IPHS Community Health Centres

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Indian Public Health Standards

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Indian Public Health Standards:

Indian Public Health Standards Community Health Center (CHC)

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All “Assured Services” should be available - which includes routine and emergency care in Surgery, Medicine, Obstetrics and Gynaecology and Paediatrics in addition to all the National Health programmes. Common for PHC & CHC Appropriate guidelines for each National Programme for management of routine and emergency cases - provided to the PHC. All the support services to fulfill the above objectives will be strengthened Synopsis of Service Delivery in a CHC

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Projected based on an average bed occupancy of 60%. If the utilization goes up, the standards would be further upgraded. As regards, manpower, 2 specialists namely Anaesthetist and Public Health programme Manager will be provided on contractual basis in addition to the available specialists namely Surgery Medicine, OG & Pediatrics - support manpower will include a Public health Nurse and ANM in addition to the existing staff and an Ophthalmic Assistant Minimum Requirement

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PHC To provide comprehensive primary health care to the community To achieve and maintain an acceptable standard of quality of care. To make the services more responsive and sensitive to the needs of the community. Bed strength – 2 to 6 CHC To provide optimal expert care to the community To achieve and maintain an acceptable standard of quality of care To make the services more responsive and sensitive to the needs of the community. Bed strength – 30 Objective of the Institutions

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CHCs - to provide referral health care for cases from the primary level and for cases in need of specialist care. 4 PHCs are included under each CHC - 80,000 population in tribal / hilly areas and 1, 20,000 population in plain areas. CHC is a 30- bedded hospital providing specialist care in medicine, Obstetrics and Gynaecology, Surgery and Paediatrics. Upgradation to handle higher patient load, emphasis given to quality aspects to increase the level of patient satisfaction. Basic concept of a Community Health Center

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Care of routine and emergency cases in Surgery: -includes Incision and drainage, surgery for Hernia, hydrocele, Appendicitis, haemorrhoids, fistula, etc. Handling of emergencies like intestinal obstruction, haemorrhage etc. Care of routine and emergency cases in Medicine: All emergencies in relation to the National Health Programmes 24-hour delivery services including normal and assisted deliveries Essential and Emergency Obstetric Care including surgical interventions like Caesarean Sections and other medical interventions Full range of family planning services including Laproscopic Services and Safe Abortion Services New-born Care Routine and Emergency Care of sick children Other management including nasal packing, tracheostomy, foreign body removal etc. Assured Services /Functions at the CHC..1

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All the National Health Programmes (NHP) Integration with the existing structure: Blindness control - eye care services diagnosis and treatment of common eye diseases, refraction services & surgical services including cataract by IOL (1 eye surgeon for every 5 lakh pop.) Integrated Disease Surveillance Project – the end peripheral surveillance unit and to collate, analyse and report RNTCP: CHCs to provide diagnostic services with microscopy and treatment services HIV/AIDS Control programme: National Vector –Borne Disease Control Programme: provide diagnostic & treatment facilities for routine & complicated cases of malaria, filaria, dengue, JE and Kala-azar National Leprosy Eradication Programme: diagnosis and treatment of cases and reactions of leprosy along with advice to patient on Prevention of Deformity. Detection of faecal contamination of water and chlorination level. Others: Blood Storage Facility; Essential Laboratory Services; Referral (transport) Services: Assured Services /Functions at the CHC..2

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CHC should have 30 indoor beds, one Operation theatre, labour room, X-ray facility and laboratory facility. guidelines: the centre should be located at the centre of the block head quarter in order to improve access to the patients. (This may be applicable only to centers that are to be newly established. However, priority is to be given to operationalise the existing CHCs.) Essential Infrastructure: I

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Equipment Equipment provided under the CSSM may be adequate for providing all services in the CHC. Before ordering new sets, the existing equipment should be properly assessed. For ophthalmic equipment wherever the services are available Equipment required under various National Health programmes Blood storage Facilities Cold chain equipment -under Immunization Programme 2 Refrigerators, one for the ward and one for OT should be available in the CHC. Periodic stock taking of equipment and preventive/ round the year maintenance will ensure proper functioning equipment. Back up should be made available wherever possible. Maintenance of equipment: It is estimated that 10-15% of the annual budget is necessary for maintenance. Essential Infrastructure: II

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Personnel Minimum Proposed Desirable Justification General Surgeon 1 1 MS/DNB Physician 1 1 MD/DNB OG 1 1 MD/DNB/ DGO Pediatrician 1 1 MD/DNB/ DCh Anesthetist -- 1 MD/DNB/DA Essential / Contract basis PH Programme manager -- 1 MD/DNB/ DPH For National Programmes and training Eye Surgeon -- 1 MS/DNB/DO For 5 lakhs Pop. Total 4 6/7 Essential Infrastructure: III – Manpower

