rupees per month.  There are no technicians in the immediate local area; as such the technician would have to be recruited from outside.  If only minimal training is required, someone could certainly be recruited locally.

  

Training and Maintenance Manuals

We need to develop specific training materials for staff.  Much of these have already been produced by Dr. Palmer. 

 

Communications

We have VSAT connection over a 0.96 meter VSAT dish delivering 64 kbps wireless internet service.  This also provides phone service.  We additionally have CDMA cellular phone service.

 

Computing

Our physician and pharmacist use computers regularly.  Our midwives have been training in computer literacy for the purposes of data entry into our EMR.  Three laptops are available for use by staff, in addition to laptops brought temporarily by volunteers.

 

Dell D800 Specifications

Version 6.0.6000 Build 6000

Other OS Description Not Available

OS Manufacturer Microsoft Corporation

System Name OWNER-PC

System Manufacturer LENOVO

System Model 8932A17

System Type X86-based PC

Processor Intel(R) Core(TM)2 Duo CPU T5250 @ 1.50GHz, 1500 Mhz, 2 Core(s), 2 Logical Processor(s)

BIOS Version/Date LENOVO 7OET24WW (1.03 ), 6/28/2007

SMBIOS Version 2.4

Total Physical Memory 2,037.69 MB

Available Physical Memory 1,023.75 MB