According to the WHO, approximately two-thirds of the world’s population lacks access to diagnostic X-Ray. Nyaya Health aims to develop a scaleable model for X-Ray that can reach the rural poor. This page details the installation and operational details of our X-Ray program.
Note that much of the text is adapted from Dr. Phillip Palmer's textbook.
Workplan
Our project implementation form is here:
http://docs.google.com/a/nyayahealth.org/Doc?id=df8rgpnb_41fqzzs9fm
This provides the human and material resources and the timeline. The remainder of this page provides the technical details.
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.
Siting and Renovations
Primary X-Ray Room
Where the X-Ray machine is physically located
Size: minimum of 225 sq ft
Location: with easy access to inpatient services
Walls: Protected with either 9 inch with plaster of Paris or 6 inches with 0.2mm of lead barrier. Walls should be protected up to 2.2 meters off the ground.
Features: Weatherproof, ventilated
Floor: Concrete, weight-bearing to the weight of the machine (need to get from the supplier prior to shipment). The weight-bearing part for the column (approximately 1.0 x 1.0 m, or 40 x 40 inches) may need to have steel plate reinforcement.
Roof: Must be at least 2.5 m high (8 ft) , preferably 3 m (9.5 ft ).
Windows: Fine for light/ventilation. No radiation hazard if no people within 2 meters of the window. If there is a risk of people outside, the window should be 2 m above the ground outside.
Lighting: Should have a few fluorescent tube lights for night cases
Outlets: Should have well-positioned based on the orientation of the X-Ray machine. Will need to optimize once we decide upon the specific machine.
Control Room
Where the operator of the X-Ray sits, and where any digital analysis computers are (when digitizing happens).
The X-ray control station will be fixed at least 1.02 meters from any open edge of the cubicle wall. At least one viewing window will be included so the operator can view the patient during exposure, with a size of at least 30 cm x 30 cm. The lead glass will overlap protective material by at least 25 mm on all sides. The minimum height of the cubicle will be 2.2 meters. The protective cubicle will also have adequate space needed for a computer workstation and CR unit in order to operate the scanner, view and verify image integrity safely.
Changing Room
Where patients can prepare for the X-Ray study in a private manner.
This should be out of access to the primary beam and should not be connected to the main X-Ray room, so as not to allow for accidental entrance and subsequent exposure during a film.
Dark Room
Size: No side of the darkroom can be less than 2 m (6.5-7.0 ft). Area of the dark room should be approximately 10 m^2. Larger is NOT preferred.
Location: The wall of the dark room should NOT be continguous with a wall within the primary X-Ray room on which the primary beam may fall, as this compromises film quality.
Windows: All windows in a darkroom must be completely lightproof, fitted with:solid internal shutters or a heavy, totally opaque, black blind running in an inside-frame of wood. This frame must be permanent, at least 8 cm (3.5 ins) wide all around. It should allow the window to open: any retractable blind should run behind the frame, next to the window. Paint the outside of the windows white to reflect heat.
Inner Wall and Ceiling Paint: Cream colored; dark colour leads to the use of stronger light bulbs. The finish should be semi-gloss to avoid reflections and to facilitate cleaning.
Floors: The floors can be any colour but must be washable and moisture-proof.
Lead Protection Equivalence
At 100 kV (from Dr. Palmer's Imaging manual):
mm mm material g/cm3
0.5 1.0 lead 11.3
3.2 6.4 iron 7.9
44 80 concrete 2.2
70 120 solid brick 1.8
110 200 gypsum 0.84
135 270 porous concrete 0.63
Note that the government regulations mention specifically only plaster-of-paris and lead, but it can be assumed that any wall of 2.0 mm lead equivalence will suffice.
Present Design Issues
X-Ray room site diagrams:
potential_xray_room.pdf
1. The clinical building roofs are made from corrugated zinc and are prone to leaking during the monsoon season. Based on discussions with local contractors, we are considering putting solid tarp over the roof as a cheap option. Do you have any particular solutions for this?
2. Currently the inpatient unit is in the room next door. We are considering placing the X-Ray such that the beam is shot in the direction away from the door towards the wall facing the stone wall on the outside. Is sufficient space and wall between the x-ray room and the inpatient unit for it to not matter.
3. We are still awaiting a final quote and specs from SEDECAL. In the meantime, what are the dimensions of the WHIS RAD? Can you advise about how the actual machine/other equipment will be set up in the room? We are thinking that the little "alcove" on the right side of the main x-ray room can be covered with leaded glass and become the rad assistant's control unit.
