St. Joseph‘s Healthcare MANUAL Section Pages Number Hamilton CORPORATE Administration 1 of 9 119-ADM Subject: Date: Use of Wireless Transmitting Devices February 5, 2008 Supersedes: Cross Reference: Issuing Authority: NEW 043-ADM Videotaping Operations Council 092-ADM Breach of Patient‘s Right to Privacy 106-ADM Wireless Communication Policy 113-ADM Encryption Policy Charlton Campus West 5th Campus King Campus 1.0 Purpose & Goals Description 1.1 St. Joseph‘s Healthcare is dedicated to maintaining a safe patient care environment. As part of this philosophy, we acknowledge that certain radio frequency (RF) transmitters, such as but not limited to: cellular telephones, two- way radios, wireless networking, mobile computing devices, and other wireless transmitters, may, in extremely rare occasions, affect certain susceptible electromedical devices. However, St. Joseph‘s Healthcare recognizes that effective and timely communication is essential to optimum health care. While we recognize the need to adopt new technologies for our business communication we also recognize the need to provide patients and visitors increased flexibility for personal communication. We must continue to provide a best practice model to ensure the security of patients and personal health information, including images, are protected against unauthorized capture and disclosure. As a result, this policy was developed to manage the electromagnetic (EM) environment present in St. Joseph‘s Healthcare including RF transmitter usage, new equipment purchases, and education of staff, patients, and visitors. 1.2 A substantial increase in the production and use of communication devices has taken place over a short number of years. As a result, there have been many studies investigating the effects of EMI on medical devices including the development of Electromagnetic Capability (EMC) standards for medical device manufacturers. However, there has been no recognition for any particular study resulting in regulatory control in hospitals. This policy comes with references and supporting documentation (in appendices) from government, radio frequency experts, ad hoc testing, peer facilities, publications, and Internet sources. 2.0 Policy Scope The policy applies to employees‘ affiliates, patients and visitors using St. Joseph's Healthcare facilities, or anyone having access to use of the St. Joseph's Healthcare Hamilton network infrastructure. The policy consists of multiple sections of applicable technology dealing with cellular phones, two-way radios, wireless networking, mobile computing devices, and other wireless transmitting devices. 3.0 Usage Due to the intrusive nature of these devices, in keeping with our mission statement and service excellence, we have developed a recognized protocol on ―reduced restriction usage‖ sort of like an ―acceptable use‖ policy. The use of any camera, video, or audio recording capability in any area is strictly prohibited without consent. Refer to policies 043-ADM Videotaping, 092-ADM Breach of Patient‘s Right to Privacy and 090-ADM Privacy of Personal Information. Use of devices owned or approved for access by St. Joseph's Healthcare Hamilton for patient and/or support purposes may be used in all public areas as well as defined locations set out below in subsections of this policy. All devices that have audible alerts should be placed in VIBRATE mode only. 4.0 Issues and Control Process Cellular Phones, Mobile Computing, and Two-way Radio Transmitting Devices have been identified as having a possible negative impact on some medical devices within a 1 to 3 metre range. Effects such as uncontrolled variation in functional settings and unusual alarm activation may be noted in some medical devices when exposed to some wireless devices. Wireless Computing Equipment poses a risk to the security of the organization and patients, as such only authorized users and devices will be allowed wireless network access through the control of the IS department and their Corporate policy 003-IS Wireless Communication. 4.1 Wireless device usage is acceptable only if evaluated by Biomedical Engineering, Telecommunications, and the IS Departments with respect to their specialties for determination of their effect on medical devices, communication equipment, and the internal wireless network prior to use within the hospital. 4.2 Wireless devices that are deemed to have a detrimental effect on any of the above will be prohibited from use within St. Joseph‘s Healthcare Hamilton. (A list will be developed and added to this policy). 4.3 Purchase requisitions for all wireless devices must be reviewed by Biomedical Engineering, Telecommunications, and the IS Departments to ensure the device(s) have been tested, evaluated, and impacts determined. 