The Role of Physiotherapy Helpers in Out-patient Physiotherapy Services

RESEARCH PAPER

The Role of Physiotherapy Helpers in Out-patient Physiotherapy Services Liz Saundem

Introduction The physiotherapy profemion in the United Kingdom has reached an important stage in its histay. Qualification is n m by honours degree and helpers have been invited to join the Chartered Society as m i a t e members The climate is right far the profeseion to make decisions on skill mix, the role of the degree physiotherapist and the delegation of tasks to helpers. A tank was defined by Drury et a1 (1987) as a set of human actiona that contribute to a specific fundional objective and ultimately to the output goal of a system. In carrying out taeke three type8 of behaviour have been described by Raamussen (1982): skill-baaed behaviour, governed by stored patterns of pre-programmed instructions, rule baaedbehaviour,when familiar situations are dealt with by learned production rules, and knowledge baeed behaviour, umd to deal with completely new situations for which no actions have been pre-planned. M q taske in physiotherapy are uaed frequently and am skill- and rule-bad, yet may require knowledge because each patient ir an individual. Delegation of tasks allowe for the pemn with the knowledge to supervise mbordinatea who have gained the skills r e q u i d

and who can work to rules. Delegation was described by McBreath (1966) as the allocation of tasks from the position holder with responsibility for achieving objectives to a subordinate who has been given the authority to carry out the task and who reports to the position holder. Recent changes in the Health Service following publication of the White Papers ‘Working for Patients’ (DOH, 1989) and ‘Caringfor People’ (DOH, 19891 have resulted in the need for skill mix to be examined by all health care professionals, as purchasers demand a more cost-effective service without lose of quality. Physiotherapy was defhed in the 1984Curriculum of Study as: ‘A systematic method of assessing musculoskeletal, cardiovascular, respiratory and neurological disorders of function including pain and those of psychosomatic origin and of dealingwith or pmmting those problems by natural methods based essentially on movement, manual therapy and physical agencies.’ In out-patient departments physiotherapists specialise in musculoskeletal disorders. The role of the physiotherapist is to make a clinical diagnosis, to set a care plan, which will involve education and treatment, and to evaluate the progress of the plan and the final outcome for the patient. The helper assiets the physiotherapist to carry out care delegated at the physiotherapist’s discretion, according to the plan. How much can the helper assist the physiotherapist? How much does the physiotherapist’s discretion allow delegation? Should there be some rules of delegation to assist the process? The need to address task allocation between physiotherapists and helpers is not new. Twentyfive years ago Holmes (1970) made recommendations that physiotherapistsshould concentrate on decision making, planning and evaluating by supemsing delegated care; quantity would be increased while maintaining quality. The following year Watts (1971) described a theoretical framework to divide tasks between physiotherapist and helper. Yet in 1995 there is still no national system for the allocation of tasks between physiotherapist and helper. Physiotherapists in this country have been keen to avoid the compartmentalising of care as designed by Watts (1971) and have emphasised the need for close supervision and monitoring of the tasks delegated to helpers (Physiotheraw, 1989).

385

In January 1991 the Chartered Society issued guidelines for the delegation of tasks to helpers and other support workers (CSP, 1991)and ultimately left the decision on the delegation of tasks to helpers up to the individual physiotherapists; the physiotherapist’s judgement on the task and the competence of the helper being the deciding factor. This situation leaves open the considerable possibility that professionalism will bar the delegation of even simple tasks to helpers, and leave jobs in the profession undesigned. The division of labour between physiotherapists and helpers may vary on location due to the wide variations in staffing levels that exist nationally (Stock and Seccombe, 1992).

and Seccombe study (1992).Before a greater use of helpers can be considered, it is important to find out about present usage and training. A survey was therefore carried out in Trent Regional Health Authority.

