Becky Crossley

BMETs Are Essential to Effective ECG Monitoring

We care because ECG lead placement and patches affect how equipment is perceived to be running or not running. Very simply, the placement and condition of patches affects us as BMETs immensely. On countless occasions, I have been called because a monitor won’t read any ECG rhythm, only to find out that the leads and patches had been on the patient for 48 hours. Most monitoring companies cover this in the in-servicing of the monitors when they are new, but staff may still think that the monitor is at fault. When properly attached, ECG electrodes will reduce the electrical resistance of the patient’s skin, from approximately 10,000 Ω to about 500 Ω. If this step is overlooked, it can cause the nurse a lot of unneeded havoc. Here are some simple steps to go over with staff to determine whether you should be suspicious of bad lead attachment: 1. Was the skin cleaned with soap and water or alcohol to clear the skin of oil and dirt? 2. Was the skin dried after being cleaned? 3. Were the electrodes used new? This should ensure that they are moist. 4. Were the patches firmly placed on the skin? Some companies include a pad feature that lightly scratches the surface of the skin to ensure tight placement. 5. Was the lead set secured to prevent wandering baselines? Tape can be used for this. Some companies include a clip on the cable, which enables it to be secured to bed sheets. Next, we need to be aware of lead placement. As a BMET, sometimes you will need to look at the patient to troubleshoot a device. Start by checking the limb leads (LA, RA, and LL, which refer to left arm, right arm, and left leg, respectively), being particularly watchful for electrodes and leads placed over pacemakers and bone. Pacemakers will cause excessive noise on some monitors and “spikes” on others. Bone is dense and will disrupt the electrical conduction. Sometimes, the LA lead will need to be placed on the back of patients with pacemakers in order to eliminate spikes. For basic placement of leads, remember Einthoven’s triangle, which says that lead I and lead II should equal lead III. Lead I is RA to RA, lead II is RA to LL, and then lead III will be LA to LL, thereby providing medical staff three different views of the heart. More TROUBLESHOOT IT BMETs Are Essential to Effective ECG Monitoring

Video Integration Systems and Electrosurgical Units

Different vendors have their own proprietary components, but the systems are, in their basic form, the same. There are inputs from various sources, including physiological monitors, surgical site cameras, C-arms, ultrasound, and computers running clinical information retrieval programs such as picture archiving and communication systems (PACS). These inputs are then routed to different monitors throughout the room. Because all input sources do not use the same format, each integration system must be designed specifically for the inputs that each facility uses. Integration systems can be as basic as routing images or as complex as video streaming and conferencing during procedures. The PM for these systems varies by vendor, and it’s important to read the specific instructions and recommendations. At the very least, the system will need to be cleaned of dust, updated with new software, and protected with backups as appropriate. Also, if the monitors in the field are touch screens, they will need to be recalibrated. Heat and dust seem to contribute to problems with these systems, so it’s important to keep them clean and ensure there is enough air circulation. As for training, that’s a decision for each healthcare facility to make and would likely depend on how savvy the technician is with video towers, computer systems, and routers. I believe training is always important and beneficial. Video integration systems may have proprietary hardware and software that can make it more difficult to service these systems without a contract. At our hospital, we get patient return electrode alarms on our electrosurgical units. Do you have any suggestions on how to reduce these errors?

Electric Blankets and Ethylene Oxide Sterilizers

The short answer: No, electric blankets should not be allowed in the hospital setting. Let me elaborate. NFPA 99 Health Care Facilities Code 2012 Edition 10.2.2.1.1 states, “All cord-connected electrically powered appliances that are not double insulated and are used in the patient care vicinity shall be provided with three-wire power cord and a three-pin grounding-type plug.” This regulation alone would discourage the use of any electrical blanket that is on the market. Another consideration: Blankets are used in areas that are likely to be wet due to incontinence, IV fluids, and blood. Electric blankets are not designed for that type of environment. There are other dangers, particularly with dialysis patients who are usually very ill and could very easily develop a “burn” from an electric blanket due to compromised skin integrity. What’s sad with such a scenario is that instead of helping to sustain the patient’s life, a staffer who allows the use of an electric blanket could be compromising the patient’s life. In sum, it’s much safer and smarter to not take chances and to have a policy that does not allow the use of electric blankets in the hospital.

