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i

Introduction to Biomedical Instrumentation

The Technology of Patient Care

This fully updated second edition provides readers with all they
need to understand the use of medical technology in patient care.
Incorporating the most recent changes in healthcare, regulations,
standards, and technology, coverage is expanded to include new
chapters on device testing, with a particular emphasis on safety
inspections, and the interface of medical technology with the
electronic medical record. A wide variety of medical instrumenta-
tion is discussed, focusing on device types and classifications and
including individual manufacturers as examples. It is designed
for readers with a fundamental understanding of anatomy, phys-
iology and medical terminology, as well as electronic concepts
such as voltage, current, resistance, impedance, analog and digi-
tal signals, and sensors. Additional documents and solutions to
end-of-chapter questions accompany the book online, providing
biomedical engineering technicians with the resources and tools
they need to become knowledgeable and effective members of the
patient care team.

Barbara L. Christe PhD is Associate Professor and Program

Director of Healthcare Engineering Technology Management at
Indiana University–Purdue University Indianapolis (IUPUI).
“Barbara Christe has excelled at updating this text to keep pace
with today's medical technology. The ‘For Further Exploration'
section in each chapter provides supplemental reference mate-
rial and valuable links to the most up-to-date information,
which transitions the text from an ‘Introduction to Biomedical
Instrumentation' to a living document. This book should be the
go-to resource in all HTM educational programs.”

Ted Lucidi, The Pennsylvania State University

iii

Introduction
to Biomedical
Instrumentation
The Technology of Patient Care
Second Edition
Barbara L. Christe
Indiana University–Purdue University, Indianapolis
Shaftesbury Road, Cambridge CB2 8EA, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre, New Delhi – 110025, India
103 Penang Road, #05–06/07, Visioncrest Commercial, Singapore 238467

Cambridge University Press is part of Cambridge University Press & Assessment,

a department of the University of Cambridge.
We share the University’s mission to contribute to society through the pursuit of
education, learning and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107185012
DOI: 10.1017/ 9781316882740
© Cambridge University Press & Assessment 2018
This publication is in copyright. Subject to statutory exception and to the provisions
of relevant collective licensing agreements, no reproduction of any part may take
place without the written permission of Cambridge University Press & Assessment.
First edition published 2009
Second edition published 2018
A catalogue record for this publication is available from the British Library
Library of Congress Cataloging-in-Publication data
Names: Christe, Barbara L., 1962– author.
Title: Introduction to biomedical instrumentation: the technology
of patient care / Barbara L. Christe.
Description: Second edition. | Cambridge, United Kingdom;
New York, NY: Cambridge University Press, 2018. | Includes index.
Identifiers: LCCN 2017035382 | ISBN 9781107185012 (hardback)
Subjects: | MESH: Biomedical Technology – instrumentation | Patient
Care – instrumentation | Biomedical Engineering – instrumentation |
Electronics, Medical – instrumentation
Classification: LCC R856 | NLM W 26 | DDC 610.28–dc23
LC record available at https://lccn.loc.gov/2017035382
ISBN 978-1-107-18501-2 Hardback
Cambridge University Press & Assessment has no responsibility for the persistence
or accuracy of URLs for external or third-party internet websites referred to in this
publication and does not guarantee that any content on such websites is, or will
remain, accurate or appropriate.
v

Contents

Preface to Second Edition page vi

1 A Career in the HTM Profession 1

2 Patient Safety 20
3 NFPA and Other Guidelines 30
4 Device Testing 45
5 In the Workplace 55
6 Electrodes, Sensors, Signals, and Noise 66
7 The Heart 81
8 Cardiac Assist Devices 96
9 Blood Pressure 110
10 Respiration and Respiratory Therapy 119
11 The Brain and its Activity 133
12 The Intensive Care Unit 143
13 The Operating Room 158
14 Imaging 175
15 Clinical Laboratory Equipment 189
16 Intravenous Pumps and Other Pumps 199
17 Electronic Medical Record and IT 206
18 Miscellaneous Devices and Topics 213

Index 225
vi

Preface to Second
Edition
This book is designed to introduce the reader to the fundamental
information necessary for work in the clinical setting, support-
ing the technology used in patient care. Beginning technicians/
technologists can use this book to develop a working vocabu-
lary and fundamental knowledge of the Healthcare Technology
Management (HTM) profession. Content includes a wide variety
of medical technology, with an emphasis on device types and
classifications; individual manufacturers are utilized as examples.
This work is intended for the reader with a fundamental under-
standing of anatomy, physiology, and medical terminology
appropriate for their role in the healthcare field, and assumes the
reader’s understanding of electronic concepts, including voltage,
current, resistance, impedance, analog and digital signals, and
sensors. The material covered in this book will assist the reader in
the development of his or her role as a knowledgeable and effec-
tive member of the patient care team. The second edition features
revisions to all of the content to reflect changes in healthcare,
regulations, standards, and technology. A new chapter addresses
device testing, with emphasis on safety inspections. A second
new chapter explores the interface of medical technology with
the electronic medical record.
A vital connection exists between technology and the care of
patients. In many cases, healthcare workers depend on technology
to administer care or treatment or to make a diagnosis. This book
helps readers understand how technology is tightly woven into
vii

vii PREFACE TO SECOND EDITION

patient care. The role of technical support for the medical team
is, therefore, essential in the delivery of effective medical care.
The section of each chapter entitled “For Further Exploration”
encourages readers to use the Internet to obtain in-depth infor-
mation about a related topic. The questions are designed to push
the reader to integrate concepts and ideas using external sources.
Answers to the questions are not specifically available within the
chapters. Research exercises encourage one of the most important
professional skills – the ability to investigate topics that are not
well understood. In the clinical setting, it is virtually impossible
to be an expert about all technology and aspects of patient care.
The ability to effectively search for information is vital.
For the second edition, I am in debt to those who have worked
tirelessly to improve an understanding of the HTM profession,
including Mary Logan, retired president of the Association for
the Advancement of Medical Instrumentation (AAMI) and my
colleagues in higher education, Steve Yelton and Joe Tabas. My
gratitude extends to the graduates of my program who always
respond positively when I reach out to them, especially Matt
Dimino. Lastly, I am grateful to my sister for her unwavering
support, and to her daughter, my niece Sarah, who taught me so
much about healthcare from the patient perspective.
Those who support the technology used in patient care are a
dedicated and selfless part of the workforce, offering a unique
combination of technical skills and compassion for the sick. May
this book be the beginning of a transformation that increases
career awareness, improves enrollment in training programs, and
expands the recognition the profession deserves.
viii
1

1
A Career in the
HTM Profession
Learning Objectives
1 Characterize the HTM profession.
2 Describe the role of an HTM technician.
3 List and describe potential employers of HTM technicians.
4 Characterize field service representatives.
5 List and describe the many job functions of an HTM technician.
6 List and characterize the certification types.
7 List and describe related professional societies and publications.
2

2 A CAREER IN THE HTM PROFESSION

What is the Name of this

Career?
Complex healthcare technology is utilized to support safe and
effective patient care. Clinicians depend on devices to monitor
and treat patients. Healthcare Technology Management (HTM)
professionals are part of the healthcare team, utilizing technical
expertise to ensure the safety, effectiveness, and availability of
critical medical technologies including devices, applications, and
software. The HTM discipline interweaves patient safety, medical
technology, and financial stewardship as illustrated in Figure 1.1.
HTM professionals collaborate with many groups within health-
care organizations including clinicians, risk management, infor-
mation technology, facilities management, and administration.

