Break me if you can - Draeger6 DRÄGER REVIEW 101.1 | NOVEMBER 2010 NEWS PRIVATE PHOTOGRAPHY: MESSE...

Concepts for combating germsHand Signals of Hygiene

User Tests Break me if you can

Risk Management New norm for more IT

transparency and security

Webinars Learning via the Internet

The Magazine for Technology in Medicine November 2010

Dräger Review 101.1

EN_01_Hygiene_M 2 03.11.2010 12:31:38 Uhr

2 DRÄGERHEFT 385.1 | JUNI 20102 DRÄGERHEFT 385.1 | JUNI 2010

It’s a Riddle!Quality is a matter of details. Top quality is found in every Dräger product – and is rigorously tested. But what’s being tested here? You’ll find some hints starting on page 24!1. Gas detector test using talc2. Stress test of a manhole cover in winter3. Test of a drug test cartridge using cocaine

Send us the correct answer via e-mail to [email protected] or on a postcard to our editorial address (you’ll find it on page 30), and you may win one of a total of 100 pairs of sports sunglasses.

The deadline for entries is December 15, 2010. The winners will be notified in writing, so please provide name and address. Prizes cannot be paid in cash. A drawing will determine the winners if over 100 correct entries are received. Dräger employees cannot participate. Participants waive all legal rights to enforce any award.

EN_02_Rätselhaft_M 2 20.10.2010 16:32:32 Uhr

3Dräger review 101.1 | November 2010

Contents

experienCe 4 people Who perform one is a

Technical inspector for Firefighting, the other is a Professor of Neonatology and Pediatric intensive Care medicine.

neWs 6 news from the World of Dräger

Simulations on the iPhone, respiratory protection becomes lighter, an or light with an HD camera, a second skin for tough assignments, and other topics.

FoCus 8 Hygiene New concepts are helping

clinicians successfully wage up the battle against germs in hospitals.

ManageMent 14 risk Management A new norm

for hospital iT systems offers increased transparency and security.

16 Cooperation between hospitals and industry saves money and improves equipment. gesundheit Nordhessen Holding Ag is a case in point.

report 20 smartpilot View easily interpretable

displays in the or – just like those in a pilot’s cockpit.

22 Myths Can a drunk driver deceive an alcohol screening instrument?

insigHt 24 application engineering in this lab,

researchers systematically create problems.

outlook 28 Webinars How the internet helps users

share their experiences with colleagues.

serViCe

30 Where and Who? Dräger worldwide, publishing information

Close-up 32 Water trap This accessory helps

protect the lungs during ventilation.

up to 500,000 infections occur every year in german hospitals, according to the german society of Hospital Hygiene. You can read more starting on page 8.

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ExpEriEncE PeoPle Who Perform

Dräger revieW 101.1 | November 2010

What Moves Us – Dräger Worldwide

philipp Hildbrand, Technical inspector for Firefighting in Sion, Switzerland“one hundred and twenty fire departments and 6,000 firefighters – some speak french, some speak german. The long and deep rhône valley, with mountains on both sides rising up over 4,000 meters to the matterhorn. That’s my home – and my responsibility.

We are ready to pitch in anywhere, anytime. first and foremost we are firefighters, and we want to help where help is needed. That often means we have to go up against powerful forces of nature. in such cases we all must stand together, like during the devastating storm in the bernese oberland. mudslides had swept through villages, and the suffering was great. but so was the fighting spirit of the helpers and volunteers. i was the head of operations there, and a large number of people came to help, including many who made generous donations in addition to volunteering

their labor. We have to work together to succeed. fighting a forest fire in dry valais canton, for example, is a major operation for everyone. Some-times we spend weeks dealing with flare-ups and glowing embers. The spirit of solidarity is strong, but the equipment varies widely. Some bought theirs in france, others in the german-speaking world. my challenge is to standardize the technology for all 120 departments. it’s a long-term proj-ect, but it will further strengthen the feeling of togetherness.

As a respiratory protection trainer, i appreciate precisely matched tech-nology. The trick is to bring all the interests together. valley dwellers nat-urally prefer large, heavy vehicles, while departments in the mountains prefer small all-terrain vehicles. i work with my colleagues to ensure that everything fits in the end.”

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Prof. Wolfgang Göpel, University Medical Center Schleswig-Holstein, Lübeck, Germany“The NICU – what a wealth of experience! As a young intern assigned to the intensive care ward, I had the opportunity to treat a very, very small premature newborn together with an experienced staff phy-sician. The baby was in an incubator, and the parents couldn’t pick it up and hold it at first. It was difficult for them to build up a bond with their ‘preemie’.

But everything turned out fine in the end. Thanks to the good care and our technical capabilities, the baby grew quickly. It was a very moving experience for me. And since then we’ve learned a lot more in this area. Today we can even stabilize very small preemies with-out using ventilation. And ‘kangarooing’ makes it possible in many cases for premature infants to have their first skin-to-skin contact with their parents just a few days after birth. Contact is crucial – for

us as practitioners too. We all benefit from cooperation and sharing our experiences, that’s why we founded the German Neonatal Net-work (GNN). We gather data – genetic and family history information, but also intensive care parameters: Which medications were admin-istered, how was breathing supported? And much more. From this big database we aim to gain the far-reaching knowledge needed to develop optimal care strategies. We are all committed to improving our performance, and we are already seeing successful results.

As an intensive care physician, I treat children of all ages. Every one of them is a challenge, but every day I also see the progress that we have been making. The most important question asked by parents and doctors alike is always the same: Will this child have a good, happy life? That’s the objective of our work, every day.”

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6 DRÄGER REVIEW 101.1 | NOVEMBER 2010

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Dräger – New Member of the Executive BoardDr. Carla Kriwet will join the Dräger Executive Board effective January 1, 2011. Kriwet, 39, has a Ph.D. in business administration and will be responsible for Marketing and Sales. She is currently employed by the Linde Group as Head of Healthcare Europe for the Hospital Care and Homecare in the Central and Northern Europe division. Immediately after graduating from high school, she assisted a doctor in AIDS campaigns in the Republic of Burundi, East Africa, before studying in Würzburg, Germany. She completed her doctoral studies in St. Gallen, Switzer-land, and New Delhi, India. After working for a plant engineering company and then in London, U.K., for the Boston Consulting Group, she joined Linde in 2003, where she began an extraordinary career.

Last year Handelsblatt honored Kriwet, a mother of three, with its “Career of the Year 2009” award. In the eyes of the jury, “She never lost her balance despite her rapid professional develop-ment.” At that time, no one could suspect that Dr. Kriwet would be attracted to Dräger and the city of Lübeck, Germany.

Likes Lübeck: Dr. Carla Kriwet.

Useful Assistants on the iPhoneMillions of people already use cellular phones to navigate their way through their daily lives. With the GPS capabilities of these phones, you can take that literally, but it also applies in the figurative sense. With the appropriate application software, called “apps,” the cellular phone becomes an oscilloscope or a medical manual. It can also simulate a great many aspects of very complex devices and thus be used for train ing. The iPhone has proved to be a multifunctional trendsetter in all of these areas – using algorithms derived from experience and studies. For instance, it can visualize and document complex processes. All of these capabilities have long been the subject of intensive research by Dräger. The company now plans to release two Dräger apps in the fourth quarter of 2010. Information about the latest products from Dräger is available on the Dräger homepage: www.draeger.com

Expertise in the pocket of your lab coat.

MEDICA 2010: Take a look!“Intelligent visualization in acute care medicine” is the focus of the Dräger booth at MEDICA 2010, the “World Forum of Medicine” in Düsseldorf, Germany. From November 17 to 20, roughly 4,300 com-panies will be exhibiting everything that’s needed for the treatment process in doctors’ offices and hospitals, including medical technology, physical therapy, and medical information technology (IT). The event’s organizer regards the smooth linking of hardware and software with existing IT infrastructures as a major trend this year: “Hospitals are striving to find solutions with no breaks in communication and information.” Anyone who has come to appreciate the advantages of apps and touchscreens for personal use will also want to take advantage of these in the tur-bulent daily routine at the hospital. Many examples will be on display at MEDICA. Dräger at MEDICA 2010: Booth J39 in Hall 11.

World Forum of Medicine: MEDICA

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Respiratory protection can be light.

Dräger Review: French as Fourth LanguageFrench is the lingua franca of almost 130 million people worldwide. Beginning with this edition, Dräger Review now appears in French in addition to German, English, and Spanish. This is an ac -k nowledgement of the continued growth and need for information in the franco-phone countries. Dräger Review has been reporting on the company’s technology and its applications in German since 1912. Publication in English began in 1959, and Spanish was added in the summer of 2010. Dräger Review appears three times a year and has a total circulation of approximately 80,000 copies.