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Personnel Nurse Midwife 7+2 (ANM & PHN to be appointed under ASHA scheme) Dresser 1 Pharmacist 1 Lab Technician 1 Radiographer 1 Ophthalmic Assistant 1 (on contract where ever post are not sanctioned) Ward Boy/ MNA 2 Sweeper 3 Chowkidar 5 Flexibility may rest with the state for recruitment of personnel as per needs. OP attendant Stat.Asst / Data Entry Op OT Attendant Registration Clerk Total 22 + 2 Essential Infrastructure: III – Support Staff

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Drugs: Essential drugs; Emergency drugs; Programme specific drugs Investigations: ECG should be made available in the CHC with appropriate training to a nursing staff. Lab - necessary reagents, glass ware and facilities for collecting and transport of samples should be made available . Essential Infrastructure: IV - Consumables

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Entrance zone: Prominent display boards providing information regarding the services available and the timings of the institute Registration counters Pharmacy for drug dispensing and storage Clean Public utilities separate for males and females Suggestion/ complaint boxes for the patients/ visitors. Outpatient department: clinics for Various Medical Disciplines: General medicine, General surgery, Dental (optional), Obstetric and Gynaecology, Paediatrics and F W. cubicles for consultation and examination - doctor’s table, chair, patient’s stool, Follower’s seat, wash basin, examination couch and equipment. Family Welfare Clinic – Treatment room should act as operating room for IUCD insertion and investigation, etc. in close proximity to Obst. & Gynae. OPD. Waiting room for patients Drug Dispensary - accessible from all clinics- two dispensing windows, compounding counters and shelves. cold storage and blood and emergencies kept in refrigerators. Emergency Room/ Casualty - The emergency cases may be attended by OPD during OPD hours and in inpatient units afterwards. Essential Infrastructure: V- Building areas/ space

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Treatment Room: Minor OT Injection Room and Dressing Room Wards: Separate for males and females Nursing Station– have provision for: Injections, Dressings, Examination and dressing table, Bins for waste material, Wash basins, Syringe destroyer, Needle cutter. Patient Area: Enough space between beds. Toilets: separate for males and females. Separate space/ room for patients needing isolation Ancillary rooms: Nurses rest room There should be an area separating OPD and Indoor facility. Operation theatre/ Labour room: Patient area : Pre-operative and Post-operative (recovery) room Staff area: Changing room separate for males and females Storage area for sterile supplies OT/ Labour room area: Operating room/ labour room Scrub area Instrument sterilization area Disposal area Public utilities: Separate for males and females Essential Infrastructure: V- Building areas/ space

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CSSD: Sterilization and Sterile storage Laundry: Storage: separate for Dirty linen and clean linen; Outsourcing is recommended - after appropriate training of washer man regarding separate treatment for infected and non-infected linen. Services: Electricity/ telephones/ water/ civil engineering: Maintenance of proper sanitation in Toilets and Public utilities- Sufficient funding for this purpose; or may be outsourced. Water Supply –to supply 10,000 litres of potable water per day except fire fighting. Storage capacity for 2 days requirements should be on the basis of the above consumption. Separate reserve emergency overhead tank shall be provided for operation theatre; overhead tanks with pumping/boosting arrangement shall be made; Piped water supply system with Cold and hot water supply; piping in concealed form Geyser in O.T. / L.R. and one in ward also should be provided. Wherever feasible solar installations should be promoted. Emergency lighting – Emergency portable/fixed light units in the wards and departments; Generator back-up; Use of solar energy encouraged. Telephone: minimum two direct lines with intercom facility; Administrative zone: Separate rooms should be available for Office: Stores Essential Infrastructure: VI- Support Service

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Capacity building: Training of all cadres of worker at periodic intervals is an essential component. Multi-skill training for paramedical workers Quality Assurance in Service delivery: Quality of service should be maintained at all levels. Standard treatment protocol for all national programmes and locally common diseases is the “Heart” of quality and cost of care. All the efforts that are being made to improve “hardware i.e. infrastructure” and “software i.e. human resources” are necessary but NOT sufficient. These need to be guided by Standard Treatment Protocols. Diet: Diet may either be outsourced or adequate space for cooking should be provided in a separate space. Blood Storage Units: as per guidelines Waste disposal: As per National guidelines applicable to 30 bed CHCs or may be outsourced to agencies trained in this. Charter of Patient Rights: It is mandatory for every CHC to have the Charter of Patient Rights prominently displayed at the entrance. Essential Infrastructure: VII- Others

