System Needed for Equipment and Monitors
There now seems to be agreement that safer anesthetic care is facilitated by: 1) a better trained and better coordinated anesthesia care team through better recruiting and improved4onger training; and 2) more complete monitoring of the patient and the anesthesia delivery system.
An area lacking general agreement (eg., due to differing philosophies, lack of data, etc.) is what kind of Support/Service System is needed to facilitate item #2 – the support of monitors (both patient and delivery system) and the anesthesia delivery system itself.
Support/Service Systems are broadly defined (for the purpose of this discussion) as: procedures/ personnel/space/budget to facilitate the acquisition, utilization, and service of the monitors (patient and delivery system) and the anesthesa delivery system. Service per se is defined as set-up, calibration, testing, troubleshooting, and repair of anesthesia equipment (monitors and delivery system). There are several other areas interdependent with the issues of support/service, but which are beyond the scope of this article (e.g., education of users in the operation and interpretation of monitors, research and development, and feedback from the field to the manufacturers).
Equipment Accidents
The relationship between equipment performance (failure, ease of use, etc.) has been considered by Westenskow and Cooper “2 in their introductory articles in a special symposium in Medical Instrumentation (“Symposium on Safety in Anesthesia”). Issues of Clinical Engineering support and the roles of anesthesia department support personnel were also addressed in this symposium 3,4 Cooper states that “equipment failure rarely contributes to anesthesia related injuries (less than 5% of all deaths)”. Yet, these incidents do exist and the public, legal, and regulatory communities expect us to reduce this ” 5%” incidence to near zero. Furthermore, just as there are no hard numbers to document the role of better monitoring/delivery systems in assuring safer anesthesia care, there are no hard numbers to delineate the role of anesthesia Support/Service Systems in assuring better function of monitoring/delivery systems. Preliminary data indicate that technical assistants do seem to make a contribution to monitoring and delivery systems, but studies in many clinical settings are needed to document what such assistants do nationwide. (4)
It is unlikely that any study will be designed to prospectively test & efficacy of anesthesia Support/ Service programs (i.e., no institution would volunteer to be the control group). We, therefore must rely on common sense and anecdotal data (i.e.-, cases of monitor and/or delivery system failure) to guide us in a national program to improve and standardize our Support/Service programs. How extensive should these programs be and where will we get the budget and personnel to support them?
People Needed
In terms of in-house personnel, anesthetists who have special experience in this area often help with managerial functions, but it is likely that specially trained workers will be needed, especially in many of the larger departments. It is known that many departments already have significant efforts to train in-house personnel to assist with Support/Service functions and in the near future a survey of the characteristics of such personnel should be available. 5 In California, a group has been organized on a state-wide basis to assist with coordination and communication in this area.
The personnel available to anesthesia departments to manage and carry our specific Support/ Service programs can be categorized in the following ways:
1. Anesthesiologists and anesthetists with special interest and training in equipment design, function, and service;
2. In-house (departmental) specialist (“Anesthesia Monitoring and Equipment Specialist”) who perform various functions which range from setting up monitors to much more complex tasks including some checks and minor repairs of anesthesia machines; (4)
3. In-house specialists (usually with a background in Biomedical Engineering Technology i.e.-, BMET’S) who perform major repairs and who work out of the central Biomedical Engineering Department or may be in an advanced support group directly attached to the anesthesia department; (3)
4. Contract Specialists i.e., service representatives of the manufacturers and/or independent service companies.
Given the considerable implications of support of the functions of monitors and critical life support systems (i.e., anesthesia machines), there are serious questions concerning the recruiting, training, and qualifications of personnel in the categories 2, 3, and 4 above. It is likely that individuals in category 2 are largely trained on the job, although some are likely to have backgrounds in Respiratory Therapy, Biomedical Engineering, and other related fields. 5 Although progress has been made in making the needs of anesthesia known to the BMET and clinical engineering groups (at national biomedical engineering meetings, largely through the efforts of Cooper, Welch, Newbower, and Philip of the Harvard group), it is doubtful that this is yet reflected in training programs and certification exams. In regard to category 4 (i.e., factory and “third party” service representatives), they are, in many instances, likely to be well trained, but there is no assurance that this is so, especially if “third party” service representatives have not been to a “factory” authorized school. Also, there is no assurance that factory authorized service representatives are trained to standards which the larger anesthesia community would support.
