Author(s): Liz Langley. Published on January 4, 2016.

Hearth, Home, Hemodialysis

The rise of home healthcare means larger and more sophisticated medical equipment in residential settings. But are caregivers, fire responders, and patients themselves prepared to handle the complications? BY LIZ LANGLEY

WHEN YOU'RE SICK, the last thing you need is to be left hanging. Literally.

Mary Brady, who worked as a registered nurse for 30 years and served in a variety of capacities for the Food and Drug Administration (FDA), likes to tell the story of a man who was prescribed a piece of durable medical equipment, or DME—in this case a hydraulic patient lift—for use in his home. “It’s usually for one elderly person to lift another elderly person onto a chair or toilet and back into bed again,” says Brady, whose FDA work included the development of national policy for home-use medical devices.

As Brady tells it, an elderly couple had just received the lift, and the woman put her husband into it on their first day of using the machine. “And it stopped working while he was in midair,” Brady says. “Now he’s dangling up in this seat and she could not get him down. She didn’t have instructions for how to even operate the thing. She calls the company that manufactured the lift to say it had stopped working and what should she do, and they tell her, ‘That doesn’t happen,’ and she says, ‘It’s happening right now!’ She ends up calling 911, and the fire department has to come and get her husband out of this seat up in the air. Fortunately he wasn’t hurt.” „

The episode with the lift demonstrates some of the challenges associated with the growing trend of medical equipment in the home. DME is defined by Medicare as equipment for use in the home for a medical reason that’s long-lasting and would not be useful to someone who isn’t sick or injured. Such equipment ranges from simple devices like walkers to more sophisticated items like ventilators or hemodialysis machines. They’re a boon to patients young and old who can now recover at home instead of in a clinical setting, but they also present potential problems, starting with users who may not fully understand how to operate or maintain the equipment. First responders, too, may not be familiar with the operation of some DMEs, either in emergency situations like fires or when the equipment malfunctions. Much of the equipment is electrically powered, a factor healthcare experts say needs to be considered in emergency planning.

NFPA is joining the discussion. The topic of medical equipment in the home and its ramifications for the health, life safety, and emergency responder communities were addressed at the recent “Summit on Safe, Independent Living: Home Health Care, Aging Populations, and the Residential Environment,” organized by the Fire Protection Research Foundation and NFPA and held in Orlando in November. Participants agreed on a central idea: that the definition of “home medical equipment” needs updating to accommodate its modern variety and complexity. Not that long ago, the concept was mostly covered by the wheelchair a patient would receive when they were discharged from the hospital. Those days are gone, healthcare experts say, with the coming wave of DME to include “smart” and wireless technologies like those that monitor vital signs and stream data outside the home—equipment that promises to stretch the concept of home healthcare even further while presenting new challenges for caregivers, first responders, emergency planners, and patients themselves.

Marilyn Neder Flack, senior vice president of patient safety initiatives at the Association for the Advancement of Medical Instrumentation (AAMI) and executive director of the AAMI Foundation, told the NFPA summit that it’s time for “policymakers, the Centers for Medicare & Medicaid Services (CMS), and other regulators to realize that the simplistic current ‘wheelchair’ model of home healthcare no longer works.”

The rise of home healthcare

The surge of medical equipment—much of it large, complex, and expensive—moving into patients’ homes is part of the larger trend in healthcare to minimize the length of patient hospital stays and facilitate recovery at home. About 12 million people in the U.S. receive home healthcare annually, according to the National Association for Home Care & Hospice, and by 2050 that number is expected to reach 27 million annually—a jump fueled in part by a growing number of older Americans, as well as efforts to curtail the high cost of hospital care by moving more of it into the home. Patients range from infants to seniors, and many of them will rely on DME, which is prescribed to patients who are discharged from clinical settings such as hospitals or nursing homes.

“Typically you’re going to go home pretty sick, and more than likely you’ll need technology to help you recover,” Brady says. The DME could be a glucose meter, an insulin pump, a ventilator, or wound care technology. DMEs are numerous; the CMS lists 128 categories.

DMEs allow patients to manage their own care and avoid lengthy hospital stays that can be difficult, stressful, and expensive. Neder Flack notes an AAMI/FDA report from 2013 that found that, aside from reducing the cost of treatment, healthcare delivered in the home rather than in the hospital can also produce better patient outcomes.