Patient Safety

Improved Effective
Clinical Equipment
Outcomes Use

HTM

Medical Financial
Technology Repair, Stewardship
Purchasing,
& Equipment
Management

FIGURE 1.1. The HTM Profession

(courtesy of AAMI)
3

3 WHAT DO HTM TECHNICIANS DO?

At different hospitals, HTM technicians may have a wide vari-

ety of job titles, including HTM technician or BMET. There are
many definitions for what the letters BMET stand for – biomedical
equipment technician, biomedical electronics technology, medi-
cal maintenance, biomedical engineering technologist, biomedi-
cal engineer, medical engineer, and medical equipment repair
technician. In general, BMET or HTM technician may be used as
title for a person with technical training who works in the clini-
cal setting and supports the equipment involved in patient care.
Technicians may be called the “biomeds,” “clinical engineers,”
or the “equipment guys.” The name of the HTM-related depart-
ment within a healthcare organization may vary but is often
healthcare technology management, medical engineering, clini-
cal engineering, or biomedical engineering. In some hospitals,
HTM technicians may be responsible for everything from printers
to computers to DVD players in the rooms of patients. In some
hospitals, HTM technicians work for the maintenance depart-
ments and are dressed similarly to the maintenance workers.
Other hospitals hire a wide range of technical staff who wear sur-
gical scrubs, lab coats, monogrammed polo shirts, or dress shirts.

Who Employs HTM Technicians?

Generally, three groups of employers hire HTM technicians: hos-
pitals, outside service providers, and the equipment manufactur-
ers. Those who work for the hospital directly or an outside service
organization (OSA) or independent service organization (ISO)
may appear the same to clinical staff. Some employment issues
(benefits, etc.) could be different, but the work-related duties are
likely to be similar. Often, when employees work for a manufac-
turer, they are identified as field service representatives or FSRs.

What do HTM Technicians do?

Although the titles may vary, the core functions of HTM techni-
cians are relatively consistent across patient care environments.
Most HTM technicians perform several main categories of job
4

4 A CAREER IN THE HTM PROFESSION

functions. In general, technicians are responsible for the support

of the technology used in healthcare. This support assures the
safe use of equipment and the best possible patient care. HTM
technicians work closely with medical staff to make sure technol-
ogy is available, used safely, and performs as designed.
Indirectly, the customer of technical support services is ulti-
mately the patient, although many times the patient and techni-
cian are not in the same place at the same time, nor are patients
the users of medical technology. Because the clinicians depend on
medical technology to deliver patient care, the most direct cus-
tomer would be the clinician who uses the equipment. However,
most experienced HTM technicians define the best employee as
one who thinks of each patient as a relative or loved one. The
care and attention one would expect under these circumstances
should drive high quality job performance.
Hospital-employed technicians generally have the following
responsibilities:
■ Equipment repair and troubleshooting – Technicians fix equip-
ment that is not functioning as expected. This repair may or may
not be done in the HTM department work area. Technicians may
need to retrieve equipment that has a “broken” sign attached to
it within the patient care department, or they may be called to
the operating room during a surgical case to diagnose and repair
malfunctioning devices. Figure 1.2 shows a technician work-
ing on a physiological monitor at her workstation in the clinical
engineering department of the hospital.
■ Preventative maintenance (PM) – Technicians routinely verify
the performance of almost all healthcare equipment at a par-
ticular time interval. This involves evaluating the performance of
every aspect of a device and checking or replacing parts to ensure
consistent, dependable service. PM may include conducting cali-
brations and safety checks as well as removing the “white dust”
that comes from bed linens. Technicians in the early stages in
their career may spend a great deal of time conducting PM evalu-
ations. Performing preventive maintenance procedures is a great
way to learn about all the features of a device, and the experi-
ence can assist in future troubleshooting. This type of activity
5

5 WHAT DO HTM TECHNICIANS DO?

FIGURE 1.2. A HTM Technician Works on a Physiological Monitor

is sometimes called performance assurance. Figure 1.3 shows a

technician performing a PM on a ventilator.
■ Staff support – Technicians provide both formal and informal
equipment instruction to many groups including the users of
equipment and other technicians. In-service training or an in-
service meeting may be managed by the HTM technician dur-
ing a clinical staff meeting to introduce users to the features of
a new device, offering information needed for effective usage.
Technicians also work one-on-one with clinical staff members,
addressing user challenges. Excellent customer service and
6

6 A CAREER IN THE HTM PROFESSION

FIGURE 1.3. A HTM Technician Calibrates a Ventilator

7

7 WHAT DO HTM TECHNICIANS DO?

communication with patient care providers are vital to effective

job performance.
■ Pre-purchase evaluation – As new equipment (new models or
entirely new devices) is considered for purchase, many techni-
cians are involved in the selection decisions, usually working very
closely with the medical staff. As patient care technology becomes
interwoven with other medical equipment in the hospital utilizing
information technology networks, the cross-departmental interac-
tions often fall to HTM technicians.
■ Incident investigation – When there are problems with equip-
ment, experienced technicians are often part of the team that
evaluates circumstances surrounding a malfunction.
■ Incoming inspections/assembly – When new devices arrive at
the hospital, technicians must verify that every aspect of every
piece of equipment functions properly.
■ Adaptations/modifications – HTM technicians are occasionally
asked to modify equipment to better medically serve clinical staff
or better serve a patient with restrictions or limitations.
■ Documentation/departmental development/training classes –
Medical device management plans, utilizing thorough docu-
mentation of technical support efforts, offer a roadmap for
lifetime device support. In addition, accreditation bodies have
a policy that basically concludes: “if it is not written down,
it did not happen.” HTM-related departments have meetings
and other activities that must be documented. In addition,
HTM technicians are often expected to participate in ongoing
training throughout their careers to explore new devices and
technologies.
■ Updates/recalls – When manufacturers change, recall, or update
equipment (for example, software updates) the technician must
locate devices, remove them from service, or make the necessary
changes.
■ Safety board/disaster planning – Technicians help to set poli-
cies, plan for emergencies, and investigate problems, especially
regarding hospital-process efficiency and staff training.
8