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The CHC should have an ambulance for transport of patients. – Punjab Model Referral Transport Facility: an ambulance for transportation of emergency patients; Referral transport may be outsourced. Transport for Supervisory and other outreach activities: The vehicle can also be outsourced for this purpose. Transport Facilities

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Internal monitoring: Social Audit: through R K S / Panchayati Raj Institution etc Medical audit Others like technical audit, economic audit, disaster preparedness audit, etc. Patient care: This shall include: · Access to patients; Registration and admission procedures Examination Information exchange Treatment · Other facilities: waiting, toilets, drinking water Indoor patients: Linen/ beds Staying facilities for relatives Diet and drinking water Toilets External Monitoring: Monitoring of laboratory: Internal Quality Assessment scheme External Quality Assessment scheme Quality Control

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Water harvesting should be introduced in all new buildings Computerisation is a must and would be essential for record maintenance and surveillance. To maintain the hospital landscaping, a room to store garden implements; seeds, etc, should be provided. Based on the above minimum requirements, the standards need to be developed by a professional body. Suggested innovations:

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Services Existing Remarks Population covered Specialist services available Medicine Surgery OBG Paediatrics NHPs Emergency services Laboratory Blood Storage Checklist for minimum requirement of CHCs - 1

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Infrastructure Existing Remarks Area of Building OPD Rooms / Cubicles Waiting Room No. of male No of Female OT Labour Room X-Ray Room Blood Storage Pharmacy Water Supply Electricity Garden Transport Facility Checklist for minimum requirement of CHCs - 2

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Equipment Existing Remarks As per list Drugs Existing Remarks As per EDL As per emergency drug list Checklist for minimum requirement of CHCs - 3 Checklist for minimum requirement of CHCs - 4

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Particulars Available Whether Functional as per norms Patient Charter RKS – Patient Welfare Society Internal Monitoring External Monitoring Availability of SOP / STPs* * Standard Operating Procedures / Standard Treatment Protocol Checklist for minimum requirement of CHCs - 5

Operationalising First Referral Units:

Operationalising First Referral Units Guidelines

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Emergency Obstetric Care - close to the community was taken up under the Child Survival and Safe Motherhood (CSSM) Programme by setting up FRUs at the CHC /sub-district level hospitals. for carrying out Laporotomies, Caesarean Sections and other surgical interventions for Emergency Obstetric Care and New-born Care. Identified FRUs could not become fully operational due to: (i) Lack of provision of emergency drugs (ii) Inadequate infrastructure in terms of Operation Theatre and Labour Rooms (iii) Non- availability of blood banking facilities, and (iv) Lack of skilled manpower, particularly Anaesthetists and Gynaecologists (12 types of equipment kits – Assistance was from GOI – 1724 – FRUs established ) Concept of FRU -1

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Under the RCH programme provision has been made for supply of drug kits to the FRUs in the form of Emergency Obstetric Drug kits containing 65 items of drugs @ 3 Kits in 'C‘ Category Districts and 2 Kits in each of the 'B' Category Districts in the states. Provided assistance for civil works for OT and Labour Rooms. Drugs and Cosmetics Rules -amended to set up blood storage centers at the sub-district level health facilities identified as FRUs. Experience indicates lack of specialist/trained providers (Anaesthetists and Gynaecologists) is the single most important cause for inadequacy Private Anaesthetists for conducting emergency operations at a payment of Rs. 1000/- per case. non-availability of such specialists even in the private sector. Concept of FRU - 2

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Tenth Five Year Plan - establishment of fully functional and operational FRUs as the priority area for the provision of Emergency Obstetric and New-born Care. Each district should have at least 3-4 fully functional facilities which are equipped to provide the full range of Emergency Obstetric and New-born Care on a round-the-clock basis. Mapping the existing health facilities, available manpower and other resources for each district. To draw the district-wise action plans for operationalising FRUs in a phased manner. Overall requirements of the State in various areas, like infrastructure, equipment, manpower and training – the needs for operationalising FRUs Concept of FRU - 3

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Existing facility (district hospital, sub-divisional hospital, community health centre etc.) can be declared a fully operational First Referral Unit (FRU) Provide round-the-clock services for Emergency Obstetric and New-born Care, in addition to all emergencies that any hospital is required to provide Critical Determinants of FRU

