PLANNED PREVENTIVE MAINTENANCE PPM.

PLANNED PREVENTIVE MAINTENANCE PPM.

Maintenance is the act of getting equipment to be functional, available and reliable in this case our dialysis machine. PPM involves daily inspections, cleaning, fine-tuning and adjustment of equipment to keep the machine in good condition.  It is regular repetitive work done to keep the machine working.  In this case, the operator is also the maintenance person engaged in PPM activities. The attitude of the user is that he/she has all business with the maintenance of the dialysis machine unlike in Corrective maintenance where the user has no business with even simple maintenance activities like cleaning but stick strictly to only machine operations. Common language heard is that it’s not my work. The attitude in corrective maintenance is that I operate to breakdown and the maintenance personnel has to fix it, ‘I have no business with maintenance’. It’s such a rude statement but unfortunately, this happens often. Esprit de corps principle is very important. Apply French Industrialist Henri Fayol Administrative Management Principle no.14 of working together in harmony/unity.

Just like human life is extended by preventive medicine, the equipment service life can be extended by carrying out PPM.PPM will prevent almost all equipment failures and prolong its service life.

This type of maintenance is good for dialysis equipment’s and RO whose downtime significantly affects health outcomes of the patient.

TYPES OF PPM

·         In house PPM

·         Outsourced PPM.

INHOUSE ppm involves raising the maintenance team within the system whereas OUTSOURCED ppm involves raising the same team but now outside the system.

MAJOR ADVANTAGES OF INHOUSE PPM COMPARED TO OUTSOURCED PPM.

In house ppm is preferred for various reasons as compared to the outsourced one;

1. Quick response time to distress calls due to proximity to point of service thereby reducing equipment downtime.

2. Ease of control within the system.

3. Reduction in cost of maintenance.

OBJECTIVES OF PPM

  Ø  Prolong machine life

  Ø  Cutting down on the cost of breakdown

  Ø  Cutting down on downtime.

  Ø  Preventive breakdown.

BENEFITS OF PPM.

    1.      To maintain effective use of existing equipment.

    2.      Ensure accurate management of dialysis equipment and tools

    3.      To educate, train and empower manpower for effective dialysis maintenance and enhance the       

           quality of care.

    4.      To make dialysis centers comfortable and friendly.

    5.      To increase the reliability of dialysis services deliver in the centers

    6.      To create attitudinal change among operators from ‘I operate to breakdown and maintenance         

           personnel does the fixing’

    7.      Decreased in cost of maintenance and services.

    8.      Reduce machine downtime.

      SERVICE KITS FOR ANNUAL SERVICING OF A HEMODIALYSIS MACHINE FRESENIUS 4008S.

 






HEMODIALYSIS MACHINE CLEANINGS AND DISINFECTIONS.

Disinfection prevents transmission of infections between patients. The disinfection may be performed using bleach, citric acid (Citrothermal Disinfection) or heat.

Disinfection with bleach is recommended at least once a week and after any blood leak into the dialysate.

Disinfection with Hot citric acid may be performed daily. All steps for sterilization recommended by the manufacturer must be followed.

With standard disinfectant fitted to the rear of the machine, bleach must be administered via the pickup stick (concentrate connectors) at the front of the machine.

Diagram of a disinfection display program on the screen.

TYPES OF CLEANINGS.

   1.Disinfection-Kill of germs/harmful pathogens… Disinfection prevents transmission of infections between patients. The disinfection may be performed using bleach, citric acid (Citrothermal       

     Disinfection) or heat. We have cold and hot disinfection.

      2.Decalcification-Removal of deposits like calcium and magnesium which causes blockage of tubing, rusting which leads to non-functioning of moving parts and deposits on sensors lead to their inaccuracy in the machine.

                                                                                                              3.  External Surface Cleaning.

CHEMICALS/DETERGENTS USED FOR DISINFECTION.

      1.Citric Acid-This chemical is effective while using hot disinfection. Thermoaction is required,    not effective without heat. Available in 21% and 50% concentration. Effective for doing both disinfection and decalcification.

1. Peracetic acid-Effective for disinfecting RO membrane. This will contain Acetic acid which is very corrosive so it will cut the salts to remove clogging’s in the pores.

