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welcome to the medical equipment donations webinar this webinar is presented jointly by the clinical engineering Society of Ontario and the Canadian medical and biological engineering Society my name is Bill gentles my co-presenters are Sarah Kelso and Marat ferret this slide shows a brief outline of the webinar first we'll start with introductions then there'll be a poll question we'll ask the audience for some input we'll discuss briefly the issues with donations then show a brief video produced by CMP yes that gives a brief outline of the issues around donations we'll talk about the new CMB es guidance document on donations morat will give a brief presentation on the Ontario Surplus hospital equipment Network and then we'll have about 10 minutes for questions and discussions Peter can you um send out the poll question to the audience and we'll give them a couple of minutes to answer so the questions are what types of equipment have you donated recently and you can check all its apply it's a multiple choice question we just put on the list the most common things um but if you've donated a lot of equipment that's not on the list you might put it in the chat for us just to help but check off anything that um you've been involved in donations of in the past year or so and we'll give a couple of minutes for people to answer that and then we'll look at a summary of the results see some comments here none not in good enough conditions fridges and freezers yes incubators in the process of donating prismaflex and RO water treatment systems for dialysis some people are saying they have not donated just one housekeeping issue um we'll be having a q a at certain times so you can ask your questions then yeah there's a q a button at the bottom of the screen um you can ask questions in the chat but we're able to manage them better if you put them in the Q a feature rather than the chat feature of Zoom thanks only some patient monitor accessories like pulse oximeter probes or I think Martin okay do you think we've got some data Peter we could display the results yep we do I'll display it in a second okay so the most common that's not surprising actually the most common is beds followed by patient monitors infusion pumps ultrasound machines small number of X-ray units and some dialysis units but a lot of other as we saw in the comments anyway that's that's most interesting on um perhaps it'll raise some questions as we talk some more about the um the the pitfalls of making equipment donations to low resource countries okay moving right along on to the next slide um just see if I can get this to change slides okay so just some of the sources we're using for information to um present in this webinar there's um three key documents the first is a who medical device technical series document called medical device donations considerations for solicitation and provision this is available on the wh who website I'm going to put the link to that in the chat let's see if I can do this uh okay that's a link directly to this document it's a PDF document and it'll allow you to download it it's a very useful document but I'd keep an eye on the who website because they're in the in the middle of updating this document in 2023 there'll be a new edition that uh deals with um deals a bit more with um recipient responsibilities in equipment donations second thing we're going to be using as an information resources a study that was conducted um by the international Outreach Committee of cmbes between 2015 and 2017 in which we surveyed 41 donation organizations across Canada to um inquire about Their donation practices we also looked um we hired a research assistant in Ghana to interview uh representatives of 28 Healthcare institutions in Ghana to talk about their experiences in receiving equipment donations not all from Canada but from many countries around the world and the third document which we'll talk more about a bit later is the new CMB es guidance document on donations um so just let's talk about the need first of all uh this is a statistic that's published in the who document that in some countries nearly 80 percent of the health care equipment is donated or funded by International donors or foreign governments in in low resource countries the budget for Health Care is extremely small and high-tech equipment is simply beyond the reach of of the finances of of Health Care Systems in low resource countries so they're extremely dependent on equipment donations from organizations that do charitable work around the world and also wealthier countries that have Surplus medical equipment so there's an urgent need for donated medical equipment um but the problem is ing to one estimate and this varies depending on who's donating and who's receiving it but only 10 to 30 percent of donated equipment actually becomes operational in developing countries and we'll talk about the reasons for this but it it's um it's a rather troubling statistic that indicates that there's a very high failure rate in the um donation activity around the world and many people are not managing the equipment donation process properly as a result of which they're placing an undue burden on these low resource countries by sending them equipment what they can't use and it ends up in equipment graveyards we'll show you some pictures of those a bit later um goes to landfill sites in the lower resource countries so we've spent all of that energy all of that funds loading up shipping containers sending them Halfway Around the World getting them to a healthcare institution that can't use the equipment if all of the money spent on those Logistics were just donated to that country they'd be much farther ahead in their Health Care system so there's a an extremely important incentive for people to get this right because otherwise you're placing instead of helping you're placing an undue burden on the recipient country so the problems with equipment donations um in our study as I said we looked at 41 organizations um both registered and non-registered charity ngos non not-for-profits