8 A CAREER IN THE HTM PROFESSION

Non-hospital-employed technicians engage in a number of the

previous responsibilities in addition to some of the following
functions:
■ Telephone support – Some technicians answer phone lines to
assist users of equipment as well as technicians who are attempt-
ing to make a repair.
■ Sales – Some technicians work for a manufacturer, outside ser-
vice organization, or repair depot as a salesperson.
■ New equipment design – Some technicians work for a manufac-
turer and design new devices.
In general, most hospital-based technicians work typical hospital
first-shift hours, often 7 A.M. to 3:30 P.M. Monday through Friday.
While some institutions do staff HTM departments on weekends,
most departments do not provide staff during the night or on
weekends. Policies for on-call coverage vary, although most hos-
pitals easily deal with problems outside of work hours with mini-
mal weekend and night trips back to work.
Table 1.1 contains standardized job descriptions to help
HTM professionals understand the career and its opportunities.
Detailed information is provided related to the entry-level posi-
tion, level I. Additional details are available on the Association
for the Advancement of Medical Instrumentation (AAMI) website,
www.aami.org. The Career Planning Handbook, available free
from AAMI, offers a deeper understanding of the skills and expe-
rience needed to advance in the profession, including leadership,
public safety and regulatory requirements, customer service, and
specific equipment expertise.

Field Service Representatives

FSRs are generally employed by the manufacturer of a medi-
cal device or technology. The person represents the company by
servicing or supporting (by offering clinical staff training, for
example) a particular device or group of devices at various clini-
cal sites. Sometimes these workers are called field service engi-
neers, equipment specialists, or customer engineers.
9

9 FIELD SERVICE REPRESENTATIVES

TABLE 1.1. AAMI HTM Job Descriptions

Healthcare Engineering Technician I (or BMET I or other title)

Summary: Maintains clinical equipment through the effective use of

the Medical Equipment Management Plan. Performs a variety of routine
tasks associated with the installation, maintenance, calibration, and
repair of a limited scope of biomedical equipment under the guidance
and direct supervision of an experienced healthcare technology
management (HTM) professional.
General Guidelines: Demonstrates basic knowledge of the job, activity
or function, needs supervision or mentoring on advanced assignments.
Entry-level position.
Education: Associate’s degree, military training, or academic work
aligned with AAMI’s Core Competencies for the Biomedical Equipment
Technician, and a basic knowledge of mathematics, anatomy,
physiology, biology, physics, chemistry, medical terminology, English,
computer and networking peripherals, and professional skills.
Leadership: Demonstrated ability to learn from others on the job. Can
teach some basic skills to new hires or interns.
General Skills & Experience: Possesses basic understanding and skills
related to general electromechanical systems and devices.
Specific Experience:
• Exhibits a basic understanding and can communicate the use of
devices supported.
• Can provide basic support of acuity equipment for direct patient care.
• Is familiar with the operations and environment that they support
(hospital, clinic, etc.).
• Has minimal experience in their assigned clinical environment.
Public Safety & Regulatory Requirements: Has a basic understanding
of both local and national public safety and regulatory issues.
Customer Service: Able to solve basic front-line customer service
issues.
Equipment Expertise: Demonstrates a basic understanding of clinical
equipment, radiological, laboratory and network medical systems.
Other: Has a basic understanding of project management terms and
methods.
Healthcare Engineering Technician II (or BMET II)

Maintains clinical equipment through the effective use of the Medical

Equipment Management Plan. Performs a variety of tasks associated
with the installation, maintenance, calibration, and repair of biomedical
equipment with minimal supervision.
(continued)
10

10 A CAREER IN THE HTM PROFESSION

TABLE 1.1. (cont.)

Healthcare Engineering Technician III (or BMET III)

Maintains clinical equipment through the effective use of the Medical

Equipment Management Plan. Demonstrates a mastery of skills and
tasks associated with the installation, maintenance, calibration, and
repair of complex biomedical equipment. Capable of educating others
including clinical staff related to the technical integration of the
device/system.
Specialist (Radiology/Network Systems/Laboratory/Project)

Recognized as field modality expert. Highly competent in area of

specialty, spending 70% of time or more in repairing, inspecting,
installing, troubleshooting, and calibrating equipment in area of
specialty. Serves as a front-line responder for escalated service events.
Network Integration Engineer

Assists department director with all aspects of program management,

including work-history data analysis, staffing allocation, budget
control, equipment acquisition planning, installation and testing,
outside vendor management, development of policies and procedures,
and provision of clinical engineering services. Ensures all program
components support accreditation and other state and local codes
related to electrical and mechanical equipment safety. Performs
rounds on clinical units to verify proper equipment use and operation.
Develops and monitors compliance with equipment preventive
maintenance schedules. Understands data transfer, platforms used to
transfer data, and interconnectivity.
Healthcare Engineer (commonly referred to as Clinical Engineer)

Assists department director with all aspects of program management,

including work-history data analysis, staffing allocation, budget
control, equipment acquisition planning, installation and testing,
outside vendor management, development of policies and procedures,
and provision of clinical engineering services. Ensures all program
components support accreditation and other state and local codes
related to electrical and mechanical equipment safety. Performs
rounds on clinical units to verify proper equipment use and operation.
Develops and monitors compliance with equipment preventive
maintenance schedules.
11

11 FIELD SERVICE REPRESENTATIVES

TABLE 1.1. (cont.)

Senior Healthcare Engineer

Looked to by senior hospital leadership for expert guidance on

healthcare technology. Assists department director with all aspects of
program management, including work-history data analysis, staffing
allocation, budget control, equipment acquisition planning, installation
and testing, outside vendor management, development of policies and
procedures, and provision of clinical engineering services. Ensures all
program components support accreditation and other state and local
codes related to electrical and mechanical equipment safety. Performs
rounds on clinical units to verify proper equipment use and operation.
Develops and monitors compliance with equipment preventive
maintenance schedules.
From the www.aami.org website

In general, field service representatives perform many of the

job functions of general HTM technicians. The proportion of the
time spent on the various facets of the work shifts when FSRs
focus on one type or group of equipment. In addition, some FSRs
are very specialized as trainers or perform repairs on complex
devices and, therefore, have a very narrow range of duties with a
very high level of technical expertise.
Generally, FSRs are commonly used in such areas as radiology
(imaging), clinical laboratory, anesthesia, LASERs, and operating
room equipment, to name a few. Most common is imaging and
clinical laboratory devices since these areas involve very com-
plex, very expensive equipment that requires in-depth training
(i.e. weeks or months). It is a significant financial and personnel
commitment for individual institutions to train people to support
a single device (or a few) that one hospital owns. By spreading the
technical skills of an FSR over several hospitals, support expenses
to the institution may be lower. Or, contracting for service may be
the only option an institution has to provide a skilled technician
who can support the device (irrespective of cost).
Most field service representatives work under a service con-
tract purchased by a clinical facility. Some manufacturers require
that service only be performed by their own FSRs. In addition,
service contracts can be efficient for the institution because a
12

