The Upgrading and Replacement of Anaesthetic Equipment: Robert M

889

Occasional Review The upgrading and replacement of anaesthetic equipment: Robert M. Friesen MO ~CPC,* Gill Hatton R'rr (Anaesthesia),t Janet Bjomson 8sr Pharm~ a provincial approach

A formal on-site survey of all anaesthetizing locations in the manitobaines d~cid~rent de rajeunir leur flotte d'appareils Province of Manitoba was initiated in the Spring of 1988. d' anesth~sie. Des 203 appareils inspectrs (dont I I I en milieu Serious deficiencies of anaesthetic equipment previously noted urbain ) dans 66 hrpitatLr, 167 avaient did utilisds durant I'annde on random survey were confirmed. Recognizing a need for prdcgdant r inspection. On procdda ti des amdliorations sur 66 improved standards for deliver, of anaesthetic services through appareils et on remplafa 92 des 137 appareils mis au rancart. safe, fimctional anaesthetic equipment, the province undertook Mgme si la responsabilitd de I'entretien et de la modernisation to fund the upgrading of all anaesthetic gas delivery, systems des gquipements revient finalement d chaque hOpital, tree under its jurisdiction. Sixty-six hospitals were surveyed for a approche intggrde r I'dchelle pro vinciale s'est a vgrde rentable. total of 203 anaesthetic machines (111 urban, 92 rural). One C'est peut-rtre tr module r suivre ailleurs au Canada. hundred and sixty-se yen machines had been used at least once in the previous year. After careful assessment 92 machines were replaced, 66 machines were upgraded and 45 machines were In 1980 the Province of Manitoba Anaesthetic Machine deleted from further service. Although the maintenance and Program was completed ~ to accommodate the then recent upgrading of medical equipment is the individual health care Canadian Standards Association Z 168.3-M 1980, "Con- facility's responsibility, substantial benefit was recognized by a tinuous Flow lnhalational Anaesthetic Apparatus; (An- provincial approach. The authors recommend a similar ap- aesthetic Machines) for Medical Use. ''2 Further Canadian proach ,['or other Canadian provinces. Standards Association (CSA) publications have since been developed and released 3-4 which define more A u printemps 1988, on entreprit taw inspection syst~matique de completely the operational standards for anaesthetic gas tous les appareils d'anesthrsie par inhalation r Manitoba. delivery systems. Subsequent to the 1980 program, Cela permit de confirmer les ddficiences suspectres Iors d'une informal surveys of anaesthetizing locations throughout pr~c~dente enqug,te sur dchantillon. Reconnaissant I'importan- the province suggested that serious anaesthetic equipment ce de disposer d' rquipements st2rs et fonctionnels pour amrlio- deficiencies continued to exist. In order to address this rer le standard de qualit~ des soins anesth~siques, les autoritrs issue, a repeat, more intensive province-wide anaesthetic upgrade program was initiated in the spring of 1988.

Methods Key words A working committee was established in order to effect a EQUIPMENT: anaesthesia machines, exhaust systems, province-wide upgrade. Formation of the Manitoba An- vaporizers, ventilators. aesthetic Equipment Upgrade Program (MAUP) Advisory Committee included representation of urban and rural From the *Department of Anaesthesia, University of Manitoba, physicians involved in the active practice of anaesthesia, St. Boniface General Hospital, Winnipeg, Manitoba; tHealth the Manitoba College of Physicians and Surgeons, the Sciences Centre, Winnipeg, Manitoba; ;tUrban Health Manitoba Health Services Commission and the Manitoba Facilities Division, Manitoba Health Services Commission. Health Organizations, Inc. The mandate of the MAUP Address correspondence to." Dr. R.M. Friesen, Department was to improve standards of care in regard to the of Anaesthesia, St. Boniface General Hospital, 409 Tache administration of anaesthetic services in the Province of Avenue, Winnipeg, Manitoba R2H 2A6. Manitoba through the appropriate provision of anaesthetic Supported by the Manitoba Health Services Commission. equipment. Patient monitors were not included in this