medical clinics and hospitals and we looked also at the recipients in 28 hospitals in Ghana to get an understanding of their experiences so just to summarize some of those results for many Canadian donor organizations there is great room for improvement and these are just some of the following areas a lack of formalized procedures so they don't have standard operating procedures they don't have anything written down it's all done on the seat of the pants nobody can pass on to others if they leave the organization what the best practices are that they've developed during their tenure in the organization nothing's written down that's a common problem in small charities where everybody thinks they're doing some good work from the goodness of their heart and they shouldn't have to do all these bureaucratic formalities second problem testing equipment make sure the equipment's working before you send it off make sure it's got all the necessary accessories so that it can be put into use third problem providing additional support for the recipients in the form of manuals spare parts and training because this equipment is going into it in many cases an extremely hostile environment there may be no air conditioning in this a very hot country it may be Dusty the users may be poorly trained and unfamiliar with the equipment and so there's a very high failure rate of donated equipment that goes to low resource countries so it's essential that user manuals be provided with the equipment and it's almost equally important that maintenance manuals be provided as well because in one of the small studies we did we followed a container load of equipment to a low resource country after about a year 50 of the equipment that was functional when it arrived was out of service and the reasons were lack of spare parts mostly but also lack of training people didn't know how to fix it when it broke and the final um shortcome of many donor organizations is the lack of a long-term monitoring process to follow up with the recipient country and see if the donated items met the needs if they're still working if they've had problems keeping them working if they've run out of accessories or spare parts the feedback every time you make a donation is an essential part of that donation process and so just talking about briefly about the recipients the most common challenges faced by the recipients were a lack of spare parts and a lack of operating or service manuals in some of these countries if a patient cable comes apart or breaks and they need to replace it there's no distributor for that manufacturer in the country you may be in Europe it might take months for them to get a replacement for a patient cable so it's important to send as much in the way of accessories as is possible now as the next item on the agenda we're going to show a brief video that talks about best practices in donating equipment all right so I'm just going to see if I can start the video it'll just take about seven minutes one day there was this 12 year old boy named Moses that I made friends with he was admitted to the male War he was one of these cases that on the third day after the staff had actually reported that he was getting better and his condition was stabilizing he died three hours later after I left the hospital they were some internal bleeding the staff wasn't aware of and they had no idea that its heart rate would be rapidly increasing his blood pressure was rapidly decreasing and uh candidup died and I went back in the next day and I found out and I was pissed because in my mind I knew uh without a doubt that he never would have died in the most basic facility in Canada and so it became a human's rights issue to me it became a social justice issue to me because what by virtue of being born in that facility in this community does that justify and make it okay that he can die there when he never would have to die here and the answer was no of course not so I saw a basic diagnostic medical equipment as a way to address this issue and empower the staff to be able to provide care for other patients and Save Somebody Like Moses oh Kelly's story is not unlike the countless told by dedicated volunteers and organization leaders across Canada who have created special projects Charities and non-profits to address crucial medical equipment needs around the globe to date Canadian Goodwill has provided critical medical equipment to over 48 countries from Frontline equipment to more complex and larger devices donations address everything from basic health care to supporting a healthy Community the value of which is considerable this simplistic Act of generosity is actually overwhelmingly complex posing numerous hurdles that donors and recipients face to ensure equipment arise safe and sound so we do a lot of due diligence in equipment acquisition to ensure that we're only providing the medical equipment that has the durability and robustness to last and function for years at a time in the conditions in Northern Ghana that they'll find our primary sources are manufacturers and medical equipment Charities that receive Mass amounts of equipment donations from hospitals from manufacturers and then they deal it out to the smaller Charities 85 of our equipment is brand new and on you which is fantastic the remaining 10 to 15 that isn't if it's equipment that needs to be plugged in that's slightly more comprehensive like an oxygen concentrator it has to be certified by biomedical engineer that it has functionality to ensure that we're not providing something that will spoil when it goes over because equipment graveyards are a huge issue in research success often block hating Hospital floors creating landfills and placing undue pressure on a system that is already heavily taxed too often the majority of this charitable act goes to waste donating poorly functioning equipment at the outset is one of the reasons that donations can go awry research has shown that Canadian organizations often fail when it comes to inspecting equipment and checking for compatibility of electricity Supply when donations are received few organizations