12 A CAREER IN THE HTM PROFESSION

highly trained person will respond quickly. This may be especially

true when the downtime of a particular device adversely affects
patient care or has significant associated cost to the institution.
There are generally two types of service contracts. A full ser-
vice contract specifies that an FSR will respond within a cer-
tain period of time and repair the equipment with no additional
costs. The exact financial arrangement and details are usually
negotiated. Another category of service contract provides less
comprehensive service. For example, the contract may be “time
and materials” – this allows a hospital to have access to an FSR
and still pay an hourly rate (usually with a minimum number
of hours) as well as the cost of the parts. Some service contracts
allow HTM technicians employed at the hospital to examine the
device to try to identify any simple issues; this first-response
technique may also include phone technical support for the in-
house technician.
Many FSRs travel between clinical sites. In some territories,
this travel may require minutes, in larger states, the amount of
time on the road can be hours. The territory that an FSR covers
may also impact the number of nights that are not spent at home.
Many FSRs work out of their car, stocking parts in the trunk
and completing documentation in hotel rooms or at home. Many
FSRs are on call 24/7 and may be required to stay at a site until
a repair is complete. Overtime is relatively common, and their
schedule may not be very predictable. To compensate FSRs for
these challenges, the salaries offered to field service representa-
tives are usually very good (and often higher than hospital-based
technicians). Benefits often include a company car and other
travel expenses. There may be incentives and bonuses available.
Long-term salary surveys show large salary improvements for
those technicians who specialize in areas such as imaging and
the clinical laboratory.
Many students express an interest in specialization, mainly
because of the high salary potential. It may be difficult to secure
a position as an FSR without some clinical experience or a college
degree. An FSR is the only person at a site to solve a problem.
Very few companies will consider hiring a person who has never
13

13 IS THERE A NATIONAL LICENSE OR CERTIFICATION?

worked as an HTM technician, and never been in the clinical

setting (except perhaps during their internship) to shoulder the
heavy responsibility of expensive equipment and corporate repu-
tation. Willingness to relocate may also be required. Lastly, in
addition to excellent technical skills, FSRs must also have well-
developed customer service skills. The ability to communicate
with the medical staff, especially when there are difficulties and
delays, can be vital to the relationship between the manufac-
turer and the clinical site. Personality and professionalism will be
required to fill a position as an FSR.

Is There a National License

or Certification?
Unlike nursing and other medical professions, no government
licensure is required to become a technician who supports medi-
cal technology. Voluntary and optional certifications are avail-
able. Employers vary as to the emphasis and/or reward placed on
the attainment of certification credentials.
The most common certification is offered by the AAMI
Credentials Institute (ACI). This group offers five types of cer-
tification, identified in Table 1.2. Most commonly, early career
technicians seek the general Certified Biomedical Equipment
Technician (CBET) credential. The first step to obtain certifi-
cation is to take a national exam (there is a separate exam for
each type of certification). Applicants with academic or military
credentials can take the CBET exam as a candidate. Applicants
who have a 2-year degree and 2 years of work experience in the
field can take the exam in full certification status. Requirements
for each of the other types of exams are available by visiting
the AAMI website. There is a fee to take the written exam, but
most employers will reimburse the cost if the employee is suc-
cessfully certified.
There are six sections of the CBET exam:
■ Anatomy and Physiology (12% of the exam)
■ Safety in the Healthcare Facility (15% of the exam)
14

14 A CAREER IN THE HTM PROFESSION

TABLE 1.2. Types of ICC Certification

Certification Credential Certification Title

CBET Certified Biomedical Equipment Technician

CRES Certified Radiology Equipment Specialist
CLES Certified Laboratory Equipment Specialist
CHTM Certified Healthcare Technology Manager
CQSM Certified Quality System Manager

■ Fundamentals of Electricity and Electronics (13% of the exam)

■ Healthcare Technology and Function (25% of the exam)
■ Healthcare Technology Problem Solving (25% of the exam)
■ Healthcare Information Technology (10% of the exam)
The exam duration is three hours and consists of 165 multiple
choice questions. A passing score is 116. Most successful candi-
dates review the test content areas and study groups are common.
Certification can improve pay rates but generally not a great
deal. Certification is not required for employment by any govern-
ment body. Very few employers require certification for employ-
ment but many employers recommend the credential and will
work to support employees who attain it.

What Regulatory Agencies

Govern the Work of the
HTM Profession?
All of the efforts of HTM technicians are aligned with local,
state, and national standards, regulations, and best practices.
Numerous governing bodies and associations guide the support
and use of equipment in healthcare. Many groups do not regulate
utilizing laws but offer guidelines and validation of compliance
with standards of best practice. All hospitals are legally regu-
lated by the board of health for a specific municipality. However,
most specific guidelines do not come directly from state and
local legislatures.
15

15 WHAT ARE SOME WAYS THAT HTM PROFESSIONALS STAY CONNECTED?

The most prominent agency offering guidance is The Joint

Commission (previously known as The Joint Commission on
Accreditation of Healthcare Organizations, or JCAHO). The Joint
Commission is an independent, not-for-profit organization that
does not specifically “regulate” hospitals but offers voluntary
accreditation. With this accreditation, a hospital is eligible for
Medicaid and Medicare payments. While technically optional,
almost all hospitals are inspected by the Joint Commission in
order to be reimbursed for patients covered by Medicare and
Medicaid insurance. The Joint Commission guides many hospital
activities, not just the support of technology.
Other guiding agencies and associations include the National
Fire Protection Association (NFPA), the Compressed Gas
Association (CGA), the College of American Pathology (CAP), the
Occupational Health and Safety Association (OSHA), the Laser
Institute of America (LIA), and the AAMI. Compliance with the
many recommendations, regulations, and standards of best prac-
tice is a collaborative effort between technicians and clinicians
toward continuous education, to remain up-to-date as guidelines
change. HTM technicians will be expected to have a commitment
to lifelong learning and professional development to ensure safe
and effective patient care.