4. The main clinical building faces the windows of the potential x-ray room. The space between can be blocked off so that patients/staff do not walk there. However, is it advised that we get leaded glass windows in the main x-ray room?
5. The walls are quite thick (20 inches) made from stone and mud as adhesive (we've been told by current staff) but the outer layer at least is quite "soft". Is this a problem?
6. Is the proposed dark room big enough?
7. We wanted to get some more information about the false ceiling suggested in Dr. Palmer’s manual - the need for one, normal materials used to build one, etc.
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.
Patient Flow
Patients would be directed to the X-Ray facility by the prescribing clinician.
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
The energy system for WHIS-RAD requires a reliable, single-phase electricity source connected to a standard 220V/10amp outlet.
Formal requirements are here: Pre-Inst BRS pages from SM0521R3i.pdf Pre-Inst Gen BATT pages from PI1005R4i.pdf
Technician Support
We will be negotiating these details with the x-ray provider.
Additional Safety Features
Warning lights will be connected to the generator in such a way that it will illuminate during activation of the tube. A radiation warning notice will be displayed at all entrances to X-ray rooms. Above the sliding access door is wiring for an Emergency Light.
All safety personnel must wear a radiation badge. These should be changed every three months and sent to KTM for analysis.
We will need two double-sided radiation protective aprons and two pairs of gloves made of lead-rubber (lead equiva¬lent 0.25-0.5 mm). These must be worn by any person who will be close to the x-ray beam during the exposure, even a relative or friend of the patient. This is particularly important when the only person who can hold the patient is a nurse, a nursing aide or any other member of the hospital staff.
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. Further details on computing are available here: Computing
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.
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.
| mm |
material |
g/cm3 |
| 1 |
lead |
11.3 |
| 6.4 |
iron |
7.9 |
| 80 |
concrete |
2.2 |
| 120 |
solid brick |
1.8 |
| 200 |
gypsum |
0.84 |
| 270 |
porous concrete |
0.63
|
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.
Full diagnostic imaging requirements are available:
in Nepali: www.nyayahealth.org/Library/moh_guidelines_radiology_np.pdf
in English (translated by Nyaya volunteers): www.nyayahealth.org/Library/moh_guidelines_radiology_en.pdf
Monitoring and Evaluation
A simple-to-use form that is integrated with our existing clinical records system will be filled out by the provider on each digital image submitted. This will follow a similar protocol to that currently undertaken for our digital ultrasound program. A group of Yale-based volunteer radiologists will undertake external quality assurance on these images. The following are the three key outcomes that will be assessed:
- number of encounters, by provider, clinical indication, and ultimate disposition (to home, delivery, referral)
- quality and appropriateness of digital images provided (assessed by a standardized quality assurance protocol by external specialist reviewers)
- appropriateness of the treatment plan based on the diagnosis
Nyaya Health will compile reports with the detailed performance markers, case reports, estimates of clinical impact, X-Ray images, and photos of the machine in use. To the extent possible in keeping with research ethics and publication guidelines, these reports will incorporate whatever operations research has been conducted at the clinic.
Operations Research
Although the up-front cost of X-Ray equipment is significant to resource-strapped governments, the donors and governments are unwilling to invest in X-Ray due to the lack of trained personnel for maintenance, servicing, and implementation. In addition, there is a lack of operations research that identify scalable models that can inform health planners to roll-out X-Ray services. Patient-oriented clinical research that is feasible in our setting is critical to developing such models.
For this purpose, we will use the machine to develop a clinical research program. The aim of this research would be to develop strategies to increase the feasibility of delivering effective essential X-Ray services to rural, resource-poor areas. Some initial research topics of interest may include:
- design and evaluation of a telemedicine-based quality assurance program in X-Ray diagnostics
- evaluation methodologies for X-Ray diagnostic skills assessment of rural generalist practitioners
- training strategies in X-ray diagnostics for rural mid-level health practitioners
- efficacy and cost-effectiveness of digital X-Ray for the evaluation of pneumonia and tuberculosis
- efficacy and cost-effectiveness of digital X-Ray for the evaluation of long-bone fracture
WHO Technical Manuals
http://www.who.int/diagnostic_imaging/publications/en/index.html
Nyaya Resources
Our original workplan is available for download here, created with colleagues at WHITIA:
http://www.nyayahealth.org/Library/WHIA_nyaya_xray.pdf
Our accompanying fundraising campaign:
http://www.nyayahealth.org/Library/xray_campaign.pdf
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