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24-hour delivery services including Normal and assisted deliveries Emergency Obstetric Care including surgical interventions like Caesarean Sections(*) and other medical interventions New-born Care(*) Emergency Care of sick children Full range of family planning services including Laproscopic Services Safe Abortion Services Treatment of STI / RTI Blood Storage Facility (*) Essential Laboratory Services Referral (transport) Services (*): Critical determinants of functionality Minimum Services to be provided by FRU

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Infrastructure Needs A minimum bed strength of 20-30; A fully functional OT equipped for surgical procedures including Caesarean Sections and Laporotomies; A fully operational Labour Room; An area for New-born Care in the Labour Room and also in the ward – equiped; A functional laboratory - all essential investigations. Blood storage facility; 24-hour water supply; Arrangements for waste disposal; Regular electricity supply with back-up arrangements - to the operation theatre and labour room, cold chain and blood storage facility; Telephone connection; Ambulance (owned or arranged through local hiring). Selecting the facilities for FRU

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Under the RCH Programme funds were provided for civil works – to operationalisation of operation theatre, labour rooms and provision of regular water supply etc. at the CHCs and district hospitals. Similarly, civil works have been undertaken at many sub-district facilities as part of the Health Systems Projects. Caution - to upgrade a CHC (a) the people are likely to by pass it and go to the district hospital (b) the staff posted would tend to stay in the district headquarter. Ensure proper selection - to develop a network of 3-4 facilities in the district that it can ensure that all emergency cases in the district can access the nearest facility within a maximum travel time of 1 hour. Selecting the facilities for FRU

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Twelve types of equipment kits (Kit-E to Kit-P) Kit-E: Standard Surgical Set-I (instruments) FRU Kit-F: CHC Standard Surgical Set-II Kit-G: IUD Insertion Kit Kit-H: CHC Standard Surgical Set-III Kit-I: Normal Delivery Kit Kit-J: Standard Surgical Set IV Kit-K: Standard Surgical Set-V Kit-L: Standard Surgical Set VI Kit-M: Equipment for Anaesthesia Kit-N: Equipment for Neo-natal Resuscitation Kit-O: Equipment for Laboratory Tests and Blood Transfusion Kit-P: Materials Kit for Blood Transfusion Equipment for blood storage Procured and supplied equipment for the district and sub-district level facilities. Assessment of earlier supplies – CSSM, AIDS, HSP

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Re-deployment & multi-skilling - Re-deployment of the resources existing within the districts State Government of West Bengal announced an infrastructure rationalization and manpower redeployment policy • Strengthening of Block PHCs (BPHCs) and PHCs - will be need based for each individual institution. • All the block PHCs shall have minimum 30 indoor beds • Efforts will be made to provide same facilities in the BPHCs as are available in rural hospitals (Community Health Centers) Well-functioning PHCs running with indoor facilities will be identified and their infrastructure strengthened. Strengthened BPHCs / PHCs by withdrawing and posting of manpower from PHCs that are providing only OPD services. PHCs with only outdoor services shall be withdrawn and OPD of these PHCs shall be done from the BPHCs by deployment of manpower for required work on rotation basis. Assessment of Human Resources -1

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Re-deployment & multi-skilling – Provision of other support services like blood storage, Laboratory services, pharmacy services should be planned primarily on the basis of multi-skilling and re-deployment of available paramedical staff. After selection of the facilities to be operationalised as FRUs and assessment of available manpower and other resources has been completed, it would be necessary to re-deploy the specialists and other manpower to the facilities designated as FRUs. The State Government has to steer this process since the process may also require inter-district redeployment. Assessment of Human Resources -2

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Re-deployment & multi-skilling - Considering the general lack of specialists particularly that of anaesthetists, it is imperative to train the MBBS doctors in life saving anaesthetic skills for emergency obstetric care. A training programme on this has been designed for this purpose and a pilot course already implemented by officers of Chhattisgarh. Similar training programme is being designed by the Federation of Obstetrical and Gynaecological Societies of India (FOGSI) to train the MBBS doctors for management of obstetric emergencies (including C-section) and New-born Care. Multi-skilling training of paramedical workers will also be necessary in the critical area of Obstetric Care, New-born Care and Blood Storage and Laboratory Services. Assessment of Human Resources -3

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Empowering the FRU - facilities to respond to emergencies. Once an FRU becomes operational, ensure that there is no disruption in the services due to lack/absence of staff and/or minor requirement of funds. In other words, formulate appropriate guidelines for providing some functional and financial autonomy (e.g. retention of user charges, if any) for the hospitals to enable them to: (a) Hire locally available specialists and/or paramedical workers from the private/NGO sector in case of need (b) Make local arrangements for referral transport (c) Generate resources locally and (d) Out-source non-clinical services. Community participation in the management of facilities DHO / CMO to identify and re-deploy specialists and paramedical staff Identify the para-medical cadres which can be merged and decentralized Design training programme for the multi-skilling Functional Autonomy of FRU