Closer to customers: Dräger Review

Konzepte im Kampf gegen Keime

Handzeichen der Hygiene

Das Magazin für Technik in der Medizin November 2010

Drägerheft 386.1

Anwender-Tests An den richtigen Stellen das Falsche tun

Risikomanagement Neue Norm für mehr Transparenz und Sicherheit in der ITWebinare Lernen via Internet


User Tests

Break me if you can

Risk Management

New norm for more IT

transparency and security

Webinars

Learning via the Internet

The Magazine for Technology in Medicine November 2010

Dräger Review 101.1


Conceptos para la lucha contra los gérmenes

Signos de higiene

Pruebas de usuario Cometiendo errores para dar en el clavoGestión de riesgos Nueva norma para más transparencia y seguridad en TI

Seminarios en la web Aprendiendo por Internet

La revista de la tecnología en medicina Noviembre de 2010

Revista Dräger 2.1

Closer to customers: Dräger Review

Concepts for combating germs Concepts for combating germs

Conceptos para la lucha contra los gérmenes

Signos de higiene

Concepts de lutte contre les germes

Le langage des mains dans le domaine de l’hygiène

Tests utilisateur Faire ce qu’il ne faut pas au

bon endroit

Gestion des risques Une nouvelle norme pour la transpa-

rence et la sécurité en informatique

Les webinaires Apprendre par Internet

Le magazine de la technique en médical Novembre 2010

Revue Dräger 1.1

A Second Skin for Tough AssignmentsDräger uses the innovative suit material D-mex for the CPS 7900, its new gas-tight and reusable chemical protection suit. D-mex exhibits particularly high resis-tance to a variety of toxic substances and offers comprehensive protection against dangerous chemicals, infectious agents, and radioactive particles. It is suitable for operations in explosive atmospheres and for handling of liquefied gases at temperatures as low as -80° Celsius.

OR Lights: Sharp ImagesFollowing the introduction of the Polaris line of LED OR lights with SD cameras, the 560/760 models with HD cameras are expected to be available in the first half of 2011. These OR lights comply with the Full HD 1080i standard to deliver high-definition video images of the opera-ting field with great color fidelity. This makes it possible to clearly identify layers of tissue, sections, and vessels. HD images are optimally suited for medical docu mentation, as well as for basic and advanced training. The camera with a 120x zoom function is mounted in a sterile sheath and can be controlled remotely.

Outstanding Annual ReportOpenness is a key criterion for the assessment of annual reports performed each year by manager magazin. The German business magazine expressly praised this aspect of the Dräger annual report. The 160 publications sub-mitted were assessed by hundreds of professionals from the fields of capital mar-kets, communications, and design with the support of a number of universities. In its first year of participation, Dräger received a bronze award for its 2009 Annual Report in the category of Tec-DAX listed companies.

PAS Lite – Lighter Respiratory ProtectionWith the PAS Lite, its latest compressed air breathing apparatus, Dräger has intro- duced a particularly lightweight self-con- tained breathing apparatus for use in indus-trial and maritime applications. The com-bination of durability, reliability, and light weight is made possible by a newly devel-oped carrying system – a frame structure made of a carbon fibre composite mate-rial and weighing just 2.7 kilo grams. The PAS Lite was developed specifically for use in industrial firefighting and emergency situations on land and at sea. The straps allow for the weight to be evenly distributed across the shoulders and keeps the centre of gravity close to the body enhancing wearing comfort. These new materials are also ergonomically shaped to relieve the load on the hips and shoulders. As a result, the wearer experiences less tension and fatigue. Furthermore the high and intermediate pressure hoses are en-capsulated in the carrying frame to reduce the risk of anything getting hung up.

EN_06-07_News_M 7 20.10.2010 16:42:37 Uhr

Focus Hygiene

8 Dräger review 101.1 | november 2010

T he summer of 2010 was rather unsettling as far as patients in German hospitals were con-

cerned. First it was revealed that a hospi-tal in southern Germany had been using non-sterile instruments in the operat-ing room over a period of months. Then three infants undergoing treatment in a university hospital died from contam-inated infusions. The subject of hospi-tal hygiene once again dominated the headlines, and fear of the hospital as a potential death trap made the rounds. In response, politicians were soon calling for stronger legislation and additional regulations.

Public discourse repeatedly over-looks the fact that hospital hygiene is by no means a new topic. Once you look

beyond the unfortunate incidents that capture the headlines, it becomes clear that dedicated experts are engaged in a long, ongoing battle on many fronts against the pathogens that cause hospi-tal infections. And it is not as if German hospitals do particularly poorly in inter-national comparisons – on the contrary. According to a report by the European Center for Disease Prevention and Con-trol, 3.5 percent of patients in German hospitals acquire a nosocomial infec-tion – in other words, an infection as a re-sult of treatment in a hospital – whereas the European average is 7.1 percent.

Don’t forget to disinfect your hands!

Nevertheless, the problem continues to be serious. The German Society for Hos-pital Hygiene (DGKH) estimates that up to 500,000 infections occur in Ger-man hospitals, with as many as 20,000 deaths each year. Behind every one of these cases is a personal tragedy that pos-sibly could have been prevented by rela-tively simple measures.

The number one demand by the ex-perts continues to be for improved hand hygiene. “About 90 percent of the infec-

tions transmitted from the environment via somebody’s hands could be prevented by a measure as simple as hand disinfec-tion,” says Professor Axel Kramer, who heads the Institute for Hygiene and Envi-ronmental Medicine in Greifswald, Ger-many. Kramer has seen the use of hand disinfectants nearly double in many hos-pitals as a result of campaigns such as Aktion saubere Hände (Clean Hands Campaign). Kramer has no doubt that this alone has prevented much suffering. “We know from earlier studies – mostly from the U.S. – that such improved com-pliance has a powerful effect on the rate of infection.”

Proper hand hygiene has meanwhile become a separate field of research. The message has long since been received that washing with soap and water sel-dom helps and can even be counterpro-ductive in some cases. This is because frequent hand washing attacks the skin. Well cared-for hands with intact skin are the basic prerequisite for effective hand disinfection. “Skin protection and skin care in Germany do not enjoy the importance that they deserve and in some instances are neglected out of ignorance,” says Kramer. “People with

The Battle Against GermsHygiene in german hospitals is better than average. nevertheless, roughly 3.5 percent of patients acquire an infection in hospitals here, too. modified behavior plus new concepTs for devices and hygiene are expected to further reduce this percentage in the future.

In BrIeF The german Society for Hospital Hygiene registers up to 20,000 deaths each year in german hospitals. This figure can be reduced by means of systematic hygiene programs and improvements to medical devices. initial successes can already be seen.

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Germs are invisible. Visible cleanliness

is a first step toward optimal hygiene.

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10 Dräger review 101.1 | November 2010

irritations on their hands are also reluc-tant to disinfect.”

The key is to always use the disin-fectant dispenser before and after ev-ery patient contact. This dispenser con-tains a mixture of alcohols. According to Kramer, “Some manufacturers add other active substances, but their sup-plementary disinfecting action has not been proven.” The disinfectants are gen-erally effective against bacteria, fungi, and sometimes against viruses. “How-ever, there are only a few products that are effective against unsheathed viruses such as noroviruses,” he adds. Kramer developed one of these, a synergistic mix-ture of three alcohols, himself. In the event of an acute outbreak of norovirus infections at a hospital, Kramer would replace the disinfectant dispensers. “Un-fortunately, these agents can’t be used for extended periods because they are not very skin-compatible.”

Everyone needs to be motivated if hygiene is to succeed

Ignaz Semmelweis proved that clean hands can save lives back in the mid-dle of the 19th century when he first instructed his medical students to dis-infect their hands before helping with births. The difficult question remains, however: How do you motivate doctors and caregivers to repeatedly take the time to disinfect their hands during the hectic daily routine of a hospital? Onno Helder (MSc) is researching this ques-tion in the Netherlands at the Univer-sity Hospital in Rotterdam. He succeeded in substantially increasing the reliability

Sometimes shorter is better – a lack of time can impede systematic hand hygiene

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First disinfect, then take other measures to protect against germs.

Hygiene is a holistic concept that must be implemented systematically.

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of hand disinfection by means of an educational campaign. “You first have to clearly communicate what sort of hazards can be created through poor hy-giene,” explains Helder. “Then you have to get each member of staff to realize what sort of mistakes he or she is mak-ing. Most people we talk to think that they are already pretty good. We make it clear to them that this is not always the case. It is also important to involve au-thority figures such as hospital directors in the campaigns and encourage them to speak out openly in support of better hygiene.” Helder can already point to an initial success. During the course of the hygiene campaign, the rate of blood-stream infections detected in the inten-sive care unit for premature infants de-clined from 44 percent to 22 percent.