CAN I ANAESTH 1990 / 37:8 / pp889-95 890 CANADIAN JOURNAL OF ANAESTHESIA

and function, oxygen flush mechanism, locking common ANAESTHETIC EQUIPMENT SURVEY gas outlet, back bar vaporizer lock-out mechanism, flow

Name of Facility: Completed by: meters, vaporizers, ventilators, absorbers, breathing circuits and a CSA approved 4 waste anaesthetic gas scavenging system. The presence of functioning oxygen in-circuit Position Title: Date: Phone #: analyzers, high/low pressure anaesthetic circuit monitors 1. Machine Type: 2. Model: with alarms and provision for circuit spirometry were also 3. Purchase Dale: 4. Location: recorded. All hal vaporizers were subjected to an 5. Last Maintenance: Completed by: Inspection anaesthetic agent output check at a two per cent setting Frequency: with a fresh gas flow of 4 L. min-'. Patient monitors such 6. Hours of Use/12 months: # of Anaesthetics/12 months: as an electrocardiogram, non-invasive blood pressure machine, pulse oximeter, capnograph and temperature 7, Gas 13 Yes 13 No 8. C02 Absorber? O Yea O No Scavenging Equipment? Bypass? [] Yes [] No monitor were noted on site but their frequency of use [] Active [] Passive System could not be verified. Preventative maintenance arrange- 9. BackBar OYes ON 10. Ventilator? ON ments and records, preoperative check lists and the Lockout? availability of equipment operating manuals were veri- 11, Monitors: a) ECG []Yes []No b) NIBP []Yes []No fied. All surveyed anaesthetic machines were photo- c) Oxlmelry [] Yes [] No d) Capnograph [] Yea O No graphed in at least two views. In those cases where major e) Temperature O Yes [] Nr f) Oxygen analyzer O Yes 13 No hazards were identified (example: back bar not connected g) Pressure Alarm 13 Yes ONc h) Spirometer nYea O No to the vaporizer) the hospital was notified immediately, I) Blockade Monitor [] Yes ONc both verbally and in writing. 12. Preventative Maintenance Program for Monitors? n Yes O No Each health care facility was provided with a detailed [] Monthly O Semi-Annual O Annual [] 3 Yrs O 5 yrs 13. Are CSA Standards Available In your Hospital? O Yes 13 No written report for every anaesthetic site surveyed. This 14, Related Equipment: report not only detailed the anaesthetic equipment present 15. Comments: and its function, but also a recommendation for either upgrading existing equipment or its replacement. Recom- mendation for upgrading rather than replacement was based on the number of "faults" addressed, anaesthetic FqGURE I Mail survey form. One form completed for each anaes- machine age, preliminary cost estimates as well as thetic machine on site. manufacturer assurance that parts and service would continue for upgraded machines. A representative MAUP mandate although their presence on site was to be survey summary and recommendation form is shown in surveyed. Recognizing that substantial funding would be Figure 2. required to effect a province-wide upgrade, provincial All data collected were filed in a computer registry at funding was sought and approved prior to initiation of the the Manitoba Health Services Commission. program. All hospitals in the Province of Manitoba were In order to familiarize health care facility personnel included. with present and proposed CSA standards, the results of The process consisted of a mail survey followed by an the on-site technical survey, and state-of-the-art anaes- on-site technical inspection of each anaesthetic machine. thetic equipment development, the MAUP hosted a The on-site inspection also served to verify the informa- one-day exhibition in Winnipeg. This also provided a tion provided on the mail survey. The mail survey forum for lecture and film presentations on pulse oximet- questionnaire sought information about the number of ry, capnography, pre-anaesthetic check lists and Canadi- anaesthetic machines present, machine type and age, an Anaesthetists' Society guidelines of practice. 5 frequency of use, preventative maintenance arrangements Health care facilities with very low case loads of as well as ancillary machine and patient monitors provid- general anaesthesia (less than 100 cases per annum) were ed at each site (Figure 1). The on-site technical inspection requested to consider seriously the advisability of contin- verified the presence and function of the numerous uing such a service. Individual consideration was given components on a functioning anaesthetic machine which for geographically isolated locations, specially approved included appropriate DISS* fittings, medical gas hoses provincial programs or university-affiliated remote north- which were CSA colour-coded, gauges, medical gas ern surgical programs where staffing was provided by cylinder pin-indexed yokes, oxygen fail-safe presence itinerant medical teams. Once the MAUP recommendations had been carefully *Diameter index safety system. studied by each hospital and a consensus achieved of the Friesen elal.: UPGRADING ANAESTHETIC EQUIPMENT IN MANITOBA 891

