RAPID Response to questions from readers

(formerly Dear SIRS)

Clinician Recognizes Importance of Machine Checkout

Clinician Recognizes Importance of Machine Checkout

Michael Olympio, MD, Chair of the APSF Committee on Technology and Co-Founder of the SIRS Initiative.

Dear SIRS:
I am an anesthesiologist in practice in Santa Barbara, CA. The issue I am concerned with involves both organization and anesthesia machines. We put into service 18 months ago 15 Datex-Ohmeda anesthesia machines, which equip every OR. At the time of rollout, we received 1 mandatory inservice training session. In the intervening 18 months we have spent a lot of time tweaking the automated record keeping system. We have not, however, paid any organized attention to further developing our familiarity with the machine.

I recently had 2 machine incidents that involved aborted checkout sequences. When I told others about this, some shrugged their shoulders and said they never use the machine checkout sequence; others were appalled that everyone did not know 3 ways to rapidly troubleshoot the machine.

I want to propose to my group that we really need to pay some organized, formal attention to increasing our facility with our machines. Our current, “If you need help, ask someone” approach seems to leave too many loose ends, and assumes we are aware of the gaps in our knowledge before they become apparent. I saw the “HRO” concept on one web page but was unable to pursue it. Can you suggest how I might propose to our group changing our approach? Do you have some personal experience in this, or could you direct me to some readings?

Thank you very much.
Michael Cox, MD
Anesthesia Medical Group of Santa Barbara, Inc.
Santa Barbara Cottage Hospital


Attending machine technology lectures and workshops can reinforce your training.

Response:
Dear Dr. Cox:
Please allow me to assist you in your dilemma of providing adequate inservice to your anesthesia personnel. Having enjoyed teaching the anesthesia machine for a number of years, I will share some of my experiences below. I am forwarding your letter to my Committee members who might also share some of their expertise with you. In particular, Michael Dosch, CRNA, just lectured recently at the South Carolina Association of Nurse Anesthetists on troubleshooting your modern anesthesia machine. He might also send you some helpful hints.

  1. Identify who is in charge of your capital equipment. If that person is not the one most interested in machine technology, then find someone who is. It is no secret that you must find someone who has the curiosity to ask how these machines function, and who enjoys knowing something “unique” that no one else does. Most people cannot or will not learn about their machine without guidance.
  2. That person should be recognized for his service and contributions to the group either through academic or practice incentives, since he will provide a tangible benefit of safety and enjoyment in using and troubleshooting the machine (thus saving down-time).
  3. Identify the responsible internal biomedical service person whom the hospital employs. If they do not employ such a person, then ask your hospital administrator to consider hiring one to participate in anesthesia technology maintenance. (This individual can receive biomedical factory service training.)
  4. Once these key personnel are identified, I recommend a better relationship with the industry sales representative. Call them back for further inservice, if only for the education of your key persons. In fact, it might be more beneficial for the rep, or an official company service person, to spend all of their time with your key personnel alone. In the interest of patient safety, the hospital might even be willing to pay for several hours of the service technician’s time to educate your staff person(s).
  5. Keep in mind that the most highly knowledgeable technicians are usually those employed and trained directly by the manufacturer.
  6. Before these representatives return to the hospital for additional training, learn as much as possible about your particular machine. Start with the website, which typically has introductory descriptions, and READ the USERS MANUAL! There is a tremendous amount of information there, and typically something about theory of operation. Ask the manufacturer if they have any special learning materials for your particular machine.
  7. Read the ASA Refresher Course lectures that deal with anesthesia machines: Andrews, Eisenkraft, Olympio, Abenstein are well recognized authors who have recently contributed. Look at the APSF website presentation on Comparative Anesthesia Machine Breathing Circuits for an anatomical description of the newest circuits. Use the APSF sponsored Virtual Anesthesia Machine and Workbook program to learn the basics of the generic gas machine.
  8. Consider sending your key individual to the ASA Annual Meeting for the express purpose of attending all machine technology lectures and workshops, and for attending the floor demonstrations.
  9. Your key person, having developed his own understanding of the machine, should be given additional time to learn how the machine responds to various perturbations, and I would recommend that the official service technician be present when so doing.
  10. Next you must conduct a mandatory anesthesia machine workshop in your own institution, perhaps in lieu of an M&M conference or during a prolonged evening staff meeting. I have conducted several of these over the years, typically giving lectures for 2-3 hours one evening and then hands-on workshops the next day for another 3 hours or so. I have contests to see who could discover the “rigged” problems by following the official checkout recommendations. Company reps are also willing to participate in these type sessions. My students also find the “anatomy” lessons very helpful, whereby our biomedical service technicians take off the machine panels, and I label the internal parts with numbered tags. The students then have to identify the part, its function, and its “problem list” by referring to the schematic or my lecture materials.
  11. Finally, once your key individual is recognized as the local expert, he should (and will) be informed of all machine problems, sometimes acutely if you have no in-house technician. You will soon be amazed at how often the great majority of problems are very simple to diagnose.

