Newer software-driven systems are simplifying old-school PM procedures
Much like other advanced medical technologies, when it comes to servicing and maintaining anesthesia machines, things certainly have changed over the past several years.
“We’ve gone from the mechanical to the electronic,” says Tammy Noll, GE Healthcare’s general manager for anesthesia and respiratory care. “In the past, biomeds had expertise in the mechanics of things like flowmeters. Now there is a need for more knowledge on the electronic side.”
“The biomed’s responsibilities have grown over the years,” adds David Karchner, director of marketing in North America for Dräger Medical. Before, technicians’ responsibilities were limited to break/fix work.
Dräger’s Perseus A500 anesthesia platform is the first system to enable delivery of airway pressure release ventilation in the OR.
“Today’s anesthesia equipment has a lot more technology in it and is networked into the hospital’s IT system,” Karchner says. “So what we are seeing out in the field is that biomeds not only do the break/fix work they’ve always done, but they are much more involved in the IT strategies of the hospital.”
Bart Onoday, CBET, a biomedical technician in the Clinical Technology Services department at Oregon Health and Science University (OHSU) who specializes in surgery, agrees that biomeds have had to broaden their skills with the development of new anesthesia technology.
“In the older days, we had to do a lot of mechanical checks on the machines,” he says. “Now, we’re basically required to carry a laptop and interface more with the software rather than the mechanics of the machine.”
Consequently, biomeds like Onoday and his colleagues are taking on roles that are a little more expansive than normal. For example, Onoday says it’s not unusual for biomeds to be very involved in making sure that users are adequately trained on newer anesthesia platforms.
“We’ve gotten away from the mechanical components like your [bobbin or ball] flowmeters, and that’s a challenge for older providers,” he says.
Older anesthesia machines consist of tapered glass tubes containing bobbins or balls that float on a stream of moving gas so that as the gas flow rate increases, the ball or bobbin is carried further up the tube, indicating the flow rate.
“In our [biomedical technology] career field, we adapt to new technology much more easily than other people do,” Onoday says. “And there are challenges associated with going from the old mechanical flowmeters to the digital versions—a lot of people just can’t get the concept simply because they like to see the ball in those old-school flowmeters. They like to see the movement and going to a digital representation of that is challenging.”
These days, Onoday might find himself in a role where he is training users—or at least assisting them as they transition from one generation of an anesthesia machine to the next.
“We’re not always the experts, but we do get trained to a certain level. While providers also get those services, we’re always there as a backup to kind of get them past that transition from mechanical to electronic,” Onoday says.
Acquisitions
The biomeds’ expanding role in anesthesia settings also extends to vetting equipment purchases.
Recently OHSU went through a rigorous acquisition process for new anesthesia machines at Doernbecher Children’s Hospital in Portland. According to Onoday, there was a realization that the hospital needed to upgrade its anesthesia machines with a specific focus on getting a better ventilator for the pediatric patient population.
OHSU went through a process in which it set up 3-week trials of three different machines from three different vendors. The first week involved parking the machine in the anesthesia tech room with a manufacturer’s representative to allow potential users to get their hands dirty and learn something about the machine’s functionalities. The final 2 weeks served as a clinical evaluation period in which the machine was actually moved into an operating room so that providers could see how the units worked with patients.
“It took more than 9 weeks to get the three vendors through the process,” Onoday says.
The Clinical Technology Services department “absolutely” played a role in vetting this acquisition, says Onoday, considering that while the Perseus has been available in Europe since 2012, it has only just recently been released in the United States.
“Obviously, costs come into play, as well as issues like ease of service and parts availability,” says Onoday. “The Dräger machine is new to the States, so we wanted to make sure that parts are readily available in case something goes wrong.”
Onoday also says that it was important that training at a service school was included in the acquisition cost because of the machine’s advanced ventilation technology.
“With the Perseus A500, we’ve introduced a new ventilation technology that’s called the TurboVent,” says Karchner. ‘It’s not a bellows and it’s not a piston. And the reason we introduced the TurboVent was to improve the ventilation capabilities in the OR.” Specifically, Karchner says, the TurboVent allows the delivery of airway pressure release ventilation, which is very common on ICU ventilators but has never been introduced into the OR until the Perseus.
And that’s why the cost of training was “a big issue for us,” says Onoday. “The ventilator is drawn more from an ICU ventilator, and that is pretty much new technology to the surgery biomeds.”
Noll pointed out that vendors like GE are sensitive to the fact that in today’s healthcare environment, it is essential for hospitals to drive down costs.
“We’re getting smarter with design and designing parts that will last longer and fail less, so that you’ll eliminate the service opportunity altogether,” she says.
Karchner says that Dräger is also committed to driving down the overall service costs of the equipment itself. “Some of that is in labor,” he says. “And as our technology continues to advance, we require fewer PMs than the legacy machines that are out there.”
Biomeds should also have an understanding “of the total cost of ownership” when it comes to acquisitions, says Karchner.
“Typically, vendors are going to provide the costs associated with the preventive maintenance of the machines,” Karchner says. “But it’s important for hospital biomeds to understand that the PM costs are just part of the overall cost of the machine. You also have to look at repair parts as well as repair labor costs, which is something vendors are unable to share because they are unpredictable.”
Karchner suggests that biomeds reach out to vendors and ask for quotes for comprehensive service contracts. “Only then can you see what vendors are charging for full-service contracts. That can give you true visibility into the costs of ownership,” he says.