active treatment beds and service communities of less ANAESTHETIC SITE EVALUATION SUMMARY* than 20,000 population each. HOSPITAL Sixty-six hospitals (8 urban, 58 rural) were surveyed EQUIPMENT SURVEY # MACHINE Ohio for a total of 203 anaesthetic machines (111 urban, 92 MODEL Unttrol SERIAL NUMBER ABOH rural). The number of active machines (used at least BAR BACK LOCK N ABSORBER Boyle 3 once in the past year) was 167. Seven machines were LOCKING COMMON GAS OUTLET N HALOTHANE VAPORIZER Fluolec 3 designated as malignant hyperthermia standby units. ENFLURANE VAPORIZER Ohio Anaesthetic machines were located in the emergency ISOFLURANE VAPORIZER N O. ANALYZER N rooms of three rural health care facilities although the P~IESSURE ALARM N SPIROMETER N previous upgrade had not recommended this practice. The VENTILATOR Ohio Fluidic; OISS Y number of active anaesthetic machines identified in 1980 HOSES CSA COLOR N SCAVENGING Y was 195. Several anaesthetic machines never approved SVG INTERFERENCE N for sale in Canada or thought to have been deleted in the TEMPERATURE N NERVE STIMULATOR N 1979 upgrade program continued to be in active service. ELECTROCARDIOGRAM Y BLOOD PRESSURE Y Ninety-five per cent (193/203) of the mail survey forms OXIMETER N CAPNOGRAPH N were returned after telephone follow-up. Sixty-two per

N = NOt present or not functional cent (120/193) were completed and returned with correct Y = Present end functioning information. Five per cent ( I 0/193) were completed with RECOMMENDATIONS such inaccuracy and error as to be deemed totally

Upgrade anaesthetic machine subject to provincial tender pricing unreliable. Fifty-nine per cent of the anaesthetic machines sur- Requires locking common gas outlet, back bar lock out complete with two vaporizers, carbon dioxide absorber, ventilafor, CSA approved veyed had been manufactured between 1970-80, while waste gas scavenging Interface and medical gas hoses seven per cent were manufactured before 1970 and 34 per

Also requires oxygen analyzer, volume and pressure anaesthetic cent after 1980. Vaporizers surveyed on the 167 active circuit monitor, temperature monitor, nerve stimulator machines included halothane (n = 165), enflurane (n =

