Purchasing EMS Monitoring Equipment: Balancing Price, Purpose and Performance

EMS equipment-purchasing managers should be delighted with the vast array of technology currently available in the healthcare market. Regardless of the preferred vendor, one thing is certain: Options, features and improvements abound within practically every aren of this technology. In reality, vendor options and offerings can seem endless and confusing, especially if the purchasing manager neglects to outline specific needs and objectives prior to reviewing the selections. A good practical strategy before purchasing anything is to define organizational objectives that account for the price, purpose and performance requirementsof all the EMS monitoring and defibrillation equipment your agency will need.

Price Considerations

Although sometimes regarded as a sticky subject by quality-conscious and patient-care driven clinicians, return-on-investment (ROI) objectives are an important consideration for making a prudent purchase. Quality healthcare is sustainable to the degree that current and future patients can be treated adequately. In this regard, pricing considerations should be understood and accounted for within the product comparison and vendor review process. The information below outlines some of the critical issues that should be addressed as part of this balanced approach to purchasing EMS monitoring equipment.

Purpose Considerations

EMS monitors and monitor/defibrillator combinations are available to meet just about any conceivable need, whether it is routine EMS care or a demanding critical-care transport application. Monitoring systems can be integrated with existing systems or purchased as complete stand-alone systems. Likewise, features and benefits are associated with the type of EMS delivery environment inherent to the EMS agency.

For this reason, purchasing agents must correctly identify current and future needs of the organization, so equipment comparisons can be adequately assessed during review. The following questions highlight issues to consider:

• Where will the monitors be used (BLS or ALS ground transport ambulances, helicopters, fixed-wing aircraft, or moved between these transport vehicles)?
• How will the monitors be used (portable, fixed in the ambulance, integrated with existing equipment or stand-alone application)?
• What features are necessary/required for normal usage (automated noninvasive blood pressure, 12-lead ECG analysis, pulse oximetry, capnography, display func-tions/capabilities, invasive pressure monitoring)?
• What minimum specifications are necessary (battery life, parameter measurements, analysis functions, cable lengths/types)?
• What features/benefits are desired by prehospital clinicians (alarms, color versus monochrome screen, software enhancements, user interface factors, automatic calibration)?
• Is the current practice indicative of the future direction and use of the monitoring solution (i.e., what features need to be available tomorrow)?

Performance Considerations

Reliability, durability, ease of use, functionality and quality differ significantly among vendors. This reality is especially prevalent with EMS monitors, which are subject to changing environmental conditions, transport and multiple users. For this reason, it is important that purchasers develop an apples-to-apples comparative process that reduces the potential for error regarding performance-based criteria.

Performance issues affect pricing and purpose considerations as well. A good performance-based comparative process should seek to account for differences in quality, reliability and other factors. A product with an unknown reliability index or rating can often be adequately dealt with by negotiating longer warranty coverage and bigger discounts on future repairs, parts and labor. Depending on variability, this action might suffice to create equitable comparisons during the decision-making process.

Negotiating for more training when and where it is needed can often resolve ease-of-use issues. Whatever the performance-based differences, EMS purchasing managers should seek to equalize them as much as possible so that a competitive vendor environment can be maintained throughout the evaluation and selection process. Balancing price, purpose and performance objectives will help organizations achieve greater success with their EMS monitoring purchase projects. Additionally, a well-executed process should ensure that financial officers and other key EMS decision-makers commit to purchase initiatives.

Criteria to consider include:

• Competitive vendor environment
• Return-on-investment (ROI) objectives
• Related supply or repair costs
• Training/retraining costs due to staff turnover
• Upgrade path/hardware/software costs for new features
• Accessory or disposable item costs
• Availability of demo/used equipment
• Option package availability/cost/use
• Incentives/discount opportunities
• Add-on cost considerations
• Infrastructure/integration costs
• Biomedical training/diagnostic costs
• Service costs/maintenance agreement/warranty issues
• Alternate purchase price/lease fee
• Battery costs
• Trade-in credit for existing equipment
• Multiple unit purchase incentive.

