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As a reader of Scope I have long considered there to be alack of articles covering the work of Technologists.Recently I contacted Peter Harding the Technology Editorof Scope to share my concerns with a view to contributingan article. If you are a Technologist member let this be anudge in your direction – please consider contributingarticles, papers, meeting reports, and other relevantinformation to Scope to highlight the valuable workperformed by Technologists within healthcare.

Queen’s Medical Centre Nottingham NHS Trust was thefirst purpose built teaching hospital in the UK. It operatesin conjunction with the University of Nottingham’s Facultyof Medicine and Health Sciences to provide a teachingenvironment. Queen’s has an enviable internationalreputation for patient care, teaching and research. Itadmitted its first patient in August 1978 and replaced 5other hospitals in the area that together had a history ofhealthcare in Nottingham of more than 200 years.

Queen’s provides elective, emergency and day careservices to over 650,000 people together with specialistand tertiary services to over 2 million people. It employsaround 6,000 staff with an income of over £200 million.Queen’s has gained national and international recognitionin many of its specialities.

The Medical Equipment Service Unit (MESU) wasestablished just before the opening of Queen’s with theremit of managing the increasing number of medicaldevices. Presently MESU provides specialist medicaldevice management services for in excess of 20,000assets valued at £25.5 million.

MESU employs 36 staff. Of these staff 27 are qualified ClinicalEngineering Technologists with the remaining staff beingclassed as Library/Portering and Business Support staff.

The main core services of MESU are Medical DeviceManagement, Equipment Library, Medical Device UserTraining, and Medical Device Maintenance. To provide themaintenance services MESU technologist staff is split into 3operational teams to allow work effort to be directedtowards core duties:

• The Response Team - respond to all customer requestsfor maintenance with a remit to sort out any problemsthat can be resolved speedily.

• The Repair Team - responsible for any repairs thatrequire more in-depth fault finding together with theacceptance of new medical devices into service.

• The Scheduled Maintenance Team - responsible forperforming routine maintenance on medical devices.

The remaining staff in the department comprise of:

• The Business Support Team - provide administrativeand operational support services to all areas of thedepartment.

• The Equipment Library and Stores Team - responsiblefor the provision of equipment library and logisticalservices.

• Medical Devices Trainer – responsible for ensuringdevices are used competently and safely by all users.

• The Management Team - determine the strategicdirection and operational strategy of the department.

MESU Staffing and Organisation

Introduction

A Focus on MESU (MedicalEquipment Service Unit), QMCNHS Trust, Nottingham – The Roleof TechnologistsMark L Callaghan, Assistant Manager, MESU

Queen's Medical Centre, Nottingham NHS Trust

features

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The structure of these all of the teams permits MESU torespond in a more timely fashion to operational needs. Italso means that a focus is maintained on the differentareas of work to ensure that for example, scheduledmaintenance does not fall behind. The MESUDepartmental Manager reports directly to the OperationsDirector of the Trust. This ensures that he has completeautonomy regarding making decisions on staffing,changes of establishment, procedural changes,equipment purchasing, and managing budget. Thisflexibility permits a great deal of freedom to react speedilyto change.

The Equipment Library provides a pool of devices that areavailable centrally for use wherever there is a clinical need.In order to obtain a device, the clinical staff contacts theLibrary with a request for a device for a particular patient.This in turn will be delivered directly to the ward ready foruse. One advantage of the Equipment Library is that it savesclinical staff searching or ringing around for devices aswould have happened in the past. Often they would not befound or there would be a delay in locating them, thusresulting in delays to patient treatment together with anexacerbation of patient condition. From a budgetaryviewpoint the Library permits increased asset efficiency byutilising a lower number of assets more effectively – fewerassets in use more of the time.

The Medical Device Trainer provides user training to clinicalstaff. Scheduled training sessions for wide usage devicesare arranged and ad-hoc sessions are provided wherenecessary. Clinical staff can attend sessions to improvetheir knowledge and understanding of the medical devices

that they are using, which. In turn promotes better patientcare because clinical staff use devices more effectively,with improved confidence and most importantly improvedsafety. Information is also made available via the MESUwebsite at http://www.qmc.nhs.uk/Divisions/Diagnostics/MESU to promote a greater understanding and knowledgeof medical devices. This information (under the “ProductInfo” section) provides users with product overview articlesand product selection information, as well as in somecases full user manuals. It must be appreciated that peoplelearn in different ways, so providing a variety of sources ofinformation is beneficial to helping clinical staff gain betterunderstanding of medical devices. Self DeclarationCompetence Statements are also available on the websitefor users to download and print. These are designed tocheck whether user knowledge on products is adequate byasking a series of questions that a competent user isexpected to know. Some generic examples of question areregarding settings for the device and what action to take inthe event of alarm conditions.

One important aspect of the work of the department, thatworks hand-in-hand with the Library and Medical DeviceTraining, is standardisation of medical devices. Byfollowing an approach to standardisation numerousbenefits can be achieved:

• The prime one focuses on training. Staffs that comeacross only one product (for example the same syringepump) are more likely to be able to use that oneproduct safely.