ask for confirmation that the equipment arrived in working order or are provided status reports on the functionality of the equipment over time donating equipment that isn't truly needed can also lead to poor outcomes I think it's immensely important to stick to the research that you've done so even though we have offers all types of items sometimes expired sometimes not it's extremely important to still say you know when you go to research items that we know are the most needed in our hospitals and going away from that means you're going to be providing things they don't really need and they don't have a way again to safely dispose of it's easy to fall into this top-down donor approach where you have a lot of sources of medical supplies and you're looking for a place to give them and I don't find that's necessarily the most effective way because then sometimes you're projecting somebody's needs for them and that can create errors in the impact your projects it's going to have so with all this generosity and support to Nations around the globe how can Canadians improve how can we strengthen A system that has tremendous impact on a person's health and a community's sustainability ideally any donation initiative should be part of an ongoing partnership consisting of Three core elements consultation ensuring that the needs of the recipient are well understood and have been established through a consultation with all parties involved planning and process having a clear donation plan identified and agreed to in advance by all stakeholders monitoring and follow-up perhaps the most important element is a sustained and supportive relationship with the recipient institution ensuring long-term success and impact I think it's important to work with a researcher if it's possible because they'll just ask questions that maybe you're not used to thinking of um and they'll keep you in check to ensure that the projects are meeting a sustainable end or are reflecting an expressed need that you're not targeting things and slipping into what's easy teaming yourself up with other individuals other corporations that are critical and that are always going to try to make your projects as strong as possible is always a sure bet to accept that for more guidance on all of the steps involved in an effective donation process several online resources are available including the World Health organization's guideline document and the tropical health education trust making it work to okay because what starts as Goodwill and a desire to make things better should ultimately create an equally promising outcome [Music] [Music] you know [Music] okay can you hear me okay yeah yeah great thanks the next item on our agenda is for me to tell you about the donations guidance document that cmbs has been working on so first a little background on the project cmbs executive recognized the value of medical device donations done properly and the pitfall of poorly coordinated donations as bill has just told us about in detail and we also saw it in the video we also recognize there are regulatory requirements for donor hospitals that may not be well understood and that many hospitals may be hesitant to engage in the donation process due to a potential liability issues and so the executive determined that it would serve cmbs members and the clinical engineering biomedical engineering community well to address some of these information gaps the work started with our professional Affairs chair which is a position on cmbs Executive the key rules of that chair to address clinical engineering biomedical engineering practice issues draft reference documents when applicable ing the webinar series and overseeing other practice related activities and so the initial goal was to deliver a clear donation related information to members via webinar and we were hopeful to engage a representative from Health Canada to join us in that webinar and really offer some hopefully Clarity with respect to donation related regulations we still would like to do this and hopefully it's an event that will come together in the future but we just haven't made it happen yet around the same time a former executive member offered to share some information collected by a clinical engineering intern regarding the regulations and liability surrounding medical equipment donations so of course we accepted this generous offer and this provided us with an excellent first track draft of a document to work with our executive committee reviewed that document and updated it a number of times but we really struggled to find the right tone and balance that would was suitable for addressing all the different issues that we wanted to cover in the document and we also found it difficult to make progress in that larger group setting so we formed a smaller working group to set some objectives for the document focus on each of the essential elements that we needed to cover review some of the finer regulatory details and address all of the feedback that we had collected up to that point it was interesting working in the small group because when we started our different group members seem to come with different perspectives that initially seemed like they might be competing perspectives but in fact were just different critical elements that we needed to make sure made it into the final product and I think we were successful We've Ended up with a document that's practical balanced and useful and now we're looking to forward to sharing it more broadly starting with this webinar today the title of the document is guidance for hospitals donating medical devices and the objectives are threefold to provide Canadian hospitals with information required to undertake medical device donations in a manner that provides the best possible value to donation recipients is compliant with Canadian regulations and minimizes Zone reliability and I'll speak to each of these in a little more detail in the coming slides the document is not intended to be legal advice or a position paper but rather to support hospitals who are considering medical device donations by providing