ASTUDYTODETERMINETHECAUSESOFINACCURACYINBLOODPRESSUREMAC

HINEATKARIRAHOSPITAL

BY

SAMUELMUWATAMUTETI

MS21/175416

MEDICALENGINEERINGDEPARTMENT

ARESEARCHSUBMITTEDTORIFTVALLEYINSTITUTEOFSCIENCEANDTECHNOL
OGYININPARTIALFULFILMENTOFTHEREQUIREMENTSFORTHEAWARDOFDIP
LOMAINMEDICALENGINEERINGTECHNOLOGY.

RIFTVALLEYINSTITUTEOFSCIENCEANDTECHNOLOGY
DECLARATION
Iherebydeclarethismyoriginalworkgoodandacceptableandhasnotbeenpresentedforanyawardinanyi
nstitutionforacademicpurpose.

Signature......................Date..................

SamuelMuwataMuteti

Ms21/175416

ACKNOLEDGEMENT
IhighlygivethankstotheAlmightyGodwhohasgivenmethestrengthtoliveandcompletethisstudy.Ialso
thankmycolleaguesforthesupporttheyhavegivenmethroughoutthecourseofmystudy.Ithankthelectur
ersfortheypatiencewithmeandfortheirsupporttowardsmycompletionofstudy.Preciousthankstoallen
gineersandnursesatKariraHospital.

Listofabbreviations

B.P-Bloodpressure

mmHg-millimetersofmercury

LVAD-Leftventricularassistdevice
ICU-Intensivecareunit

ABSTRACT

Bloodpressuremachinesareacriticalmachinewhenitcomestodiagnosisofhumanbody.Itmeasuresbothsystol

icanddiastolicpressure.Systolicbloodpressure,thetopnumber,measurestheforcetheheartexertsonthewall

softhearterieseachtimeitbeats.Diastolicbloodpressure,thebottomnumber,measurestheforcetheheartexe

rtsonthewallsofthearteriesinbetweenbeats.

Togetanaccuratebloodpressuremeasurement,yourhealthcareprovidertypicallyconsiderstheaverageoftwo

ormorebloodpressurereadingsfromthreeormoreofficevisits.Anaccuratemeasurementdetermineswhatkin

doftreatmentyoumayneed.Abloodpressuremeasurementover180/120mmHgiscalledahypertensiveemerg

encyorcrisis.Seekemergencymedicalhelpforanyonewiththesebloodpressurenumbers.

Ifyouareanadultwitha10%riskofdevelopingcardiovasculardiseaseinthenext10years,orifyouhavechronickid

neydisease,diabetesorcoronaryarterydisease,yourtreatmentgoalistypicallylessthan130/80mmHg.Ifyou're

ahealthyadultage65orolder,yourtreatmentgoalalsoisusuallylessthan130/80mmHg.

IfyourbloodpressureisOK,maintainingoradoptingahealthylifestylecanpreventordelaytheonsetofhighbloo

dpressureorotherhealthproblems.Ifyourbloodpressureishigh,ahealthylifestyle—
oftentimesalongwithmedication—canhelpbringitundercontrolandreduceyourriskoflife-

threateningcomplications.

CHAPTER1

1.1 background

Asphygmomanometera.k.a.abloodpressuremonitor,orbloodpressuregauge,isadeviceusedtomeasure

bloodpressure,composedofaninflatablecufftocollapseandthenreleasethearteryunderthecuffinacontr

olledmanner,andamercuryoraneroidmanometertomeasurethepressure.Manualsphygmomanometer

sareusedwithastethoscopewhenusingtheauscultatorytechnique.

Asphygmomanometerconsistsofaninflatablecuff,ameasuringunit(themercurymanometer,oraneroidg

auge),andamechanismforinflationwhichmaybeamanuallyoperatedbulbandvalveorapumpoperatedel

ectrically.
Inhumans,thecuffisnormallyplacedsmoothlyandsnuglyaroundanupperarm,atroughlythesamevertical

heightastheheartwhilethesubjectisseatedwiththearmsupported.Othersitesofplacementdependonsp

eciesandmayincludetheflipperortail.Itisessentialthatthecorrectsizeofcuffisselectedforthepatient.Toos

mallacuffresultsintoohighapressure,whiletoolargeacuffresultsintoolowapressure.Forclinicalmeasure

mentsitisusualtomeasureandrecordbotharmsintheinitialconsultationtodetermineifthepressureissigni

ficantlyhigherinonearmthantheother.Adifferenceof10mmHgmaybeasignofcoarctationoftheaorta.Ifth

earmsreaddifferently,thehigherreadingarmwouldbeusedforlaterreadings.

[17]Thecuffisinflateduntilthearteryiscompletelyoccluded.

Withamanualinstrument,listeningwithastethoscopetothebrachialartery,theexaminerslowlyreleasest

hepressureinthecuffatarateofapproximately2mmHgperheartbeat.Asthepressureinthecuffsfalls,a"wh

ooshing"orpoundingsoundisheard(seeKorotkoffsounds)whenbloodflowfirststartsagainintheartery.Th

epressureatwhichthissoundbeganisnotedandrecordedasthesystolicbloodpressure.Thecuffpressureisf

urtherreleaseduntilthesoundcannolongerbeheard.Thisisrecordedasthediastolicbloodpressure.Innois

yenvironmentswhereauscultationisimpossible(suchasthescenesoftenencounteredinemergencymedi

cine),systolicbloodpressurealonemaybereadbyreleasingthepressureuntilaradialpulseispalpated(felt).
 Inveterinarymedicine,auscultationisrarelyofuse,andpalpationorvisualizationofpulsedistaltothesphyg

momanometerisusedtodetectsystolicpressure.