What Are Some Ways that HTM

Professionals Stay Connected?
■ Join the Association for the Advancement of Medical
Instrumentation. AAMI has several excellent publications as well
a large annual conference. For students enrolled in at least 12
credit hours, the cost is extremely low. The website for AAMI is
www.aami.org.
■ Join your local society. Many areas of the United States have
HTM organizations. A list of regional groups is available on the
AAMI website www.aami.org.
■ Subscribe to 24x7, a free trade magazine focused on the HTM
profession. Visit www.24x7mag.com to subscribe.
16

16 A CAREER IN THE HTM PROFESSION

■ Subscribe to TechNation, a free trade magazine that contains

articles for technicians. To subscribe, visit their website at http://
1technation.com.

Engineering Versus Technology

While career pathways and job titles vary widely, general differ-
ences between the focus of an engineer and technician can be
identified. From an academic perspective, the coursework may be
different, with technicians focused on the applications of math-
ematics or current technologies utilizing hands-on experience.
In the HTM profession, distinctions may be visible in position
responsibilities or employment tracks. However, overlap exists in
some circumstances. For example, the credential Certified Clinical
Engineer (CCE) can be earned by HTM professionals who have
earned a bachelor’s degree in engineering technology from an
institution with ABET accreditation. Figure 1.4 illustrates the
career relationships between technician, engineer, and leadership.
Note that the HTM profession is sometimes confused with the
discipline of biomedical engineering (BME). Most biomedical
engineers are focused on research, investigating complex medi-
cal questions, rather than the support of existing devices and
technologies. Many biomedical engineers examine issues at a
cellular level, exploring biomedical implants or nanotechnology.
The Biomedical Engineering Society website at www.bmes.org
can clarify the differences with the HTM discipline. There is the
potential for great confusion to occur when hospitals and societ-
ies label HTM technicians as biomedical engineers.

Study Questions

1. Write a brief “Want Ad” you might see for an entry-level posi-
tion. Include typical duties and qualifications.
2. Where does an HTM professional usually work? Who are typi-
cal employers?
 17

C-Suite

Manager
(Department Level)

Supervisor

Team Leader

Senior Networked
HTM LEADERSHIP Systems/
Specialist Engineer
Integration
Level III Engineer
Staff
Level II Engineer

Level I
CLINICAL ENGINEER
TECHNICIAN

FIGURE 1.4. HTM Career Progressions

(courtesy of AAMI)
18

18 A CAREER IN THE HTM PROFESSION

3. What is an in-service meeting? Who would attend?

4. What is done during a PM? Why is the task beneficial?
5. Describe a typical day for hospital-based, entry-level technicians.
What would be worn at work? How might the workday be spent?
Where in the hospital would they be doing these activities?
6. Make a list of the advantages and disadvantages of field
service work.
7. Define and describe certification. Is it voluntary? Why might a
person become certified?
8. Being inspected by the Joint Commission is technically optional,
but why is it important to so many facilities?
9. Make a list of some of the groups that you might consider join-
ing as part of your career. List some of the benefits of joining
associations and societies.

For Further Exploration

1. The lack of career awareness can be a significant hurdle. Read

the government’s Occupational Outlook Handbook (from the
U.S. Department of Labor at www.bls.gov/ooh/) and search
for “medical equipment repairers.” Summarize the information
presented. Does the information look accurate for the positions
in your area?
2. Visit AAMI’s career website at www.IamHTM.com. Review the
brochures available for download. Summarize the information.
3. Watch a video made about the HTM field. You can find many
on the AAMI website, labeled “Videos from the Field.” Identify
any interesting points.
4. In what year was nursing founded? Now, consider that technol-
ogy was not used in healthcare until the 1970s. Hospital-based
technicians did not exist prior to the introduction of technol-
ogy into patient care. What kind of impact has the relatively
short history of biomedical instrumentation had on the prestige
and recognition of technology support within the hospital? For
19

19 FOR FURTHER EXPLORATION

example, can you understand how space allocation in a hospital

is influenced by “who got there first?” Use the Internet to col-
lect references to substantiate your answers.
5. A significant rise in HTM-related career awareness occurred
with an article written by Ralph Nader in the Ladies Home
Journal in March 1971. The author claimed that there were a
large number of hospital electrocutions each year. Search the
Internet for this notorious article and summarize it. Evaluate
the prestige and style of the article. Discuss the impact of the
article on the career today.
6. What hospital employees make up a hospital safety committee?
Why should HTM professionals be on this committee? What
role do they play in hospital safety and emergency planning?
7. How can technicians promote good communication with staff
about devices that do not work? Design and propose commu-
nication methods that would enhance the relationship between
technicians and the staff who use the equipment.
8. Visit the website for the journal 24x7 or TechNation. Look in
the archives for an article that interests you. Summarize the
article. Include a reflection on how this information might have
an impact on your career when you are working in the field.
9. Explore generic websites that post employment ads, such as
monster.com. Search for positions that are related to HTM-
related work. Summarize the number and type of positions
you find. Now search websites such as AAMI’s job postings.
Describe how the opportunities are different. Visit major HTM
employers such as www.philips.com (search in “Healthcare”)
and www.aramark.com (search “Healthcare Technology”) and
explore the employment/career sections. Summarize a position
that you find that seems appealing to you.
20

2
Patient Safety
Learning Objectives
1 Describe the types of healthcare technology.
2 Identify why patients are at risk in the clinical environment.
3 Describe the challenges associated with the utilization of medical
technology in a non-clinical environment.
4 Define the types of currents related to the human body.
5 Identify the amount of current related to physical sensation, pain,
injury, and death.
6 Define microshock and macroshock.
7 Define the hazardous currents in clinical electrical equipment.
21

21 HEALTHCARE TECHNOLOGY

Introduction
An important responsibility of the HTM profession is related
to patient safety. Ensuring the safe use of technology is a vital
role of the HTM technician as part of the medical care team.
Understanding the human body and its interaction with technol-
ogy is critical to patient safety.

Healthcare Technology
Many forms of technology are utilized as tools in medical care.
The devices must be safe and effective. In addition, the devices
must perform in a way that healthcare providers expect, con-
sistently and reliably. Devices range from very simple (without
electricity or moving parts) to highly complex (imaging devices).
In general, devices fall into three categories: therapeutic, moni-
toring, or diagnostic.
■ Therapeutic devices generally offer support or treatment to the
patient, such as ventilators that provide assisted breathing for
patients who cannot breathe on their own.
■ Monitoring devices gather physiological information for clini-
cians to interpret and utilize for treatment decisions, such as an
automated device to measure blood pressure.
■ Some devices are diagnostic, offering information about the
patient, such as an X-ray machine producing internal images to
identify a broken bone.
Medical devices can also be categorized by inherent risk. High-
risk devices are associated with the functions critical to sustain-
ing human life (life support) and can result in serious injury or
death to a patient if they malfunction. An example would be an
anesthesia machine utilized during surgery. Medium-risk tech-
nology is important to patient care but a malfunction is unlikely
to cause serious injury. An example of a medium-risk device
would be an ultrasound machine, whose images are extremely
useful but not critical to patient survival. Lastly, low-risk devices
have few consequences related to malfunction other than staff
22

22 PATIENT SAFETY

or patient frustration. An infant scale would be an example of a

low-risk device.

