Larry Fennigkoh: Let’s Stay Technically Practical with Relocatable Power Taps

Before the HTM community goes off of the electrical deep end and starts to indiscriminately remove relocatable power taps (aka power or outlet strips) from its patient-care areas, we should first be strongly encouraged to revisit, relearn, and then apply some basic principles associated with alternating current (AC) circuit analysis and electrical power distribution systems.

Then, let these principles–and the immutable laws upon which they are based–be our guide, rather than the Centers for Medicare & Medicaid Services (CMS) or any other agency that attempts to claim electrical dominion over our healthcare environments.  The proliferation of medical devices requiring access to AC line power has made the use of outlet strips a simple and practical necessity.  Properly designed, specified, used, and monitored, outlet strips offer an intrinsically safe, practical, and most cost-effective alternative to adding multiple wall outlets.

Electrical surge protection is also an added benefit provided by many of these strips.  Rather than force the removal of these essential accessories, let’s focus our attention on simply applying some sound engineering principles to each facility’s electrical needs and then proceed accordingly–even if it means ignoring the mandates of CMS and others.

Unlike many of our important codes and standards that continue to be argued and evolve, the principles embodied in Ohm’s and Kirchhoff’s voltage and current laws and their judicious application should not be up for debate or left up to subjective regulation.

Larry Fennigkoh, PhD, PE, is a professor of biomedical engineering at  the Milwaukee School of Engineering.

5 thoughts on “Larry Fennigkoh: Let’s Stay Technically Practical with Relocatable Power Taps

  1. I would like to take this opportunity to (a) add my full support to the basic contention advanced above by Drs. Larry Fennigkoh and William Hyman that the regulations governing patient safety should be based on sound analytical methods, (b) to add some further comments on the need for the clinical engineering community to participate effectively in the regulation-making and changing process, and (c) make an appeal for some immediate action.

    1. Why we need to pay attention. The recent changes to the very important CMS regulations which began two and a half years ago with the new PM “dictates” should remind us that a substantial part of our clinical engineering work practices are determined by a relatively small group of individuals (in this case, staff at the CMS) who are usually not conversant with the sometimes-esoteric concepts and terminology of clinical engineering. There is nothing wrong with this because the totality of all the CMS regulations under their purview addresses all aspects of the safety of the nation’s patients – so the decision makers on the staff do need a much broader perspective. Of course, it goes without saying that, as competent professionals, we should be quite capable of presenting our arguments to these staff members in simple easy-to-understand layman’s language and terminology.

    2. How are the decisions made? A good way to think of the staff at the CMS is as layman-like members of a “techno-safety jury” who have to weigh our input (on the equipment-related aspects of patient safety) the way a regular jury weighs the input from the dueling expert witnesses called by both sides in a legal trial.

    3. Key segments of the medical device industry monitor the regulation-making process very intensely – because of the get a very good return they get on this investment. Unfortunately, as seems to have been the case with these most recent changes, the members of CMS’s “techno-safety jury” are often persuaded by the omnipresent “expert witnesses” representing some key segments of the medical hardware industry that some of the changes they suggest are no-brainers, obviously in the best interest of the public and not needing independent evaluation. And without making or intending any specific allegations we do need to keep in mind that this often-omnipresent influence from industry representatives has the potential to be self-serving, at least to some degree. Some apparently spontaneous changes, such as the recent prohibition of relocatable power taps do not appear to have any technical analysis supporting the conclusion that this change will significantly enhance overall safety. There are some measures built into most of the standard and regulation-making processes that are supposed to ensure that the merits of any significant changes are subjected to arguments from both sides, but these mechanisms require considerable due diligence on the part of the non-industry representatives and they do not always seem to work as intended.