In consideration of Support/Service Systems for anesthesia departments, the issues of procedures/ space/personnel/budget are interdependent, but the most fundamental is personnel. It is unlikely that enough are available who have the right training. Once we have decided on the tasks which need to be performed (a major undertaking), we can recruit/train/examine the personnel to carry out these procedures. This takes a great deal of planning, effort, and time. Once we know what kind of support personnel we need (and how many such personnel), we can negotiate for space and budget.
Nevertheless, discussions as to what kinds of monitors and delivery systems are going to be utilized are common and purchases are proceeding at a very rapid pace independent of preplanning as to what kind of support/service program is needed. Due to this lack of a pre-existing Support/ Service System, anesthesia may he on a collision course for unfortunate incidents. There is already a serious question as to whether or not we are supporting even the machine-s/monitors that we now have. There is an even greater question as to whether we will be able to plan and implement a service program in time to adequately meet the needs of the next decade.
By analogy to the automobile industry, it is as though the manufacturers and their consuming public had decided to take a 1940 car and add to it an automatic transmission, air conditioning, disc brakes, turbo-charging, fuel injection, trip computers, and stero without retraining the mechanics (to say nothing of the drivers), and without enlarging the service departments. Even before we have support systems in place to deal with yesterday’s needs, the new day is upon us OR’s abound with pulse oximeters, capnometers, mass spectrometers, new indirect blood pressure monitors, EEG analyzers, etc. and new (partially electronic) anesthesia machines are here or just around the comer.
Proposed Action
What do we do now? The following outline and brief discussion offers some suggested actions:
1) Evolve a plan of action on a departmental basis
a. Assess current programs and new needs;
b. Draw up a stepwise plan (timetable) to make improvements;
c. Assign specific responsibility to designated persons;
d. Negotiate with hospital for space and personnel (budget) to establish or enlarge efforts;
e. Document methods of periodic assessment of proper operation and results of the overall plan.
2) Review departmental Support/Service program to assure availability of
a. Job descriptions of (assisting) personnel;
b. An inventory of equipment (including labeling);
c. Procedures for set-up, calibration, testing, troubleshooting, and repair;
d. Policy for division of responsibility between in-house personnel and outside contractors (e.g., factory service personnel);
e. Documentation of manufacturer’s recommendations for service;
f. Operational manuals.
3) Support national efforts to establish guidelines for different types and sizes of hospitals:
a. Types of in-house Suppor/Service personnel needed;
b. The type and amount of Support/Service expected from contract organizations (e.g., factory service personnel or “third” party service companies);
- Performance standards for in-house and contract personnel including educational and certification procedures analogous to personnel in Respiratory Therapy and Medical Engineering (e.g., BMET’s and Clinical engineers).
A national effort is needed to survey the activity of anesthesia Support/Service personnel (an extension of the McMahon-Thompson study) and to define a continuum of skiffs and roles ranging from a simple “bedside” support role all the way up to the more sophisticated repair tasks (analogous to national certification for BMET’s and others). Eventually, educational programs may emerge that can assure the anesthesia community (prac6tioners, hospitals, manufacturers, etc.) of a steady supply of qualified anesthesia specialists in a broad range of important skills to assure proper and efficient utilization and service of monitors and anesthesia delivery systems.
Dr. Frazier is Associate Professor of Anesthesiology and Director, Division of Instrumentation and Monitoring, Emory University School of Medicine.
References
1. Westenkow DR and Cooper IB (1985). “Safety in Anesthesia: The Role of Engineering”. MEDICAL INSTRUMENTATION, 19 (3): 104.
2. Cooper IB (I 985). “Anesthesia Can Be Safer: The Role of Engineering and Technology”. MEDICAL INSTRUMENTATION, 19 (3): tO5-108.
3. Welch JP (1985). “Clinical Engineering in Anesthesia”. MEDICAL INSTRUMENTATION, 19 (3); 109-112.
4. Frazier WT, Kelly PIT-and Lewis JE (1985). “The Anesthesia Instrumentation and Monitoring Specialist”. MEDICAL INSTRUMENTATION, 19 (3): 113t IS.
5. McMahon. D and Thompson G (1987). “A Survey of Anesthesia Support Personnel in Teaching Departments”. (Virginia Mason Clinic, Seattle, Washington. in preparation.)