Although not included In the funding of the MAUP, the availability 73), isoflurane (n = 91) and methoxyflurane (n = 5). of pulse oximeter and capnography are recommended at each Ether bottles were noted on the back bar of three anesthetizing location anaesthetic machines. A back bar lock-out device was a Hosplial name and machine serial number deleied present on 26 per cent (43/167) of the machines surveyed. One hundred and thirty-four anaesthetic patient ventila- FIGURE 2 Technical survey reporl. Representative anaesthetic site tors were identified and classified according to bellows including site-specific recommendations for upgrade. function as well as circuit alarms present (rising bellows = 74, hanging bellows = 56, internal factory pre-set low anaesthetic equipment to be upgraded, replaced or delet- pressure alarm = I 16, separate circuit pressure monitor = ed, a group tendering process was initiated to encompass 55). all anaesthetizing locations in the Province of Manitoba. A waste anaesthetic gas scavenging system was identi- Anaesthetic equipment manufacturers with a local provin- fied on 86 per cent (145/167) of the machines surveyed; cial presence were invited to bid on fulfilling the however, only 36 per cent of these devices were CSA- anaesthetic site specific recommendations of the MAUP. approved devices which included a waste anaesthetic gas This process was coordinated through the offices of the scavenging interface. Thirty-one health care facilities Manitoba Health Organizations, Inc. Hospitals were provided for paediatric anaesthetic services of which 55 encouraged to utilize this process to acquire additional per cent provided for scavenging of waste anaesthetic gas. anaesthetic equipment or machine features not included in Less than one-half of the health care facilities surveyed MAUP funding in recognition of the anticipated monetary could provide information on the mechanics of their savings by group purchase. Major manufacturers invited operating room ventilation systems or the estimated to tender included Penlon, Drager and Ohmeda. number of fresh air exchanges provided to each suite. Fourteen anaesthetic machines in service received no Results regular preventative maintenance; however, only one of Urban health care facilities in Manitoba are confined to the these was being used on a regular weekly basis. Preventa- cities of Winnipeg and Brandon and all have more than tive maintenance arrangements in place at the time of Ihe 130 active treatment beds. Rural hospitals, as defined by MAUP survey are summarized in Table I. the Manitoba Health Services Commission, are located The monitoring devices available with each active outside the above cities, range in size from four to 105 anaesthetic machine are documented in Table 11. 892 CANADIAN JOURNAL OF ANAESTHESIA

TABLEI Prevenlative maintenance arrangemenls TABLEIll Anaesthetic machine functional faults j

No regular preventative maintenance 14 High-pressure leaks 2 24/167 Factory personnel 82 Low-pressure leaks ~ 11/167 Independent privale conlraclor 68 Non-functioning oxygen fail sate 4/167 In-hospital technicians 39 Regulator malfunction 4/167 No emergency oxygen supply4 2/167 Total 203 Inaccurate halothane vaporizer output s 2/165

1167 active anaesthetic machines. TABLE II ZGreater than 100 PSI pressure loss over five minutes. -~Less than 50 ml flow to maintain pressure at 22 mmHg wilh occluded A Anaesthetic machine monitors~alarms fresh gas outlet or 15-second negative bulb test. Oxygen monitor (FIO2) 110/167 66% '~Oxygen yoke inlet occluded by plastic protector cap which had nol been Ventilator low-pressure alarm 116/134' 87% removed. Separate circuit high/low pressure monitor 55/134" 41% 5Greater than ten per cent error in vaporizer output when dial set at two Spirometer 70/167 42% per cent. Oxygen pressure fail safe (~) 167/167 100%(98%)