Preventive Maintenance
“The first suggestion I have for biomeds is to maintain the equipment,” Noll says. “It sounds basic, but a lot of hospitals just won’t follow the PM schedule. They’ll lengthen the intervals or put it off altogether. But we’ve done this [established PM schedules] for a reason. We’ve tested the parts and the equipment and know when things need to be replaced.”
Karchner agrees that it’s important for biomeds to understand the maintenance intervals of these anesthesia machines. “You must plan accordingly because these machines have become more complex over the years,” he says. “And this requires more training than for the legacy systems that have been in the market for years. It’s important to plan that training in advance so you can take care of those machines.”
At OSHU, “we go by the manufacturer’s recommendations,” says Onoday, “and we have a few different flavors of machines.” OHSU is mostly a GE shop, which means there are quite a few Aestiva machines in the operating rooms. But the organization uses GE Avance units as well.
The problem, according to Onoday, is that GE recommends that the Aestiva undergo preventive maintenance twice a year. On the other hand, the Avance is a newer platform with a once-a-year PM recommendation.
“But we still do it twice a year,” Onoday says. “We have 60 ORs and [the two platforms] are mixed and matched so they are all over the place. So just to keep everything on the same schedule, we do everything twice a year. The second check is basically just a functionality and cleaning check rather than a full PM.”
According to Karchner, ease of maintenance was one of the concerns driving the design of the Perseus. “We tried to simply the service process with the Perseus,” he says. “[Biomeds] have easier access to the critical parts of the system than they do in the legacy systems that are on the market.”
While it’s never really “easy” to service and maintain anesthesia machines, Onoday says that it has gotten easier with the new generation of machines because they are software-driven.
“Instead of hooking up all those mechanical components and doing all those old-school checks we used to do, it’s much more simplified,” he says. “There’s a lot less opening up the machine and taking things apart. Now we run the service software to do tests for us, so we’re letting the software do much of the work.”
As far as troubleshooting problems with anesthesia machines, many issues come down to operator error or “physical abuse,” Onoday says. “We are such a big institution and we have so much [patient] turnover that providers have a lot of worries beyond what kind of condition they are leaving the anesthesia machines in when they leave the operating room. So there are a lot of flow sensor problems and that kind of thing.”
Other issues are essentially “byproduct[s] of using the machine,” Onoday says. One common problem is the buildup of moisture in the machine, which can cause water droplets to form on the flow sensors.
“We get a lot of moisture problems, and pretty much every manufacturer has that problem with their anesthesia machines,” Onoday says. “For our machines, the cure is simply giving them time to dry out.”
Onoday points out that he and just two other biomeds have responsibility for his institution’s 60 operating rooms, which can cause coverage issues. So the facility relies on the anesthesia technicians to be the “first-call folks” when there is a problem.
“There are a lot of consumable parts in a machine that need to be changed out between patients, and anesthesia technicians learn that process,” he says. “That’s part of our training, too, but we’re not in the OR and turning over the machine after every case. That’s their job.”
The anesthesia technicians are familiar enough with the biomed side of the equipment that they can often provide Onoday with information about a problem so that he can help resolve it from a distance. At the least, he says they can usually give him a better idea of what’s wrong so he can bring the right parts and equipment to service the machine, achieving a faster turnaround.
As for the future, Onoday thinks the new Perseus machine and the turbine ventilator represents a significant change. Still, he thinks there could be some resistance to the newer technology from older providers who are more comfortable with the mechanical components of a ventilator and seeing bellows move up and down. “I think not seeing anything move is really going to throw them for a loop,” he says.
He predicts manufacturers will produce both types of machines for the foreseeable future. “But I think as more people accept this new technology and how much better it is for the patient, [the manufacturers] will probably move in that direction.”
Mike Bassett is a contributing writer for 24×7. For more information, contact chief editor Jenny Lower at [email protected].
As an anesthesia biomed (in a large academic medical center), one of the interesting roles one has is to be called into a situation where an anesthesiologist or resident is experiencing either a perceived or actual machine/technology failure during surgery and having to solve their problem in real time. The MD and caregivers, the patient, and the machine form a system you must understand and troubleshoot. You need a good grasp of the dynamic components of your particular institutionally unique “system of systems” that surrounds the anesthesia machine and its users to be an effective anesthesia biomed. We more often fix things other than “hardware” failures of technology. Your carefully built reputation as “fixer” along with building a circle of trust with your caregivers are often your most important “tools” in your tool kit. The anesthesia machine can sometimes be the least likely thing that is actually “broken” when one gets called into an OR room for what has been labeled as an anesthesia machine problem. I hope this also helps.
As discussed in the article, the anesthesia market is in a transition phase, from mechanical to digital components, but I don’t think the traditional preventative scheduled maintenance philosophy has caught up with the changes in technology yet. OSHA’s Technical Manual, Section IV B-3 recommends the anesthesia machine should be inspected every four months. The latest models of anesthesia machine incorporate an automated checkout for both the machine and the vaporizers. That means a leak check is being performed at least every day the machine is being used. If the machine or vaporizer fails the checkout, a customer calls and reports the failure. The newer anesthesia machines have integrated respired gas monitoring. The vaporizer output is compared to the gas monitor and any aberrant readings are reported by the user and the vaporizer is removed from service. Spacelabs Healthcare has also incorporated a gauge on the Arkon to represent the flow for the AGSS, anesthetic gas scavenging system. If the flow is out of range the scavenger hose image flashes, indicating the abnormal flow. These changes in technology are making the anesthesia world safer and PM or SM recommendations should be updated by the appropriate agencies. At a minimum, they should differentiate between the old and new technology for PM or SM requirements.