a summary of the relevant information that they should be aware of through the donation process so the first element is the collaboration piece um to ensure we are providing value to donation recipients it's vital that the donor engage with the recipient to confirm that the device is to be donated will meet the needs of the recipient and that the recipient has the resources to operate and maintain the equipment and we certainly have touched on the these elements already from a practical perspective this means that the donor hospital as much as possible should include any supporting materials available in their shipment this could be user or technical manuals or training guides if available also including any remaining spare parts parts or test sets that are required for maintaining the equipment and from a clinical perspective also donating any accessories or consumables that are available a donor Hospital might not know how to connect with a recipient organization and there are third-party groups that that can help with this there's organizations that can facilitate donations or facilitate connecting donors with recipients and we'll hear more about one of these later in the webinar as far as regulations go there's two elements to the Canadian regulations that we need to be aware of and the first one is the hospital taking on the role of a distributor so many of us are aware that the sale of medical devices is regulated by Health Canada under the Canadian medical devices regulations and health Canada considers a donation as a sale without consideration in fact Health Canada considers anytime a device changes ownership as a sale even if it doesn't look like a traditional sale hospitals are actually exempt from the need to hold an establishment license so we don't need to go through the application process to get an establishment license or play pay the associated fees however hospitals still need to comply with the requirements of being a distributor and for the most part this means keeping distribution records which is essentially contact information for the future location of each donated device sufficient that the hospital can forward any alert or recall information or permit commit complete and Rapid withdrawal of the devices from the marketplace if required hospitals also have to have a complaint handling process sufficient to carry out an investigation into any problem that may be reported back to them from the donor organization I'm sorry from the recipient organization the second part of the regulations that we need to pay attention to relative donations is active device licenses so the regulations say no person shall import or sell and now we know that cell the definition of cell includes a donation a class two three or four medical device unless the manufacturer of that device holds active medical device license for that device and this can be an issue because sometimes devices that are mature in their life cycle the manufacturers will just decide not to continue maintaining the active device license so if you are considering donating a device and you're not sure if it still holds an active device license you can Google mdoll and you'll arrive at the health Canada medical device active license listing sorry medical device active license listing which is a reasonably searchable database of all active medical device licenses this requirement does not apply to class 1 devices which never require a medical device license or donations intended for veterinary use only and the final element that we cover in the guidance document is to minimize liability for the donor organization most of the information that we have here comes from High Rock which is the health insurance reciprocal of Canada it's a not-for-profit health care safety advisor and the primary insurance provider for Health Care Facilities across Canada and they have a really good resource on their website where they provide detailed guidance for hospitals to minimize their liability when donating which includes complying with all Canadian regulatory requirements which we've just covered uh and also providing detailed documentation for each donated device and uh the list of what they think should or or suggest should be included is quite um extensive including serial number model manufacturer license status history of all PM repairs alerts and recalls and corrective actions taken over the life of the device all inspections tests and cleaning performed at the time of donation and a statement of the condition of the device at the time of donation they also strongly encourage the use of a liability waiver which is a document signed by the donor and the recipients intended to waive the rights of the device recipients to seek compensation from the donor if there are any future problems with the donated equipment and in our guidance document we actually have two tools in the appendices the first of which is a sample waiver document which was based on a waiver document used by a Canadian Hospital and the second tool we have in the appendices is a donation checklist which essentially covers all of the requirements that we've listed in the document but in an abbreviated checklist form to hopefully facilitate consideration and compliance with the requirements also at the end of the document there's an excellent reference section which includes links to that High Rock document I just mentioned as well as the who document Bill mentioned previously and some other good resources um so in conclusion many of the factors that we've discussed today are going to help a hospital decide whether or not to engage in the donation process in addition to the hospital's own level of risk tolerance what we wanted to do was provide objective factual information that hospitals can use to make the decision that best fits their organization and if they decide to donate used medical equipment to do so in a way that provides the best value to the donation recipients is compliant with Canadian regulations and minimizes donor liability as far as next steps following this webinar cmbs will share the full guidance document with