The purpose of the survey was to: OExamine the skill mix. 0 Establish what tasks were being carried out by helpers and physiotherapists. 0 Determine task frequency and therefore determine opportunity for practice. 0 Determine what training helpers have had and what training physiotherapists feel helpers should have. Helpers have been recognised as a valuable part of the physiotherapy service (Physiotherapy, 0 Discover what attitudes physiotherapists have 1992; Samuels, 1991). However, it appears that to using helpers for routine clinical tasks. helpers may be used to carry out clinical tasks 0 Discover what attitudes managers have to more in some areas than others. Figures for increasing the role of helpers. funded establishments for physiotherapy staffhg from the Joint National Professional Manpower Method Initiative for 1992/93 (JNPMI,1993) found a marked variation in the proportion of qualified A total of 65 physiotherapists and 30 helpers were staff to helpers between the Regions, with surveyed by questionnaire and physiotherapy Trent Regional Health Authority with the lowest managers were interviewed at ten sites in the physiotherapist :helper ratio at 3.56 : 1 and Trent Region. Scotland the highest at 8.3 :1 (table 1).

Sample

W e 1: Fbtb ofphvlrothsnpktrtohelpemIn the Unlted K-I by Regional Health Authority in i RHA

mm

Physiotherapists tmr helmr ~ _ _ _ _

Northern Yorkshire Trent E Anglia NW Tharnes NE Tharnes SE Tharnes SW Tharnes Wessex Oxford S Western W Midlands

Mersey N Western Wales Scotland

4.96 4.48 3.81 4.06 6.85 5.18 4.63 5.95 5.16 4.86 6.8 4.67 5.17 4.27 3.98 8.31

As Trent has the lowest ratio of physiotherapists to helpers, can the profession gain from the skill mix experience in Trent? What tasks are being undertaken by helpers in Trent, and what training have the helpers received? What do physiotherapists and managers in Trent feel about delegation of tasks to helpers? Out-patient departments were identified by physiotherapy managers as an area where helpers could be used more than a t present in the Stock

Five physiotherapy departments in District general hospitals and five in community hospitals were selected. The sites were chosen to include five large physiotherapy departments serving cities, and five community hospitals serving small towns, and were chosen at random from hospitals in the Region.

Interview Schedules A semi-structured interview was drawn up to obtain information and opinions about staffing levels, the role of helpers in out-patient departments, ratio of qualified staff to helpers, clerical support, waiting list initiatives, work loads, and training of helpers.

Questionnaires Questionnaires were designed for physiotherapists (A)and helpers (B) to identify what tasks they were carrying out and how frequently. Questionnaire A also focused on the delegation of tasks to helpers and perceived training needs of helpers and asked what physiotherapists’ concerns would be if helpers carried out a treatment such as ultrasound under their supervision. Questionnaire B also investigated the extent of helpers’ training, asking whether it had been formal by physiotherapists, on the job, for NVQs, or other. Both questionnaires asked respondents about their grade of post,hours worked per week and length of experience.

m k 3 l The questionnaire contained an identical list of tasks grouped into five sections: procedural, clerical, electrotherapy, manual and exercise therapy, and assessment. Respondents were given a choice of frequency at which each task was undertaken: 0 = ‘I don’t ever do that task’; 1 =‘I do that task about once a month’; 2 = ‘I do that task about once a week’; 3 = ‘Ido that task about once a day’; 4 = ‘I do that task two to five times a day’; 5 = ‘I do that task over five times a day!

Pilot Test

Two questionnaires were designed and pilot tested

which tasks were carried out by physiotherapists and helpers. This test was used because the data were non-parametric and there were more than two choices of frequency. Calculations were done by pencil, paper and calculator

Results tnterviews with Managers 1. Ratio of Physiotherapists to Helpers The ratio of physiotherapiststo helpers ranged from 1.5 : 1to 8.5 : 1with a mean of 4.1: 1. Six of the ten sites had in addition receptiodclerical support. The District general hospitals had the highest physiotherapist :helper ratio when compared with community hospitals (table 2).