Unfortunately, there is no substitute for knowledge and the investment in knowledge, if you want to have a pleasant experience with your gas machine. And why shouldn’t it be valued? You spend more time with it than you do driving your car, and it’s essential for it to work properly. You need only explore the FDA Center for Devices and Radiological Health MAUDE (manufacturer and user device experience) website to read about dozens of near-catastrophes and even death/brain damage resulting from machine misuse or failure. Deliberate omission of the machine checkout is inexcusable and has had serious consequences. I hope this helps.

Dr. Mike Olympio

NOTE: These are the personal opinions of Dr. Olympio, and do not represent any official opinions of the Committee on Technology or the APSF.


Response:

Dear Dr. Cox:

I would add to Dr. Olympio’s comments:

  1. We devote a section of our regular department meetings to equipment issues. We try to benefit from each other’s mistakes, humbling experiences, insights, and so forth. Our own individual practices sometimes benefit from being aired out in front of others.
  2. You should do whatever you can to create a culture in which not checking machines is substandard practice, dangerous to your patients, and poor risk management. With the ADU in particular (but all machines truly), not checking is a recipe for inaccuracy at best, disaster at worst. Further, regular machine checkout helps one to learn each model’s idiosyncrasies, and how to troubleshoot.

A fairly large section of the talk was about troubles encountered in checking ADU (as well as Aestiva). I would be happy to discuss; if you have specific questions please call.

Mike Dosch, CRNA, MS
Chair, Nurse Anesthesia
University of Detroit Mercy


Response:

Dear Dr. Cox:

I read Dr. Olympio’s response to your email with great interest, and I could not agree more with his suggestions and observations.

An initial, thorough, in-service is invaluable. However, you do need a local “champion” who is willing to serve as the in-house technical expert on equipment, which probably represents a major investment for your institution. For that reason your institution, as Dr. Olympio points out, has to support that person in this role. In addition to the Operator’s and Service Manuals, most vendors have ancillary training materials such as CD-ROMs and on-line training tools. However, it is your “champion” who will become your go-to person and make the experience with your equipment a rewarding and safe one, rather than a frustrating one. Lastly, and very significantly, your vendor must play a crucial role with continuing after-the-sale support. Don’t hesitate to ask for it.

Abe Abramovich
Director, Anesthesia Systems Development
Datascope Corp., Patient Monitoring Division


Response:

Dear Dr. Olympio:

My colleague forwarded your exceptionally thoughtful and thorough response to me. Since you have been educating residents for many years and have a personal interest in equipment and in educating, your approach to managing anesthesia delivery technologies in an ever-changing hospital environment is based on great experience. As the leading provider of anesthesia delivery systems in the world, we are currently in the process of developing educational programs that far exceed current standards. We are incorporating many of the concepts that you discuss about developing an in-hospital expert and resource.

Bonnie J. Reinke
General Manager, Anesthesia Delivery
GE Healthcare