5.0 Allowable Locations and Use Visitors and Patients: may use their personal devices in all Public Areas defined below. Restricted use in Patient Rooms to be approved by the Unit Manager in consultation with Biomedical Engineering, Telecommunications, and the IS Departments. Patients and visitors are prohibited from using two-way radios (walkie- talkies, GMRS, FRS) in all indoor areas and entrance vicinities of the hospital. Also see the restriction on camera, video and audio recording devices in 3.0 Usage Statement. Staff and Affiliates: may use their personal devices for personal use in Public Areas. Staff and Affiliates: may use their approved devices in all Public Areas, Approved Use Zones, Patient Rooms, and Critical Care Areas where applications are approved for such use and must abide by the 1 Metre and 3 Metre Rules below. 1 Metre Rule: Cellular Phones, Mobile Computing, and Wireless Computing Equipment must not be used within 1 metre of a medical device(s). 3 Metre Rule: Two-way Radios and similar equipment must not be keyed to transmit for talking within 3 metres of a medical device(s). Talking on these devices should be discouraged within the Clinical Environment where possible. Specific Areas of Restriction: will be posted, and approval for use must be obtained from the area manager. 6.0 Other Controls Inadvertent or Improper Use of RF Transmitting Devices 6.1 In the event that an RF transmitting device becomes activated within a high-risk area, or that policy is not being followed, staff are requested to inform the user to immediately refrain from using the device or move to an unrestricted area. 6.2 If a person continues to use the device in a restricted area after being made aware, staff must notify the area charge person who will notify Security Services. 6.3 Persons refusing to comply with this policy (whether they be hospital staff, physicians, visitors, etc.) may be removed from the premises. 6.4 If clarification is required to resolve a particular problem, contact the appropriate Director of the service involved for recommendations (Biomedical Engineering, Telecommunications or IS). 6.5 If the incident may have resulted in a breech of patient privacy, please notify the Chief Privacy Officer and report the incident as per Policy 092-ADM. Patients who are discharged with medical devices associated with continued treatment (e.g. Enteral feeding pumps, ventilators, etc.) must be cautioned not to use a wireless transmitting device while these devices are operating and it must be emphasized that visitors and family maintain a minimum distance of 1 metre from the devices. 7.0 Monitoring the Electromagnetic Environment Any equipment problems or failures suspected as EMI problems should be reported to Biomedical Engineering immediately. Make note of date, time, any electronic equipment in the proximity, a complete description of the nature of the problem, and any other circumstances that may be noteworthy. Problems that cannot be duplicated will be investigated and trend analysis performed to determine if there is some correlation to EMI; ad hoc EMI testing might need to be performed. 8.0 Pre-purchase Evaluation for Electromagnetic Compatibility (EMC) All medical devices must meet requirements pertaining to EMC. Pre-purchase evaluations of medical devices include criteria for compliance with relevant EMC standards. Medical equipment manufacturers must provide evidence of the extent to which their devices conform to current electromagnetic susceptibility performance levels (e.g., guidelines, standards). An example of such evidence would be a certificate of compliance with any of the following standards: IEC601-1-2: 2004, EN60601-1-2, CAN/CSA – C22.2 No. 601.1.2 – 94 (R2004) (see Appendix D in Standard). Note: Compliance with such standards does not guarantee that a device will be totally immune to EMI but represents a minimum immunity level. Purchase requisitions for all wireless devices must be reviewed by Biomedical Engineering, IS, and Telecommunications, to determine potential for interference. 9.0 Definitions Affiliate: a person, whether or not the person is employed by the organization and whether or not the person is being remunerated by the organization, when that person acts for or on behalf of the organization in exercising powers with respect to personal information. This is also meant to include Police, Fire, and EMS staff for purpose of this policy. Approved Use Zones: Reading or Learning Resource Rooms, nursing stations, open public areas, staff or patient lounges, staff offices. BlackBerry©: Copyrighted term referred to a hand-held device made by RIM (Research In Motion) and is marketed primarily for its wireless email, web, and mobile phone capabilities. Through commercial partners, BlackBerry