Older male on dialysis machine.
​Aging in place often means performing medical procedures, like dialysis, that were once reserved for hospitals. ​Photograph: Newscom

But moving healthcare to the home is not without risks. As Brady observes, the arrival of DME in residential settings has happened quickly, “and sometimes there aren’t the resources out there to help prevent problems.”

One problem are the gaps that can occur during the handoff of care from hospital to home, omissions that can lead to patients ending up with DME they don’t know how to use. “My neighbor came home with infusion therapy and had a PICC line,” Brady says, referring to a “peripherally inserted central catheter,” a soft plastic tube for intravenous access to provide medication over a prolonged period of time. Instructions for managing and maintaining the line consisted of a vague list hand-written by a nurse. “One of the instructions said, ‘If you see any air in the line call 911.’ How much air? What does that mean?”

Patients are typically trained on devices before they’re sent home, but the quality of that training can be inconsistent, Brady says. They might be trained on one device in the hospital, for example, but a different brand is delivered to the home. Sometimes, Brady says, the person who delivers the equipment will set the patient up and show them the basics. A DME quality standards guide produced by CMS calls for the supplier of the equipment to provide instructions, but that doesn’t always happen. When equipment is rented privately, instructions can get lost along the way. Sometimes the instructions that accompany DME are written for medical professionals rather than lay people. “I’m a health care provider, and even I don’t understand some of the things that come through,” Brady says.

Patient missteps can be fatal. NFPA data indicates that smoking is the leading cause of medical oxygen-related burns seen in emergency rooms, accounting for 73 percent of cases. Stephen Hrustich, assistant chief at Gwinnett County Fire and Emergency Services in Lawrenceville, Georgia, recounts a fatal fire that occurred when he was fire chief in Endicott, New York. The fire likely started from smoking, Hrustich says, while the victim used an oxygen generator with a nasal tube. The fire was relatively contained and easily extinguished, but the woman died from her injuries. “The issue around home oxygen therapy is that the patient will sit there and the clothing and furnishings become saturated with oxygen,” Hrustich says, which helps combustibles burn more vigorously.

Home environments can include variables that do not occur in clinical settings. Neder Flack says that DME in homes can be subject to temperature variations and other atmospheric conditions, including dryness, which can cause static shocks that can disable, damage, or reset DME settings and alarms. Electromagnetic interference from TVs, microwaves, and other devices can also interfere with equipment, as can children who may fiddle with knobs and switches. Pets can chew medical tubing. It’s not uncommon for pests such as ants and roaches to take up residence in the equipment, Neder Flack says.

Many health professionals advocate for home healthcare assessments before medical equipment is delivered, including checking the safety of home conditions and making sure patients have emergency plans. But such assessments are not always completed, Brady says.

Power problems

DME problems can also stem from a variety of home electrical issues, including old or substandard wiring. “Many homes still have two-prong outlets that do not accommodate the medical devices with three-prong grounded plugs,” Brady says. Work-arounds for the mismatch can produce electrical outages, shocks, and other problems.

According to the U.S. Department of Health and Human Services, 2.4 million people who are Medicare beneficiaries are on DME that depends on electricity, a number that doesn’t include those who have privately rented or purchased equipment or are privately insured for DME. Even so, there are currently no guidelines addressing DME use in homes. NFPA 99, Health Care Facilities Code, addresses the electrical safety of medical equipment only in healthcare environments, such as hospitals or nursing homes. The provisions of NFPA 99 ensure that medical equipment is properly wired or insulated, which would reduce shock to the patient, and mandate the inspection and maintenance of that equipment.

A concern for NFPA is the issue of DME power supplies and the impact of prolonged power outages, says Jonathan Hart, senior fire protection engineer at NFPA and staff liaison for NFPA 99. Hart says the code requires that electrical equipment that the patient is dependent on be provided with backup power. “But that’s not something we necessarily have in the home,” he says. “Most don’t have backup generator power.”

That’s why it's critical for patients who use DME that provide life-sustaining functions, such as ventilators and home hemodialysis machines, to have an emergency plan in the event of power outages or disasters, Hart says. Patients need to understand the capabilities of their equipment and what kind of backup battery the equipment uses. Hart urges patients to contact their utility provider to see if power can be prioritized in their area in an emergency. It's also important for people to know where to go in the event of a prolonged outage, as well as where to look for emergency planning resources. Maps of the nearest open shelters, for example, are available on redcross.com.