Patient Safety and Risk

Medical care and treatment of patients depends on a balance
between benefits and risks. If safety alone is the focus, then the
safest approach in healthcare would be to offer no treatment, and
utilize no techniques, or technology. This would be safe but not
beneficial. In contrast, interventions are integral to healthcare.
The HTM profession works to minimize any risks associated with
use of technology. Understanding why patients who seek medical
interventions are at risk from technology is important to mini-
mizing potential hazards. Issues include:
■ The number of devices incorporated into patient care. Many hospi-
tals utilize thousands of devices throughout hundreds of categories.
■ The patient care environment can be very challenging for
devices, including exposure to fluids of various types, sudden
or unplanned motion, and unintentionally damaging actions.
Healthcare providers focus on preserving the patient as their first
priority, and preserving technology is less of a priority.
■ Patients are directly and electrically connected to technology.
■ Fluid-filled tubes (catheters), metal beds, and fluid-drenched
environments can make effective and unintended conductors of
electricity.
■ Medical care providers may have a limited knowledge of technol-
ogy and/or electricity.
■ Patients may be unconscious or unable to move away from haz-
ardous situations involving technology.

Healthcare Environments
Technology is utilized outside of the clinical setting when health-
care is delivered in the home, assisted care facilities, or other
environments. Although often referred to as homecare, the wide
23

23 ELECTRICAL SHOCK

variety of locations include schools, cars, planes, and public

spaces, all areas that lack the controls and regulations of a clini-
cal setting. The environment may be unreliable, unsanitary, clut-
tered, or noisy. For example, while emergency power is required
to be restored in a hospital within 10 seconds, power restoration to
homes after a storm can take days or weeks. In addition, patients
or their caregivers must manage complex medical devices such
as monitors, ventilators, dialysis machines, and infusion pumps
in non-clinical settings.
While healthcare services provided outside of the clinical set-
ting cost less and may offer better patient outcomes, the support
of the technology requires technicians to rethink service models
to ensure patient safety and minimize risk. Training for users
must extend to caregivers who are tremendously diverse, varying
in age, education, skill, physical condition, and language profi-
ciency. Many device–user interfaces were not designed for use
by non-clinicians and may not be intuitive for a layman. HTM
technicians must creatively address the challenges related to the
use of technology in home healthcare settings, developing best
practices and support tools to promote the use of medical equip-
ment safely and appropriately.

Electrical Shock
In 1971, Ralph Nader wrote a widely read article in Ladies Home
Journal explaining that “at least 1,200” patients were electrocuted
each year because safety measures were “grossly neglected.”
Nader cited the lack of technical staff within the hospital as con-
tributing to this situation. Medical technology had just begun
to expand to the patient bedside with Nader’s article prompting
much debate about safety in healthcare and dramatic increases in
awareness of the need for medical equipment maintenance.
An injury related to electrical shock may occur in any environ-
ment, but there is a higher potential for electrical injury in the
hospital because of the direct contact of patient or caregiver and
equipment. In addition, a great many devices may be associated
24

24 PATIENT SAFETY

TABLE 2.1. Human Detection of Current

Current description Current (mA) Physiological effect

Threshold 1–5 Tingling sensation

Pain 5–8 Intense or painful
sensation
Let go 8–20 Threshold of involuntary
muscle contraction
Paralysis >20 Respiratory paralysis and
pain
Fibrillation 80–1,000 Ventricular and heart
fibrillation
Defibrillation 1,000–10,000 Sustained myocardial
contraction and possible
tissue burns

Note: These values will vary based on the person’s gender, size and weight, skin
moisture content, and pain tolerance levels.

with one patient. The sensations or characteristic symptoms of

various levels of electrical current are described in the following
paragraphs and summarized in Table 2.1. The effects of electrical
currents on the human body and tissue may range from a tingling
sensation to tissue burns and heart fibrillation leading to death.
Electrical energy has three general effects on the body:
1. Resistive heating of tissue
2. Electrical stimulation of the tissue (nerve and muscle)
3. Electrochemical burns (for direct current)
When the human body is exposed to current, reactions can be
grouped based on the quantity of current. The six categories are:

Threshold current (1–5 milliamperes (mA)): This is the level of

current required to perceive the feeling of current. A slight fuzzy
feeling or tingling sensation is common at this current strength.

Pain current (5–8 mA): This current level will produce a pain
response, which may feel like a sharp bite.

Let go current (8–20 mA): This current level results in invol-

untary muscle contraction. Nerves and muscles are strongly
25

25 ELECTRICAL SHOCK

stimulated resulting in pain and fatigue. At the low end of Let go

current is the maximum amount of current from which a person
can move away voluntarily (about 9.5 mA). At these levels, inju-
ries may result from the instinct to pull away, for example, arm
dislocation or broken bones from falls.

Paralysis current (>20 mA): At levels greater than about 20 mA,

the muscles lose their ability to relax. This includes the muscles
involved in breathing. The breathing pattern can no longer be
maintained and results in respiratory paralysis. Respiratory paral-
ysis can result in death.

Fibrillation (80–1,000 mA): At levels between 80 and 1,000 mA,

the heart goes into fibrillation. Fibrillation is the unsynchronized
contraction of the muscle cells within the heart. During fibrilla-
tion, the heart is ineffective in pumping blood to the body. Heart
fibrillation will result in death.

Defibrillation (1,000–10,000 mA): The delivery of electrical

energy to the fibrillating heart is called defibrillation. A large cur-
rent delivered by paddles at the skin, through muscle and bone,
can resynchronize all of the cardiac muscles. Then coordinated
electrical generation can return to the heart. During open-heart
surgery, spoon-shaped paddles can deliver much lower currents
directly to the heart to induce fibrillation (to perform bypass sur-
gery, for example) and then defibrillate the heart after the proce-
dure is complete.
Researchers at Massachusetts Institute of Technology would
like these current ranges redefined. One reason to change the
limits is the vast differences between people in their size and
perception of pain. Because there is such a great variance from
person to person, keep in mind that the current ranges listed here
are only guidelines and approximations.
The electrical shock situations described in Table 2.1 are iden-
tified by the term macroshock. Macroshock is a physiological
response resulting from electrical current in contact with the skin
of the body. Macroshock can occur when a person makes an elec-
trical connection with two parts of the body (arms, for example)
26

26 PATIENT SAFETY

or a person is connected to “earth ground” (a lower potential

area) and makes an electrical connection with one point of an
energized source.
The skin of the body provides some protection from electrical
hazards because of the skin’s resistive properties. Dry, unbroken
skin acts as an insulator. In the hospital environment, a patient
may be especially susceptible to small electrical currents because
the skin may be wet or open from wounds.
A patient may be connected to fluid-filled catheters (tubes)
threaded into blood vessels, the urinary tract, or located close
to the heart. If these pathways are used to bypass the insula-
tor qualities of the skin, electricity may be conducted directly to
the heart. This very dangerous situation is termed microshock.
Microshock is a physiological response resulting from electri-
cal current applied to the heart. Microshock currents are often
tiny, so they are measured in microamperes (μA). Because there
is conduction to the heart, even these small currents can be large
enough to cause fibrillation of the heart. Be aware that very little
can be done within a power system to protect against micro-
shock. Isolated power, ground-fault circuit interrupters, line iso-
lation monitors, and other safety precautions do not protect the
heart directly from these low current levels.