Digitalinstrumentsuseacuffwhichmaybeplaced,accordingtotheinstrument,aroundtheupperarm,wrist,

orafinger,inallcaseselevatedtothesameheightastheheart.Theyinflatethecuffandgraduallyreducethepr

essureinthesamewayasamanualmeter,andmeasurebloodpressuresbytheoscillometricmethod.

1.1Problemstatement

Toprovidequalityhealthcaretopatient,theirbloodpressurehastobeaccuratelymeasured.Thereisneedtohav

eproperfunctioningbloodpressuremachines.Duetolackofcorrectivepreventivemaintenance,therehavebee

nfrequentbreakdownsthusincreasingdeathratesinhospitals.

1.2Purposeofstudy

toinvestigatefactorsthatareassociatedwithinaccuratemeasurementofbloodpressuremachine.

1.3 objectives

1.3.1 broadobjective

toaccessthemaintenancepracticesonBPmachineatKarirahospital.

1.3.2 specificobjectives

 todeterminethemaintenanceproceduresofbloodpressuremachineatKarirahospital.

 ToaccessthetechnicalskillsofbiomedicalengineersonBPmachine.

1.4 justificationofstudy
Bloodpressuremachinesareverycriticalmachinesinthemedicalfieldsincebloodpressureisoneofthevitalsigns

toassessapersonshealth.Thisresearchwillbeofgreatsignificancesinceitwillhelpfindouthowcarefullybpmach

inesaremaintainedhenceanincreaseinbetterandreliablehealthcarewillbeattained.

Chapter2

LITERATUREREVIEW

2.1BACKGROUNDINFORMATIONOFBPMACHINES

Asphygmomanometera.k.a.abloodpressuremonitor,orbloodpressuregauge,isadeviceusedtomeasure

bloodpressure,composedofaninflatablecufftocollapseandthenreleasethearteryunderthecuffinacontr

olledmanner,andamercuryoraneroidmanometertomeasurethepressure.Manualsphygmomanometer

sareusedwithastethoscopewhenusingtheauscultatorytechnique.

Asphygmomanometerconsistsofaninflatablecuff,ameasuringunit(themercurymanometer,oraneroidg

auge),andamechanismforinflationwhichmaybeamanuallyoperatedbulbandvalveorapumpoperatedel

ectrically.

2.2Typesofbpmachines

Bothmanualanddigitalmetersarecurrentlyemployed,withdifferenttrade-

offsinaccuracyversus.2.1Manual

Astethoscopeisrequiredforauscultation.Manualmetersarebestusedbytrainedpractitioners,and,whilei

tispossibletoobtainabasicreadingthroughpalpationalone,thisyieldsonlythesystolicpressure.
Mercurysphygmomanometersareconsideredthegoldstandard.Theyindicatepressurewithacolumnofm

ercury,whichdoesnotrequirerecalibration.Becauseoftheiraccuracy,theyareoftenusedinclinicaltrialsof

drugsandinclinicalevaluationsofhigh-riskpatients,includingpregnantwomen.Afrequentlyusedwall-

mountedmercurysphygmomanometerisalsoknownasaBaumanometer.

Aneroidsphygmomanometers(mechanicaltypeswithadial)areincommonuse;theymayrequirecalibrati

onchecks,unlikemercurymanometers.Aneroidsphygmomanometersareconsideredsaferthanmercury

sphygmomanometers,althoughinexpensiveonesarelessaccurate.Amajorcauseofdeparturefromcalibr

ationismechanicaljarring.Aneroidsmountedonwallsorstandsarenotsusceptibletothisparticularproble

m.
2.2.2Digitalbpmachine

Digitalmetersemployoscillometricmeasurementsandelectroniccalculationsratherthanauscultation.Th

eymayusemanualorautomaticinflation,butbothtypesareelectronic,easytooperatewithouttraining,and

canbeusedinnoisyenvironments.Theymeasuresystolicanddiastolicpressuresbyoscillometricdetection,

employingeitherdeformablemembranesthataremeasuredusingdifferentialcapacitance,ordifferentialp

iezoresistance,andtheyincludeamicroprocessor.Theymeasuremeanbloodpressureandpulserate,while

systolicanddiastolicpressuresareobtainedlessaccuratelythanwithmanualmeters,andcalibrationisalsoa

concern.Digitaloscillometricmonitorsmaynotbeadvisableforsomepatients,suchasthosewitharterioscl

erosis,arrhythmia,preeclampsia,pulsusalternans,andpulsusparadoxus,astheircalculationsmaynotcorr

ectfortheseconditions,andinthesecases,ananalogsphygmomanometerispreferablewhenusedbyatrain

edperson.(Booth,J1977)

Digitalinstrumentsmayuseacuffplaced,inorderofaccuracyandinverseorderofportabilityandconvenienc

e,aroundtheupperarm,thewrist,orafinger.Recently,agroupofresearchersatMichiganStateUniversityd

evelopedasmartphonebaseddevicethatusesoscillometrytoestimatebloodpressure.Theoscillometricm

ethodofdetectionusedgivesbloodpressurereadingsthatdifferfromthosedeterminedbyauscultation,an

dvaryaccordingtomanyfactors,suchaspulsepressure,heartrateandarterialstiffness,althoughsomeinstr

umentsareclaimedalsotomeasurearterialstiffness,andsomecandetectirregularheartbeats.

