AAMI-sessionI usually avoid keynotes like the plague, but I'm glad I caught this one. Mae Jemison is a polymath (biomedical engineer, physician, astronaut) and expert at reframing assumptions about life and health care in surprising ways. She explored health care, examining the intentions and objectives of the industry, and suggesting alternate metrics of performance. Where other industries track performance based on quality or success, health care tracks things like clinical procedures simply on the number of procedures performed with no consideration on patient outcomes. Sure quality is a secondary consideration, but to her point, doesn't that in itself say something? Jemison is funny too. An entrepreneur herself, her definition of an entrepreneur is, "someone who wants to make a lot of money, do it their own way, and isn't so broke they need a real job." Commenting on the considerable changes being wroght in health care, she observed, "committees are cul-de-sacs where ideas are lured and quietly strangled." Jemison provided the right note of inspiration, motivation, insight and direction for kicking off this year's conference.

The first session I attended was "New WMTS Band Interference Issues and the Future of Telemetry Equipment." This was a panel presentation that included John Collins, ASHE; Rick Hampton, Partners; Terry Hinkle, RF Monolithics; and Nancy Pressly, FDA. It seems that many hospitals that migrated from VHF to 608 MHz are having RF performance problems. In my experience, some of this is trying to cram too many transmitters into a channelized system (>240 transmitters), and part of the problem is allowable interference from adjacent digital TV stations. The presenters expect most markets (at least the 100 largest TV markets) to have both channels 36 and 38 by 2009. According to John Collins, the FCC created the 3 WMTS bands (608-614, 1395-1400, and 1429-1432) with the expectation that at least one of those bands would not be available to a hospital, due to co-primary users (radio astronomy) and adjacent frequencies (high power military radar and digital TV). The upper 2 WMTS bands can also be occupied by Itron utility meter reading radios. Makes you wonder why so few vendors using WMTS have products that use the two upper bands, doesn't it? John also emphasized the importance of registering your WMTS use, in order to facilitate frequency coordination. He noted that only 2000 hospitals in the US have registered their WMTS with ASHE. Rick Hampton emphasized the importance of managing and coordinating RF use in the hospital, and with facilities outside the hospital. He also showed examples of intentional interference (digital TV and water meter readers) and unintentional interference (Rick hates paper shredders). Nancy Pressly broached the subject of reporting problems to the FDA (which many hospitals mistakenly do not do). Nancy also mentioned that the FDA will have a guidance document on wireless out in the fall. The bottom line: 15 years ago, you could throw up a telemetry system according to the manufacturer's specs and it just worked. Now a days, things are more complex, and designing and deploying a traditional telemetry system takes real engineering - RF site surveys, a truly balanced antenna, and fiddling with expensive narrow band filters. The contemporary analog is the hospital WLAN. Most WLAN resellers (and their hospital customers), typically throw up a WLAN by placing access points (APs) every 100 meters - and for simple data apps like meds admin or computers on wheels (COWs) they just work. Once you try wireless VoIP, or wireless medical devices, you've got to do some real work. Just like today's telemetry system, WLANs require extensive site surveys, design, deployment, and post installation fine tuning.

The next session was "Physiologic Alarms: Techniques for Standardizing Alarms in Your Institution." Tobey Clark, from the University of Vermont Technical Service Program, talked about alarm notification issues, and Alan Lipschultz, of Christiana Care, described how they implemented standardized alarms throughout their 2 hospital system. Alarm notification is a pet peeve of mine, and an area where clinical practice and technology can greatly improve patient safety. Tobey described some ACCE efforts that are very important. Alarm standardization is clearly a best practice for hospitals. Tobey mentioned a number of interesting facts, like research that's shown that individuals can't learn more than 6 different alarm sounds. Another study showed caregivers could not identify even one half of common ICU critical alarm sounds when played back. The alarm fatigue problem results from alarms that are inconsistent with the clinical situation. A 2006 paper in the Am. J. Emerg. Med showed that 99.4% of alarms were determined to be false with less than 1% of all alarms resulting in a change in patient management. Many manufacturers' "better safe than sorry" philosophy has led to an increase in the number of alarms, volume and degree of irritation. In addition to all this, many alarms are set improperly - at the wrong limits, alarm priority, volume, or even turned off. The Biomed Listserv was even quoted:

"Just a question. We determined that our bedside monitors hade over 400 different alarm potentials. That is high low pressures, NIBP, Pulse Ox, Heart Rate, arrhythmias, mean pressure alarms, etc."

"Do you test them all?"

A search of the FDA's MAUDE database shows alarm related deaths are increasing. In response to this patient safety situation, ACCE has created the ACCE Healthcare Technology Foundation (known as the AHTF) to tackle alarm issues through education and awareness, clinical engineering certification, and researching ways to improve clinical alarm management and integration. The AHTF is looking specifically at alarm design, environmental factors, the role of clinical engineering, and care management. This was the perfect segue to Alan Lipschultz's talk on alarm standardization efforts at Christiana Care. Alan started with a litany of alarm problems, especially nuisance alarms. He described how they assembled a team to evaluate alarms and define standard alarm limits in order to reduce alarm fatigue and zero in on clinically relevant alarms. A great example of this was SpO2 alarms. Manufacturers frequently sent their alarm default at 92%, and physician orders often aim to maintain 92% or better saturation. Because SpO2 fluctuates wildly, alarms set at 92% frequently become nuisance alarms. The Christiana alarm team decided to set default SpO2 alarm limits at 87% (89% in PACU where are less mobile), resulting in a drastic reduction in SpO2 nuisance alarms. Alan provided many more great examples of the alarm policies they've developed. Their patient alarms group is a subgroup under their patient safety committee. To be successful, Christiana learned the team must include strong clinical leadership, and have the backing of both key medical staff and nursing management. Improving alarm management was a great opportunity for Clinical Engineering to take a lead role. They found that once they started working on alarm standardization, different groups of clinicians started talking to one another and to question practices that "have always been done that way."

Pictured right is Dara McLain, RF interference guru from Philips, during educational session on RF wireless medical devices.

Since the meeting started around noon today, there were a limited number of sessions. More later!

UPDATE:  Be sure to check out AAMI Exhibits and AAMI - Day Two.