Prof. Kramer and his colleagues in Greifswald are also investigating the question of staff motivation. Manufac-turers specify that disinfectants be used for 30 seconds. Since Kramer considers the frequent lack of time to be a major problem for systematic hand hygiene, he wonders if it wouldn’t make sense to re-duce this time. According to his studies, hands are just as thoroughly disinfected in 15 seconds. He therefore started an experiment and instructed nurses on a ward for premature infants to rub their hands with alcohol for only 15 seconds per use during an entire shift. He ob-served a significant increase in the fre-quency of hand disinfection thereafter. “We were able to show that a 30-second application is superfluous,” says Kramer. Anyway, as it turns out, this duration is

How does sterilization work?The goal of sterilization is to achieve the greatest possible freedom from germs. operating instruments are considered sterile when a process is validated which ensures that only a single germ can be found per one million instruments. objects are typically sterilized using moist heat, which denatures the proteins. A temperature of 121 °C used to be common such processes. nowadays, it is 134 °C. This higher temperature is necessary in order to also eliminate prions. microorganisms can be killed more quickly in moist heat than in dry heat because water vapor conducts heat better than air and also causes bacterial spores to swell. To heat the water vapor to such a high temperature, it is necessary to use overpressure – as in a pressure cooker – and then generate a vacuum so that the steam penetrates into every cavity of the instrument. This is done using a vacuum steam autoclave. The word comes from the greek auto for self and clavis for key. The lid of the overpressure vessel is designed so that it is held tightly shut by two to three bars. How long the sterilization process lasts depends on the contents. How- ever, all objects must be cleaned thoroughly prior to sterilization because any stuck-on debris could shield the microbes.

frequently not observed in practice. If the requirement is adapted to reality, the willingness of those involved to dis-infect their hands apparently increases. If Kramer is successful in implement-ing his requirement, one small change in the details could possibly bring about a major improvement.

The patient is the source of one-third of the infections

Of course, hand disinfection is only one of a number of measures that together form an overall concept. Roughly one-third of all infections occurring in hos-pitals are endogenous – in other words, they are brought in by the patients. The large number of infections occurring at hospitals is not due solely to laxity on

the part of caregivers and doctors. There are several other reasons why such in-fections are difficult to avoid: Modern medicine makes it possible to carry out increasingly intensive procedures; patho-gens can enter a patient’s body through catheters and ventilator tubes; and inten-sive medicine succeeds in keeping weak-ened and susceptible patients alive with increasing frequency. In addition, the common use of antibiotics has resulted in increasing numbers of resistant bac-teria that are difficult to combat.

As far as patients are concerned, ven-tilator-associated pneumonia is particularly dangerous. In addition to being the most frequent type of infection in intensive care units, it is also the most deadly of all nosocomial infections. >

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Painstaking hand hygiene is also of cen-tral importance here, although a series of other factors also play a role. “An anes-thesia device is not just a piece of equip-ment, but rather an entire workstation,” says Professor Michael Wendt, Head of the Clinic of Anesthesiology and Inten-sive Medicine at Greifswald University Hospital. “As a result, it should include a meaningfully integrated hygiene con-cept. Certain areas, such as the touch-screen, some tubes, and ECG wires, should be disinfected after every use. Instead of just relying on logic to pre- vail, these areas should be clearly marked with waring colors.” Wendt and his colleague Kramer want to introduce such a warning color system in Greifswald.

Optimizing hygiene and avoiding pneumonia is also an important issue when it comes to the advancement of anesthesia devices and ventilators. “We provide support with the development of hygiene standards,” says Michael Klein, an respiratory specialist of Dräger, “and are regularly in dialog with doctors, care-givers, and hygiene specialists.”

One important innovation in recent years involves the so-called HME (Heat and Moisture Exchanger) filters. With every natural breath, the inhaled air is moistened and purified by the mucous membranes of the upper respiratory tract. With artificial ventilation, technol-ogy must assume this function. Rather than applying active moisturization, an HME filter extracts water from the re-spiratory air on exhalation and releases it again upon inhalation. This reduces

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New developments in medical technology optimize hygiene

Maximum hygiene prevails in the operating room, where only sterile instruments are used.

What to do about multiresistant germs?Hospital infections are particularly dangerous when the pathogens are resistant to a multitude of antibiotics. multi-resistant Staphylococcus Aureus bacteria (mrSA) are a serious problem in many european countries. Four countries – the Netherlands, Norway, Sweden, and Denmark – have managed to achieve extraordinarily low mrSA rates, however. what do these countries do better than their counterparts? one important aspect here is surely the traditionally restrained use of antibiotics. Another key to success, however, is rigorous procedures such as those practiced in the Netherlands. All at-risk patients are examined for mrSA. Patients testing positive for mrSA are isolated in private rooms and the pathogen is eliminated completely. mrSA bacteria are not the only multiresistant pathogens, however. And, of course, hospitals would soon be bumping up against their limits if every infected patient were to be isolated in a private room.

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Further information online, including Product information Care lists for anesthesia

devices and ventilators www.draeger.com/101/hygiene

condensation – which facilitates the pro-liferation of pathogens – in the tube sys-tem. Furthermore, the filters trap 99.99 percent of all viruses and bacteria in the respiratory air, thereby help-ing to reduce the incidence of ventilator-associated pneumonia. Another approach taken by Dräger is to offer a complete accessory kit of disposable products, be they ventilator tubes, face masks, expiration valves, or water traps (also see p. 32).

However, these measures can only be part of an overall concept that must be continuously evaluated and improved. “The position of the patient also plays a role, as does the use of muscle relaxers to prevent expectoration,” says Wendt. Patients should avoid smoking before a scheduled operation and should get up as quickly as possible afterwards. This is important so that the circulatory sys-tem can be stimulated, the atelectases opened, and the muscles exercised. The goal is for active patients who have the strength to expectorate.”

Hunting germs – even in the hospital kitchen

A lot of work still remains to be done if the improvements required for better hy-giene are to become increasingly auto-matic. In Germany, around 200 hospi-tals have joined the National Reference Center for the Surveillance of Nosoco-mial Infections. The systematic collec-tion, analysis and reporting of infection data is intended to improve the hos-pitals’ internal quality management. One of the participating hospitals is

Südharz-Krankenhaus Nordhausen, Ger-many, where nurse Bärbel Knopf works as a hygiene specialist. After complet-ing a three-year advanced training pro-gram, she now goes hunting for germs. In order to track them down, she goes through the wards, studies microbiolog-ical findings, and also carries out me-ticulous checks in the kitchen and the central sterilization department. Depart-ment-specific statistics warn the staff repeatedly about the hazard, which is initially invisible. Not only are the appli-cable standards continuously updated; the staff’s awareness is also improved through further training.

Even though there are still many problems, Knopf has noticed signifi-cant improvements over the last few years. “The attitude of the doctors has changed,” she says. “We used to be the ones who went sniffing around, so to speak. The doctors often didn’t even pay attention to us. Now they increas-ingly come to us on their own and ask us to look at the findings.” Kramer also calls on hygienists and doctors to work collaboratively and imaginatively in or-der to implement a multi-barrier strat-egy that will help to prevent infections. “Often the measures involved are rel-atively simple. However, to make prog-ress in this area, we need the innovative power of the team.” Dr. Birgit Herden

“Trivial considerations are often overlooked”ProF. Axel KrAmer heads the institute of Hygiene and environmental medicine at the University of greifswald, germany.

reliable hygiene – what’s that?Two things are important. First, the team must have been trained in, and have inter-nalized, the culture of safety. Second, the ergonomic conditions must be favorable.What do you consider to be good ergonomics?Dispensers for disinfectants must always be within reach, for example. Such trivial considerations are frequently overlooked. Plans call for at least four dispensers in each two-bed room in the new building at greifs wald University Hospital: a dispenser within reach of both beds, one in the sanitary cell, one that can be used when entering the room and one that can be used when leaving the room.Are disinfected hands all there is to it?we need a strategy that is based on a number of different measures. These would include the disinfection of surfaces in the vicinity of the patient, preparation of the instruments, an oral antiseptic prior to ventilation, the monitoring of tap water in the form of a water safety plan, and the use of terminal water filters at the water outlet. it is important to express the concepts in simple algorithms – ideally in the form of graphics for the employ-ees – and also to repeatedly remind them of weaknesses.

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RepoRt ieC 80001-1

Etymology can often simplify things. Take the word “risk,” for example, which comes from the Latin word

for “cliff.” In that sense, risk manage-ment is the art of steering clear of a dan-gerous coastline. Risks are all around us, and the likelihood of suffering some kind of injury from one of them is reflected in, for example, the premiums charged for business liability insurance. Gut feeling is a poor guide here, because the subjec-tive assessment of a risk can diverge rad-ically from its objective probability.