(Mourad,Adnan;Gillies,Alastair;Carney,Shane2005)
2.3Operation

Thecuffisnormallyplacedsmoothlyandsnuglyaroundanupperarm,atroughlythesameverticalheightasth

eheartwhilethesubjectisseatedwiththearmsupported.Othersitesofplacementdependonspeciesandm

ayincludetheflipperortail.Itisessentialthatthecorrectsizeofcuffisselectedforthepatient.Toosmallacuffr

esultsintoohighapressure,whiletoolargeacuffresultsintoolowapressure.Forclinicalmeasurementsitisu

sualtomeasureandrecordbotharmsintheinitialconsultationtodetermineifthepressureissignificantlyhig

herinonearmthantheother.Adifferenceof10mmHgmaybeasignofcoarctationoftheaorta.Ifthearmsread

differently,thehigherreadingarmwouldbeusedforlaterreadings.Thecuffisinflateduntilthearteryiscomp

letelyoccluded.(Mourad,Adnan;Gillies,Alastair;Carney,Shane(2005)

Withamanualinstrument,listeningwithastethoscopetothebrachialartery,theexaminerslowlyreleasest

hepressureinthecuffatarateofapproximately2mmHgperheartbeat.Asthepressureinthecuffsfalls,a"wh
ooshing"orpoundingsoundisheard(seeKorotkoffsounds)whenbloodflowfirststartsagainintheartery.Th

epressureatwhichthissoundbeganisnotedandrecordedasthesystolicbloodpressure.Thecuffpressureisf

urtherreleaseduntilthesoundcannolongerbeheard.Thisisrecordedasthediastolicbloodpressure.Innois

yenvironmentswhereauscultationisimpossible(suchasthescenesoftenencounteredinemergencymedi

cine),systolicbloodpressurealonemaybereadbyreleasingthepressureuntilaradialpulseispalpated(felt).

Inveterinarymedicine,auscultationisrarelyofuse,andpalpationorvisualizationofpulsedistaltothesphyg

momanometerisusedtodetectsystolicpressure.(Mourad,Adnan;Gillies,Alastair;Carney,Shane2005)

Digitalinstrumentsuseacuffwhichmaybeplaced,accordingtotheinstrument,aroundtheupperarm,wrist,

orafinger,inallcaseselevatedtothesameheightastheheart.Theyinflatethecuffandgraduallyreducethepr

essureinthesamewayasamanualmeter,andmeasurebloodpressuresbytheoscillometricmethod.

2.4History

AFrenchsphygmomanometerusedduringWorldWarI

ThesphygmomanometerwasinventedbySamuelSiegfriedKarlRittervonBaschintheyear1881.ScipioneRi

va-

Rocciintroducedamoreeasilyusedversionin1896.In1901,pioneeringneurosurgeonDr.HarveyCushingbr

oughtanexampleofRiva-

Rocci'sdevicetotheUS,modernizeditandpopularizeditwithinthemedicalcommunity.Furtherimprovem

entcamein1905whenRussianphysicianNikolaiKorotkovincludeddiastolicbloodpressuremeasurementf

ollowinghisdiscoveryof"Korotkoffsounds."WilliamA.BauminventedtheBaumanometerbrandin1916,w

hileworkingforTheLifeExtensionInstitutewhichperformedinsuranceandemploymentphysicals.In1981t

hefirstfullyautomatedoscillometricbloodpressurecuffwasinventedbyDonaldNunn.Booth,J(1977)

2.5Commoncausesoffaultsinbpmeasurement

 YOU’REUSINGTHEWRONG-SIZEDCUFF
Themostcommonerrorwhenusingindirectbloodpressuremeasuringequipmentisusinganincorrectlysiz

edcuff.ABPcuffthatistoolargewillgivefalselylowreadings,whileanoverlysmallcuffwillprovidereadingsth

atarefalselyhigh.

TheAmericanHeartAssociationpublishesguidelinesforbloodpressuremeasurement.recommendingtha

tthebladderlengthandwidth(theinflatableportionofthecuff)shouldbe80percentand40percentrespecti

vely,ofarmcircumference.Mostpractitionersfindmeasuringbladderandarmcircumferencetobeoverlyti

meconsuming,sotheydon’tdoit.

ThemostpracticalwaytoquicklyandproperlysizeaBPcuffistopickacuffthatcoverstwo-

thirdsofthedistancebetweenyourpatient’selbowandshoulder.Carryingatleastthreecuffsizes(largeadul

t,regularadult,andpediatric)willfitthemajorityoftheadultpopulation.Multiplesmallersizesareneededify

oufrequentlytreatpediatricpatients.

