In Home, In-House

Using hospital biomed resources to repair home care equipment has its challenges, but nuisances of the six-legged variety are often overlooked. Call it a job hazard of leaving the sterile confines of the hospital, but feeding pumps subjected to the crumbs and drippings of daily meals are undeniable magnets for cockroaches.

The biomeds at San Diego-based Rady Children’s Hospital successfully manage, repair, and track equipment that comes in from the home, but no amount of experience can completely ward off the uneasy feeling brought on by full-blown infestations. Nestor Damasco, JD, the team’s home care coordinator at Rady, once stored returned devices in the refrigerator in hopes of killing the unwanted passengers.

Damasco’s unusual improvisation highlights the contrast between the tight regulations that govern virtually every aspect of the hospital environment with the relative anarchy of the living room. Calling the brief room infestations “absolutely unacceptable,” Chris Abe, RN, BSN, CIC, HEM, senior director of safety and support services, admits that the incidents are an inevitable hurdle when dealing with homes. “At first we said, ‘Oh, no. What have we gotten ourselves into?’ ” Abe says. “We have had families who are missing floors, and it can be unsafe for our staff members to go in. There are occasionally dangerous animals, and the equipment is stored in places that are not necessarily sanitary.”

To deal with the messy nature of the non-hospital world, Abe and her colleagues focus intently on proper tracking, which differs vastly from the tidy accounting found within the white walls of most medical facilities. While staff members are notoriously good at properly tucking away equipment, family members may hoard devices and keep dust-collecting extras squirreled away in closets.

Why did Abe and her colleagues decide to complicate their lives with the unpredictable nature of home care? In short, the home care department at Rady had identified that the durable medical equipment (DME) companies were not performing to a high standard.

When the call for help came about 5 years ago, it quickly became evident that the additional responsibilities made financial sense and, more importantly, would improve patient care.

“By bringing the equipment in and maintaining it correctly, we have saved the hospital a lot of money,” Abe says. “This has all driven down our overhead costs, and rental costs have gone down. Savings are close to $200,000 a year, and that is factoring in even the salaries associated with performing the maintenance.”

From the Outside

Parents who come to rely on home equipment are occasionally reluctant to use the hospital’s own devices. George Panfili, manager of biomedical engineering at Rady Children’s Hospital, sees the “nervous mom” reaction firsthand and believes the phenomenon is yet another reason to take charge and make sure the home equipment is working properly.

Part of the problem is the way insurance carriers pay for medical equipment. After a family has had a pump for about 10 months, insurance carriers often transfer ownership to the family. From then on, family members are responsible for getting the equipment repaired and maintained, which they often fail to do. But not everybody ends up owning equipment after 9 to 10 months. Sometimes pediatric patients need just a few weeks of treatment. In these cases, turnaround and proper maintenance requires tight organization through a reliable tracking database.

Before taking on responsibility for the home machines, Panfili says it was a good bet that patients were not taking items to the DME company, and even if they did, service was often lacking. “Patients flat out do not get that maintenance done, and one of the reasons is that there is no place to go, or it costs too much, because these people are usually short of money due to the illness of their child,” he says. “These people are comfortable with their own equipment, but it is usually not up to proper working conditions. We do not want to use it because it has not been tested and it has not been taken care of.”

Jennifer Jackson, president of the American College of Clinical Engineering, is very impressed that Abe and her staff decided to expand into home health care services. Calling it “quite an undertaking,” Jackson says she hopes others will be able to follow based on the best practices shared by those already fully immersed in home health care.

Panfili understands Jackson’s surprise, but after doing it successfully for 5 years, he believes that the hospital has no option. “We had to get into that business,” he stresses. “We care about those children, and we want to make sure they are getting the best quality of care. I don’t see any other choice but to take that home care equipment and make sure it works so that our children are taken care of.”

Prior to repairing the equipment, drivers from the hospital’s home care division were doing basic checks, a system that worked but was not ideal. Getting started and changing the paradigm ultimately depended on solid assessment, organization, and making sure equipment such as pumps were tested and tried in an effort to eliminate the third party and bring rental costs down.

“It took a year, but we put a database in place and talked to our purchasers to try to get more equipment in-house—rather than renting it out from a third party,” Damasco says. “Eventually we could eliminate the rental company, and I could do all the repairs and maintenance. The turnaround time, which used to be 1 to 2 weeks, is now often just a day or a few hours.”

Now Damasco runs the preventive maintenance (PM) reports with a reliable database. Pharmacists and nurses know who was on the equipment, how long they were on the equipment, and what is actually considered purchased by the patient. Private insurance, MediCal, or Medicare are all on record, and biomeds know exactly where the equipment is and how much they have to get done.

The not-so-simple task of effectively tracking PMs means that Rady is renting less because it is getting higher utilization out of the equipment it owns. In other words, patients do not need another unit because the one unit they are using is getting effective and timely maintenance.