for clarity and content on five physiotherapistsand four helpers, who were asked if there were any Wle 2 Phydotheraplst:helper ratio at sites surveyed tasks that they carried out that were not included. n Mean sd Range These staff were asked to complete the question- Hospitals naires for a second time six weeks later when it was Community 5 3 1.1 1.5-4.5 considered that they would have forgotten their District general 2.3 3.5-8.5 5 5.3 original responses. Many of the questions on the Total 10 4. I 2.1 1.5-8.5 questionnaires for helpers and physiotherapists were the same and these were tested for reliability by the test-retest method (r = 0.91). 2. Waiting Lists and Waiting List Znitiatiues

Procedure The ten physiotherapy managers were invited by letter to participate in the survey and then contacted by telephone to arrange an interview in their department. The same person interviewed all managers and notes were taken of the responses. The interviews took about 40 minutea At the end of the interview questionnaires were left with them to distribute to their staff. Anonymity and coniidentiality were assured in covering letters which explained the purpose of the survey and stamped addressed envelopes were attached for return of the completed questionnaires.

Analysis of Data Data from the questionnaires were put on to an Excel spreadsheet and descriptive graphs were generated. For the purpose of this study, to look at tasks that were carried out frequently by staff, tasks carried out two to five times or more than five times daily were described as being carried out frequently. The more detailed analysis of task frequencies was collected for a further study to make decisions on tasks suitable for delegation by using the criterion of task frequency giving opportunity for practice and therefore skill building. Interview notes were analysed by hand per question. The extended chi-squaredtest as used to determine significant differences between the frequency at

In all ten sites there were waiting lists for first physiotherapy appointments ranging from two to 26 weeks from referral, with a mean for the group of7.8, standard deviation of 8.7 weeks. When asked how, given resources, they would help supply to meet demand, all ten managers said they would emplcry more physiotherapists either as additional staf€ or by using current staff to work overtime. Only one thought that, in addition to employing more physiotherapists, another helper could be useful;this manager’s physiotherapist:helper ratio was the highest in the group at 8.5 :1.

3. f i l e s of Helpers At nine of the ten sites helpers assisted physiotherapists with patient treatments; a physiotherapist was always in the department supervising the helper. When asked specifically about skill mix and about enlarging the role of the helper, four managers thought helpers could be used more, so long as physiotherapists supervised the helpers’ work. Five managers felt that the helpers’ role had become more of a clerical support role, due to increasing information requirements. 4 . Training of Helpers All ten managers felt that learning on the job was the most important means of the helper developing skills, but that this should be supplemented by formal education from physiotherapists. Three managers felt that National Vocational

Qualification (NVQ) training should be used by helpers; seven felt that the NVQ skills were too broad to be appropriate for out-patient helpers. 5. Work Loads When asked about the specific effects of using helpers under the supervision of physiotherapists to carry out routine clinical tasks, eight managers felt that outcomes to episodes of care would not change and that quality would not be lost. Nine felt that costs would be reduced and seven that throughput per physiotherapist would increasa There was concern that the physiotherapists would lose touch with their patients and that average attendance per condition could then increase The need for physiotherapista to supervise delegated tasks was stressed by all managers, and for helpers to be tested for com&tence

ndcs

Procedural and Clerical lhsks Both physiotherapists and helpers carried out this type of task (table 4). Over 90% of the helpers carried out the p d u r a l taeks more than five times a day. Physiotherapists were escorting patients from the waiting area and preparing patients for treatment a~ frequently as the helpers (fig 1 overled. Helpers were more likely to tidy up, answer the telephone and deal with referrals.

Questionnaires The response rate was 94% in total, with physiotherapists 92% (n = 60) and helpers 97% (n = 29).

