To eliminate clinically obsolete and high-ownership-cost devices, develop a medical-device-replacement program.

Biomeds and clinical engineers have not historically been leaders in instituting equipment-replacement programs. Part of the reason for this may be that we think we can keep anything going, regardless of age, cost, or condition. Or maybe we feel that replacing something is an admission of our inability to perform our job function. Both motives contribute to the number of clinically obsolete and high-ownership-cost devices in our hospitals and clinics.

And high cost of ownership and clinical obsolescence are the two major reasons to replace equipment in health care settings. Cost of ownership includes expenses associated with repairs, energy consumption, downtime, and device usage. Clinically obsolete devices do not provide results as quickly as clinically required or cannot perform some clinically needed functions. Since every device is different, there is no magic number of years of useful life.

What To Replace
To start an equipment-replacement program, we first must look at our inventories and determine how many of those companies listed as manufacturers are still in business; and if so, under what name. Then, we must look for information on which devices are no longer supported by their manufacturers.

A great source for this information is a listing¹ located on www.mymeta.org, the Web site for the Medical Equipment and Technology Association. The listing is extensive but not all-inclusive, as www.mymeta.org is a voluntary site that is updated as members send in information. In some hospitals, you may find that more than 50% of your devices are covered in this listing. Don’t panic and request that everything be replaced at once, though. Just because a device is no longer supported by its manufacturer does not always mean it is clinically obsolete or has a high cost of ownership.

After reviewing this list, examine your inventory for problem devices. Most of us have a few of these in our hospitals. Run a repair history on those devices, considering repair costs and, if possible, length of downtime. To financial people determining equipment-replacement feasibility, downtime may be a more important factor than repair costs since downtime equates to lost earnings.

To find all problem devices, the process gets harder. Now, you have to meet with the clinicians to find out what issues they have with equipment. Many of their problems may be user difficulties that were never referred to the biomed shop. Clinicians may experience trouble with devices that are difficult to set up, difficult to use, or uncomfortable for the patient. Problem devices usually wind up not being used while other, more-user-friendly devices are overused.

Device overuse can negatively impact patient care, and device underuse can impact the hospital’s bottom line. To illustrate this point, at one hospital, no one wanted to use a particular problem x-ray room. We put a time recorder on the rotor circuit of the tube. Over the course of 1 year, the rotor was powered up for 45 seconds, and about 30 of those seconds were consumed by the physics testing that was done. One major repair on the room during that year cost more than $10,000 in parts and labor—so that was a very expensive 15 seconds of use! Yet, it still took us 2 years to get the room replaced because Dr X used it before he became chief and might want to use it again when his appointment was up.

In determining what equipment should be replaced, you should also look for clinically obsolete devices or systems. This is becoming a common problem with some of the computer-based devices, since new software sometimes cannot be run on old machines.

Also, we are seeing new devices on the market that functionally replace two or more devices—often at a lower cost and with better clinical results. In intensive-care-unit settings, many monitors feature parameters that are not, or are very rarely, used. This occurs not only at the bedside but also in the central station and with the computerized arrthymia systems, which are nice on paper but often generate so many false alarms that the staff simply ignores them.

Unfortunately, many clinically obsolete devices are not removed from service. Instead, they are left in the corners of rooms and remain in the biomed equipment-management plan, meaning that they have to be tested and inspected in accordance with your outlined management schedule—your real one, not the one you showed to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) during its last visit. About every 3 years, just before JCAHO arrives, a multitude of obsolete devices arrive in our shop and are declared as surplus. At that point, we generally have four options: sell, store, donate, or dump. If your facility is a for-profit, it may be better to donate the device and take the tax write-off.

What to Present and to Whom
So, you know what equipment needs to be replaced. Now, the fun starts: deciding how to present your findings and to whom. Let’s start with the who. In my experience, equipment-replacement requests should be addressed to the department head where the device is located, with copies distributed to the finance and materials departments and to your boss. Remember to speak with the department head before you publish to ensure that they agree with you. If they do not agree, your plan will get shot down. In certain cases where there is a major risk of injury, the risk manager should be included. In most hospitals, the safety committee is not active in replacement planning or approval and may just complicate what you are trying to do. Target your reports to those people who have the financial interests of the hospital under review and to those in charge of the department where the device is located. For doing this, you may catch some grief from others, especially from the planning group, which may feel that you are infringing on their turf, but it will pay off in the long run.

How you present your findings can vary widely; one format that has been used effectively is to put a column labeled “Replace in” on a spreadsheet of the department inventory and then fill in fiscal year (see Table 1). If at all possible, provide 2 to 7 years’ notice of when a device or system will need to be replaced, as such a time frame allows an orderly budget process. This is a good format for a yearly report; remember that the capital budget cycle generally starts in the spring, so get this information out early. Most hospital budgets are set and approved in August.

Another format is a simple memo that states:

The device(s) listed below has reached the end of its manufacturer’s support. While there may be repair parts for the device(s) available on the secondary market, such support cannot be guaranteed. As a department, we will pay close attention to these devices and do our best to support them. By using a device that is out of support by the manufacturer, the hospital may assume an increased legal exposure if the device fails or is not available to treat a patient on a timely basis because of a service problem.

This will get some attention.

For devices that are costing too much to keep running, you can use something like:

This device, (insert asset number and description), manufactured by (insert manufacturer), located in (insert department), (OPTIONAL: is no longer supported by the manufacturer and) presents problems both financially and in the quality of care delivered by the hospital. This unit has been in service since (insert date), and over the past 12 months, the hospital’s hard cost of keeping this device in service has been $_________, plus downtime of (insert hours or days). The potential loss of revenue because of the downtime is estimated at $_____________. This estimate is based on the average number of cases that use the device per day, multiplied by the average billing for that service (you can obtain this information from the department head). It is our suggestion (get this signed by the department head) that this device must be replaced in the upcoming fiscal year to provide optimum quality of patient care.

Always—and I mean always—end with a closing line such as:

The department of (insert whatever name you go by) will provide assistance in developing a more refined plan, preparing specifications for the purchase or lease of device, and will research various databases, if any exist, on problems associated with new devices or their application.

Basically, you are saying that you will “Google” the new device selections.

Each of these reports targets a specific process in the equipment-replacement program that should be part of your equipment-management plan. The simplest report, the excel sheet (Table 1, page 24), provides administration with an overall 2- to 7-year projected expenditure program. The second report, the simple memo, provides a 1- to 3-year plan that allows the finance department to better budget for devices before the facilities and other groups get their requests in. The more-detailed memo should only be used when there is a current and pressing problem. With this report, you are basically asking for emergency funding.

Final Thoughts
By sending out equipment reports, you will be proactive, and people will ask you for help in the future. This is a good thing. Do not rely totally on formulas or “packaged data,” such as the American Hospital Association’s Estimated Useful Lives of Depreciable Hospital Assets.² Instead, combine that information with your own experiences and, if possible, those of surrounding institutions. Watch the Food and Drug Administration notices, and check MedSun and ECRI on a regular basis for problems in other facilities. Make equipment planning a departmental priority. 24x7

David Harrington, PhD, director of staff development and training at Technology in Medicine (TiM), Holliston, Mass, is a member of 24x7’s editorial advisory board.

References
1. Equipment End of Life. Medical Equipment and Technology Association Web site. Available at: http://www.mymeta.org/documents.html. Accessed August 31, 2005.
2. American Hospital Association: Health Data Management Group. Estimated Useful Lives of Depreciable Hospital Assets, Revised Edition. Chicago: American Hospital Association; 2004.