B Patient monitors most cases the anaesthetic equipment on-site was re- Electrocardiogram 12/I 67 74% moved. Seventeen rural anaesthetic machines were up- Automaled non-invasive B.P. 121/167 72% graded while 38 rural anaesthetic machines were re- Temperature 75/167 45% placed. Thirty-seven rural anaesthetic machines were Nerve stimulalor 112/167 67% Pulse oximetry 44/167 26% deleted from further service. Table V summarizes this Capnography 10/167 6% data. Many of the no or low anaesthetic case load facilities (n = 167 active anaesthetic machines surveyed) welcomed the opportunity to rid themselves of the *Machines equipped with ventilator. tPresent on all machines; however, 4/167 had significant operational responsibility of continuing to maintain anaesthetic equip- faults as to make them ineffective. ment. These facilities did not perceive a demand for such service and frequently had no documented anaesthetics adminstered in the past one to five years. Although informal conversation with physicians prac- All anaesthetic equipment identified as obsolete has tising anaesthesia throughout the province suggested a now been designated as NOT FOR PATIENT USE in high utilization of pre-use machine checks, only 17 per Manitoba. Disposal of such equipment included: cent of the anaesthetic sites surveyed could provide a i Dismantling of equipment with physical destruction of pre-use check list. Many of the anaesthetic machine various components (n = 22). A destruction certificate functional faults demonstrated at the time of our technical was provided for each machine destroyed. on-site survey (Table II1) would have been detected by the ii Retained on site but clearly marked as not for patient use of a comprehensive routine pre-use check list. We do use (n = 3) not have any information on whether any of these listed iii Donation of equipment to third world mission health faults resulted in adverse patient outcome although the care facilities (n = 5). potential was there for such adverse events to occur. The ingenuity of local maintenance personnel without regard to and/or knowledge of present CSA standards as TABLE IV Anaesthetic machine set-ups which could result in adverse well as the "I'11 make do" philosophy of many practising patient outcome anaesthetists resulted in some potentially dangerous anaesthetic machine set-ups (Table IV). - "H"-size nitrous oxide cylinder with oxygen regulator, green The MAUP-hosted product exhibition was very well high-pressure hose and DISS (oxygen) couplers to nitrous received by 138 registrants. The majority of registrants oxide inlet of anaesthetic machine (I) - Numerous plastic washers left on yoke inlet so as to defeat the were from rural Manitoba. This exhibition, as well as pin index system (3) local manufacturer sales representative activity, facili- - Oxygen DISS coupler on nitrous oxide high pressure hoses (2) tated individual hospital participation in equipment - "Home made" anaesthelic circuits often utilizing Ruben valves selection. (connections frequently affected by tape) (6) - Carbon dioxide absorber by-pass valve taped in permanent Forty-nine urban anaesthetic machines were upgraded, "off posilion" (2) 54 urban anaesthetic machines were replaced while eight - Portable vaporizer downstream from common fresh gas outlet (3) were deleted from further use. Twenty rural health care facilities ceased to provide anaesthetic services and in ( ) Number of sites at which inappropriale set up noled. Friesen el al.: UPGRADING ANAESTHETIC EQUIPMENT IN MANITOBA 893

TABLE V Anaesthelic machine disposition TABLE VI MAUPcontracts awarded

Urban Rural Total Anaesthetic machines replaced (total = 92)