cmbs members and Cecil members by email and we'll open a member review period of two weeks over which time we're happy to accept any comments or feedback at our Secretariat cmbs.ca email and then once we've had a chance to consider all of that feedback we will publish the final document on the cmbs website I do need to take a moment to acknowledge this group of people who made significant contributions to the development of the guidance document um cmps can't produce high quality materials like this without members stepping up and volunteering their time and expertise so thank you and mercy to all of them and all of you for your time and attention today and now I'm going to pass the screen to Murat who will tell us about the ocean initiative thank you Sarah and I'm gonna be talking about the ocean on top of this very useful guidance document and the challenges um ocean is let me change the slide okay um ocean is short for Ontario circles house hospital equipment Network and I want to be clear even though there is a world of Ontario in the title there is currently no active collaboration with the Ontario government unlike the Quebec there is because there is no centralized Surplus hospital equipment coordination activity in Ontario so ciso or thought there is a need and ocean is a seesaw project and I will start first acknowledging the team behind the ocean the concept the website and the process was developed by a team of volunteers some group or same group of ciso volunteers are now running and maintaining the ocean since 2020. but the alarm will gentle zantimu thank you for their help ocean has been a really low budget initiative I think it cost us about not including the volunteer time hours of volunteer time about hundred dollars to initiate and now it's costing just the cost of websites running the website at the moment now having said that there hasn't been a very high volume activity which I will talk about it later so our mini poll results show that many of us get involved in donation of surplus hospital equipment and we all know that properly done donation required considerable amount of time and effort challenges include finding the trusted and reputable recipients and completing the completing the transaction transparently efficiently and properly Ocean's goal is to help for this simply put ocean is an exclusive online platform to connect Healthcare organizations with verified recipients unlike Twitter's verified by the way ocean team reviews each applicant and certifies the registration as donor for recipients also did I mention that it is free for both donors and recipients um before switching to okay sorry um oceans is neither a donor nor a recipient as I mentioned it is a platform enabling donations doesn't get involved with the actual donation transactions we may say that ocean is an exclusive and focused Kijiji for medical equipment and furniture and like a transparent tender platform hospitals will have the ability to offer their Surplus equipment and donate them to the trusted organization which is suitable for their own criteria the goal is to create exclusive trusted Network for healthcare facilities and trusted recipients usually when hospitals acquire new equipment and Furniture the priority is to get the new equipment implemented and remove all the equipment efficiently we don't have the Storage storage is a premium in the healthcare facilities we all know that and at that last moment if we didn't made already connections and plan for it we need a recipient at that moment and they need the right they need to come and pick up the items as fast as possible so from recipients perspectives uh potential recipients really appreciate the knowledge of available equipments for donations an Ocean's goal is to fill the need for both hospitals and recipients One Stop Shop for all foreign so what you're seeing here is the after the recipient's login they see the screen by the way there are currently 27 verified and registered donor and recipient organizations and um I think ocean team rejected seven applications um because they didn't fit into our criteria uh as experienced a not-for-profit or Hospital uh criteria within that and as early uh I mentioned earlier this review process really maintains the exclusive trusted and verified platform for all ocean users so that they don't have to worry about that aspect of the transaction we have several categories in the available items and the donors or sorry recipient can click one of them and when for example when the recipient collects the electromedical equipment they get to see whatever available at that moment and they can big deep click the pictures and see the information posted by the donors and then have the ability to contact the donors and provide their intention to pick them up and either donate them to third or countries and or or sometimes the recipient could be in hospital who wants to use them as spare parts um so ocean is not just limited to donations by the way it's open to the hospitals sharing their Surplus equipments for parts as his purposes or even sell them this is what the um donors see and as you see um from the picture it kind of looks like a KGG it's it's uh e-commerce product uh offered from a company called salacious salacious we simply customize it for oceans uh um use and so you will see some terminology um towards selling buying items online and posting from the donor perspective is quite easy you just fill a few Fields uh mandatory fields and you can put as many pictures as you like you can even put a fee if you want to sell the equipment uh considering you're from a hospital or you're complying with the regulatory requirements as indicated by Sarah's presentation and then the potential recipients will see what's available they will get in contact with you since they are all trusted and verified you can uh very comfortably communicate and proceed to the transaction despite its small budget and limited resources ocean is up and running ready to serve Canadian and Global Health Care ocean is still in infinitious stages by the way and I believe our timing has been a bit