• When purchasing devices you are in a strong negotiatingposition to obtain discounts for quantity orders.

MESU Equipment Library providing device pool

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• By following a careful selection process it is possible toselect the product that meets all of your needs.

• It is easier to reduce downtime on devices by onlyhaving to keep a limited range of spare parts available.Linked in with this it is possible to negotiate volumediscounts on spares.

• If a device fails in use, the same product can beborrowed from the Library without any confusion arisingover how to use it.

Due to changing health needs, expectations regardinghealthcare are increasing rapidly. Healthcare isincreasingly reliant on the development of medicaltechnology to permit advancements in medical carewhich reduce the patient’s length of stay. Thistechnology needs to be managed effectively to enableclinicians to deliver the better quality of care that isexpected. The majority of procedures that arecommonplace today are assisted by advances inmedical technology. If you were to conduct a survey say,down at the local pub, of healthcare professions, itwould be a long time before you came across anybodywho ventured anything approaching “looking after theequipment”. But if on the other hand you asked whatmight be used to aid a person suffering a heart attack?,most people would name a defibrillator (even thoughthey may call it the “electric shock thing”). These devicesgain a high profile and most lay people would be awarethat they have the ability to restart the heart by deliveringan electric shock. However most people would beunaware of the work performed by technologist’s behindthe scenes to ensure that the defibrillator will save liveswhen called upon – if a defibrillator fails to deliver itsenergy the most likely outcome is that the patient will notsurvive the cardiac arrest.

Medical Device Management involves looking aftermedical devices throughout the complete life cycle of thedevice. This life cycle starts before the device ispurchased, when a need for a new device is identified andinvolves a number of distinct stages:

• Evaluation – If new devices are to be purchased theymust be trialled and evaluated to ensure that they are fitfor purpose and meet the user’s needs. Technologistsworking within the department participate in thisevaluation work together with clinical users to allow aconsensus of opinion to be reached on the mostappropriate device.

• Purchase – When new devices are purchased thedepartment works with users and the SuppliesDepartment to ensure the most suitable product is

purchased. This works in tandem with thestandardisation policy. If the purchase is large capitalreplacement procurement program an advert willhave been placed in the OJEC European Journalinviting manufacturers to tender for the business.Approval for purchasing involves certain controls,which include the manufacturer completing a Pre-Purchase Questionnaire (PPQ). Smaller one-offpurchases will require advice being given to users onsuitable products.

• Acceptance checks for newly delivered devices –Newly delivered devices require safety and functionalchecks to be performed to ensure that the deviceswork as intended. These checks include the verificationof any delivered energy, of general device function,and electrical safety (especially regarding patientconnections). The device is entered onto a databasesystem that permits a service history to be recorded.This enables uniquely identifiable information to bekept over the life cycle of the device to inform anydecision process.

• Useful Life – This can be broken down into scheduled andnon-scheduled maintenance. Certain devices requireroutine scheduled maintenance to be performed atregular intervals throughout the life of the device to helpensure continued operation. However, due to thetechnological nature of modern devices it is impossible topredict when failure will occur, hence the need for non-scheduled maintenance when a device fails unexpectedly.

Work Undertaken by Technologists

Technologist performing electrical safety tests

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• Disposal – For disposal of a device to occur it mustsatisfy one of the following requirements. It must betechnically obsolete, clinically obsolete, or be beyondeconomical repair. Once disposal is decided as thecourse of action the technologist must render the deviceinoperable to prevent the possibility of an untrainedperson using a potentially dangerous medical device.They must then decide if any component parts warrantcontrolled disposal – for instance batteries must bedisposed of in an environmentally sound manner.

Evaluation of New DevicesWhenever new devices are to be selected an evaluationprocess needs to be undertaken to inform the decisionprocess. This can involve quite a comprehensive series oftests being performed which will vary from item to item butinclude tests for compatibility and a comparison withexisting methods. These tests will permit a conclusion to bereached regarding the suitability of the device.

Development of TechnologyTechnologists can contribute to the development oftechnology by sharing their practical experience withmanufacturers. An example of this at Queens is the ongoingdevelopment of continuous veno-venous haemofiltration(CVVH) fluid balance systems. Technologists in MESUworking closely with clinical specialists were able to delivervaluable feedback to the manufacturers that permittedcontinual development of the product. These developmentshave included:

• Development of the software due to issues withdisconnection of treatment

• Development of a more robust transducer design

• Addressing issues associated with self-test failures

• Addressing weigh scale drifts

• Modification of syringe pump sensing to preventspurious alarms, syringe siphoning, and syringedisplacement

• Blood Leak module development to prevent falsetriggering due to UV sensitivity

These developments have resulted in better management ofpatients suffering Acute Renal Failure in the Intensive Careenvironment.