Anaesthetic machines at initial survey I I I 92 203 Manufacturer Model n Anaesthetic machines at upgrade completion 103 55 158 Anaesthetic machines replaced 54 38 92 Ohmeda Modulus I I Plus 45 Retrofit upgrade 49 17 66 Ohmeda Excel 210 3 Anaesthetic machines deleted from service 8 37 45 Ohmeda Excel 310 3 Drager Narkomed 2B 34 Drager Narkomed 3 7 iv Utilization of obsolete equipment by animal research facilities (n = 6) Anaesthetic machines upgraded (Iotal = 66) v Utilization of obsolete equipment by local veterinarian Company providing upgrade Machine make~model n clinics (n = 9) User preference, warranties, service contracts, contin- Ohmeda Ohio Unitrol 33 Boyle MS 21 uing preventative maintenance as well as price were all Boyle 8000 6 determining factors in the awarding of the MAUP Drager (Brathwaites-Olivier*) Narkomed 2 contracts for replacement or upgrade (Table VI). Anaes- Narkomed 2A I thetic machines designated as malignant hyperthermia Penlon (Medigas*) Ohio Unitrol I standby units were upgraded or replaced as required Penton AM 1000 2 although this may no longer be necessary. 6'7 Cost savings recognized by tendering on a provinical *Local manufacturer representative. basis were substantial. Although further saving could have been effected by eliminating user preference from morbidity and mortality, t2 Technologically related im- the formula for contract award, it is estimated that the cost provements can improve the standard of patient safety, t~ saving over retail was between 41 and 45 per cent on new The role of improved training in technology, the use of anaesthetic machine purchases alone. The cost of this preoperative check lists, hospital-administration aware- program, including technical and administrative fees, was ness and increased anaesthesia professional society activi- 3.2 million dollars. ty are of equal or even greater importance to sustain further improvements in safety for the anaesthetized Discussion patient. The Canadian Anaesthetists' Society, the Canadian Stan- With the dialogue that surrounded the creation of the dards Association as well as numerous similar American MAUP it was evident that there were many issues other regulatory agencies and medical societies continue to than just the physical upgrading or replacement of strive for higher standards with regard to anaesthetic anaesthetic equipment which would have to be addressed equipment manufacture, anaesthetic equipment upgrade in order to influence the practice of anaesthesia in as well as the routine utilization of appropriate monitoring Manitoba. These issues and their subsequent resolution devices. 5'8'9 Our survey would suggest that these guide- included: lines are not well followed. Serious equipment deficiencies were identified in both urban and rural health care I Was it appropriate to upgrade or replace all present facilities. Similar inadequacies of anaesthetic equipment anaesthetic equipment whether or not it was being were identified by Kumar et al. to in the State of Iowa. The utilized? MAUP differed from that of Kumar et al. in that the The MAUP Advisory Committee unanimously agreed present survey was not random but included all hospital that it was not. Only anaesthetic equipment that was anaesthesia locations. The MAUP not only identified clearly identified for specific use was considered in the deficiencies but sought to remedy them on a provincial upgrade program. Preventative maintenance costs make basis in spite of the cost implications. the retention of unused or under-utilized anaesthetic Equipment-related anaesthesia incidents continue to be equipment prohibitive. At the time of tendering this reported in the medical literature, it-14 Cooper et al. 14 upgrade program, the lowest estimated bi-annual preven- suggested that technologically related improvements as tative maintenance contract was costed at $1230 p.a. per part of serious incident-prevention strategies would have machine. The preventative maintenance costs saved by been effective in 18 of 70 incidents which they investigat- the deletion of 45 anaesthetic machines from service ed. Incidents involving the breathing system account for (Table V) is then at least $55,350 per annum. The above the largest category of equipment-related anaesthetic estimate does not include initial capital expenditure, 894 CANADIAN JOURNAL OF ANAESTHESIA subsequent upgrade costs, 15 finance charges or anticipat- machine design or an uncertain future parts supply. The ed annual increases in service costs. medicolegal liability concerning the utilization of obsolete equipment by the veterinarians was expressed by 2 How wide a scope should the anaesthetic survey and Ohmeda representatives. subsequent upgrade have? Specific documentation of obsolete equipment disposal Ideally, all anaesthetic gas delivery systems in the