Characteristics of Respondents Physiotherapists who responded held the following grades of post Superintendent Senior 1

Senior II 32 JuniorM 8

6 14

Physiotherapisb’ experience in oubpatients ranged from less than one year to 31 years, helpers from under one year to 28 years (table 3). 39% of physiotherapists had one year’s experience or lees in the specialty,compared with 41% of helpers; 17% of physiotherapists and 52% of helpers worked part-time. Of the physiotherapists, 23% did not delegate clinical tasks to helpers. lbble 3: L o m h of ~ r l s n c (ep a n ) in out-patlenl departments of s t ~ U Staff

n

Mean

sd

Range

Physiotherapists

60

29

5.37 7.71

6.85

Helpers

1-31 1-28

7.67

Helpers7 Training 93% of helpers responded that training had been ‘on the job’, 76% also had formal lectures from physiotherapists, one helper had NVQ training to level 2. 75% of physiotherapists felt that training should be formal by physiotherapists, 65% felt it should also be ‘on the job’. 13% thought NVQs should be used. 3% felt training should be given by physiotheraw education institutes.

Answerphone

Dealwith refenals

m UP

PT H

2 0

3 0

PT H

63 34 8 0 0 7 3

28 17 15 0 7 0 5 4 42 7 20 4 13 0

m H

PT H Preparepatients PT H lntsrferential PT H Laser PT H Ultrasound PT H Pulsed shortmnre PT H TENS PT H WaX m H ICe PT H Hot packs PT H MOnitor exercises PT H progPT exercises H Suspension PT H Cervical traction PT H Lumbar traction PT

Escortpatients

Mobilisations

Reassessment Plantreatment Discharge Write in notes

8 79

50 78

3 76

8 69

10 62

22 4 73

0

65

12

45

55 53

40 34 39 38 45

7 28 14 88 17 58

21 17 21 8 48 35

59 54

52 5

t0.m
7 12 7 0

3 0 4 4 14 3 14 55

25

0 62

38

60

24

11

73

2 3 57 21 47 3

23 48 3

3

PT

0 97

0 0 0 10 0

0

80 0 90 0

90 0 87 0

38

3 0

3 8 3 0 17

Phy&#mpy,

62

8

21 45 24 50 I8 35 3 2 10

13 7 13 7 57 10 2 31

NS NS NS NS

6 16

48

30


7 2

40

55


a
3 10

42

PT H PT H

9

28

2 17

3

H

79

17 23 14 30 10

50

79

PT H PT H PT

37

21

14 42 31 30 17 37 14

H H Take history

6

58



< 0.01

12 NS 10 NS 5 NS 0 NS 5 < 0.01 0 65 <0.01 0 98 < 0.01 0 87 <0.01 0 07
July lseS,v d 81. no 7

389

Tasks Takinn

Discussion

1

Skill Mix The debate on skill mix in the physiotherapy profession is not new. In 1970 in an article on supportive personnel and supervisory relationships Holmes wrote: ‘To gain an understanding and consequent acceptance of the physical therapy assistant, all of physical therapy must be studied - not the assistant alone nor the therapist alone.’

c Progress assessment

h

Wriino

UD

Holmes went on to recommend that assistants carried out the routine clinical tasks, with physiotherapists evaluating, making decisions and supervising delegated care. She argued that the effective use of assistants would improve patient care and make physiotherapy available to all who needed it.

h 0

20

40

60

80

100

Percentage of staff Fig 4: Comparison of percentage of physiotherapists with percentageof helpers carrying out patient assessment, planning and admlnistration tasks frequently

Table 5: Numbers of helpers carrying out cllnical tasks and the number of sltes where they do so Task

Helpers (n = 29)

Sites (n = 10)

WaX

27 26 25 23

9 9 9 9 5 3 3 3 2 2

Hot packs Ice Monitor exercises Suspension therapy Progressing exercises TENS Pulsed SWD Ultrasound Laser lnterferentiai Cervical traction Lumbar traction

15

12 11

9 7

7 6 6 6

2 3 2

Attitudes of Physiotherapists to Using Helpers to Treat Patients 82% of the physiotherapists responded that they had concerns, see table 6 , about supervised helpers performing a task such as ultrasound, 9% were not concerned, and 9% did not respond to this question. Table 6: Concerns expressed by physiotherapists regarding helpers carrying out supervised ultrasound treatments Concerns