New Defibrillation Technologies

The standard for judging performance of the new defibrillation mode—biphasic defibrillation—must start with the patient and provider benefit aspects. Ultimately, all patient-related technologies should demonstrate at least a comparable benefit to other existing technologies. Likewise, any vendor claiming to have exceeded existing industry standards should be met with a thorough analysis to ensure the realities of the technology are separated from the marketing ploys used for and/or against these claims. The following list outlines the critical aspects that should be considered when making vendor comparisons regarding technologies:

• Clinical performance
• Improvements in outcomes (neurologically intact discharge from the hospital)
• Realistic comparisons of data
• Independent aspects of information, clinical acceptability and research
• Comparisons of evidence-based medicine and randomized trials
• Relative vendor-to-vendor equipment comparisons
• Cost-effectiveness of technology
• Quality of technology compared to existing market offerings
• Impact and/or potential changes to current industry practices
• Similar technology claims from competitive vendors
• Ventricular fibrillation sensitivity (detection of VF in AED units).

Technological changes within the defibrillation marketplace clearly affect many important decision areas for EMS managers and clinicians. Better technology can translate into improved patient care, lower overall operating costs, a safer environment and lower patient treatment risks. The market has changed, and each organization must effectively evaluate these changes and decide to what extent these changes will bring improvements in service. New defibrillation technology usage may also bring about clinical practice and patient treatment changes. Improvements in technologies must be matched by improvements in patient outcomes.

Finally, defibrillation technology review comparisons between vendors should be orchestrated to objectively challenge existing defibrillation performance values. Data collection, patient outcomes, response times and geographical differences must be accounted for in order to make sure organizations are truly testing existing standards against the new measures of performance that are now achievable within the defibrillation arena.

Upgrades—Hardware and Software

Today’s monitors and defibrillators are closer in technology to the laptop on your desk than the old “bouncing ball” ECG monitors of the past. These systems are software-driven, not entrenched in the hardware of the past for modifications and upgrades. Few EMS organizations operate with 5–10-year-old computer systems running the original software program. The monitoring technology available today relies upon these upgrades to maintain and enhance performance. Software updates with new features to complement your hardware maintenance options ensure that you maximize the clinical performance of your equipment.

Evaluate Current and Future Needs

Before choosing a monitor for your facility, consider your EMS staff’s skills and your patients’ acuity. The typical need is for a monitor that is quickly set up, then easily modified for the next patient. Reviewing previous cases to ascertain average patient acuity will help determine the features you’ll most often use in a monitor. If your medical director is seeking a secondary method for confirmation of intubation, you may want to purchase a monitor/defibrillator that measures capnography.

Choosing a monitor is a more difficult decision than it was in the past. There’s a lot more to consider than whether it has an ECG and pulse oximetry. Following healthcare trends in general, EMS systems are moving, albeit slowly, toward electronic medical records. It’s inevitable that future monitor/defibrillators will be required to not only display, but also collect, store and transmit patient data. EMS monitoring systems will be linked with other providers in order to facilitate transfer of information and to enhance patient care. Collected data will also be used to optimize efficiency. So, consider future communication capability if you’re buying monitors that you hope will last a decade.

Multi-parameter preference

Although the bottom line is definitely a key factor when purchasing patient-monitoring equipment, an increasing number of healthcare providers are realizing the value of buying multi-parameter monitor/defibrillator systems. Although they are more expensive, they can be more cost-effective than buying individual systems.

Demanding quality

While those in the market for patient-monitoring equipment certainly have access to more buying options, they still need to be aware of all options offered by each company. Purchasers should be wary of refurbished-equipment or providers who don’t use new accessories. A hole in a hose, for example, can dramatically impact the performance of the equipment and sour a customer on the whole buying experience.

Warranties

Warranties should also be a big part of the purchasing picture. Review the warranty carefully, and ask the vendor to provide clarification in writing should any questions arise prior to the purchase.

Equipment evaluation

Evaluate equipment for a defined period of time to determine if it meets clinical needs and performs optimally. Extended equipment evaluations lasting weeks to months may simply prolong the purchasing cycle without providing any additional information for a purchasing decision. Some companies offer free loaner equipment when systems require servicing and charge no labor fees for the life of the equipment.