unfortunate considering the pandemic so the utilization of the platform is very low at the moment we hope it will eventually pick up if there is actually a need that ocean effectively fulfills and that takes me to the last slide and looking at the time I think we have more than enough time for questions I ended up going through really fast through my slides these are the contact information of the um the presenters of the session as well as the organization information including cmbsc store in ocean so we can switch to questions and Q a um build back to you okay thanks Morad um we have some questions in the um q a and so maybe the panel can all turn on their cameras and microphones because we may need feedback from everybody on these oh yeah but um so the first one Anders angstrom hello Anderson Anders nice to hear from you um his question in my experience working in lower resource countries and issues with donations number one North American 110 volts as essentially all recipients are 220 volts solution convert to 220 volts before sending that's um and be aware of the voltage of the country you're sending it to um a very good point there's a lot of equipment Goes Up in Smoke because it's been sent to a country without paying attention to the voltage number two um Ops such as dialysis pumps or infusion pumps use disposables that are in most cases not available in the recipient country yeah this is a big problem with infusion pumps that the way the manufacturers make their money is on selling the consumables that go with it lower Source countries can't afford those consumables so an infusion pump should only be sent if it can use a a generic infusion set number three send user manuals well yes exactly we already all agreed with that uh second question I'll throw this over to Sarah perhaps when the recipient institution is not in Canada does the hospital need a distributor license okay so um based on our group's understanding the requirements of whether the recipient institution is in Canada or outside of Canada the health Canada requirements are the same which is that the hospital does not need an establishment license but the hospital does need to comply with the requirements of being a distributor which are to track where the equipment goes be able to forward any alert and recall information and also be able to expect accept problem reports and deal with them and and document that process I hope that answers the question thanks Sarah um third question from Martin do you think Health Canada classifies the donation of parts for medical technology um boy that's an interesting question I I'm not sure I know the answer to that um I think they're only interested in devices that are actually licensed so I would add I guess it depends if the part is considered uh device or if it's just a repair part like if the part is in fact an accessory that holds a device license then I think Health Canada would consider that as the donation of a medical device but I'm not sure if it's a repair part how they regard that yeah I think we need somebody from Health Canada to answer that question that's um interesting question um I I would agree with Sarah's interpretation though I haven't seen any uh mention of parts in the medical device regulations next let's go to the next question um I'm Jennifer McGill has there been success getting shipping covered by recipients of donations that's um that's an interesting question because the shipping costs are often a considerable fraction of the total value of the uh the shipment like a a shipping container to send um across the ocean I think the costs are around ten thousand dollars uh recipient countries typically don't have that kind of money um I'm not aware of anyone perhaps if you've anyone in the audience has information on that they could put it in the comments but um in most cases Charities who are donating equipment overseas their biggest challenge is is funding the shipping costs because the recipients and in most cases could not possibly pay for those costs question from Martin has anyone in Canada set up a process for distribution record tracking morat I don't know maybe you could try and tackle that one it's a bit like ocean but not quite um unfortunately I haven't heard anyone trying to tackle with that I don't know or um other than knowing essentially what would that really help to having said that if one day our vision is if ocean becomes a widely used Network the information will be readily available for the member hospitals or Healthcare members of the ocean but at the moment I'm not aware of such a setup foreign I was going to say depending on the um the way that the hospital cmms is set up um there could be ways to kind of utilize that same function but potentially set up um donors as other sites or properties within the organization and and still track the location of medical equipment in the same way that we do for internal equipment I haven't done it myself so maybe that's overly simplistic view but also in terms of Distributing alerts and recalls we do that throughout our organizations so again depending on how the system is set up it could just be another layer of distribution kind of beyond the hospital campus um if if the question was around that I agree Sarah I from for the donations that we do from my hospital we do Mark the asset information uh with the recipients and and the where it's donated to so we can if ever need to keep communicating the alerts recalls or manufacturer information just to fulfill that obligation as a distributor next question do you know of any hospitals that have complied with the requirements of becoming a distributor um the requirements to become a just you don't need the establishment license so that's the first thing um but beyond that um as we've discussed before it most of the requirements can be um met by keeping the data in your cmms um and just regarding the recipient as another site so that they would receive um any notifications about that equipment Sarah or Morant other comments on that I agree I think it's uh with this presentation we're trying to raise the awareness that