Physiotherapists (n = 60)

Assessment Dangers Localisation Legalities Professional erosion

Concerns

Reduced advice Loss of quality Unhappy to allow it Training

11 0

7 6 6 ~~

~

Physiotherapists (n = 60)

3 3

2 2

Watts wrote in 1971 of the unwelcome pressures on therapists to change a familiar and satisfying style of work, to relinquish tasks regarded as important and to assume new responsibilities for other workers and went on to attempt t o divide tasks between therapists, assistants and aides. Despite these papers written more than two decades ago, there is still no acceptable system, as this survey shows, for allocating tasks between physiotherapists and helpers in this country. Wide variation was found in skill mix between the outpatient research sites; the physiotherapist to helper ratio varied between 1.5 : 1 to 9.5 : 1. The clinical tasks carried out by helpers varied between sites, the helper from the 8.5 : 1site not carrying out any clinical tasks. This begs the question, what should the physiotherapist to helper ratio ideally be? Should each physiotherapist be able to supervise two to four support workers working in close proximity, as a joint Canadian physiotherapy and occupational therapy working party recommended (Brockett, 1993) or should the ratio be dependent on site, be it a nursing home or a hospital setting, as discussed by Schunk et a2 (1992)? The answer surely depends on what tasks a helper can carry out under supervision.

Task Allocation There was a wide variation in the tasks being carried out by helpers in the study, ranging from no clinical tasks at one site, to technical tasks requiring adjustment, such as traction, and to all electrotherapy tasks; a position found in similar studies (Bashi and Domholdt, 1993; McNeil et al, 1990). Assistants have been used to help provide a service and compensate for a desperate shortage of physiotherapists by specific formal in-service training to enable them to treat common conditions and to become competent through experience and repetition (Murray, 19881, and by informal training ~~~~~

Physiotherapy, July 1995, vol81, no 7

‘on the job’(Skhdield, 1992).’Raining, opportunity to practise and experience have thus produced the skills in helpers to assist physiotherapists to treat more patienta From this study in Trent, tasks that are carried out frequently can be identified as tasks that provide opportunities for skill building in those who practise them regularly; but still the question remains: which tasks can be delegated to the helper? Rrry (19661points out that delegation of planned rehabilitation programmes that include the application of therapeutic machines does not relieve physiotherapists of the responsibility to judge patients’ responses and adapt treatment, and emphasises that delegation is sharing. Fkrhaps the answer lies in the development of a close working relationship between physiotherapists and helpers, the helpers becoming extra pairs of hands for the physiotherapists. Physiotherapists were frequently carrying out tasks that were procedural non-clinical tasks, such as eecorting patients in from waiting areas observed to be, at some sites, well outside of the treatment area. These tasks could be carried out by helpers, or the use of space in treatment areas could be studied to introduce sub-waitingpositions and allocate treatment areas to groups of staff, in order to reduce time spent walking between treatments, waiting areas and telephones. It may be that the increased information requirements in recent years have changed the helpers’ role to reduce the clinical input in favour of clerical work. This was voiced as a problem by managers in the survey.

Training Training for the helpers studied in Trent was largely ‘on the job’ supported by some formal lectures by physiotherapists. Only one helper had undertaken the NVQ training to level 2. The majority of physiotherapists and managers favoured ‘on the job’ and in-house training and it seems this approach has adequately provided the helpers with the skills to help the physiotherapists with a wide variety of tasks both in Trent and elsewhere. The breadth of skills acquired by NVQ training were felt by the majority of physiotherapistsand managers to be inappropriate for out-patient physiotherapy helpers. Many of the skills learned on NVQ courses would not be used in out-patients, such as nursing, occupational therapy and speech therapy tasks. The electrotherapy skills included in NVQ level 3 training wre already being carried out at nine out of ten sites by the helpers in Trent. Occupational therapists also have concerns about the training and usefulness in their field of generic workers. Green (1991) mentions the strong case for enhancing specific skills of less qualified workers