Risk evaluation is a complex under-taking, but one that is based on a specific strategy: objective analysis followed by a minimization of the various factors that can lead to injury. The rest is cold sta-tistics, which take no account of individ-ual cases. In principle, that’s all there is to it. “But risk management in a clini-cal environment is different from the same thing in other sectors,” insists Dr. Maria Inés Cartes. A physician by train-ing, Cartes is a Risk Manager at the Ha-nover Medical School (MHH) in north-ern Germany. “Clinical risk management has to protect the hospital, safeguard pa-tient welfare, and take into account the professional ethics of all the doctors and nursing staff,” she says. If something goes wrong at a hospital, not only are pa-tients’ health or even lives put at risk, but hospital staff also suffer from feelings of guilt. The MHH therefore places a major emphasis on professional ethics – an ap-proach that Dr. Cartes would like to see in other areas of the economy as well.

The MHH follows the example set by high-risk sectors such as the airline and

nuclear industries. “Risk management,” explains Cartes, who was born in Chile, “is a systematic procedure for identifying and evaluating potential risks, and then selecting and implementing appropriate countermeasures.” It sounds easy, but in fact it requires a highly professional approach that involves all the partners, both internal and external, with which the clinic has dealings.

Cartes and her team have developed, and to a large extent implemented, a sys-tem to identify potential risks. It consists of the following nine components:u Data from surveys (patients, referring

physicians) u Complaint managementu Data from external quality control

(EQS)u Injury data statistics u Injury management (analysis of alle ga -

tions) u Reports from the 3Re system (CIRS +

additional components)u Process-oriented risk analysis (PORA)u Risk management map/risk inventory

(2011)u Risk management reports

As the insurance broker Ecclesia Milden-berger confirms, the MHH is at the fore-front of risk management in Germany, thanks in large part to its holistic ap-proach. In 2008 the medical school’s 3Re system for “near incidents” was awarded a prize as a model project for the advance-ment of patient safety in hospitals. Accord-ing to Cartes, the system is more than just a Critical Incident Reporting System (CIRS), since it also includes tools for “re-porting, responding, and remedying.” It is based on anonymized reporting proce-dures, which, as Cartes explains, avoids finger-pointing. Risks are then evaluated and catalogued according to fields such as medication, sample management, and processes. The risks are then further di-vided into those that can be minimized by the department in question and those that only can be reduced by overarching measures and projects implemented by the clinic as a whole.

Norm brings greater transparency and reduces risk

The new IEC80001-1 norm extends the process of risk management to IT net-works. In addition to specifying system-atic procedures for the construction, op-eration, and modification of networks, it also governs the responsibilities of the people involved. Whereas the operator is responsible for the general implementa-tion of the process, the manufacturers of medical equipment and network hard-ware are obliged to supply the required data pertaining to their devices. At the start of a network project, an agreement to implement the norm is completed by all g

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Managing risks: Dr. Maria Inés Cartes

Risk Management Supports Greater Safetymost medical equipment in hospitals generates digital data. Networking this equipment enables hospitals to treat patients more efficiently – but it can also lead to safety risks. a New NoRM, which dovetails perfectly with clinical risk management, can now help reduce the associated danger.

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IEC 80001 REPORTIEC 80001 REPORT

the parties involved. Dräger has made ex-tensive preparations for the introduction of IEC80001-1 and it will strongly recom-mend its use and offer technical expertise on how to meet its requirements. Renatus Beck, Project Manager Key Accounts at Dräger, explains the benefits of the norm: “It will give hospitals greater transparency with regard to their network and the med-ical equipment connected to it, thereby guaranteeing network and data security as well as efficient operation.” In view of the ever greater networking of medical equipment – and the ever greater hetero-

geneity of networks, both wired and wire-less, in hospitals – there have long been calls for such a norm.

“A security vulnerability at just one PC,” says Beck, “can introduce malware into the network. The malware can sub-sequently spread to the medical equip-ment in the operating theater, for exam-ple, and then knock out vital functions.” As Beck explains, the norm offers system-atic guidelines, particularly with respect to design and documentation, which will enable hospitals to identify, control, and minimize such risks. G

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Networking helps to provide a complete

picture. To prevent any disruptions, all the equipment must work

together smoothly.

“Thanks to this norm, I can see the light at the end of the tunnel,” says Ma-ria Inés Cartes with enthusiasm. “It will take care of approximately 80 per-cent of all cases in this area and provide us with greater security.” At the same time, she is already thinking about the next step – namely, ensuring that the net-works in hospitals function as simply as “the power supply system with its stan-dardized plugs. That’s why it would make sense to introduce a uniform interface description for a medical information bus,” she explains. Nils Schiffhauer

EN_14-15_Academy_M 15 20.10.2010 16:49:05 Uhr


MANAGEMENT COOPERATION

IN KÜRZE Velesting elisislor amcommodit atie ming esequi te dignis nit ad tio odigna conum iure eu feum veliquam, vendre feum vendreet lan verc iduissi bla faccumsan utpatem nonsenibh atuer ostrud do elis nullaortio eros autatdas. Ut in eumsandre tie do dunt augait wisi exeros null utpat la feugait alis alismol oboreetuertre aliq uis del eugiatue dit aliquis velessenim alis quam.

A New Approach to Modernization

In a time of shrinking budgets, how can hospitals succeed in modernizing in a sustainable manner while also staying up to date with the latest technology?

The company GESUNDHEIT NORDHESSEN HOLDING AG decided the solution was to rely on an innovative model of cooperation. It’s an approach

that could also show other hospitals the way forward.

Out with the old: Technology, some of it decades old, is being weeded out.

EN_16-19_GNH_M 16 20.10.2010 16:52:29 Uhr


COOPERATION MANAGEMENT

Anyone interested in the history of medical technology would have had a field day: The oldest piece of

equipment at the Klinikum Kassel (a ma-jor medical center in Kassel, Germany) is a patient monitor nearly 40 years old. It shows only black-and-white images, no color. And sometimes it shows nothing at all, when it’s not working – again. Since it was manufactured, at least four new gen-erations of monitors have appeared on the market, some of which also can be found in the medical facility.

Contract ensures state-of-the-art technology

The old monitor isn’t an oddity at the med-ical center. Most of the medical equip-ment is outdated, having been in service now for an average of 10.2 years. A third of it is even more than 20 years old, and the average age of some of the OR equip-ment is 17 years. But historians don’t have to flock to Kassel to view such “museum pieces.” They can be found in almost ev-ery hospital in the country. Many Ger-man hospitals are working with medical equipment that is in part outdated. This is because the facilities’ owners – in many cases municipalities with strained bud-gets – frequently can’t afford to buy new systems and devices.

Gesundheit Nordhessen Holding AG (GNH) company operates not only the medical center in Kassel, but also five smaller hospitals, a medical rehabilita-tion facility, and two nursing homes in and around the city. All the institutions urgently needed new medical equip-ment. It would have taken investments

of roughly 40 million euros to update all the equipment – a sum GNH simply didn’t have, since it had just spent 152 million euros, including funding, on a substantial amount of new construction, including a diagnostic center with a central emer-gency room and two floors of patient wards; a center for women, mothers, and children; and a reception building.

In order to be able to purchase all the medical equipment it needed, GNH de-cided to take a creative approach to fi-nancing the equipment rather than purchasing it outright. This was made possible by the “ELT” (short for “electro-medical technology”) project with Dräger. The project included a ten-year contract between the hospital’s operator and the medical equipment manufacturer. The contract calls for Dräger to equip all GNH hospitals with new medical systems and devices in the years ahead. The equip-ment doesn’t have to become GNH prop-erty, and the agreed-upon functionality and availability of the medical technol-ogy is to be provided during the contract’s entire duration. Dräger is also taking on the maintenance and supplying the mate-

rials needed to use the equipment, in ad-dition to updating the delivered technol-ogy whenever needed or when required to provide good care. This entire package has a contract volume of more than 60 million euros over the next ten years.

Rapid modernization with an innovative model

Through the ELT project, GNH and Dräger are realizing an innovative model. Dräger is supplying more than 35 million euros worth of new equipment to GNH. About half of the planned volume of equipment will be provided in the first two years. The existing equipment will also be quickly upgraded, with 10,000 devices slated for replacement and 7,700 supplied new. The total number of medical devices will de-crease because much of the new equip-ment serves multiple functions and can be used more intensively. The latter will be achieved thanks to improved processes in the hospital – resulting, for example, in fewer operating rooms and better use of their capacity. And there’s less down time with the new equipment.