uh for hospitals since you don't need establishment license all you need to do is uh don't delete the asset records and make sure the electrical distribution if ever happens for those items uh from Phil you know all happens as usual with the rest of your assets and you communicate the information with the area that you distributed to now having said that the question I can't answer and I don't know what happens if you donated that equipment through a charity to a third world country I don't think you need to distribute that alert or recall information or manufacturers letters to outside the country it should be within the Canada that's my interpretation but we need to find out the actual answer from out Canada I guess thanks Matt and um Jennifer's got a follow-up question who covers that cost then and um there was actually an answer in the chat to that um I'll just read that off because um makes the comment we used GoFundMe to get the public in the community to cover his shipping cost on our last donation a year ago there is a charity in British Columbia called rotary World help that does a lot of shipping overseas and they use their own fundraising um mechanisms to fund all of their shipping containers they ship quite a few shipping containers every year um so it is a significant cost um Parisa says she has a case where a recipient paid for the shipment that's quite unusual but I guess that's an example that proves that it it uh can happen in some cases Mario has a good question here is there some consideration to get free storage area where we could send the equipment to be donated our Hospital keeps asking us to get rid of the unused equipment yeah storage space is very tight um marant you want to try and pick up on that yes uh I I think that would be wonderful I totally agree with Mario and um but how I see that happening at this moment there is no initiative this is a a more centralized governmental practice almost like the similar program in Quebec uh where uh government collects the um donatable usable Surplus equipment from hospitals and coordinate ingly um maybe one day if again ocean picks up and if there is a need we plan to collaborate with Ontario government towards that Direction at the moment I'm not aware of any other Province other than Quebec doing that kind of service and coordination thanks marant um let's move on we've got a couple more minutes um Martin makes a comment maintaining distribution records and expecting our old slash out of support technology to be licensed are barriers to donate under the regulations um that is a requirement under the regulations that you must um you should not be uh quote selling anything that doesn't have a medical device license from Health Canada and if the manufacturers let the license expire strictly speaking you should no longer be donating that device um Moran over to you oh sorry I clicked the link um button by mistake Bill you're answering it already sorry okay okay I didn't know there was a right answer live button yes I see and Anders comments most recipients don't have a data entry system where they can track the equipment in their country um good point uh once it arrives in a lower resource country there may be no records kept as to which hospital it ends up in Rosanna um welcome glad you could join us in low income settings some taxes and costs of shipping are not applied or to reduced if an academic organization is engaged engaged in the use of the donation so the recipient if the recipients as I understand it is an academic organization they may be hit with local taxes um import duties um that's that's a serious problem we don't um and donors again would be unaware of the um the tax and and Duty implications of in the recipient country unless they have very good communication with the recipients because obviously the donors are much better able to assist with those costs than the local academic organization I I think the answer is to make sure you got good communication with the donor and explain to them all the costs that Their donation is going to incur once it lands in your country because it may be significant and it may prevent the use of the equipment um but thank you for that comment Rosanna uh Bassett any plans to consider user or be met training all right do you want to pick that up um yeah I don't I haven't heard any specific plans or including that in in the ocean I'm just promotion perspective um answering that it's it's not in the works um we're running over I think we're we'll just try and Tackle one more question the if I may suggest Kevin's question is interesting and clarifying one about he says so if we donate it to a NGO that distributes to unknown other locations we would then need to only send the recalls to that NGO and the expectation on them would be to forward that from hospital perspective since you distributed the equipment to the NGO that will be correct that would satisfy your requirements for the as a distributor would you agree Sarah yeah I agree I agree and there's a quick one here from krita is there any concern if the license of the device becomes not active after the donation um yeah no the device license is an issue at the point of sale so if um if once the donation changed or once the device changes ownership the device license could um expire the next day that wouldn't affect the hospital's um obligation because they would have maintained that the device was in place at the time of uh change in ownership and and just to think of the example of the hospitals hospitals many hospitals are using devices well past their expected Lifetime and they've no longer covered by a licensed hospitals continue to use them so it's it's the same situation I'm afraid we're going to have to wrap it up there perhaps we can um keep track of this quite a stack of questions still coming in um we'll try and answer these offline so um we'll figure out how to distribute them to the registrants and thank you all for attending the webinar that's been great and wonderful to see so much um interest in the topic from Canada and outside the country so thanks everybody and bye for now