who can then become more specialisedin a limited area. The need for helpers to take the training route to become professionals was questioned by Green, who postulated that fewer professionals should be used to deploy an extensive workforce of skilled workers. In-house training is being used to extend the skills of professionals in the Health Service. One of the most radical examples is the extended role of the nurse to strip and prepare veins for heart by-pass surgery (Dimond, 19901, normally a task carried out by surgeons. An example of the extended role of a physiotherapist in an orthopaedic out-patient clinic has been given (Hockin and Bannister, 19941, where a physiotherapist has undergone in-house training in orthotics and local steroid iqjections. If the professional role is to be extended, should the professional not consider the training and monitoring implicationsofextending the role of the helper? The question may be: Are the investments in training and monitoring worth the benefit to the service?

Nurses have undergone changes in skill mix and have shared patient care tasks with nursing assistants (O’Brien and Stepura, 1992;Neidlinger et al, 1993): some see this as a welcome extension to help the overburdened nurse (Donovan et al, 19881,others are concerned that quality may be lost (Kennerley, 1989;Sullivan and Brown, 1989). A study into the effectiveness of nursing care by Can-Hill et al (1992) at York University’s Centre for Health Economics found that there was a positive correlation between the grade of nurse and quality, and concluded that investment in qualified staff paid dividends in the delivery of good quality patient care. The major concern of any skill mix adjustment must be to ensure that the needs of the patient are met as they were before the change, that quality of care must not be lost.

Attitudes of Professional Staff and Managers to Task Delegation In occupational theraw Atkinson (1993)advocated the use of skill analysis to reprofile the service, with occupational therapists analysing their work so that their detailed knowledge of the skill and knowledge required to carry out tasks could be used; however, Atkinson pointed out that professional staff may have views that are heavily influenced by tradition, past practices and protectionism. Because of this it was essential that managers gained the commitment and motivation of the staff. The result of such a skill analysis, Atkinson postulated, will lead t o decisions on task allocation between therapist and helper, and ultimately to effective patient care without loss of quality, a more efficient service and a balanced skill mix.

301

Physiotherapists in the study were concerned about delegating the application of ultrasound to helpers working under their supervision. The greater concerns were expressed by physiotherapists working in sites with a high proportion of physiotherapists to helpers. Managers were concerned that the increased use of helpers could lead to lack of assessment and longer episodes of care. This was found to be the case by Williams (1991)who found that junior staff without adequate supervision had, on average, a 25% increase in numbers of treatments per case. This concern may be invalid when using helpers, as junior physiotherapists are qualified to treat patients independently, but helpers share in the care of the patient for the physiotherapist who retains responsibility. In research analysing the relationship between occupational therapists and their helpers, Green (1991)found that occupationalkherapists appeared to be preoccupied with their professional status and the pursuit of knowledge and qualifications, yet gave little recognition to the possibility that helpers could gain knowledge through experience. The helpers, nearly 50% of the workforce, were said to be the ‘invisible’ workers, whose potential was not being fully tapped by the therapists who were reluctant to pass on knowledge or use helpers effectively. Professional protectionism may bar the delegation of tasks to helpers in the absence of a structured approach to task delegation. Many repetitive tasks in physiotherapy may be skill- and rule-based, requiring little knowledge to carry out once the decision to treat has been made. If these tasks were delegated to helpers, close communication between physiotherapist and helper could ensure that knowledge is available to make necessary modifications as required. A structured approach to task delegation would need to address the communication network between physiotherapists and helpers. In Trent a t nine of the ten research sites helpers were involved in hands-on treatment. Hopefully this experience will help departments where helpers are carrying out clerical and domestic tasks only, to think again. The physiotherapists might find their job is enriched as they have more time to analyse their work; helpers may well enjoy their increased input into patient care.