Dräger has agreed to guarantee an equipment level of uptime of between 95 and 98 percent – depending on the safety-relevance of a given equipment cate-gory. That was rarely possible with the old equipment. Should a device malfunc-tion, Dräger can immediately replace it. The company has set up a workshop and replacement parts storage facility in the medical center, with trained personnel on site at least six days a week. A hotline is also available for requesting assistance, 24 hours a day. Dräger also is responsi- >

Ready to go: The latest technology will soon be put to work.

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ble for the equipment testing that is re-quired by law. “Dräger can handle that a lot better than we can,” says Dr. Thomas Fischer, the Chief Physician on the proj-ect team.

The contract took effect on June 1 of this year, and the first devices have been replaced since then. The work started in the medical center’s four intensive care wards and the two intermediate care units. All intensive care stations will be re-equipped according to uniform standards by the end of 2010, ensuring improved pa-tient care and work procedures. Eleven operating rooms will be re-equipped by mid-2011. “Almost everything that can be plugged in will be replaced,” reports Fischer. Dräger is supplying nearly half of the equipment being replaced in the form of ventilation machines, anaesthe-sia machines, patient monitors and the OR lighting systems. Other companies are supplying the rest of the equipment for the medical center, including operating tables and ultrasound, infusion, and flexi-ble endoscopy equipment. The next phase of the project will address the smaller hos-pitals, the nursing homes, and the med-ical rehabilitation center – for example with occupational therapy equipment.

Last to be equipped, in late 2011, will be the new center for women, mothers, and children. “The best thing about the con-tract with Dräger is that the equipment isn’t replaced only once; it is continually upgraded to state-of-the-art standards,” adds Fischer.

Cutting costs

This yields yet another benefit: significant cost savings. Previously, the latest model of each individual device would be pur-chased. For example, there are currently 14 different monitors with more than 60 different specifications. That complicates employee training and increases the risk of user error because not everyone knows how to use every model. Now, thanks to the thorough, rapid modernization, many of the devices meet the same technical standard, which means that training is easier, personnel can be more flexibly as-signed, the risk of user error decreases, and costs are reduced. In addition, re-placement parts and accessories are more interchangeable and can be purchased in larger quantities. This doesn’t only ben-efit Dräger; it also translates into lower annual fees for GNH. Dräger expects the project will help it to penetrate a promis-

ing market segment. It considers its part-nership with GNH a pioneering under-taking and expects that it can leverage the experience gained to help other hos-pitals, as well. Many hospitals in Germany are confronting a similar problem of hav-ing to replace a large backlog of medical equipment despite small budgets. “In ad-dition to handling our own equipment, we’re also supplying products from other companies and are providing mainte-nance and availability guarantees on that equipment. This comprehensive ap-proach is what makes us stand out from our competitors,” says Robert Pann witz, Managing Director of Dräger Medical Deutschland GmbH and Dräger TGM GmbH. Pannwitz sees a growing market, but not a mass market. “It takes an enor-mous amount of time to finalize a con-tract, and many hospitals also won’t en-trust the management of their equipment to an outside company.”

About five percent of Germany’s hos-pitals are potential partners for such con-tracts, particularly publicly owned facili-ties. Short-term financial interests aren’t the primary aim of the cooperation with GNH: “Above all, we want to gain knowl-edge of the processes in hospitals and un-

>

A broad spectrum of expertise formed the basis of the “best practice for investment planning”

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CooPerATioN ManageMent

derstand the ways in which the pieces of equipment are interdependent. That en-ables us to improve the utility of our equip-ment and services,” says Pannwitz.

Process optimization is crucial

GNH chose Dräger as its project part-ner over renowned companies that com-peted in a Europe-wide invitation to bid. “Price wasn’t the only thing that tipped the scales in Dräger’s favor; it was also the fact that Dräger has a better concept for process optimization and for standard-izing the pool of equipment,” says Mar-tin Steffen, Head of Purchasing at GNH. Dräger’s many years of experience pro-viding models for its own product port-folio served as a basis for the conceptual development of the ELT project. Dräger was able to model a “best practice for in-vestment planning” by drawing on this ex-perience and by using the expertise from working with more than 100 hospitals that are currently Dräger TGM contract part-ners. Despite the many benefits, a new concept isn’t risk-free. After all, both sides are in a binding agreement for ten years, and the contract can not be terminated early. This is why the two sides engaged in very lengthy negotiations that lasted 19

months and included protection clauses in the contract. If Dräger doesn’t deliver the equipment on time and provide the promised up to 98 percent availability, it must face considerable contract penalties. Another factor of concern to the hospital was a theoretical insolvency on the part of Dräger. Steffen feared that “an insol-vency administrator could then just come in and haul away all the equipment.” This would entirely disrupt the hospital’s oper-ations, so in the event of such a scenario GNH can pay a fee to continue to use the equipment for a period of up to two years after the contract ends.

“Flat rate versus blank check” was the theme of extensive discussions concern-ing the remuneration. GNH wanted an unconditional, fixed fee, regardless of the actual costs over the entire contract pe-riod, which would have resulted in costly risk premiums. This was ultimately dis-pensed with thanks to an ingenious in-dexing provision that ignores normal fluc-tuations but takes effect in the event of extreme risks, such as hyperinflation. And if the services provided by GNH should change, the structure of the equipment provision terms change as a result. Dräger therefore makes it possible for GNH to re-

turn a certain portion of the equipment already provided in a given year if neces-sary. Conversely, it protects Dräger from any unplanned increase in its partner’s requirements. Should the medical cen-ter develop a need for additional capac-ities not included in the 10-year master planning, the annual flat rate sums paid by GNH would increase.

During the talks, GNH had to clear ob-stacles not only with Dräger, but also in-ternally. Several users had to get used to the fact that in the future they would no longer be able to decide which pieces of equipment would be purchased, and that the decision-making would be done on an interdepartmental basis by the GNH ELT project team. Because the team is an in-terdisciplinary group, it takes the needs of all departments and interest groups into account. There were also concerns that 5.5 technical jobs would be eliminated because Dräger would be taking on the maintenance work. But those employ-ees are now either working in the Dräger workshop or coordinating the work be-tween Dräger and the hospitals. In the fi-nal analysis, the consensus among all in-volved is that the project is thus on track for success. Dyrk Scherff

a broad spectrum of expertise formed the basis of the “best practice for investment planning”

the eLt team (far left) manages the project in accordance with the latest technology standards. their efforts are backed up by work in the work-shop, training and orienta-tion (from left to right). this ensures that the lat-est technology can quickly and thoroughly deliver its benefits – for the patients and the employees, but also with an eye on sound business operations.

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Dr. René Gust is seldom satisfied with general standards. After ob-taining his medical specialist

certification, he added a degree from the European Academy of Anesthesi-ology. His habilitation thesis not only qualified him as a university lecturer, it also garnered him a prestigious award from the German Society of Anesthesi-ology and Intensive Care Medicine. And although he has worked for many years as Head of Anesthesiology, he regularly takes time to lecture at the university in Heidelberg, Germany.

Cockpit in the ORrené gust, Head of Anesthesiology at Siloah St. Trudpert Hospital in Pforzheim, germany, takes advantage of state-of-the-art medical technology to ensure that his patients have the best possible outcomes. He has come to appreciate the SmaRtPilOt View as a practical decision-making aid.

So it’s no wonder that he also pushes his employees to deliver peak performance. “We want to release our patients back to their everyday lives as fit and as early as possible,” says the 47-year-old. “This requires well-organized procedures and high-tech medicine.”

intensive care without ventilation

A look out of his office window suffices to remind the anesthesiologist of just how dynamic things are at the hospital. Cranes rising up into the sky mark the spots where construction – serious con-

struction – is under way. With 500 beds, the Pforzheim hospital is one of the larg-est general hospitals in Baden-Württem-berg, and it’s working hard to literally bring the formerly independent Siloah and St. Trudpert hospitals together un-der one roof by August 2011.

This will shorten the distances that the 80 employees of the Anesthesiology depart-ment have to cover in order to perform their roughly 12,000 anesthesia procedures each year, and it will also offer new opportunities for boosting efficiency while maintaining the same high standards of quality.

EN_20-21_SmartPilot_M 20 20.10.2010 16:55:58 Uhr

21

AssistAnce systems RepoRt

Dräger review 101.1 | november 2010

Gust has made targeted investments in technical equipment in recent years in order to meet his own standards. For ex-ample, he has equipped every anesthesi-ology workplace with the Zeus anesthe-sia system, because the closed system enables precise metering and the lower consumables costs of today’s inhalation anesthetics compensate for the higher investment costs.

Gust and his anesthesia team are also increasingly turning to larynx masks rather than traditional endotracheal in-tubation in order to avoid further stress-ing the body with muscle relaxants while under anesthesia. In addition, they use modern thermal management to keep the patient’s body temperature stable so that the anesthetic performs optimally even during lengthy procedures and the anesthesia can be better controlled. For the Head of Anesthesiology, the patients in the recovery room are proof of the suc-

cess of these measures. “We hardly have to send any patients to the intensive care unit on ventilation any more,” he says.