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Space : 10 square meters, well-lighted, clean and air-conditioned. Manpower : Designate one of the existing doctor and technician. trained in the operation of blood storage centers and procedures like storage, grouping, cross- matching and release of blood. MO designated for this purpose will be responsible for overall working of the storage center. Electricity : 24 hours supply. Back-up generator is required. Equipment : Each FRU should have the following : 1. Blood bag refrigerators having a storage capacity of 50 units of blood. 2. Deep freezers for freezing ice packs required for transportation. The deep freezers available in the FRUs under the Immunization Programme can be utilized for this purpose. 3. Insulated carrier boxes with ice packs for maintaining the cold chain during transportation of blood bags. 4. Microscope and centrifuge: since these are an integral part of any existing laboratory, these would already be available National Guidelines on Blood Storage Facilities at FRUs-1

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Consumables: adequate provision for consumables and blood grouping reagents. the annual requirement of an FRU with up to 50 beds- Consumables Quantity Pasteur pipette 12 dozens / year Glass tubes 7.5 to 10 mm - 100 dozens / year Glass slides 1" x 2" boxes of 20 or 25 each / year Test tube racks 6 racks, each for 24 tables Rubber teats 6 dozens / year Gloves Disposable rubber gloves 500 pairs per year As required Blotting tissue paper, Marker pencil (alcohol based), Tooth picks Reagents: should come from the Mother Blood Bank . (To ensure quality supply) from where blood is obtained . Anti-A 2-vials each per month Anti-B 2-vials each per month Anti-AB 2-vials each per month Anti-D (Blend of IgM & IgG) 2 vials each per month Antihuman Globulin 1 vial per month (Polyclonal IgG & Compliment) Disinfectants: Bleach & Hypochlorite Solution - As required National Guidelines on Blood Storage Facilities at FRUs -2

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Suggested quantities of Whole Blood Units to be available at a Blood Storage Units 5 units each of A, B, O (Positive) 2 units of AB (Positive) 1 units each of A, B & O (Negative) This can be modified according to the actual requirement Storage & transportation Cold chain : at all levels i.e. from the mother center to the blood storage center to the issue of blood using insulated carrier boxes. During transportation - cold boxes surrounded by the ice packs clean. The blood should be kept at 4º-6ºc ± 2ºc.- temp monitored continuously. Storage center - check the condition of blood on receipt from the mother center, during the period of storage and before use. Any problem arising from storage, cross matching, issue and transfusion will be on the storage center and should not use / receive hemolysis, turbidity or change in colour of the blood. Maintain sterility of blood by keeping all storage areas clean. Expiry blood - 35/42 days depending on the type of blood bags used. Return Unused blood bags to the mother center at least 10 days before the expiry of the blood and fresh blood obtained in its place. Not to store packed cells, fresh frozen plasma and platelets concentrate (They are to be stored in the mother blood bank) National Guidelines on Blood Storage Facilities at FRUs -3

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Issue of blood Patients blood grouping and cross matching should invariably be carried out before issue of blood. A proper record of this should be kept. First In and First Out (FIFO) policy, whereby blood closer to expiry date is used first, should be followed. Disposal Since all the blood bags will already be tested by the mother center, disposal of empty blood bags should be done by landfill. Gloves should be cut and put in bleach for at least one hour and then disposed as normal waste. Documentation & records The center should maintain proper records for procurement, cross matching and issue of blood and blood components. These records should be kept for at least 5 years. National Guidelines on Blood Storage Facilities at FRUs -4

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Training of doctors and technicians - for 3 days and venue identified center as per the guidelines. Training will include : Pre-transfusion checking, i.e. patient identity and grouping Cross matching Compatibility Problems in grouping and cross matching Troubleshooting Issue of blood Transfusion reactions and its management Disposal of blood bags Identify the institutions where training can be conducted - blood banks at Medical Colleges, Regional Blood Banks, Indian Red Cross Blood Banks, or any other well setup, licensed Blood Bank. A "Standard Operating Procedures Manual" (SOPM) to be used. Necessary that the clinicians of FRU are to sensitised – one day using "Clinician's Guide to Appropriate Use of Blood“ National Guidelines on Blood Storage Facilities at FRUs -5

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Blood Storage Facilities at FRUs Issues on quality: Blood Donation Camps Blood Units Voluntary Collected Blood Grouping and serology tests Mandatory Tests like HIV, Hbs Ag, VDR and HCV Whole Blood and Components Issues

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