Limitations of the Study This was a small study of skill mix in out-patient departments in Trent. Although Trent was chosen because of the low ratio of physiotherapists to helpers, this may not mean that helpers are carrying out more clinical tasks in Trent than in the rest of the United Kingdom. The study only looked at physiotherapy practice in the National

Health Service; helpers’ utilisation may vary still more in private practice. Helpers can be assisting in most specialties in physiotherapy; a wider study would be interesting.

Conclusions and Recommendations There is wide variation in skill mix and in the delegation of tasks to helpers within Trent. Where there has been a n investment in ‘on the job’ and formal training, helpers are carrying out clinical tasks delegated to them by the physiotherapists. Physiotherapists were more likely to expxese concern about helpers applying ultrasound, under supervision, in sites where the helpers performed mainly procedural and clerical taslte. A systematic analysis of physiotherapy tasks is called for, with criteria established for the allocation of tasks to either physiotherapid or helpers, with training and monitoring implications considered and communication networks planned, to allow for the successful delegation and supervision of tasks.This will help us to give value for money and to maintain a high quality service to patients. Author and Addmss tor Cwmspondence Mrs Liz Saunders MSc MCSP is superintendent physiathemPkt. PhysiotherapyDepartment, Derby C i General Hospital,uttoaeter Road, Derby DE22 3NE.

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NHS Information and Guidance The MedicalDcwkes Agency issues thrw types of warning notice: Safety Notkea (which mplace the old Safety Action Bulletins); Hazard Notices for urgent warnings; and Devlce Bulletins of mom general management imrC#1.

All rwf working in a health cam environment have a duty to report any Incident that occurs imrdving medicaldevices, equipmentor materlalsto the Defmrtment of Health through the Advetse incident Centre of the Msdkal M c e a Agency. Local procedures should be established for wch wo-. Thb baaebctfw notkoofsafayActlon BuWnsandGuidelines iswed in the latter half of 1994, followed by some guidelines and letters issued by the NHS Exocuthra The complete documents should be available for Inrp.ction In horpltal and local authority offices.

Satety Action Bulletins 1994 No 7W June

September fm this date bu//etins were issued wlth individual numbem only

34. Hewlett Packard M119008 pulse

R.gulaicn8 1987.

49. Portable, cordless and cellular

telephones: Interference with medical devices The Department has received reports of mobile and cellular telephones interfering with the operation of medical deviis. Portable. cordless and cellular telephones should not be used dose to patient monnoring, infusion or life support equipment because such interference may affect thek normal operation with potentially serious patient consequences. Wherever psdble. fixed cwnmunications should be used.

December 56. Glade Plug-ins electrical air fresheners: Recall notice The Departmenthas been made aware of the recall of Glade Plugins electrical air fresheners, manufacturedby Johnson Wax Ud and bearing the referew9 codes SCJOO5 and SCJOOM. Guidanceis given on identificationand return of

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NormalreadlngsweredLsplayedwhenpthts with clinical elgns of cyanosis ware being numltored,because of the use of an adult finger probe on children. Manufacturers' written inmru*kns mould be followed.

NHS Executive Health Service Guidelines 1994

October 40.Trailer towed by a tractive unit of an

43. Protection of children: Disclosure to NHS employers of criminal background of

Patienta and staff in a parked trailer escaped 8 e r h e injury when the trailer tilted from the horizontal. A modlkation is available from the manuacturer.

and 9ocla6 OtC 1-(

Draeger Evita ventilator collapsed owing to the pins securlng the arm's joints falling out.

oximeter finger probe Inappropriate use resulting in incorrect readings when used on pediatric patients

articulated vehicle: Potential risk of tilting

th.~dliea&hmmabdmporla ca#nlng I)W u ~ dy~ l l y pugs. h p l a a m dpkror w mnbnn to ma plugs

arm (supptting a breathing system f i e d to a

November 48.Breathing system hinged support arm failure A report has been received where the hinged

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those with access to children 46. Removal and associated expenses Payments to staff for loss of equity and additional housing costs 50. Clinical waste management 51. Occupational health services for NHS staff 54.NHS trading agencies: Future arrangements