Gust is hoping that the SmartPilot View (SPV) will bring further advance-ments. The new Dräger system comprises software and a touchscreen monitor that can, for example, be docked to a Zeus an-esthesia system equipped with injection pumps. The attending physician can con-trol the patient’s current anesthesia level and call up a preview without having to delve into the theoretical depths of phar-macokinetics and pharmacodynamics. That’s because the software of the new Dräger system is able to compute the com-bined effect that multiple liquid and gas-eous anesthetics have in the human body as a function of parameters such as the pa-tient’s age, weight, and gender, and com-municate this information at a glance (see Dräger Review 97.1, pp. 18 ff.).

Better orientation

Dräger consciously chose to emulate the cockpit of an airplane in the design of the SPV. The flight management systems in a cockpit not only show pilots the situation and position of their aircraft, they also look into the future and warn of danger-ous obstacles, for instance. Thus, these forward-looking assistance systems not only provide orientation, they also con-tribute to safety.

Anesthesiologists are faced with simi-lar challenges while they are monitoring a patient: The drug concentration must not be allowed to decrease during the an-esthesia to the point where the patient wakes up before the surgical procedure

is completed. Nor should the patient be so deeply anesthetized that it would pro-long the wakeup phase beyond a reason-able length of time. “The SmartPilot View helps to control the anesthesia level very precisely and thus to improve the results of our work,” says Gust when asked about the advantages of this method.

In most cases, the system offers bet-ter orientation than does personal expe-rience. “However, it does not relieve the doctor of his or her responsibility to con-trol the anesthesia,” Gust points out. In the remaining cases, the doctor is more precise because he or she has to consider additional components, depending on the individual treatment.

In addition to reliability, Gust also ap-preciates the ease of use of the device, which has been on the market since Jan-uary 2010. The teams’s acceptance of this new technology has significantly increased, which can be attributed to Dräger’s willing-ness to seriously consider improvements suggested by the users. For instance, the new color coding for anesthetics was in-corporated shortly after its adoption. “I can recognize the way I work in this product,” says Gust. That was not the case with con-trol systems from other manufacturers that he had tested. What other improvements would he like to see? “Direct integration into the anesthesia device,” Gust replies promptly. However, he admits that he re-alizes this development is still a long way off. “I’m confident that I will see this and other development stages become a real-ity, though,” says Gust with a smile. “Af-ter all, I still have a few years to go before I retire.” Frank Grünberg

Colorful graphics show the complex

relationships between pharma

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Dr. René Gust, Head of Anesthe

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works reflected in the

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tooth. The truth is that even though one or two such candies, if eaten just before tak-ing a breath test, may increase the read-ing by several tenths of a percent, the re-sulting breath alcohol content falls back to zero within just a couple of minutes.

As professor Slemeyer explains, stud-ies and food chemistry analyses show that “liqueur-filled chocolates contain so little alcohol that the consumption of normal quantities doesn’t increase the concen-tration of alcohol in the body.” Even sev-eral boxes wouldn’t be enough to cause a blood alcohol concentration of 0.03 per-cent, the minimum level at which drivers in Germany can be penalized if they drive erratically, cause an accident, or injure or endanger third parties. As a rule, that means forfeiting your driver’s license and acquiring seven points in the central register of traffic offences. By the end of the second box of candy, however, one’s blood sugar levels would soar to such diz-zying heights that even the most hard-ened chocoholic would lose the desire for them. Most people would be feeling decidedly nauseous by that point. On the

other hand, is there any way of actually reducing alcohol in the breath?

The trick with the ice cubes

Modern folklore recommends the fol-lowing strategy: Chew a mouthful of ice cubes, all the while conversing noncha-lantly with the traffic officer, and then blow confidently into the alcohol measur-ing instrument while ignoring the onset of a raging toothache. Although chilling the breath in this way would certainly pro-duce a lower reading of a screening instru-ment than one taken with breath at body temperature, the practicalities of such a ploy are highly implausible; and what is true of crushed ice also applies to – slightly warmer – ice cream. In any case, if the Dräger Alcotest 7110 Evidential were used to measure breath alcohol concentration, it would recognize the lower breath tem-perature and adjust the value on the ba-sis of a reference temperature of 34 °C in order to generate a reading that would be admissible as evidence in a court of law. Besides, by the time of the second man-datory breath test – within five minutes of

Falsehood and trickery are common bedfellows. When drunk drivers are stopped by the police, many seek ref-

uge in excuses, or even the art of decep-tion. Some will try eating peppermints, garlic, or artichokes, and others firmly be-lieve that a special breathing technique will help them beat the alcohol screen-ing instrument. “It’s all nonsense,” says Dr. Andreas Slemeyer, a professor at the Gießen-Friedberg University of Applied Sci-ences and a publicly appointed and sworn expert for the technology of breath alco-hol analysis. His conclusion on the basis of numerous scientific studies and expert reports is that “today’s analysis technology produces a reliable measurement of a per-son’s current breath alcohol content.”

Too much candy

That’s also true when drivers are tempted to explain the smell of booze on their breath as the result of eating a couple of li-queur-filled chocolate candies. The urban legend that this can bump up body alco-hol has been remarkably persistent – and not only among people who have a sweet P

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A Mouthful of Ice CubesWill sucking a one-cent coin help you pass a breath test after a couple of beers? That’s just one of many MYTHS that have become accepted wisdom. In fact, the metal in the coin has no effect at all on the breath alcohol reading. In this article we take a look at this and other urban legends.

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POPULAR MY THS REPORT

the first – the temperature in the mouth and throat would have returned to normal, thus invalidating both readings due to the significant difference in temperatures.

That’s why we should be wary of tak-ing everything at face value in an area like this. The conviction, for example, that sucking a one-cent coin has a negative ef-fect on breath alcohol content – based on the assumption that the copper in the coin interferes with the reading – already found-ers on the fact that euro cent coins have always consisted almost entirely of zinc, as have dollar cent coins since the 1980s. “Furthermore, it wouldn’t even function in theory,” says Slemeyer with a laugh. As he explains, a comparison of the reactive areas in question suffices to explode this particular ruse. A one-cent euro coin has a surface area of around two square cen-timeters, but the mouth and throat region is some 150 square centimeters in area, plus another 500 square centimeters for the upper respiratory passages and up to eight square meters for the entire surface area of the lungs. “These proportions,” says Slemeyer, “show that a dodge like that will never work. You won’t get sur-face effects of any kind whatsoever.”

Up in smoke

Does cigarette smoke reduce breath alco-hol? The answer is a definite no, since any substances that are exhaled additionally, including cigarette smoke, do not reduce

the reading produced by the sensors in a screening instruments. Too manipulate the Dräger Alcotest 7110 Evidential, how-ever, is simply impossible within the per-missible tolerances.

But in spite of all these scientific refu-tations, such urban myths are surprisingly hard to dispel. So why hasn’t modern rea-soning been able to prevent their spread? It seems that human nature leads people to believe whatever they want to, even if it contradicts their better judgment. The Internet certainly plays a part in propa-gating such legends, and some newspa-pers also prefer big headlines to properly researched stories. “We’ve become accus-tomed to believing in things that are im-possible,” says Slemeyer. What’s more, the mere existence of regulations is enough to prompt some people to start looking for dodges and loopholes.

But what about Slemeyer himself? Would he get behind the wheel of a car after drinking a couple of beers? “That depends on how quickly they were consumed and the size of the glass, but definitely not after two liters,” he replies. That would probably be his very own personal nightmare: to be caught over the limit, even though he’s an expert for breath alcohol analysis. If that happens, he adds with a smile, a number of forensic scientists would probably mark the occasion with a bottle of champagne – “par-ticularly if they were to convict me on the basis of a blood test!” Björn Wölke

Never swayed by the dodges of

drunken driv-ers: the Dräger

Alcotest 6510.

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InsIght ApplicAtioN eNgiNeeriNg

Break Me If You Canthere are standards, and then there are expeCtatIons that exCeed everY standard. when Dräger goes beyond the standards to satisfy its customers, the work of the Application engineering team has paid off. the team often finds creative ways to stress devices, so the devices don’t end up stressing customers.

Buttons have to be able to withstand being pressed forcefully many thousands of times in a row. automatically, of course.

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A nd those are our four test drink-ers!” Thomas Rodewaldt isn’t pointing to a foursome of sedate

gentlemen with red noses, but rather at four Mark II simulators, which resemble heatable tumblers with numerous hoses running in and out of them. “We use these to mix a test gas that corresponds exactly – in terms of temperature mois-ture and breath alcohol content – to what our breathalyzers will encounter in the field.” Rodewaldt, an engineer, heads the nine-member Application Engineering team at Dräger in Lübeck, Germany.

