Abstract Mobile communication and wireless data transmission are playing an increasing role in health care. Reports describing medical device malfunction related to cellular phones have raised awareness about the problem of electromagnetic interference. Although initial institutional responses were to ban cellular devices in hospitals, these restrictions are relaxing as the knowledge base in this area expands. Medical device malfunction is extremely rare if the distance from the transmitting device is greater than 1 m. This article reviews the current understanding of electromagnetic interference as it applies to the technology-rich critical care environment. D 2006 Elsevier Inc. All rights reserved.
1. Introduction
There are many causes of radiofrequency electromagnetic radiation in the hospital environment, with a dramatic increase in emission sources in the past decade. Several reports since the early 1990s [1-4] have raised awareness about electromagnetic interference (EMI) with critical medical devices, but many misconceptions persist. All electric devices have the potential to produce electromagnetic radiation, but attention has been largely placed on the use of cellular phones. Other common devices to bear in mind include walkie-talkie radios, wireless networks, personal digital assistants, and Bluetooth devices. The frequency spectra, power output, and potential risk of these sources vary significantly (Table 1). Wireless technology has potential benefits for patient care, improving communication and information access [5]. As their penetration into the health
* Corresponding author. Mount Sinai Hospital, Toronto, Canada M5G1X5. Tel.: +1 416 586 4800x3211; fax: +1 416 586 8480. E-mail address: stephen.lapinsky@utoronto.ca (S.E. Lapinsky). 0883-9441/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jcrc.2006.03.010
care environment increases, blanket bans on wireless devices are gradually being replaced by less-restrictive evidencebased policies. This article reviews current knowledge regarding EMI in health care, with particular reference to the technology-rich critical care environment.
2. What is EMI?
Electromagnetic radiation is emitted intentionally (eg, cellular phones) or unintentionally (eg, computers) by devices that generate electromagnetic fields (Table 2). Unwanted reception of this electromagnetic radiation may affect the functioning of medical devices if they are susceptible. Analog signals or digital data that have been altered by the currents produced by undesired electromagnetic fields are said to be corrupted. Data corruption of digital devices by radiated electromagnetic fields can alter data values, which may produce inaccurate results or even cause a device to freeze as a result of invalid operations. Analog devices may also suffer effects caused by changes in
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Table 1 Comparison of frequency and power output of common transmitting devices Device Two-way radio Cellphone/Blackberry Wireless local area network (802.11) Bluetooth Frequency 60 to 400 MHz 860 to 1900 MHz 2.4 and 5 GHz 2.4 GHz Power 2 to 5 W 60 mW to 2 W 10 to 100 mW 1 to 10 mW Table 3
currents, producing temporary or permanent malfunctions. Multiple devices in close proximity may interact in unpredictable ways.
ogies (Table 3) introduce new variables that may affect EMI. Wireless local area networks (802.11) and Bluetooth function at a higher frequency and lower power as compared with cellular devices and are far less likely to produce EMI.
Electromagnetic interference in critical care the radiofrequency emissions produced by other electronic devices (Table 2). Clinically significant effects of EMI from devices that are not specifically designed to transmit signals are uncommon but add to the complexity of the ICU environment. The first reports of cellular phone interactions with medical equipment occurred in the early 1990s, involving devices such as infusion pumps, infant incubator heaters, electric wheelchairs, and ventilators, usually at a close range of less than 2 m [1-3]. Of concern is that silent equipment malfunctions, occurring when normal alarm mechanisms also malfunction, were documented [3]. Pacemakers were subsequently identified as devices at considerable risk for interference by cellular phones [11]. Clinical reports of adverse effects caused by EMI in the ICU environment include rare descriptions of ventilator malfunctions and effects on pulse oximeters, all with a close range exposure [4,6]. A potentially dangerous early report affecting neonatal ICUs identified the heater element of an infant incubator being turned on to maximum heat [12]. Over the past decade, the use of cellular phones has increased dramatically, as have the number and complexity of electronic devices used in the ICU. However, the incidence of EMI has not increased owing to reduced power output from cellular phones and improved electromagnetic immunity of medical devices. Recent reports relevant to the ICU have evaluated the risk of EMI in simulated clinical situations. An early study evaluating the effects of GSM (global system for mobile communications) cellular phones and ultrahigh frequency radios on mechanical ventilators demonstrated varying degrees of temporary effects, with 3 of 22 ventilators failing altogether under some circumstances [13]. A laboratory study on 14 ICU ventilators exposed to an analog cellular phone demonstrated that interference caused the failure of 1 ventilator and affected ventilatory rate, displayed tidal volume, and alarm function in 4 others [6]. These effects only occurred in close proximity (30 cm), with no interference at 1 m. A recent study identified that at distances of less than 1 m, high-power 2-way radios caused significant operating problems for ICU ventilators, including the shutting down of 1 ventilator. Medium-power cellular phones caused some ventilator displays to give erroneous readings, whereas Bluetooth devices were innocuous [14]. The problem of EMI is a moving target as new radiofrequency communication technology is developed and proliferates. Newer cellular technologies that allow faster data transfer are being developed (Table 3), few of which have been tested in a health care environment. A study comparing a third-generation UMTS (Universal Mobile Telephone Standard) system with an earlier GPRS (general packet radio services) digital system found less interference with the newer technology [15]. Wireless area networks (802.11b initially and now 802.11a and 802.11g) are common in the non-medical environment and are now entering the health care field. These higher-frequency and relatively lower-power systems have been evaluated in
269 clinical situations and are unlikely to interfere with medical devices [15,16]. A study evaluating the short-range Bluetooth technology in the ICU, assessing 44 pieces of medical equipment, demonstrated no evidence of EMI [17]. Indeed, medical devices such as patient monitors are now being sold with Bluetooth and 802.11 wireless local area network capability included (eg, Schiller, Maglife C monitor). Most health care institutions initially responded to the problem of cellular phonerelated EMI with an institutionwide ban on cellular phone use, although walkie-talkie use was often permitted despite their higher power output. However, as the knowledge base in this area has grown and with the changing technology and standards for susceptibility to EMI, these rules are relaxing. Our institutions (University Health Network and Mount Sinai Hospital, Toronto, Canada) implemented a ban on the use of cellular phones in 1994 but have allowed such use outside patient care areas since 2000. The only reported incident, at the University Health Network in the mid 1990s, involved the sudden loss of a patients electrocardiogram waveform on an analog telemetry-based central station monitor in a cardiac unit. Prompt investigation by the nurse caring for the patient revealed that several visitors were operating cellular phones in very close proximity to the patient. Once the cellular phones were turned off, the electrocardiogram waveform was restored.
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Resources
US FDA Electromagnetic Compatibility Program http://www.fda.gov/cdrh/ emc FDA/CDRH Recommendations for EMC/EMI in Healthcare Facilities http://www.fda.gov/cdrh/emc/emc-in-hcf.html Mobile Healthcare Alliance www.mohca.org Institute for Electrical and Electronic Engineers http://www.ieee.org/portal/ site Center for the Study of Wireless Electromagnetic Compatibility, University of Oklahoma School of Industrial Engineering http://www.ou.edu/ engineering/emc
References
[1] Silberberg JL. Performance degradation of electronic medical devices due to electromagnetic interference. Compliance Eng 1993;10:1 - 8.