Korotkoffsoundsarethenoisesheardthroughastethoscopeduringcuffdeflation.Theyoccurin5phases:

I–firstdetectablesounds,correspondingtoappearanceofapalpablepulse

II–soundsbecomesofter,longerandmayoccasionallytransientlydisappear

III–changeinsoundstoathumpingquality(loudest)

IV–pitchintensitychangesandsoundsbecomemuffled

V–soundsdisappear

Intheir1967guidelines,theAHArecommendedthatcliniciansrecordthesystolicBPatthestartofphaseIand

thediastolicBPatstartofphaseIVKorotkoffsounds.Intheir1981guidelines,thediastolicBPrecommendati

onchangedtothestartofphaseV.
 2.YOU’VEINCORRECTLYPOSITIONEDYOURPATIENT’SBODY

ThesecondmostcommonerrorinBPmeasurementisincorrectlimbposition.Toaccuratelyassessbloodflo

winanextremity,influencesofgravitymustbeeliminated.

Thestandardreferencelevelformeasurementofbloodpressurebyanytechnique—directorindirect—

isattheleveloftheheart.Whenusingacuff,thearm(orleg)wherethecuffisappliedmustbeatmid-

heartlevel.MeasuringBPinanextremitypositionedaboveheartlevelwillprovideafalselylowBPwhereasfal

selyhighreadingswillbeobtainedwheneveralimbispositionedbelowheartlevel.Errorscanbesignificant—

typically2mmHgforeachinchtheextremityisaboveorbelowheartlevel.

Aseateduprightpositionprovidesthemostaccuratebloodpressure,aslongasthearminwhichthepressurei

stakenremainsatthepatient’sside.Patientslyingontheirside,orinotherpositions,canposeproblemsforac

curatepressuremeasurement.TocorrectlyassessBPinasidelyingpatient,holdtheBPcuffextremityatmidh

eartlevelwhiletakingthepressure.Inseatedpatients,becertaintoleavethearmatthepatient’sside.

Arterialpressuretransducersaresubjecttosimilarinaccuracieswhenthetransducerisnotpositionedatmid

heartlevel.Thislocation,referredtoasthephlebostaticaxis,islocatedattheintersectionofthefourthinterc

ostalspaceandmid-chestlevel(halfwaybetweentheanteriorandposteriorchestsurfaces.

Notethatthemid-axillarylineisoftennotatmid-

chestlevelinpatientswithkyphosisorCOPD,andthereforeshouldnotbeusedasalandmark.Incorrectleveli

ngistheprimarysourceoferrorindirectpressuremeasurementwitheachinchthetransducerismisleveledc
ausinga1.86mmHgmeasurementerror.Whenabovethephlebostaticaxis,reportedvalueswillbelowerth

anactual;whenbelowthephlebostaticaxis,reportedvalueswillbehigherthanactual.

 3.YOU’VEPLACEDTHECUFFINCORRECTLY

Thestandardforbloodpressurecuffplacementistheupperarmusingacuffonbareskinwithastethoscopepl

acedattheelbowfoldoverthebrachialartery.

Thepatientshouldbesitting,withthearmsupportedatmidheartlevel,legsuncrossed,andnottalking.Meas

urementscanbemadeatotherlocationssuchasthewrist,fingers,feet,andcalvesbutwillproducevariedrea

dingsdependingondistancefromtheheart.

Themeanpressure,interestingly,varieslittlebetweentheaortaandperipheralarteries,whilethesystolicpr

essureincreasesandthediastolicdecreasesinthemoredistalvessels.

Crossingthelegsincreasessystolicbloodpressureby2to8mmHg.About20percentofthepopulationhasdiff

erencesofmorethan10mmHgpressurebetweentherightandleftarms.Incaseswheresignificantdifferenc

esareobserved,treatmentdecisionsshouldbebasedonthehigherofthetwopressures.

 4.YOURREADINGSEXHIBIT‘PREJUDICE’

Prejudicefornormalreadingssignificantlycontributestoinaccuraciesinbloodpressuremeasurement.No

doubt,you’dbesuspiciousifafellowEMTreportedbloodpressuresof120/80onthreepatientsinarow.Ascr

eaturesofhabit,humanbeingsexpecttohearsoundsatcertaintimesandwhenextraneousinterferencema

kesabloodpressuredifficulttoobtain,thereisconsiderabletendencyto“hear”anormalbloodpressure.

Orthostatichypotensionisdefinedasadecreaseinsystolicbloodpressureof20mmHgormore,ordiastolicbl

oodpressuredecreaseof10mmHgormoremeasuredafterthreeminutesofstandingquietly.
TherearecircumstanceswhenBPmeasurementissimplynotpossible.Formanyyears,traumaresuscitation

guidelinestaughtthatroughestimatesofsystolicBP(SBP)couldbemadebyassessingpulses.Presenceofara

dialpulsewasthoughttocorrelatewithanSBPofatleast80mmHg,afemoralpulsewithanSBPofatleast70,an

dapalpablecarotidpulsewithanSBPover60.Inrecentyears,vascularsurgeryandtraumastudieshaveshow

nthismethodtobepoorlypredictiveofactualbloodpressure.

NoiseisafactorthatcanalsointerferewithBPmeasurement.ManyALSunitscarrydopplerunitsthatmeasur

ebloodflowwithultrasoundwaves.Dopplerunitsamplifysoundandareusefulinhighnoiseenvironments.