The team members see the evidence of their success right away. On one hand, the team represents the customers’ appli-cation environment as early as during the development of safety technology prod-ucts. On the other, it advises customers on specific potential applications or com-plex questions such as which other gases could influence the indication accuracy of Dräger tubes (see Dräger Review 100.1, pp. 16-19). Rodewaldt opens a few e-mails from customers with tricky questions and even photos. The more his team can think like the customer, the faster the problems can be solved.

Turning up the heat on devices

Every member of the team is a prod-uct specialist with the pronounced abil-ity to see things through the eyes of the customer and a creative knack for driv-ing devices crazy in a controlled man-ner. Take for instance with the “Singa-pore Test,” in which they simulate what occurs on a daily basis in the tropics: A device is taken from an air-conditioned

room into the damp heat of the outdoors. Does the internal mirror in the sensor of a gas measuring device react by initially fogging over and temporarily “blinding” the sensor? Does condensation develop anywhere inside the device? If so, does that influence its accuracy or function? “The use of a device in Singapore was what first made us aware of the need for such a test,” says Rodewaldt in explain-ing why the test is named after the coun-try in Southeast Asia.

The sooner such questions can be an-swered during product development, the better. And that’s especially true when it comes to requirements that are gleaned from practice, which can’t always be completely depicted in the standards that have to be observed in any case. “Our Al-cotest 6510 remains within the measure-ment tolerance range up to a tempera-ture of +40 °Celsius,” says Rodewaldt, citing one example. The company doesn’t simply rely on this statement, however. With an eye towards practice, Dräger per-forms tests at significantly higher tem-peratures, such as those that can occur during operation and in particular dur-ing storage. “We also want to know what happens at +70 °Celsius. And whether the device suffers irreversible damage to functions or components at +90 °Cel-sius.” Although these environmental con-ditions aren’t warranted by the manufac-turer, they could certainly correspond to improper use in the field.

The team gets involved in particu-lar when it’s about more than simple compliance with standards – in other words, when it comes to that extra bit of

safety with which Dräger products have earned their reputation. Rodewaldt ex-plains that Application Engineering, as the voice of future customers, is involved from very early on in product develop-ment. “For each new or further develop-ment, we work closely together with the Development department and others to consider the customers’ requirements with respect to functions, applications, operation, and device environment.” The team’s experience and application know-how enable it to help set the right course at a very early stage. As a result, it’s possible to create a product that will later win over the customers.

Flashover: Experience counts

This experience can’t always be acquired while sitting at a desk or from discus-sions with the customers, no matter how intense. Rodewaldt and his team there-fore also take a first-hand look on site in order to become familiar with the actual spectrum of applications for the prod-ucts and the daily routine. “That’s par-ticularly important for new development projects for which we don’t have user ex-perience to draw on,” says the engineer. For instance, he and his colleagues un-derwent a fire simulation with flashover in order to assess the suitability for use of a compressed-air breathing appara-tus in an early development phase. “And then you see how the smoke slowly fills the room from the ceiling, reaches your visor, and then reduces visibility to zero! Added to that is the heat, which makes you appreciate every insulating air buf-fer between your body and your protec-

Thomas Rodewaldt heads the team.

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tive clothing.” This very practical per-spective leads to assessments and useful suggestions that flow directly into the de-velopment process – for example, before the customer notices at an inconvenient time that the straps of a breathing ap-paratus are too narrow and thus com-press the protective clothing’s air buf-fers, which are so critical for survival.

When the sun triggers a reset

None of these findings are random, of course. During user testing of device software, for example, you don’t have to pound wildly on the keyboard. “It’s more a matter of specifically doing the wrong thing at the right places,” says Rodewaldt. Otherwise the results would also be ran-dom and not reproducible. And it is that type of unsystematic problem that gives the engineers the greatest headaches. For instance, a customer years ago dis-covered that a device with an infrared in-terface rebooted on its own, seemingly at random. An examination of the device in Lübeck confirmed what was already sus-pected. The device had been left in the sun, and the infrared receiver sometimes interpreted the sun’s rays as a reset com-mand. “Once we knew that, we changed the software.” And when an unmodified device and a reprogrammed one were then placed on the windowsill in the sun-light, only the unmodified one occasion-ally reset itself. Error reproduced, cause identified, problem solved.

Today a whole series of mobile breath alcohol testers are positioned on the win-dow sill, which is bathed in bright sun-light. They’re scheduled for testing to see

how many charge and discharge cycles their batteries can endure. Surely leav-ing them in strong sunlight violates ev-ery rule of proper use? “That’s right,” smiles Rodewaldt, “but this is what our customers can run into, so we want to see beforehand what happens.”

There are several places around the lab that make a very mundane impres-sion. Like a container of mud: top soil, clay, ash, and water. Devices are encased in this or sometimes in talc, just like peo-ple in a mud pack. The mixture bakes on really tightly as it dries. The aim in the laboratory is to see not only how the de-vice responds to this rough treatment, but also how it withstands the proper, or less than proper, cleaning procedure. What is reminiscent of a sandbox game actually follows a systematic plan in the interest of discovering application-re-lated information.

Systematic in-system testing

This systematic approach is found at all stages of the product cycle. Function pat-terns and modules are thus tested at an early stage of development. Complete sys-tems are tested at later stages, of course. Another not insignificant task of the de-partment is to test systems that have been specifically modified for a particular cus-tomer. This is done for all Dräger Alcotest devices, for example, because they must be configured differently depending on the customer and the country of desti-nation. In the U.S., for example, the laws differ from state to state. Changes made to the software of the base device result in a steadily increasing number of ready-

to-ship systems that need to be tested. The term “system” can also take on other di-mensions, however – such as when the testing is done to see if a newly developed electrochemical sensor can be fitted into a device to form a system.

“Validation” and “verification” are the terms the application engineers prefer to use when referring to the fo-cal points of their work: u Validation as-sesses a product with respect to whether it functions as expected by the customer or if it has diverged from this during the course of development. u The verifica-tion process checks whether a device complies with the technical character-istics previously defined in the require-ment or functional specifications.

What happens if there are devia-tions? “We sit down with the Develop-ment department and solve the problem from the perspective of the customer’s expectations.” And what if the Develop-ment department is stubborn? That’s never actually happened, but the team would be authorized to stop the product from being released for production. Af-ter all, it doesn’t meet the customer’s requirements.

“Again and again,” says Rodewaldt while clicking through a database built up over several decades, and which also includes exotic uses for Dräger tubes, “we receive queries about how a tube that has long proven effective for detect-ing a gas would behave if used elsewhere and in gas mixtures with an entirely dif-ferent composition.” While browsing un-der the keyword “methyl bromide,” he almost lets slip the words “We are pretty

They enjoy considering everything the customer can “do to” the devices

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DRÄGER REVIEW 101.1 | NOVEMBER 2010

much one-of-a-kind here.” And that re-ally isn’t too far from the truth.

Speaking of gases, the detection sen-sors are becoming increasingly sensitive. The move from the ppm range to the ppb range means that the detection thresh-old is dropping from a few millionths to a few billionths. Whereas it was once pos-sible to prepare the required concentra-tions in conventional glass containers with volumes of up to maybe 20 liters, performing such an operation now often requires a special container holding 414 liters of a gas mixture.

Fun isn’t really a criterion for en-gineers. Nonetheless, everyone on the team seems to like their work. They en-joy constantly developing creative solu-tions for all the things the user can “do to” the devices. In one corner is an artifi-cial index finger developed in-house that rhythmically maltreats keys and switches with a force of 500 grams – far more than twice the warranted actuations. When finished, the engineers not only look to see if the keys still work, they also check to determine how the material held up, or if maybe the labeling has suffered.

And because nature – and that means UV radiation, cold, heat, snow, hail, tor-rential rain, and so on – is every bit as mer-ciless as the engineers when it comes to creating stress for devices, they decided to mount a few Alcotest devices, among other things, at an exposed location on the roof of the building nearly two years ago. “We take a look every four weeks to see how they’re holding up,” says Rode-waldt. “And so far, they still look as good as new.” Nils Schiffhauer

Icy: Frost, so the customer doesn’t get an icy scare.

Thirsty: Alcoholized breath is produced in these simulators.

Dirty: Filthy working conditions are recreated here.

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OUTLOOK WEBINARS

When Rick Rochford talks, peo-ple listen. No matter how they earn their money, they are al-

ways captivated. This is particularly so when they are firefighters – Rick’s col-leagues. The latter hang on every word because they can empathize with what this experienced professional firefighter from Jacksonville, Florida, reports in such a lively and exciting way.