Leakage Currents
All electronic devices have naturally occurring, unintended cur-
rents within them. These are not due to any faults in the devices;
they are simply present. All devices have leakage current. For
medical devices, HTM professionals categorize and measure these
leakage currents to remove devices that have hazardous current
levels.
Four categories of leakage currents are measured and have
recommended safe limits. The categories are determined by the
method that a person might come in contact with the current
or the device. The four types of currents are: earth leakage cur-
rent (also called earth risk current); touch leakage current (also
called enclosure risk current and chassis leakage current); patient
27

27 LEAKAGE CURRENTS

leakage current (also called lead leakage current); and patient

auxiliary current. Chapter 4 will outline these in greater detail
and explore the procedures and test equipment utilized to mea-
sure these currents and assess device risk.
Leakage current is best defined as the small current that flows
from the components of a device to the metal chassis. This is
natural and is a result of wiring and components. It can be either
resistive or capacitive. Resistive leakage current comes from the
resistance of the insulation surrounding power wires and trans-
former windings. Resistive leakage current is much smaller than
capacitive leakage current. Capacitive leakage current forms
between two oppositely charged surfaces, such as between a wire
and a chassis case or between two wires, one hot, one neutral.
A capacitive current is formed between the two surfaces and
tends to stray from the intended current path. Adding a safety
ground wire is a method to reduce excessive leakage current.
The third wire acts to divert the stray or leakage current away
from the chassis (which the patient or caregiver may come in
contact with) and to the intended circuit ground in the case of a
short between a hot wire and a chassis ground. The benefits of a
ground conductor drive the requirement to have a ground con-
ductor on all devices (see Chapter 3).
Device currents are identified in two circumstances: when the
device is working properly and when there is a fault. The fault
current is the current that flows when the device is broken, the
worst-case scenario condition. The fault current is the maximum
possible current flow from a device to ground or a person or
another metal object. Types of faults occur when
■ the ground is not connected
■ each barrier of a double-insulated instrument is short-circuited
■ a supply conductor (hot or neutral) is not connected properly
■ hot and neutral are reversed
■ a single component fails
■ line voltage is applied to an input or output part or chassis (for
ungrounded equipment)
■ line voltage is applied to a patient connection (for isolated patient
connections).
28

28 PATIENT SAFETY

Fault currents related to device failures can be very hazardous.

Chapter 4 will discuss techniques used to minimize device failures
and fault currents.

Study Questions

1. Name two reasons patients are highly susceptible to electrical

shock.
2. Describe a scenario that would result in macroshock. Identify
the power source.
3. Describe a scenario that could result in microshock. Identify the
power source and describe how the current travels through the
patient.
4. Is human skin generally an insulator or a conductor? Why is
that beneficial?

For Further Exploration

1. Download the AAMI publication A Vision for Anywhere,

Everywhere Healthcare from the AAMI website. Identify the
five clarion themes. Summarize each of them. Reflect on how
home healthcare may impact your ability to support medical
technology.
2. Download the FDA publication entitled: Home Use Devices: How
to Prepare for and Handle Power Outages for Medical Devices that
Require Electricity available from www.fda.gov or here: www
.iupui.edu/~bmet/book/Power_Outages.pdf. Summarize the rec-
ommendations to caregivers and users on how to be prepared.
3. IEEE Standard 80 explores the impact of current on the body.
Search the Internet for this standard and look at section 5.2.
While the equation may be complicated, the factor that influ-
ences human harm is specifically related to shock duration.
How is the inability of a patient to move (remove their limb
from the electrical connection, for example) related to the harm
from an electrical shock?
29

29 FOR FURTHER EXPLORATION

4. Use the Internet to define and describe a Swan-Ganz catheter.

Where is this device located within the body? Does a patient
have an increased risk of electrical shock? If so, what type of
electrical shock?
5. Explore the database of device problems on the FDA site. The
address for a search is: www.accessdata.fda.gov/scripts/cdrh/
cfdocs/cfmdr/search.CFM. To enter a search string, use a device
name from this text. Search for an incident and summarize it.
Discuss the role of human error and device flaws (in design or
function) in this incident.
30

3
NFPA and Other
Guidelines
Learning Objectives
1 Characterize the NFPA 99 code in general.
2 Define the patient care vicinity.
3 Identify the maximum duration of power interruption before
emergency power is provided.
4 Identify electrical receptacle requirements in a hospital (wiring
and testing).
5 Define GFCI and LIM and the regulations regarding performance
in the clinical environment.
6 Describe NFPA 99 code requirements for relocatable power taps
(power strips).
31

31 CODES AND STANDARDS

7 Understand how NFPA 99 can be used to obtain maintenance

manuals for equipment.
8 Characterize the content of Life Safety Code 101.
9 Identify the role of the Joint Commission and the Centers for
Medicare & Medicaid Services (CMS) in patient safety.

Introduction
Healthcare settings are regulated by a wide variety of groups.
Some groups have direct control over operations, such as the
state board of health for a hospital. Others offer voluntary guide-
lines to follow in order to receive insurance payments for patients
treated. Some environments have only a few requirements, such
as when healthcare is delivered in the home. Understanding the
myriad of guidelines, recommendations, and laws is helpful in
promoting compliance and supporting safe patient care.

Codes and Standards

The Association for the Advancement of Medical Instrumentation
(AAMI) and several other non-profit organizations have devel-
oped standards for best practices through consensus within the
HTM profession. The standards are not legal requirements but
recommendations for compliance. Some examples of AAMI stan-
dards are EQ56 Recommended Practice for a Medical Equipment
Management Program and EQ89 Guidance for the Use of Medical
Equipment Maintenance Strategies and Procedures.
The National Fire Protection Association has established recom-
mendations for healthcare with NFPA 99: Health Care Facilities
Code. The National Fire Protection Association first established
the code in 1984 “to minimize the hazards of fire, explosion, and
electricity in health care facilities providing services to human
beings.” Code 99 applies to healthcare and the technology used
within many types of clinical settings. The entire code is available
online at www.nfpa.org. Some states have adopted NFPA 99 as
state law. When states adopt these standards as law, the guide-
lines become absolute legal requirements.
32

32 NFPA AND OTHER GUIDELINES

The NFPA 99 code is revised from time to time. The latest ver-
sion of the code was released in 2012. References to the 2012
edition code will be made in this chapter.