BPbypalpationorobtainingthesystolicvaluebypalpatingadistalpulsewhiledeflatingthebloodpressurecu

ffgenerallycomeswithin10–

20mmHgofanauscultatedreading.Apulseoximeterwaveformcanalsobeusedtomeasurereturnofbloodfl

owwhiledeflatingaBPcuff,andisasaccurateaspressuresobtainedbypalpation.

Inpatientswithcirculatoryassistdevicesthatproducenon-

pulsatileflowsuchasleftventricularassistdevices(LVADs),theonlyindirectmeansofmeasuringflowrequir

esuseofadoppler.

ThereturnofflowsignalsoverthebrachialarteryduringdeflationofabloodpressurecuffinanLVADpatientsi

gnifiesthemeanarterialpressure(MAP).WhileanormalMAPinadultsrangesfrom70to105mmHg,LVADsd

onotfunctionoptimallyagainsthigherafterload,someanpressuresoflessthan90areoftendesirable.
Clothing,patientaccess,andcuffsizeareobstaclesthatfrequentlyinterferewithconventionalBPmeasure

ment.ConsiderusingalternatesitessuchasplacingtheBPcuffonyourpatient’slowerarmabovethewristwh

ileauscultatingorpalpatingtheirradialartery.Thisisparticularlyusefulinbariatricpatientswhenanappropr

iatelysizedcuffisnotavailablefortheupperarm.Thethighorlowerlegcanbeusedinasimilarfashion(inconju

nctionwithapulsepointdistaltothecuff).

AlloftheselocationsareroutinelyusedtomonitorBPinhospitalsettingsandgenerallyprovideresultsonlysli

ghtlydifferentfromtraditionalmeasurementsintheupperarm.

 5.YOU’RENOTFACTORINGINELECTRONICUNITSCORRECTLY

ElectronicbloodpressureunitsalsocalledNonInvasiveBloodPressure(NIBP)machines,senseairpressurec

hangesinthecuffcausedbybloodflowingthroughtheBPcuffextremity.SensorsestimatetheMeanArterial

Pressure(MAP)andthepatient’spulserate.Softwareinthemachineusesthesetwovaluestocalculatethesy

stolicanddiastolicBP.

Toassureaccuracyfromelectronicunits,itisimportanttoverifythedisplayedpulsewithanactualpatientpul

se.Differencesofmorethan10percentwillseriouslyaltertheunit’scalculationsandproduceincorrectsysto

licanddiastolicvaluesonthedisplayscreen.

GiventhatMAPistheonlypressureactuallymeasuredbyanNIBP,andsinceMAPvarieslittlethroughouttheb

ody,itmakessensetousethisnumberfortreatmentdecisions.
AnormaladultMAPrangesfrom70to105mmHg.Astheorganmostsensitivetopressure,thekidneystypicall

yrequireanMAPabove60tostayalive,andsustainirreversibledamagebeyond20minutesbelowthatinmos

tadults.Becauseindividualrequirementsvary,mostcliniciansconsideraMAPof70asareasonablelowerlim

itfortheiradultpatients.

IncreaseduseofNIBPdevices,coupledwithrecognitionthattheirdisplayedsystolicanddiastolicvaluesarec

alculatedwhileonlythemeanisactuallymeasured,haveledclinicianstopaymuchmoreattentiontoMAPsth

aninthepast.ManyprogressivehospitalsordersetsandprehospitalBLSandALSprotocolshavebeguntotre

atMAPsratherthansystolicbloodpressures.

Finally,andespeciallyinthecriticalcaretransportenvironment,providerswillencounterpatientswithsigni

ficantvariationsbetweenNIBP(indirect)andarterialline(direct)measuredbloodpressurevalues.

Inthepast,dependingonpatientcondition,providershaveelectedtouseonemeasuringdeviceoveranothe

r,oftenwithoutclearrationalebesidesabeliefthattheselecteddevicewasprovidingmoreaccuratebloodpr

essureinformation.

In2013,agroupofICUresearcherspublishedananalysisof27,022simultaneousartlineandNIBPmeasurem

entsobtainedin852patients.Whencomparingthea-

lineandNIBPreadings,theresearcherswereabletodeterminethat,inhypotensivestates,theNIBPsignifica

ntoverestimatedthesystolicbloodpressurewhencomparedtothearterialline,andthisdifferenceincrease

daspatientsbecamemorehypotensive.
Atthesametime,themeanarterialpressures(MAPs)consistentlycorrelatedbetweenthea-

lineandNIBPdevices,regardlessofpressure.TheauthorssuggestedthatMAPisthemostaccuratevaluetotr

endandtreat,regardlessofwhetherBPisbeingmeasuredwithanarteriallineoranNIBP.Additionally,suppo

rtingpreviouslybelievedparametersforacutekidneyinjury(AKI)andmortality,theauthorsnotedthataMA

Pbelow60mmHgwasconsistentlyassociatedwithbothAKIandincreasedmortality.

Since1930,bloodpressuremeasurementhasbeenawidelyacceptedtoolforcardiovascularassessment.Ev

enundertheoftenadverseconditionsencounteredintheprehospitalortransportenvironment,providersc

anaccuratelymeasurebloodpressureiftheyunderstandtheprinciplesofbloodflowandcommonsourcesth

atintroduceerrorintothemeasurementprocess.
 CHAPTER3

METHODOLOGY

3.0RESEARCHMETHODOLOGY

Thestudydesignthatwillbeusedtoconductthisstudyisdescriptiveastheprocessofcollectingdatainordert

otestthehypothesisconcerningthestatusofthesubjectunderinvestigation.Toinvestigatethefrequentbre

akdownassociatedwithoxygenconcentratorsatKariraHospital.