      2.ZIK/Sodium Hypochlorite/Jik- of particular importance for decalcification to dissolve all precipitate. Very essential to be used while doing Loop disinfection of the distribution system/Post Treatment in the RO plant to avoid any formation of biofilm long before reaching the action level of  50cfu/ml for bacteria and 1EU/ml for endotoxin. Sodium hypochlorite solutions dissolve all clogs…  Also used in disinfecting used linen in the hospital.

      3.  Oxagon-Rarely used but is effective for disinfection.

Equipment REQUIRED FOR CLEANING

     1.      Gloves

     2.      Warm water

     3.      Mild household grade detergent

     4.      Citrosteril

     5.      Soft cloth x 2

     6.      Small paintbrush

     7.      Bucket

MAINTENANCE OF MACHINE THESE ARE CLASSIFIED INTO:

1. Before connecting patients

2. In between treatment

3. Everyday maintenance

4. Weekly maintenance

5. Preventive maintenance

6. Periodic maintenance

       1.     BEFORE CONNECTING PATIENTS.

Ø  Every morning before starting treatment, water rinse for 16minutes.

Ø  Checking of residual chemicals in the hydraulics

Ø Self-test for safety to check that all sensors are works. Self-test scrutinizes all sensors and alarms to ensure that they are working for the safety of the patients

Ø  Not to bypass any alarm condition

       2.     IN BETWEEN TREATMENTS.

Ø  Pre-rinse mandatory-Mandatory rinse requirements are Disinfection cycle incomplete or not performed.

Ø  External cleaning

Ø  Changing of transducer protectors, used saline & IV sets

Ø  Self-test

Ø  No to bypass any alarm conditions

       3.     END OF THE DAY.

A.  External cleaning: By using mild soap, a wet towel soaked in soap water or Disinfectants spray. Clean the front surface of the machines as well.

B.   Decalcification: Using citric based chemicals with heat or acetate-based chemicals in the cold rinse, which removes all the residual precipitate. Do a front supply using sodium hypochlorite to remove the precipitate of calcium and magnesium.

C.   Disinfection: By using per-acetate based chemicals in cold disinfection or citrate-based chemicals in hot disinfection.

HOT DISINFECTION.

The disinfection solution during the disinfection program is sucked by Valve no.84 with the help of the ultrafiltration pump no.22.In hot disinfection, the temperature will rise up to 83-84 deg.celcius at a disinfection dialysate flow of between 600-700ml/min.

Water from RO plus the disinfection chemical (citric acid) will help in disinfecting the machine at a dilution ratio of 25:1 …25 for water and 1 part for citric acid.

During the disinfection cycle, about 80ml of disinfection will get sucked by the help of the ultrafiltration with diasafe and 60ml of it without diasafe.

What is disinfected?

•Balancing chamber

•Flow pump

•Degassing pump

•UF pump

•Concentrate pumps (acid & bicarbonate)

•Rinse chambers

•Concentrate suction tubes (red & blue wand)

•Heater block

•DIASAFE plus filter(s)

•Tubings to remove all precipitates.

Disinfection Program Fresenius 4008s Machine.

End of hemodialysis 

    




          4. WEEKLY MAINTENANCE.

     A. BiBag connector - with the machine turned off, remove the cap from BiBag connector and wipe around outside with detergent solution.  Using a small paintbrush dipped in the detergent solution, brush the inner aspect of the BiBag connector.

     B. Hanson Connectors – with the machine turned off, submerge connectors in a weak solution of Citrosteril and warm water, ensuring that the silver connectors are moved up and down to dislodge any debris build-up.  Dry and replace on shunt interlock

           RATIONALE: Using Citrosteril will help dissolve dried bicarbonate encrusted on the
           Hanson connectors.

     C. External Fan Filter – Remove plastic guard.  Remove foam insert and brush vigorously to remove all signs of lint and debris.  Replace foam insert and plastic guard.

NOTE: External cleaning should be done after each treatment.

Expected Outcome OF THIS MAINTENANCE.

     ●  Prevent cross-contamination between patients-Virulent pathogens like HBV can be avoided due to vigorous cleaning and disinfection of external surfaces, machine and most importantly performing universal precautions which is the approach to infection control to treat blood and body fluids as if infected for HIV/HBV/HCV.

     ●  The machine will be maintained for optimal performance.