NFPA 99 Definitions
Anesthetizing locations: An area of the facility designated
to be used for the administration of nonflammable inhalation
anesthetic agents. (Flammable anesthetics, such as ether, are no
longer used in this country. There were many precautions and
regulations when flammable anesthetics were used.) Chapter 13
reviews the four types of anesthesia but only when general anes-
thesia is delivered is the area designated an anesthetizing loca-
tion by NFPA 99. The other types of anesthesia are not subject to
the requirements of anesthetizing locations.

Failure: Failure of a component, loss of grounding pathways,

short circuits, or faults between conductors and the chassis.

Fault current: A current due to an accidental electrical con-

nection between an energized conductor and ground or chassis
resulting from a failure.

Grounding system: A system of conductors that provides a low

impedance return path for leakage and fault currents.

GFCI (ground-fault circuit interrupter): A device that will inter-

rupt (this means “break” or “stop power”) the electric circuit to
a load when a mismatch is detected between the hot and neutral
conductors. When the two currents are not equal, a fault current
must be flowing through the ground. GFCIs must fault when fault
current to ground is 6 mA or greater (NFPA 99 A.6.3.2.2.8.2(2)).

Isolated power: A system that uses a transformer to produce

isolated power and a line isolation monitor (LIM). The electrical
grounds of the system are connected (on both the hospital and
33

33 NFPA 99 DEFINITIONS

isolated side). The power is isolated (hot and neutral), not the
grounds. Wet locations can benefit from the electrical safety in
the isolation of power supplies.

Isolation transformer: A transformer used to electrically isolate

two power systems.

LIM (line isolation monitor): A line isolation monitor is an in-

line, isolated-power test instrument designed to continually check
the impedance from each line of an isolated circuit to ground. It
contains a built-in test circuit to test the alarm without adding
additional leakage current. The line isolation monitor provides a
warning (usually a loud buzz or other noise) when a single fault
occurs, or when excessively low impedance to ground develops,
which might expose the patient to an unsafe condition should
an additional fault occur. When the total hazard current reaches
a 5-mA threshold, the monitor should alarm. LIMs must alarm
when the fault current (from conductor to ground) is 5.0 mA or
greater. LIMs must not alarm if current is 3.7 mA or less (NFPA
99 6.3.2.6.3.2). Be aware that the LIM does not break the circuit
like a GFCI. Excessive ground currents trigger alarms but will not
stop the power to the system.
LIMS must be tested after installation and every 6 months by
grounding hot and neutral through a resistor. Also, there must be
a check of the visual and audible alarms. The LIM must be tested
each month with the test button. LIMs with automated self-test
capabilities must be tested every 12 months (NFPA 99 6.3.4.1.4).

Medical air: Air that is 19.5–23.5% oxygen. It also has specifica-

tions that limit contaminants such as moisture or bacteria.

Patient care vicinity: Any portion of a facility where patients are

intended to be examined or treated. This environment is defined
as the area around the patient bed. The vicinity is defined as 6 feet
(ft) around the bed and 7 ft 6 inches (in) above the floor below the
patient. See Figure 3.1. The area does not extend beyond walls
34

34 NFPA AND OTHER GUIDELINES

FIGURE 3.1. Patient Care Vicinity

or move when the patient moves, for example, while walking in

the hallway. Note that non-patient care vicinities such as wait-
ing rooms, business offices, break rooms, nurses’ stations, and
corridors are not required to comply with many of the NFPA 99
electrical codes.

Patient connection: An intended connection between a device

and a patient that can carry current. This can be a conductive
surface (for example, an ECG electrode), an invasive connection
(for example, an implanted wire), or an incidental long-term con-
nection (for example, conductive tubing). This is not intended
to include casual contacts such as push buttons, bed surfaces,
lamps, and hand-held appliances.

Wet location: A patient care vicinity that is normally subject

to wet conditions while patients are present (not routine house-
keeping). An example would include physical therapy areas
where whirlpool baths are used. Patient beds, toilets, and wash-
basins are excluded as wet locations. The 2012 edition of NFPA
35

35 PROPER ELECTRICAL WIRING IN THE HOSPITAL

99 deemed all operating rooms (ORs) as wet locations (NFPA

99 6.3.2.2.8.4) and, as such, ORs were required to utilize spe-
cial protections against shock. However, the code also permits a
risk assessment to be done to determine whether each individ-
ual operating room is actually a wet location, depending on the
types of surgical procedures performed in the room. Guidance
documents for performing the risk assessment are available from
the American Society of Healthcare Engineering website www
.ashe.org.

Proper Electrical Wiring

in the Hospital
Interestingly, outlets in a hospital are usually wired with the
ground pin at the “top” of the outlet (see Figure 3.2). This is an
NFPA 99 requirement (NFPA 99 6.3.2.2.1.1). In states where NFPA
99 is law (it is law in only about half of the United States), outlets
are wired in this orientation. However, older facilities and hospi-
tals in states where NFPA 99 is not law may have outlets wired
with the ground pin below the hot and neutral pins.
Outlets should be hospital grade (a standard related to stur-
diness and manufacturing requirements). These outlets, which
have a green dot stamped on the face, undergo rigorous test-
ing during manufacture. Prior to 1996, all electrical outlets in
hospitals had to be checked (integrity, polarity, and ground con-
nection) once per year. In 1996, the regulation regarding the
frequency of testing of receptacles was changed. Hospital-grade
receptacles must be tested at the time of installation or when
serviced. No other checks are required (NFPA 99 6.3.4.1.1). Non-
hospital-grade receptacles must be tested at least once every 12
months. Therefore, most hospitals use hospital-grade receptacles
(in patient care vicinities) so that receptacles do not need to be
checked yearly. Electrical outlets also have a specified amount of
physical “holding power” for the ground pin. The code requires
retention force of grounding blade of not less than 4 ounces
(NFPA 99 6.3.3.2.4).
36

36 NFPA AND OTHER GUIDELINES

FIGURE 3.2. Hospital Electrical Outlet (dot indicates hospital grade)

Some hospital outlets are colored red (either the receptacle

itself or its cover faceplate). This indicates that the receptacle is
wired to the emergency power (see emergency power time speci-
fications) in the event of an outage. Typically, life-saving devices,
such as ventilators, are connected to the emergency red outlets.
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