    Other examples similar to this have occurred in the past. The most memorable one occurred during the 1970s when there was a landmark episode, often characterized as “The Great Electrical Safety Scare,” which was the result of allegations made by certain “expert witnesses” from the medical device industry, but championed by Ralph Nader through an article in the Ladies Home Journal, alleging that many thousands of hospital patients were being killed each year by a phenomenon that was later given the name ”microshock.” Coincidentally but particularly notable for us, this episode served as the wake-up call that kick-started the creation of the special discipline that became known as clinical engineering (recently rebranded as healthcare technology management).

    4. The past as prologue. There are parallels between what is happening now with the CMS regulations and what happened in the 1970s.The individuals who created “The Great Electrical Safety Scare” did so with the clear intent of getting the Hill Burton regulations (which were, more or less, the 1970s equivalent of today’s CMS regulations) changed to mandate widespread installation of isolation transformers throughout the nation’s hospitals. The cost of this would have been staggering but, fortunately, the proponents could bring no hard evidence to the table and a small band of precursor clinical engineers who were totally outraged by the potential cost to the nation of the proposed “cure” for this completely hypothetical hazard mounted a sufficiently formidable challenge that the proposed changes were never adopted. It is relevant to note that it was during this time, some 40 years ago, that the probability model for equipment safety was used for the first time.

    I was there and witnessed these very memorable events and would be happy to provide any of the community’s younger members with pointers to materials documenting what really happened during this very interesting time.

    5. The “not on my watch” factor. In the absence of really strong evidence, the members of “techno-safety juries” have a tendency to err on the conservative (overly restrictive) side simply because no one wants to have a major safety scandal be traceable to the time they were “on watch.”

    6. We are not helping ourselves by failing to standardize our maintenance documentation practices. How to provide lay people with a simple, quantitative “handle” on safety has been a longstanding problem, particularly for the diverse and overly analytical clinical engineering community. But our most serious shortcoming since the time of “The Great Electrical Safety Scare” some 40 years ago has been our failure to come together to standardize our data collection practices. At best, the community has amassed 40 years worth of effectively useless data. Although we have spent countless man-hours over the past 40 years documenting the results of our very extensive maintenance activities, our failure to standardize the way we do this has left us with data that we cannot aggregate. We continue to this day to squander this potentially invaluable resource.

    When we were first presented with the proposed changes in the CMS regulations to minimum equipment PM practices two and a half years ago, we should have recognized that there was an immediate need to help the CMS staff understand exactly how PM relates to equipment reliability and patient safety, and how we could prove to them that our current PM practices are providing more-than-adequate levels of safety. I was hopeful that this would be the wake-up call that we needed to kick start an initiative to standardize the way we collect data on our maintenance practices. Although, thanks to efforts of the Joint Commission, we do have some data on maintenance-related patient injuries, it is easily criticized as probably being under-reported. Collecting the data we need to make our case is well within our control – if we can only generate some enthusiasm for doing it the right way.

    7. Let’s agree to get on with it and make the necessary changes. As Larry Fennigkoh and I attempted to explain recently (see “Metrics for Equipment-Related Patient Safety” in BIT May/June 2014 pages 197-200) it is so much more persuasive if you can support your basic case by bringing factual evidence in the form of statistically valid data to the table.

    If this sounds like an appeal for action, it is. Let’s get started right away. Better late than not at all.

    • First of all, let me say that I agree with your overall point of view. However, if The Joint Commission has made the removal of RPTs a part of its inspection of facilities, we had better start removing them before the next inspection. I don’t think a TJC inspector will care about your personal opinion of the new restrictions. Fight the cause if your next inspection is a long way off, but I think we do everything we can to meet new regulations, whether we agree with the new standards or not. I think you are doing your facility a disservice otherwise.

  2. Applying good engineering analysis is of course something that should be routinely done about many issues. However, ignoring the dictates of those who do indeed have authority that can substantially impact the hospitals existence, reputation, and/or financial well-being cannot be considered good advice.

    Explaining to the C’s that “yes, CMS cut the hospital’s revenue stream because we didn’t do xxxx, but they were technically incorrect” does not seem like a winning strategy.

    Engineering analysis should be used to influence change in regulations and interpretations, not as a justification for ignoring them.

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