3.1.StudyLocation

ThestudywillbecarriedoutKariraHospital.KariraHospitalisaGovernmentHealthCentrelocatedinMjiniSu

b-location,BusiaTownshiplocation,MunicipalityDivision,NambaleSub-

County,BusiaCounty.Thehospitalhasabedcapacityof185.

TheservicesofferedatKariraHospitalare:Antenatal,AntiretroviralTherapy,BasicandComprehensiveEme

rgencyObstetricCare,CaesareanSection,CurativeInpatientandOutpatientservices,FamilyPlanning,Gro

wthMonitoringandPromotion,HIVCounselingandTesting,HomeBasedCare,Immunization,IntegratedM

anagementofChildhoodillness,preventionofmothertochildtransmissionofHIV,RadiologyServices(e.g.X

-Ray,UltraScan,MRI,etc.),TuberculosisLabsandTreatmentsandYouthFriendlyServices.
3.2StudyPopulation

Theinvestigator’sstudywillcomprisesBiomedicalEngineersandnursesatBusiaCountyandTeachingHospi

tal;inthiscasethestudypopulationis50.Thosewhoarewillingtoparticipatewillbehighlytargetedduringth

etimeofstudy.

3.3DataCollectionTools

Thedatacollectionwillbedonethroughsurveyresearch,interviewandpersonalobservationthus,thetoolst

obeusedwillbebiropen,pencils,rubber,questionnairepapersandnotebook.

3.4Procedure

Thepermissiontocarryoutthestudywillberequestedfromthemedicalengineerinchargeofmedicalengine

eringdepartmentandthenurseinchargeofdifferentwardsandNBU,thequestionnairepaperswillbegivent

othemedicalengineersandthepersonnelworkinginwardsandNBUtorespondtothequestions.Thereafter

,thisprocedurewillbepilotedinmedicalengineeringworkshoptoassesstheefficiencyofthestudy.

3.5EthicalConsideration

TheordertocarryoutthisstudywillbegrantedbytheNationalCouncilforScienceandTechnologythroughth

eDirectorKenyaMedicalTrainingCollege,InstitutionofResearchandEthicsCommitteethroughtheSuperi

ntendentofMeruCountyReferralHospitalandHeadofDepartmentMedicalEngineeringandTechnologyK

MTCMeruCampus.Consentandinformationobtainedfromtherespondentswillbeconfidentialandusedo

nlyforlearningpurposes.
3.6SamplingTechnique

Thisreferstotheprocessofchoosingasubgroupfromapopulationtoparticipateinthestudyandtheinvestig

atorwillusepurposiveornon-

probabilitymethodandthiswillallowhimtousethecasesthathehaththerequiredinformation(MUGENDA

ANDMUGENDA1999).

Fromtheformulaabove;

Interval=N/n;50/33.8=1.5≈2

Therefore,peopletobeinvestigated=SampleSize/Intervals

≈33.8/2=17

Thus,6peoplewillbeinterviewedorallywhile11peoplewillbegivenquestionnairepaperstofillinordertoob

taintheinformationrequiredforthisstudy.

3.7DataAnalysisandPresentation

ThedatacollectedwillbeanalyzedbyuseofMicrosoftExcel.Thedatawillbepresentedusingnarrativedescri

ptionanddiagrammaticpresentationbyuseoftables,chartsandbargraphs.

3.8TimeFrame

ThestudywillbeconductedbetweenSeptember2022toFebruary2023.

3.9BudgetJustification

TheexpendituretobeincurredinthefirstphaseofthestudywillamounttoKsh6200,andsincetheresearchha

snotbeenwritteninfull,typedandprintedthesumisexpectedtoincreaseevenmorethanthat.Thiswillbedu

etomovementandconsultation.

3.10InclusionCriteria
AllMedicalEngineersandnursesworkinginwardsandNBUwillbeincludedinthisstudysincethestudyneeds

onlypersonswithmoreknowledgeaboutthemachineunderinvestigation.

3.11ExclusionCriteria

Notallpeoplewillbeinvolvedinthisstudysincethestudyneedsonlypeoplewiththeknowledgeaboutthema

chineunderstudy.

3.12DelimitationoftheResultoftheStudy

TheresultofthestudywillbehandedovertothedepartmentofMedicalEngineeringandTechnologyKMTC

MeruCampus.
 CHAPTER4

4.0STUDYFINDINGS

4.1StudyApproach

ThestudywasdonetofindoutthecausesofinaccuracyinbloodpressuremachineatKarirahospital.Thecaus

esinclude:

 Usingthewrong-sizedcuff

 Incorrectpatientpositioning

 Incorrectcuffplacement

4.2DataCollection

4.2.1PersonalObservation

Theeyewitness(personalobservation)aidtocollectthedataabout:

 WrongsizeofcuffbeingusedtomeasurebloodpressureatKariraHospital.

 ii. IncorrectpositioningofpatientsatKariraHospital.