Surgical Beds and Hyper/Hypothermia Units

I typically see two issues. One is the unit will not work, even when plugged in. We have a couple of different models and vendors in our surgical suites. There are some models that once the battery gets old enough and will not recharge, the whole circuit shuts down. Staff will then bring in another bed and it will work even when plugged in. The bottom line is to have a good battery replacement program. Change those batteries regularly. Another problem I see quite often, and one that drives the technicians nuts, is an intermittent hand control. One thing that could help is that most tables have a control on the base that allows access to “important” functions: up, down, lock, unlock. Many staff members do not know this function is there. The hand control can keep a technician guessing for some time. I am fortunate enough to have a spare hand control. If able, your facility should purchase a spare. This can be a real life saver. Regardless, finding the problem is the reason we are biomedical technicians. This can be a challenge at times. Start with the connection from the control to the bed, look for cuts or tears in the wiring harness; these hand controls are flexed and stretched to their maximum throughout their lifetime. Next, if you have another hand control, put that in to determine whether the problem is the hand control. If it is not the hand control, open the base and check the wiring under the connector of the bed. If it is the hand control, carefully open it up and check the wiring. If you’ve never done this, you will be surprised at how many tiny wires there are under that cover. Although protected, these wires are frail and can get broken. Sometimes the switches are bad, but more often than not a wire has broken off either in the connector or inside the hand control. A high number of hyper/hypothermia units are reported to be malfunctioning at our facility. What troubleshooting processes and equipment management strategies can be employed to reduce the number of these reported malfunctions?

Electric blankets: not for use in medical facilities.

Q: “We recently had a request from the manager of our in-patient dialysis unit today. She was asking our biomed department to approve the use of electric blankets by patients during the treatments. My manager and our risk manager have tried to convince her that it is dangerous for several reasons, but the manager is persistent. So I’ve been asked to get the opinion of the biomed community. Do any of you allow the use of electric blankets in your facilities?”

Safety Features of Ethylene Oxide Sterilizers

A: Several features, including door interlocks, gas detector alarms, and monitors, are present in EtO-type sterilizers to insure the users’ safety. Areas around the sterilizer that could become polluted need to have alarms with visual and audible capability. The alarms need to be situated in various positions that provide for coverage of the entire sterilizer room. Most facilities group these types of sterilizers into one room, which helps contain the gas and also allows for the alarms to be situated in a “perimeter” around the sterilizer. Washer/sterilizers have door interlocks to prevent the user from opening the door during a load and being burned by hot water or steam. Most people are familiar with such door interlocks from the older washer/sterilizers. Door interlocks should be checked during the preventative maintenance (PM) process to ensure they are working properly. Other considerations that enhance safety are thermal burners and scrubbers and ventilation. There needs to be some way to minimize the release of EtO into the environment. Therefore thermal burners and scrubbers in line with the exhaust are recommended to remove the EtO. Most sterilizer companies have their own recommendations for the amount of ventilation in an EtO room. Users need to be aware that there is a ventilation system in place, and that it is physically working daily. Ventilation helps remove toxic gases from the operators work area. Two types of ventilation systems should be considered to limit gas exposure: local exhaust ventilation (for example, exhaust hoods) and dilution ventilation (for example, systems that cause air to flow away from work area). Local exhaust systems are designed to remove toxic fumes from the operators’ breathing zone. While dilution ventilation systems are implemented to remove exposure at the operators work area, neither local or dilution system alone can remove potential operator exposure because EtO is not eliminated at the source. Dilution systems designed to work with local exhaust systems are the most reliable systems in removing the potential exposure to gas toxins. Local exhaust systems should be installed as close to the sterilizer door as possible, as well as close to the exhaust drain. If there is any question about your facility’s ventilation, consult with the manufacturer of your sterilizer. n

Pinpointing critical errors; basic sterilizer tips.

A: Chances are it is a bad network card, which is an easy fix once you know which room is affected. Start by turning off your central station. Go to your database server and locate your source code control (SCC). Unplug all the rooms that correspond to that station. Turn on the central station and allow it to do a complete reboot. When the central station comes up all rooms should be present on the display. Now go back to your SCC and plug in one room at a time (it helps to have a second person so that one can watch the central station and one can plug in each room). The room that is plugged in should now come up on the display in its appropriate place. If the central station does not give the “critical error...” message that bedside is ok. When the station displays the “critical error.....” message you have found the bedside that is causing the error. Replace the network card for that monitor. Once the network card has been replaced reboot the bedside. You can now plug all of the rooms back into the SCC and reboot the central station. All rooms should come up in their appropriate location. The central should not give the “critical error....” message. If you have slaves or satellite centrals connected to your main central station, they will also need to be rebooted. If this does not work, the next step is to reload the software. This is very time consuming and will not necessarily identify or fix the problem so it should not be done unless the above steps fail to pinpoint the problem. Pinpointing Critical Errors; Basic Sterilizer Tips