Damasco admits that scheduling PMs can be difficult, but it can get done if you plan ahead. “It is a challenge to get maintenance on those pumps, because a lot of patients are not home and you have to work around their schedules,” Damasco says. “Sometimes, we have to set our PM schedule months ahead so we can get to them on time. At other times they will call and say their pump is broken. They won’t return the broken pump and instead want a new one, but there is no need to have more than one pump because there is always someone to help out over the phone or get to that pump immediately, if necessary.”

While patients are free to choose a separate DME company, most of the home care equipment used by patients at Rady now comes from the hospital’s in-house home care division, located just a block away from the main facility. All machines checked out through home care go through the hospital’s biomedical engineering department for a final check. After clinical staff members ensure that all family members are trained, delivery vehicles go out and deliver to the homes. Nursing staff will occasionally go out for follow-up, which is all standard for the home care program.

Communication and Education

Determining the status of equipment in the home depends on active communication because despite an aggressive education component, users in the home will forget basic care protocols and lose track of regular maintenance.

“People at home are not used to dealing with medical equipment, so their ability to report problems or seek service is not the same as the nurses and physicians in the hospital,” says Yadin David, PE, CCE, EdD, owner of Houston-based Biomedical Engineering Consultants LLC. “You also have users with completely different levels of competence and dexterity. The power, the utility, the plugs in the walls, the dust levels, the handling of the equipment, the foods and fluids surrounding the equipment—are all so different than the hospital.”

When it comes to home care equipment, biomeds used to running through basic diagnostics may have to pay special attention to distinctly unglamorous housekeeping matters, such as disinfecting and cleaning filters. As the media puts the spotlight on sleep disorders and mobility aids, it’s also likely that home use will jump, and biomeds who take on repairs will have to be prepared.

“As media attention grows, you may see an avalanche of equipment penetrating the home market,” David adds. “And biomeds are not necessarily ready. For example, a couple of years back, one motorized wheelchair was subject to loss of control due to radio frequency interference. How do you address this problem when there could be electromagnetic radiation present in the home that is not present in the hospital?”

The Home Team

The home care biomed division at Rady works closely with department heads from pharmacy, nursing, delivery, and intake. Responsible for almost 500 pieces of equipment, the biomed staff boasts an on-time PM completion rate of more than 95%. Upon return, all equipment is cleaned, tested, entered, and documented into the database.

If something goes wrong and a systemic equipment problem is found, strict regulatory compliance procedures swing into action. “You have Joint Commission regulations, and those regulations are similar to the hospital’s tracking and maintenance regulations,” Abe says. “Nestor had to do a huge recall on some devices and get them all back.”

Working as a team, Abe and company have worked to boost efficiencies to such a level that the financial benefits have more than matched the patient care positives. Emphasizing the ability to standardize and enact long-range plans, Abe recently outlined a convincing financial justification of biomed practices in the home care arena. The presentation highlighted five key strategies/benefits:

1. Inventory based on actual usage due to tight control of equipment;
2. Reduced usage of multiple rental companies;
3. Reduced repair costs;
4. Decrease in the amount of lost equipment; and
5. Savings of $160,000 in the first year of the program.

With numbers like that, it is no wonder that hospital administrators at Rady remain firmly behind the program. Part of the success can be attributed to consistency and an insistence on quality that always includes equipment that may not originate from the hospital. In fact, when outside equipment comes in, biomeds at Rady routinely switch it out.

“Probably 95% of the time we switch out equipment because patients can’t provide the documentation,” Panifili says. “We make the patient use something of ours until they can go back home to their home care provider and get proper records. If you bring in equipment that the staff at the hospital is not familiar with, such as a ventilator or IV pump, and something happens to that piece of equipment, we may not have the disposables and the supplies that go with that equipment—that could create a problem.”

Technically speaking, Panfili says that biomeds who can fix a hospital IV pump can be easily trained to repair a home IV model. New training is necessary for many home items, but most biomedical/clinical engineering pros will encounter little difficulty. Home care apparatus tends to be more battery-focused, but Panfili reiterates that those adjustments are not a problem. When the home care workload gets particularly heavy, Panfili and Damasco have a flexible system that allows them to draw from the hospital-based staff.

Has your team ventured into home care? Blog about it.

In the final analysis, Abe, Panfili, and Damasco agree that managing home care equipment with an in-house biomedical/clinical engineering department is well worth the adjustment period. In addition to the demonstrated cost benefits, the benefits to patients make it all worthwhile.

“At the end of the day, you feel satisfied,” Damasco says. “For these parents and children, we give them the peace of mind that everything is going to be OK. Ultimately, it is all about the safety of the kids.”

---

Greg Thompson is a contributing writer for 24×7. For more information, contact .