Everyone in the room is impressed with his 26 years of experience on the front lines, his rank of captain, and his

Far Away, Yet Close at HandHow can the Internet help to actively convey very personal EXPERIENCE AND EXPERTISE? Alongside a number of other options, the webinar – a seminar on the web – has developed into a professional form of knowledge-sharing. Already used by Dräger in the U.S., it is now also coming to Germany.

extraordinary expertise when it comes to personal protective equipment. And this respect remains undiminished even when there are hundreds of miles be-tween Rochford and the room. And ex-actly that has often been the case lately thanks to an innovative form of knowl-edge transfer that Dräger USA intro-duced this summer for America’s widely dispersed firefighting community. Fire-fighters were able to experience Rick Rochford and his colleague, Lieutenant Anthony Toro, “live” in a webinar.

“Two hundred and fifty firefighters logged in – and in some cases entire de-partments logged in all at once. They use their training rooms so that they can watch together,” says Greg Sesny, a Prod-uct Manager at Dräger in the U.S. Be-cause the combination of lectures and presentations was recorded and made available on the Internet, thousands of other participants were also able to watch. “So far we’ve had visitors from 22 countries,” says Sesny. “Rick and An-thony really seem to have struck a chord.”

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Their subject was toxic gases, particu-larly hydrocyanic acid. Toxic gases can occur in almost every fire, resulting in severe long-term damage in addition to acute poisoning. Toro knows exactly how to drive this point home. He himself was a victim, and he stresses how important it is to systematically practice with respi-ratory protection and use it on the job. Rochford contributes his extensive exper-tise in gas detection methods, the early warning system for toxins. The core mes-sages are summarized in succinct slides that appear next to the webinar’s video window. Images of typical fire scenarios also appear there. The participants can ask questions and make comments from their computers during the live webinar just as if the event were taking place in a real seminar room. The questions and comments from the firefighters are brief and to the point in what is essentially a

compact exchange of words in the pro-fessionals’ language.

The webinar has proved to be a par-ticularly efficient lecture form for the Internet. For a brief time, there were also animated classrooms with Second Life-like realism, where the participants could have rolled out virtual hoses, for instance. However, it is the webinar that seems to have found the right blend of video, presentation, and text elements. It foregoes gimmicks and instead concen-trates on the content. When a speaker is able to pack as much credibility and com-petence into words as Rochford does, it works regardless of whether he is speak-ing directly in the room or via DSL.

Webinars: Good for relationships

Professor Rolf Schulmeister, who is based in Hamburg, Germany, has been moni-toring computer-based teaching systems

since their inception. He has published dozens of studies on this topic. Accord-ing to Schulmeister webinars are not in-tended to replace conferences, on-site training, and on-the-job training – quite the contrary. “They are optimal when the participants already know a lot about their field and share information. Under these circumstances, the webinar is an ideal tool that enables them to demon-strate the latest aspects of their exper-tise and to update their own knowledge.” The key, says the expert, is that the new insights are then brought to life in the local professional groups. “The webi-nar enables you to understand the rela-tionships, but ultimately you learn how to put them into practice locally in your daily work.”

Sesny also considers this to be a ma-jor criterion for using the new medium. It complements the ongoing processes of >

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OutlOOk webiNars

Webinars help colleagues share practical knowledge with one another

> improving the technology, its use, and its integration into workflows. The new me-dium can be a valuable asset for all occu-pations in which lifelong learning is not a new discovery but part of the self-image. That has always been the case for res-cue workers, manufacturers, and med-ical personnel. They benefit a lot, par-ticularly when they can share the latest findings and information with one an-other. Of course, there are always going to be pioneers – individual organizations or departments that are the first to try out new technologies and procedures. One such pioneer was the Fire Depart-ment of Jacksonville, where Rochford turned systematic gas detection and the optimized use of respiratory protection into a natural routine.

Now also in Germany

Webinars are therefore also a logical choice for use in medicine. Hospitals that are early adopters of new technol-ogy can share valuable practical knowl-edge with their colleagues when wide-spread use of the innovation begins. Innovations and improvements can be demonstrated quickly and cost-effectively because broadband Internet is now avail-able almost everywhere, and a webinar can be produced quickly and inexpen-sively, as Sesny explains.

This new form of communication, which has been so well received in the U.S., has therefore recently made its way to Germany. In late September, a webinar on the automatic weaning of ventilator pa-tients in intensive care wards marked the beginning for Dräger. Silke umbach

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PubliShiNG iNfOrmatiON

Publisher: Drägerwerk ag & Co. Kgaa, Corporate Communications Editorial address: moislinger allee 53–55, 23542 Lübeck, germany / [email protected], www.draeger.com Editor in Chief: björn wölke, Tel. +49 451 882 20 09, Fax +49 451 882 39 44 Publishing house: TeLLUs PUbLisHiNg gmbH Editorial Consultant: Nils schiffhauer (responsible according to press law) art Direction, Design, and Picture Editing: redaktion 4 gmbH translation: TransForm gmbH Printing: Dräger + wullenwever print+media iSSN 1869-7275

The articles in Dräger Review provide information on products and their possible applications in general. They do not constitute any guarantee that a product has specific properties or is suitable for any specific purpose. All specialist personnel are required to make use exclusively of the skills they have acquired through their education and training and through practical experience. The views, opinions, and statements expressed by the persons

named in the texts as well as by the external authors of the articles do not necessarily correspond to those of Drägerwerk AG & Co. KGaA. Such views, opinions, and statements are solely the opinions of the respective person. Not all of the products named in this magazine are available worldwide. Equipment packages can vary from country to country. We reserve the right to make changes to products. The current information is available from your Dräger representative. © Drägerwerk AG & Co. KGaA, 2010. All rights reserved. This publication may not be reproduced, stored in a data system, or transmitted in any form or using any method whether electronic or mechanical, by means of photocopying, recor ding, or any other technique in whole or in part without the prior permission of Drägerwerk AG & Co. KGaA.

hEaDQuartErS: Dräger medical Gmbh moislinger allee 53–55 23558 lübeck , Germany www.draeger.com

rEGiON EurOPE CENtral aND EurOPE NOrth Dräger Medical GmbH Moislinger Allee 53–55 23558 Lübeck, Germany Tel +49 451 882 0 Fax +49 451 882 2080 [email protected]

rEGiON EurOPE SOuth Dräger Médical S.A.S. Parc de Haute Technologie d’Antony 2 25, rue Georges Besse 92182 Antony Cedex Tel +33 1 46 11 56 00 Fax +33 1 40 96 97 20 [email protected]

rEGiON miDDlE EaSt, afriCa, CENtral aND SOuth amEriCa Dräger Medical GmbH Dubai Healthcare City P.O. Box 505108 Dubai, United Arab Emirates Tel +971 436 24 762 Fax +971 436 24 761

rEGiON aSia / PaCifiC Draeger Medical South East Asia Pte. Ltd. 25 International Business Park # 04-27/29 German Centre Singapore 609916 Tel +65 6572 4388 Fax +65 6572 4399 [email protected]

rEGiON NOrth amEriCa Draeger Medical, Inc 3135 Quarry Road Telford, PA 18969-1042, USA Tel +1 215 721 5400 Toll-free +1 800 437 2437 Fax +1 215 723 5935 [email protected]

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A Trap that ProtectsSensors continuously measure the composition of the air inhaled and exhaled while a patient is under anesthesia (and also thereafter). The WaterLock 2 one-way water trap protects the gas measurement system against water, bacteria, viruses, and particles. An integrated pump diverts 200 milliliters per minute from the respiratory flow 1 and sends it to the sensors. The polytetrafluoroethylene (PTFE) membranes 2 and 3 with their different properties split the gas sample into a sam-pling gas flow and a purge gas flow. 180 milliliters of sampling gas per minute pass through a filter 4 to the sensor system.

To prevent the membrane 2 from becoming clogged with the water it retains, a 20-milliliter-per-minute purge gas flow draws the water into a 12-milliliter vessel 5 , where it collects due to the low flow velocity. The

smaller membrane 3 also protects this branch against water and resi-dues. The chamber 6 upstream of the tank 5 reduces measurement disturbances which can be caused by pressure fluctuations inside the sam-pling gas line from and to the patient. Because the membranes become spoiled to a greater or lesser degree during use, their service life is lim-ited to four weeks. Self-sealing filters protect the gas measuring system in the extreme event that the membranes would rupture. The filters 4 and 7 contain a superabsorber mixed with color pigments that swells with

the addition of water and turns blue. Condensation is drawn off through a connector 8 using a standard disposable syringe. The water trap is man-ufactured fully automatically using ultrasonic and laser welding methods. Each unit is tested for tightness to ensure maximum safety.

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