was considered necessary based on previous experience in Province of Manitoba should have been included in this Manitoba. Several anaesthetic machines designated for program. All provincial health care facilities as well as deletion in the 1979-80 upgrade program were identified two federally funded hospitals were included. Although in active service with the present survey. According to the MAUP did offer its technical on-site survey to several information received from Ohmeda the Boyle Model 50 privately funded day-surgery clinics as well as the was never authorized for sale in Canada. Three Boyle 50 Manitoba Dental Association, these groups did not avail anaesthetic machines were identified in service in themselves of this no-charge service. The College of Manitoba. Physicians and Surgeons of Manitoba subsequently sent an information letter to all physicians practising anaesthe- 5 What ,,ere the benefits of a central registry of all sia in Manitoba concerning the inadvisability of practising anaesthetizing locations and equipment? in facilities not approved by the College. One may The MAUP felt that such a system was merited. Height- speculate that equipment deficiencies and insufficient ened public awareness as well as the institution of quality monitoring of equal or greater magnitude to that revealed assurance programs suggest that hospitals have a respon- by this study could be present in these non-hospital sibility to maintain and possibly enhance medical equip- settings. A recent report by Davies and Campbell ~6 ment on site. ~s Our survey suggests that this does not confirms such speculation. happen. A central registry would provide each participating 3 What should be done with facilities where anaesthetic health care facility with a mechanism whereby: equipment was present but utilized infrequently? a Medical device warning and information bulletins This represented the greatest challenge to the MAUP could be forwarded. Advisory Committee. A trend to regionalization of b The cost implications of future anaesthetic equipment surgical and anaesthetic services was evident. ~7 The 1980 enhancements could be made. program identified 195 anaesthetic machines in active c Future anaesthetic equipment tendering processes service while this number was 167 in 1988. Five could be facilitated in the maintenance of consistent anaesthetic machines replaced in the 1979-80 upgrade anaesthetic equipment standards. program had never been used. Although the MAUP In spite of the impact that the MAUP has had, there Advisory Committee was primarily concerned with stan- were a number of limitations in its implementation. The dards of anaesthetic equipment it was not possible to survey was not all-inclusive as dental and private clinic avoid the issue of appropriate safe utilization of anaesthet- anaesthetizing sites did not participate in the survey. It ic equipment. All facilities with a total anaesthetic patient was also possible for a health care facility to disclose case-load of less than 100 cases per annum were reviewed incompletely the number of anaesthetic gas delivery in detail. In 1979-80, facilities with a recorded anaesthet- systems present and so it is still possible that some ic case load of 40 per annum were automatically upgrad- obsolete machines are operational in the province. Feder- ed. As previously stated, individual consideration was ally funded health care facilities were reluctant to partici- given to health care facilities with specially approved pate in the upgrade process but did so eventually. programs serviced by itinerant medical speciality teams. The completion of a provincial upgrade program of this magnitude is of mixed benefit. Heightened medical, 4 What should be done with old or obsolete anaesthetic public and hospital administration awareness of the equipment? speciality of anaesthesia is inevitable. The danger lies in The MAUP Advisory Committee considered that obsolete assuming that this is a one-time, permanent solution. equipment should be identified. The issue has recently Technological advances are expected to continue and been addressed by the Anaesthesia Patient Safety Founda- their impact on the safe practice of anaesthesia will need tion. 18,~9 Obsolete equipment, for the purposes of the to be assessed continually. ~s Upgrade Program, was defined as any piece of anaesthetic A province-wide tendering process, by design, results equipment which could not be upgraded to include the in some equipment manufacturers being excluded from intent of recent CSA standards or where such an upgrade being represented in the market place. Previous experi- was impractical on the basis of cost, physical anaesthetic ence with the awarding of the 1979-80 upgrade program Friesen etal.: UPGRADING ANAESTHETIC EQUIPMENT IN MANITOBA 895 to a single