4.2.2Interview
Theinterviewwascarriedouttoaidingatheringtheinformationabouttheentireknowledgeandthefrequentfau

ltsrelatedtobloodpressuremachine.4nursesand2biomedicalengineerswerehighlyquestionedtogatherthei

nformationneededabouttheoxygenconcentratorsatBCRH.

4.2.3Questionnaire

QuestionnaireswereusedtogatherdatarelatedtofrequentfaultsrelatedtooxygenconcentratorsatKariraHos

pital.Questionnaireitemsof10werecreatedandcompletedpost-

operativelyof5respondentsincludedinthestudywere3nursesand2biomedicalengineers.

Intotal,thenumberofrespondentsinthisstudywas11,7nursesworkinginNBUsandotherwardsand4biomedic

alengineerswithameanageof40.Acomprehensiveanalysiswasconductedtofindoutthenumberandageofthe

respondentsasshownintable4.0below.

Age No.ofRespondents(f) Classmid-point(x) fx

0-10 0 5.5 0

11-20 0 15.5 0

21-30 3 25.5 76.5

31-40 2 35.5 71

41-50 4 45.5 182

51-60 2 55.5 111

∑f=11 ∑fx=440.5

Table4.0aboveshowstheageandnumberoftherespondentsatBusiaCountyReferralHospital.

Π={∑fx}/{∑f}

Π=440.5/11
Π=40.0

4.3DataAnalysis

Thetotalnumberofbloodpressuremachineunderstudywas18,8bloodpressuremachineoutof18werehavingf

aultsasshownintable4.1andrepresentedinfigure4.0below.

Faults No.ofbloodpressuremachinewithfaultsoutof18 %

Looseandleakageofthetubes 4 22.2

Leakingcuff 6 33.3

Faultypump 3 16.7

Conductivityandpowerfaults 4 22.2

Table4.1aboveshowsthenumberofbloodpressurefaultsatKariraHospital.

NO OF BLOOD PRESSURE MACHINE WITH

FAULTS

35
30
25
20
15
10 Series2
5 Series1
0
Loose and leak- LEEKING CUFF FAULTY PUMP CONDUCTIVITY
age of the tubes AND POWER
FAULTS

Series1 Series2

4.3.1leakingcuff
Thenumberofbloodpressuremachinewithleakingcuffwas6.Acomprehensiveanalysiswasconductedtofindo

utthecausesofleakingcuffatKariraHospitalasshownintable4.2andrepresentedinfigure4.1below.

Table4.2:CausesofleakingcuffofbloodpressuremachineatKariraHospital.

Causes No.ofbloodpressuremachinewithfaults %

Overinflating 4 66.7

Aging 5 83.3

Table4.2aboveshowsthecausesofleakingcuffofbloodpressuremachineatKariraHospital.

CAUSES OF LEAKING CUFF IN BP MACHINE

80
60 Aging
40
20 Over inflating
0
No. of blood pressure machine %
with faults

Over inflating Aging

Figure4.1:CausesofleakingcuffofbloodpressuremachineatKariraHospital

4.3.2Looseandblockageofthetubesinbloodpressuremachine

Thenumberofbloodpressuremachinewithlooseandblockageofthetubeswas4.Acomprehensiveanalysiswas

carriedouttodeterminethecausesoflooseandblockageofthetubesinbloodpressureatKariraHospitalasshow

nintable4.3andrepresentedinfigure4.2below.
Table4.3:CausesoflooseandblockageofthetubesinbloodpressuremachineatKarira

Hospital
Causes No.ofoxygenconcentrators %

Age 2 50

Dirt 3 75

Poorhandlingofthemachines 1 25

ThetableaboveshowsthecausesofthelooseandblockageofthetubesinbloodpressuremachineatKarira

Hosital

LOOSE AND BLOCKAGE OF TUBES

80
70
60
50
40
30
20 No. of
10 blood
pressure
0 machine
Age Dirt Poor handling of the
machines

No. of blood pressure machine %

Figure4.2:CausesoflooseandblockageoftubesinbloodpressuremachineatKariraHospital

4.3.3faultypump

Thenumberofbloodpressuremachineunderstudywas3.Acomprehensiveanalysiswasconductedtoinvestiga

tethecausesoffaultypumpinbloodpressuremachineinKarirahospitalasshownintable4.4andrepresentedinfi

gure4.3below.

Table4.4:CausesoffaultypumpinbloodpressuremachineinKariraHospital
Causes No.ofoxygenconcentratorswithfaults %
 aging 1 33.3

mishandling 2 66.7

ThetableaboveshowsthecausesfaultypumpinbloodpressuremachineinKariraHospital.

FAULTY PUMP IN BP MACHINE

70
60
50
40
mishandling
30
20
10 aging
0
No. of BP machine with fault %

aging mishandling

Figure4.3:CausesoffaultypumpinbloodpressuremachineinKariraHospital

4.3.4ConductivityandPowerfaultsinbloodpressuremachine

Thenumberofbloodpressuremachineunderstudywas4.Acomprehensiveanalysiswascarriedouttodetermin

ethecausesofconductivityandpowerfaultsinbloodpressuremachineinKariraasshownintable4.5andreprese

ntedinfigure4.4below.

