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A B S T R A C T
Many industries and individuals have embraced cellular telephones. They provide mobile,
synchronous communication, which could hypothetically increase the efficiency and safety of
inpatient healthcare. However, reports of early analog cellular telephones interfering with critical lifesupport machines had led many hospitals to strictly prohibit cellular telephones.A literature search
revealed that individual hospitals now are allowing cellular telephone use with various policies to
prevent electromagnetic interference with medical devices. The fundamental principles underlying
electromagnetic interference are immunity, frequency, modulation technology, distance, and power.
Electromagnetic interference risk mitigation methods based on these principles have been
successfully implemented. In one case study, a minimum distance between cellular telephones and
medical devices is maintained, with restrictions in critical areas. In another case study, cellular
telephone coverage is augmented to automatically control the power of the cellular telephone.
While no uniform safety standard yet exists, cellular telephones can be safely used in
hospitals when their use is managed carefully.
K E Y W O R D S
Cellular telephones
Hospital
EMI
Medical devices
Distance
Power
Introduction
Inpatient healthcare requires multiple, simultaneous
processes and teamwork involving physicians, nurses, unit
secretaries, and ancillary staff. Frequent communication is
necessary to ensure safe and efficient delivery of healthcare.
The inefficiencies of traditional communications methods
were highlighted by a recent study comparing wireless
voice communications to overhead paging, estimating a
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Safety
Interference
priate management procedures with a review of the literature. A search of the PubMed database using the terms
cellular telephone identified 443 articles published as of
March 2005. Of these, 38 articles were identified as relevant
to cell phone use in hospitals. Articles were excluded that
addressed interference with implanted devices and biological effects of electromagnetic fields because those topics
are not specific to a hospital environment. Although many
articles exist, they report testing of specific devices; no
universal guidelines or management procedures have
been published.
The Science of Interference
The ability of electromagnetic emissions from cell phones
to interfere with medical devices is based on properties of
propagation of electromagnetic energy: the output power of
the cell phone (source), the frequency and modulation
technology, the separation distance between the source and
medical device, and the immunity of the medical device.
Irnich and Tobish tested more than 220 electronic
devices in a hospital environment and were able to demonstrate greater than 98 percent safety when cellular
telephones were kept more than one meter away.8
However, using different cell phones and medical devices,
various hospitals have recommended safe distances varying
from arms length to three feet, one meter, two meters, to
even five meters.6,7,8,9,10 One practical version of distancing
cell phones from critical medical devices is to allow them in
specific locations, such as non-patient care areas of the
hospital, but exclude them from more sensitive areas, such
as intensive care units and emergency departments.7
More recent policies among several hospitals have taken
advantage of the dynamic power control feature in modern
digital cell phones designed initially to conserve their
batteries by transmitting at low power in areas of good
cellular coverage. Switching to low power decreases the
electromagnetic field generated by a cell phone and its
potential to interfere with medical devices.
Thus, some hospitals have chosen to embrace and
control the technology.11 These hospitals have arranged for
installation of either microcells (small-scale base station
sites) or repeater antennas (in-building antennas linked to
an external antenna to augment interior coverage) to
increase signal coverage, thereby causing staff telephones to
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additional infrastructure,
such as microcells or
repeaters, using only
certain tested and labeled
phones, designated areas
for cell phone bans (ICUs,
operating rooms, and
EEG laboratories), designated areas for public
cell phone use, and any
and all combinations of
these and other management strategies.
The appendix to this
article documents two case
studies of controlled
implementation of cell
phones. In both cases,
considerable testing was
completed by hospital
clinical engineering staff using simplified versions of the
ANSI/IEEE ad hoc testing recommendations.20 Also in
both cases, administrative controls were developed to
regulate policies, separation requirements, signs, and
continued testing.
Texas Childrens Hospital recently conducted a cell
phone testing program in two of its inpatient areas. The
facility previously had a total ban on cell phones. Based on
the study, the facility implemented administrative controls to
allow cell phone use (from several different carriers but not
all) with a three-foot separation recommendation
throughout the institution. However, the ban will continue
in critical care areas until further testing is completed.
Shands Hospital at the University of Florida used added
infrastructure in key areas to provide coverage at reduced
transmission power (targeted 60 milliwatts maximum) in all
patient care areas. In its case, the infrastructure was funded
by the cell phone carrier, with the hospital guaranteeing an
increase in the number of subscribers to that carrier. Also,
public use of that specific carriers cell phones is allowed
within the hospital.
Conclusions and Future Directions
Safe cell phone use in hospitals requires management
controls. Patient safety should not be compromised for staff
and visitor convenience. However, cell phones offer significant communication improvements for staff, which may, in
itself, improve patient safety. Various safe methods can be
used to manage cell phones, with the primary tradeoff
being cost (for example, adding in-building cellular infrastructure) vs. coverage. Options include adding widespread
infrastructure, adding limited infrastructure in areas where it
is believed to be most essential to tightly manage cell
phone emissions, mandating specific tested cell phone
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References
1. Breslin, S., Greskovich, W., & Turisco, F. (2004). Wireless Technology Improves Nursing Workflow and Communications. Comp Informatics
Nursing, 22, 275-281.
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Appendix
Case Study No. 1: Texas Childrens Hospital
Recognizing that the probability of interference decreases
in proportion to the distance between devices, Texas
Childrens Hospital wanted to determine if a safe operating
distance between existing medical and personal telecommunication devices could be identified. A test protocol was
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are performed. Also included were common patient transport zones between these areas.
Initial testing of critical medical equipment, such as lifesupport and high-risk devices, was performed using a
modified ANSI C63.18 Recommended Practice for an OnSite, Ad Hoc Test procedure.27 The purpose of ANSI
C63.18 is to provide a guideline test method to assess in a
relatively reproducible manner the radiated RF immunity of
specific medical devices to specific RF transmitters. Based
on this testing methodology, when interference is noted, a
minimum safe distance often can be determined.
ANSI C63.18 includes guidelines on the selection of
medical devices to be tested and the selection of RF
transmitters to test and test methodology, including selections of the test area, placement of the medical device,
evaluation of medical device performance, and precautions
on RF transmitter use. In addition, it includes a specific test
procedure indicating antenna orientation, device location,
initial and minimum separation distances as a function of
transmitter power, multiple axis testing, and more.
The Shands modified procedure included all sides of
medical equipment and distances in very close proximity
less than 5 centimetersto the device being tested. The
cellular phone company was required to provide a
handheld unit of which the transmission power level could
be controlled as the distance was varied between the unit
and the medical device. In general, the test required
approaching the medical device at all sides, one at a time,
with the cell phone set to a specific transmission power
level. Records were kept of the interaction or interference
caused, and then a lower transmission power level was
selected and the test was repeated. The purpose of these
initial tests was to determine the transmission power level
at which interference could not be identified. Medical
devices tested included anesthesia machines, perfusion
systems, ventilators, patient monitors, defibrillators, and
telemetry systems.
At maximum transmission power levels, researchers
found instances of interference and, in one case, a
complete medical device shutdown, with no notice or
alarm. Decreased transmission power levels resulted in
decreased levels of interference.
Testing demonstrated that at power levels of -10db (60
milliWatts), the devices under test exhibited normal operation at all tested distances. Based on these tests, researchers
identified that the design environment was to provide a
signal strength that would enable the handsets to transmit at
power levels of 60 mW (average) or below in all patient
care areas. All other areas were required to have the vendor
minimal signal strength for adequate system use.
The final design of the cellular system included locating
a typical cell site on the roof of the building and putting a
distributed antenna system on almost every floor of the
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