Working towards Improved Patient Safety

Nowadays (quite rightly) there is an increased focus onlearning from incidents and making improvements topractice with the resultant improvement in patient safety.Technologists working in Clinical Engineering departments

have long had a role to play in improvements being made topatient safety where medical devices are concerned. Sincethe inception of the departments, technologists haveperformed routine electrical safety testing on devices withthe premise of preventing electrical safety hazards beingpresent in the patient environment. Due to the nature ofpatients being hospitalised they are more vulnerable to anykind of electrical hazard – for instance a small circulatingleakage current between patient connections could provefatal. In early designs of medical devices it was possible forcomponent failures to have an impact on patient safety.Modern devices have improved designs that safeguard thepatient; however it is still possible for combinations ofsituations to arise that may compromise patient safety.Examples include the use of “systems” (multiple devices) ofdevices around the patient – resulting in all of the devicesconnected to a patient becoming a system which can resultin cumulative effects being present. Obviously technologistswith knowledge of all of the factors involved have a valuablepart to play in maintaining patient safety.

Adverse Incident InvestigationWhen an untoward incident occurs involving a medicaldevice, technologist staff within MESU undertake aninvestigation of the incident. This involves a visual inspectionof the device as received together with any accessories.From here a course of action will be decided. This will includefunctional checks being performed together with theexamination of any event data that may be stored. There willalso be an attempt to replicate the incident conditions

Some examples of work undertaken byTechnologists in MESU:

Some of the medical technology required around an Intensive Care bed space

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described. The findings from these steps will then beexamined to help establish the causes of the incident anddraw conclusions about what happened, from whichrecommendations can be made to help prevent areoccurrence of the incident. One aspect of this is todetermine whether human error was a contributory factor andwhether user training should be considered.

Calibration and Measurement Assurance ChecksAny medical device that delivers energy requires checks tobe performed to ensure that the energy is deliveredaccurately. Some examples include defibrillators, ultrasoundtherapy devices, electrosurgery, premature baby incubators,life support ventilators, and various types of infusion deviceincluding patient controlled analgesia (PCA).

Also, devices that perform physiological measurementfunctions require the accuracy of these functions to beverified. Some examples include ECG, invasive and non-invasive blood pressure, temperature, fetal monitoring, andpoint of care testing (POCT) blood chemistry analysers.

Technologists working in MESU perform a complete rangeof checks on all of the devices listed above and many morebesides. These checks ensure that patients are notsubjected to an uncontrolled potentially harmful energy oroutput, and also that when a physiological function is beingmonitored it is reproduced on the monitoring deviceaccurately. It is worth considering this in a little more detailby means of two examples:

• Consider a baby being nursed in a premature babyincubator – in basic terms this delivers a controlledenergy (in this case heat) to a baby ensuring that thebaby’s temperature is maintained within a defined range.To ensure that this defined temperature is maintained itis necessary to monitor a physiological function (in thiscase temperature). Technologists ensure that the heat isdelivered accurately by the incubator. They will alsoensure that when measuring the temperature of the babya true reading is obtained. Should there be a failure inany one of these areas, then the baby may be subjectedto an unnecessary stress or hazard – for instance if notenough heat is delivered to the baby, it will utilise toomuch of it’s energy in an attempt to generate heat whichleads to further problems with the baby not growing anddeveloping as it should do.

• Consider a person on a life support ventilator – in basicterms this delivers a controlled output (in this casebreathing gas is forced into the lungs) to the patient toreplace the respiration function that is necessary toenable gas exchange to take place. The patients’physiological functions (in this case blood chemistry inparticular) require monitoring to ensure that an idealblood chemistry balance is maintained. Arterial bloodsamples are taken from the patient at regular intervals

and analysed in a point of care blood chemistry analyser.These blood chemistry results determine settings thatrequire changing on the ventilator for optimum effect. Ona basic level this can mean increasing the oxygen settingon the ventilator if the blood oxygen reading is low, orincreasing the ventilator breathing rate or tidal volumesettings if the blood carbon dioxide readings areelevated. There are actually a lot of other factorsregarding blood chemistry that come into effect and asample analysed in a point of care blood chemistryanalyser can be very informative about the condition ofthe patient. Technologists perform maintenance andchecks that ensure that the ventilator delivers all of itsparameters accurately, and that the point of care bloodchemistry analyser measures any of its multitudes ofparameters accurately.

As can be seen from these illustrations medical technologyhas various interactions with patients. Technologists havea key role to assume that helps contribute to advancedhealthcare outcomes. They are required to keep abreast ofall the latest advances in healthcare technology tomaintain their knowledge and skills base to enable them tocontribute to healthcare delivery.

It should be realised that the role of technologists workingin a Clinical Engineering department like MESU is far widerreaching than just “repairing the equipment” – the role ofequipment management should be to take a holisticapproach to the equipment, that is, to not consider theequipment in isolation but to consider the whole systemi.e. equipment, user, patient. Only by clinical engineeringdepartments doing this can they claim to be operating inthe true role of equipment management.

Conclusions

Technologist verifying calibration of infusion pump