An HHS emPOWER map of Manhattan, with shaded areas showing zip codes with various concentrations of patients with electrically-reliant DME.
​A new mapping tool helps health professionals prepare DME patients for emergencies–including prolonged power outages.  Photograph: United States Department of Health and Human Services.

Getting power to DME patients in emergencies is a major concern for Dr. Nicole Lurie, assistant secretary for preparedness and response at the U.S. Department of Health and Human Services (HHS). Lurie says it’s important to address the problem of people being separated from their families during emergencies by the need to power DME at shelters or other facilities. She relates a story of social media being used to help people in need in New York City following Hurricane Sandy. “We learned about a quadriplegic who lives at home on a ventilator on an upper floor of an apartment that was dark for many weeks,” she says. “He had a bunch of friends who were using Twitter to report on his remaining battery life.” People read the tweets and volunteered to take the batteries to the fire station for recharging so the man could avoid going to a shelter.

Lurie was both inspired and daunted by the story. “How do you do this for the entire city?” she asks.

Responder concerns

Part of the answer lies in the development of tools to identify where DME patients are and the equipment they require, especially in life-threatening emergencies. One tool is the HHS emPOWER map, an interactive online tool launched in June that can help community health agencies, emergency management officials, and first responders plan ahead to meet the emergency needs of residents who rely on electrically powered medical and assistive equipment to live independently. In some situations, the map can show health departments and emergency planners the specific locations of DME patients, allowing emergency services to help them prepare for a disaster and make sure they’re safe after one.

For responders and others, advance knowledge of DME patients is important because it may take significant preparation to move them in an emergency; an oxygen generator may be easy, but a ventilator or heavy-duty powered wheel chair that requires an elevator could require several people to manage. Knowing these needs in advance makes the coordination of resources easier. The federal government website disability.gov lists registries for people with special medical needs to provide information to emergency responders for help with disaster preparation.

After power outages from an ice storm last year in Georgia, Hrustich says, his fire department worked with county officials to identify and transport dialysis patients to treatment centers. “You can’t put that off for three or four days until the weather gets better,” Hrustich says. Decisions were made at the emergency operations center with input from a wide variety of disciplines, including healthcare officials, emergency services, and transportation departments. “Problems that arise during large-scale emergencies most often require comprehensive solutions involving multiple public and private partners,” Hrustich says.

Older lady working with home healthcare professional.
​Medical equipment can present another layer of patient management for home healthcare professionals. ​Photograph: BSIP/UIG via Getty Images

Sometimes the problems are on a smaller scale but are no less critical. If a patient calls 911 with a DME problem, for example, would first responders know what to do? Matt Zavadsky, director of public affairs for MedStar Mobile Health Care in Fort Worth, Texas, says unless responders have had special training, it’s unlikely a 911 responder would know how to address problems with DME function. As the fire service continues to evolve into an all-hazard response resource, Zavadsky says that NFPA, the fire service, and DME manufacturers should collaborate on DME training so first responders can address such calls. The growing fire service trend of community paramedicine, where fire-based medical resources such as paramedics and emergency medical technicians provide non-acute care to patients in their homes, means responders will increasingly encounter DME assets and will need to know how to operate, maintain, and troubleshoot them.

If emergency personnel do encounter someone with a DME, Brady says, they should know if it’s life sustaining or supporting and have a backup power source if they have to disconnect it. They should know how to pick up the equipment, whether they can put it lower or higher or beside the patient, and a variety of other factors that may not be obvious but that first responders may need to check.

Brady says DME labeling regulations also need to be addressed to meet patient needs. She’s worked on FDA guidance to improve DME designs and is currently working on guidance for consistent labeling instructions for the devices. The DME reality, she says, is that regulations need to recognize that a lot of people who aren’t healthcare professionals—patients, first responders, and others—need to know how to operate this equipment safely, too. “I am a huge proponent of people staying in their homes” for medical treatment or recovery, Brady says. “I believe people can operate technology safely and keep their family member alive, safe, and treated in the home, as long as they have the tools to do it.”

LIZ LANGLEY is a writer in Orlando, Florida. Top Illustration: James Steinberg