Table4.5:CausesofconductivityandpowerfaultsinbloodpressuremachineinKariraHospital.
Causes No.ofoxygenconcentratorswithfaults %

Powersurge/powerfluctuation 2 50
 Faultycables 3 75

UsersError 1 25

ThetableaboveshowsthecausesofconductivityandpowerfaultsinbloodpressuremachineinKariraHos

pital.

CONDUCTIVITY AND POWER FAULTS IN BP

MACHINE

80

60

40
No. of BP
20 machine
with
0 faults
Power surge/power Faulty cables Users Error
fluctuation

No. of BP machine with faults %

Figure4.4:CausesofconductivityandpowerfaultsinbloodpressuremachineinKariraHospital

CHAPTERFIVE

5.0DISCUSION
ThestudywasconductedtoinvestigatecausesofinaccuracyinbloodpressuremachineatKariraHospitalandfro

mtheinformationgathered;thenumberofbloodpressuremachineunderstudywas18.22.2%werehavingloos

eandblockageofthetubes,33.3%werehavingleakingcuff,while16.7%werehavingfaultypumpandanother22.

2%werehavingconductivityandpowerfaults.Theresultshowsthathumannegligencewasthecommoncauseo

ffaultsinbloodpressuremachineatKariraHospital.Therefore,themainfaultsinbloodpressuremachinearecate

gorizedinto:

i. Pneumaticandotherfaults

ii. Electricalfaults

5.1Pneumaticandotherfaults

TheinvestigationwasconductedtodeterminepneumaticandotherfaultsinbloodpressuremachineatKariraH

ospitalasshownbelow.

i. Looseandblockageofthetubes.

ii. Faultypump

iii. Leakingcuff

5.1.1faultypump

Thenumberofbloodpressuremachinewithfaultypumpswasfoundtobe6.Acomprehensiveanalysiswasdonet

odeterminethecausesofinaccuracyinbloodpressuremachineatKariraHospitalasshownbelow.

i. Aging(66.6%)
ii. Mishandling(83.3%)

ThesearethemajorcommonfactorsthatcausefaultypumpinbloodpressuremachineatKariraHospital.Bloodp

ressuremachinesaredelicatemachinessincetheyarepronetodamage.But,itwasnoticedthatmostnursesplac

edthemonsurfacesthatputthemachinesathigherrusksoffallingandbreaking.

5.1.2LooseandBlockageoftubesinbloodpressuremachine

Theinvestigationshowsthat,thenumberofbloodpressuremachineswithlooseandblockageofthetubesinwas

4.Acomprehensiveanalysiswascarriedouttodeterminethecausesoflooseconnectionsandblockageoftubesi

nbloodpressuremachinesatKariraHospitalasshownbelow.

i. Age(50%)

ii. Dirt(75%)

iii. Poorandroughhandlingofthemachines(25%)

Continuoususeofthemachinesforalongerperiodoftime(age)causessomeofthetubestowornoutandbecomel

oosewhiledirtcausestheblockageofthetubesinbloodpressuremachines.Poorandroughhandlingofthemachi

nesalsocausesthetubestobelooseinbloodpressuremachinesatKariraHospital.

5.1.3leakingcuff

Thefindingshowsthatthenumberofbloodpressuremachineunderstudywas3.Acomprehensiveanalysiswasc

onductedtoinvestigatethecausesofleakingcuffinbloodpressuremachinesatKariraHospitalasshownbelow.

i. Aging(33.3%)
ii. Overinflationofcuffs(66.7%)

ThecausesofleakingofcuffsofbloodpressuremachineatKariraHospitalwasfoundtobeagingandoverinflation

ofthecuffs.Cuffsaremadeofrubberandlikeanyotherrubber,theywearoffwithtime.Somenurseswouldoverin

flatethecuffstoapointthattheycantwithstandthepressurehencepunctureorrupture.

5.2ElectricalFaults

Thestudyshowsthattheelectricalfaultsinbloodpressuremachinesareconductivityandpowerfaults.Hence,th

enumberofbloodpressuremachinesunderstudywas4.Acomprehensiveanalysiswasdonetofindoutthecause

sofconductivityandpowerfaultsinbloodpressuremachinesatKariraHospitalasshownbelow.

i. Powersurge/fluctuation(50%)

ii. Faultycables(75%)

iii. Users’Error

Thepowersurgeiscausedbyelectromagneticeffectswhichcauseeffecttobloodpressuremachinescausingfaul

tstothem.Faultycablesarecausedbyaging(continuoususeofcablesforalongperiodoftime)andhighcurrentan

dvoltagewhichblowthecables.Users’errorsalsocontributetotheblowofthecables.

5.3PreventionofthefaultsinBloodpressuremachines

Dependingonthefindings,thefollowingmeasuresshouldbeputinusetopreventthecausesoffaultsinbloodpre

ssuremachinesatKariraHospital.

i. Bloodpressuremachinesshouldbehandledwithcarebytheuserstopreventanybreakdown.
ii.

Uninterruptedpowersuppliesshouldbeinstalledtopreventthebloodpressuremachinesagainstpowersurge.

iii. Nursesshouldbecarefulwhenhandlingbloodpressuremachinesatalltimes.

iv. Nursesshouldnotoverinflatethecuffswhentakingbloodpressuremeasurements.

v. Cuffsshouldbereplacedafteraperiodofoneyear.

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