vendor was not favourable. Therefore, user 4 Anaesthetic Gas Scavenging Systems. CSA Standard preference, local provincial representation, preventative CAN3-ZI68.8-M82. Rexdale: Canadian Standards As- maintenance contracts as well as price were considered sociation, 1982. before any tender awards. Many hospitals were dissatis- 5 Guidelines to the Practice of Anaesthesia as recommended fied with the manufacturer service and sales which had by the Canadian Anaesthetists' Society Council of the been provided previously and they sought the services of Canadian Anaesthetists' Society. Toronto, February, 1987. an independent third party. Our evaluation of this arrange- 6 Beebe,13, Sessler DI. Preparation of anesthesia machines ment was that it provided an exceptional service, especial- for patients susceptible to malignant hyperthermia. An- ly to remote rural communities. esthesiology 1988; 69: 395-400. At the time of implementation, the MAUP did not have 7 McGraw 7T, Keon TP. Malignant hyperthermia and the a mandate or the funding to include provision of patient clean machine. Can J Anaesth 1989; 36: 530-2. monitors such as electrocardiograms, non-invasive blood 8 Amendment to the Guidelines to the Practice of Anaesthe- pressure devices, pulse oximetry or capnography. Ideal- sia as Recommended by the Canadian Anaesthetists' ly, the provision of physiological monitors for the Society. Toronto, June 1988. anaesthetized patient as recommended by the Canadian 9 Amendment to the Guidelines to the Practice of Anaesthe- Anaesthetists' Society 5'8'9 could have been made at the sia as Recommended by the Canadian Anaesthetists' same time. Society. Toronto, February 1989. In summary, the MAUP provided a cost-effective 10 Kumar V, Hintz MS, Jacob AM. A random survey of anes- means of implementing a province-wide upgrade of all thesia machines and ancillary monitors in 45 hospitals. hospital-based anaesthetic equipment. This process re- Anesth Analg 1988; 67: 644-9. sulted in a consistent standard of anaesthetic equipment I 1 Deaths during general anaesthesia technology-related, due available throughout the province. The provincial trend to to human error or unavoidable'? An ECRI TEchnology regionalization of health care is now also reflected in Assessment. J Health Care Technol 1985; I: 155-75. health care facilities which provide anaesthetic services. 12 Lawrence JC. Breathing system gas pressure monitoring Further evolution of this process is sure to occur. and venting, ventilator monitors and alarrns. Anaesth Although legislated responsibility for the maintenance Intensive Care 1988; 16: 38-40. and upgrading of equipment rests with each individual 13 Spooner RB, Kirby RR. Equipment-related anaesthetic in- health care facility, a provincial approach is preferable, cidents, lnt Anesthesiol Clin 1984; 22: 133-47. We would recommend such a program for other 14 CooperJB, NewbowerRJ, Kitz RJ. An analysis of major provinces. errors and equipment failures in anesthesia manage- ment: considerations for prevention and detection. Anes- Acknowledgements thesiology 1984; 60: 34-42. The authors wish to acknowledge the secretarial assis- 15 Technology and the Standard of Care: the importance of tance of Mrs. Anne Cameron in the preparation of this meeting ever-advancing standards. Health Technology document as well as the countless hours and tireless 1988; 2: 61-6. efforts of Mrs. Lucille Guenette and Mrs. Phyllis Nedo- 16 Davies 3M, Campbell LA. Fatal air embolism during den- hin. Special mention and thanks are also given to Mr. Vic tal implant surgery: a report of three cases. Can J An- Mankiewicz (Ohmeda) and Mr. Dave Olivier (Drager) for aesth 1990; 37: 112-21. their cooperation and patience. 17 Webber W. Report of the invitational meetings on the training of general practitioners/family physicians to provide anaesthesia services. Reports to the General Coun- References cil of the Canadian Medical Association, Appendix I Craig DB, Longmuir J. Implementation of Canadian "B," Vancouver, British Columbia, August 22-24, 1988. Standards Association ZI68.3M 1980, Anaesthetic Gas Canadian Medical Association Ottawa, 1988. Machine Standard: the Manitoba Experience. Can 18 Schneidner AlL. Older anesthesia machines targened for Anaesth Soc J 1980; 27: 504-9. component replacement. Anaesthesia Patient Safety 2 Continuous-Flow Inhalational Anaesthetic Apparalus (An- Foundation Newsletter 1989; 4: 25, 27. aesthetic Machines) for Medical Use. CSA Standard 19 Lees DE. Old anaesthesia equipment target of study, pan- CAN-ZI68.3-M84. Rexdale: Canadian Standards Associa- el; ASA policy recommended. Anesthesia Patient Safe- tion, 1984. ty Foundation Newsletter 1989;4: 13, 15. 3 Breathing Systems for Use in Anaesthesia. CSA Prelimi- nary Standard ZI68.9-M86. Rexdale: Canadian Stan- dards Association, 1986.