What went wrong?
I learned that the types of issues and frequency with which we were experiencing them were not necessarily unusual for a busy
practice, even with minimal staff turnover. The problems we experienced with the monitors were related to monitoring knowledge,
proper use and care of the accessories and expectations regarding their durability.
Accessories are considered consumable items and, based on their direct contact with the patients, are subject to wear and
tear. They will definitely need to be replaced from time to time. This was a harsh reality for us. I was used to paying for
the highest quality equipment, and I expected it to work seamlessly without much additional expense. How often the accessories
are used and how they are cared for directly impact the frequency of replacement.
That said, the rate at which our staff went through pulse oximeter sensors seemed exceedingly high. At $250 each, according
to the distributor, most customers take extraordinary care of these and make sure that every staff member is trained and held
responsible for treating them properly—if not out of the box, certainly after the first time they need to purchase a replacement.
They generally have a warrantee of six to nine months, which is the timeline the manufacturer uses to determine where their
responsibility for production quality ends and where normal wear and tear, frequency of use and care begin to take their toll.
Photo 1: Improper storage of blood pressure cuffs.
What we learned
For us, the best approach was to schedule a formal monitoring training session for our entire technician staff. The manufacturer's
representative did hands-on training, demonstrating the tips and tricks of taking care of the monitoring equipment and accessories.
We also developed a written protocol for the "proper care and feeding" so that we will always have a reference document on
site (email me at firstname.lastname@example.org
Photo 2: Dangerous stress placed on the cuff because of improper storage.
for a copy).
Blood pressure cuffs
When a blood pressure cuff's Velcro® (Velcro Industries B.V.) wears out, it is time for a new cuff. Simply taping the cuff
will cause inaccurate readings. Also, watch closely how the blood pressure cuffs are stored after use. They should be disconnected
from the unit and stored flat. Storing them on the unit often creates abnormal stress on plastic surfaces (Photos 1 and 2).
TIP: Keep the cuff clean by wiping with alcohol after each use.
Photo 3: Pointers for pulse oximeter sensors—don't tightly wrap the wire; don't yank or pull the sensor off but unclip it
and clean the sensor with a 70 percent alcohol wipe; never submerge it or clean with chlorhexidine.
Pulse oximeter sensor
If the infrared light on the pulse oximeter sensor is intermittent, it means that the thin internal wires have frayed or are
pulling apart at the junction—a precursor to complete sensor failure. Although these can sometimes be repaired for a fraction
of the replacement cost, always have a spare pulse oximeter sensor to use in the meantime. Having a working spare will also
allow you to troubleshoot the parameter to eliminate the possibility that the problem resides in the monitor itself. TIP: Only wipe the sensor clean with alcohol; never use other cleaners that may damage plastic. Never wind the wires tightly or
yank the clips off when changing them—be sure to unclip them before moving a patient (Photos 3 and 4).
Photo 4: Proper storage of monitor wires—note the pulse oximeter sensor wires are not coiled.
Carbon dioxide sampling lines
The moment an occlusion alarm is rendered, replace the sampling line. If visible moisture is evident beyond the neoprene filter,
hang the line to dry. Failing to do this risks that the moisture will reach the internal module and burn out the circuitry
(Photos 5 and 6). TIP: Hang the line to dry between cases. Never force air through the line to expedite drying because it will destroy the filter.
Photo 5: Pointers for carbon dioxide lines—wipe the adapters to clean them, but do not force water through or submerge them;
hang them dry to allow moisture to evaporate.
ECG leads and clips
Green or black buildup on the copper clips can be part of normal oxidation and should be regularly cleaned—or the buildup
can mean your staff is mistakenly using ultrasound gel (acoustic gel) rather than electrode paste (conductive) to maintain
good contact. Ultrasound gel will not only block the electrical signal, it will also quickly degrade the clips (Photo 7).
TIP: Clean the clips by gently wiping with alcohol or by using an instrument brush. Never wind the line tightly to store, and
never ever use ultrasound gel instead of electrode gel.
Photo 6: Moisture has made it beyond the neoprene filter and stands just before the second filter at the monitor junction.
A leak test should be performed before every procedure. By verifying there are no leaks in the machine, you allow the correct
flow rate of oxygen and percentage of inhalant drug to be administered to the patient. Such leaks are not only wasteful, but
they can compromise the safety of the patient. TIP: Perform a leak test between each procedure, and replace the maintenance kit annually, including the black rubber tubing,
domes, gaskets, flutter discs, etc. These rubber parts should also be cleaned daily with mild soap and water.
Photo 7: Pointers for ECG leads and clips—use electrode paste, not ultrasound gel to maintain good contact; keep the copper
clips clean of debris and buildup; use a gentle touch when applying and unclipping leads.