With the options that are available today, both in terms of system choices and purchasing programs, buying patient-monitoring equipment doesn’t have to be a financial challenge. But it’s important to look before you leap, and that goes for any purchase. There’s often much more to a good—or bad—deal than the price tag alone.

EMS-Friendly Monitors

With the development of new EMS techniques, new medications and shifting economics, the EMS monitor and defibrillator market has continued to evolve further and further to gearing products specifically toward the prehospital environment. These changes take on several forms:

User-Friendly Displays

One common complaint about monitors is that the displays are sometimes hard to read. As monitors first became more compact a few years ago, we lost some visual ease, but today the readouts are easier to adjust and view than ever before. Keep in mind that the EMS provider does not remain in a static environment throughout the call, and not every monitor is easily visible from anywhere in the ambulance or in bright environments. Subtle variations in the readability of displays make a major difference in terms of visibility in bright sunlight or a dark scene at the roadside. Color-coded readouts, a feature that more companies have incorporated into their monitors, allow for rapid differentiation of vital signs and numeric information. The multicolored readouts serve a practical purpose—they let the provider’s eye immediately find the desired reading (ECG, for example) and return his/her attention to the patient more quickly.

Smaller, More Portable Designs

By the time you grab the jump kit, portable suction, drug box, longboard and the monitor/defibrillator, you and your partner have run out of hands to carry equipment into the scene. Most vendors now use compact design and portability as primary selling points for their monitors. Prehospital care dictates that you must be able to set up the monitor quickly and easily wherever you are working on a patient. Even with the smaller, lighter designs, integration of multiple parameters (ECG and 12-lead capability, NIBP, SpO2, EtCO2 and printer) has taken place in EMS monitoring.

Vendor Support

New-equipment vendors should not be viewed as adversaries during the purchasing process. Rely upon them as resources of information to help you make informed choices when purchasing new equipment.

Clinical Support

Many manufacturers provide clinical support on monitoring products. This customer education and follow-up support can be invaluable to an EMS organization. Educational offerings include formal classes, training in the ambulance and in workshops, often with continuing-education credit. This training is an important part of a major purchase and should be addressed in the purchasing agreement.

Product Service

Patient-monitoring equipment represents a major investment. As with most capital expenditures, there is a need to preserve that investment for as long as possible. A service maintenance agreement helps protect your investment and offers a variety of maintenance alternatives, from an exchange program to a comprehensive, 24-hour-a-day on-site maintenance program that includes all parts and labor, as well as preventive maintenance. Many vendors support your EMS system with a high level of field service from factory-trained and experienced customer-service representatives. A qualified service representative has the specialized test equipment, parts, software, engineering support and experience to ensure your satisfaction. Look for:

• Local service response or factory service center
• Factory-trained service personnel with parts, tools and instrumentation necessary to service your equipment
• Loaner equipment when required
• Complete service and preventative maintenance documentation
• Software updates to keep your systems current
• 24-hour telephone technical support
• In-service training on software changes for technical and clinical staff
• Multiple-year service contracts to enable predictable budgeting.

Sales Representative Support

The sales representative can provide you valuable information during the purchasing process. Develop a relationship with your local vendors’ sales representatives long before the purchasing process begins in order to develop an awareness of new products and technologies.

Fundamental to Success

As you begin the process of selecting the monitor that fits your EMS organization, never forget the best monitor: your staff. The EMS provider is the most significant patient monitor in your EMS system. The electronic vital signs monitors that you purchase for your ambulances should help the staff perform better, not hinder them. Monitors must be easy for your staff to use, or they may distract them from the patients they are monitoring. The monitor/defibrillator you select must complement and boost your staff’s skills and facilitate assessment of the patient’s condition, but it is not a substitute for a finger on the pulse and an eye on the patient.

Justifying the costs of capital equipment is a job few can take on full-time in EMS. It is a responsibility, however, that is simply too important not to aggressively manage. Just like knowing your EMS organization’s vision or guiding principles, having a well-thought-out process (that is understood by all employees) for examining capital project decisions is fundamental to the future success of your business.