Needs: Inaccessible Medical Equipment Problems Identified by the RERC on Accessible Medical Instrumentation, 2002-2007

Methods

The Rehabilitation Engineering Research Center on Accessible Medical Instrumentation (RERC-AMI) conducted two national surveys to identify the types of medical equipment that were causing difficulties for patients and healthcare providers with disabilities. The surveys were followed by a series of focus groups that explored in greater depth and detail the most significant difficulties identified.

National Survey Methods

The first of the two RERC-AMI surveys was of people with disabilities from across the U.S. in the role of medical patients. The study incorporated an exploratory, cross-sectional design. It targeted for participation a diverse sample of individuals with a wide range of abilities/disabilities and medical diagnoses. The primary methods of recruitment for the survey were messages posted to disability-related list-serves and Web sites, flyers distributed to and personal communications with independent living centers and at disability-related conferences and meetings. Eligibility criteria included being at least 18 years of age, self-reporting at least one disability, having ability to understand English, and having had experience with medical devices. Data from people who reported cognitive disabilities were discarded because this population was excluded.

The survey took approximately 30 to 45 minutes to complete and it could be completed in one or multiple sessions. The survey was available as an interactive form on the Internet, as a Word form that could be filled in on a computer and transmitted to the research team via email, and as a paper form in large print or standard print that could be completed and mailed to the team using a postage-paid envelope. The survey could also be completed with one of the researchers over the telephone or in person.

The survey solicited demographic information, and then asked questions about 15 broad categories of medical equipment:

• Examination Tables
• Medical Chairs (e.g., dental, oral surgery, eye exam, laboratory, reclining procedure chairs [chemotherapy, dialysis, transfusion, etc.])
• Dental Equipment (e.g., x-ray equipment, drills)
• Eye Exam Equipment (e.g., vision test, glaucoma test, peripheral vision test)
• Hearing Test Equipment (e.g., headphones, soundproof booth)
• X-ray Equipment (e.g., general x-ray, MRI, CT scan, PET scan, mammogram, bone density scan, ultrasound)
• Cardiac Stress Test Equipment (heart)
• Pulmonary Function Test Equipment (breathing)
• Rehabilitation Equipment (e.g., cardiac, pulmonary, occupational therapy, physical therapy) and/or Exercise Equipment (e.g., exercise bike, treadmill, parallel bars, exercise mats, free weights, weight machines)
• Medication Administration Equipment (e.g., IV infusion pumps, syringes)
• Oxygen Equipment (e.g., ventilators, oxygen delivery devices, nebulizers, suction devices)
• Monitoring Equipment (e.g., glucometer, spirometer, pulsoximeter, heart monitor, blood pressure cuff, thermometer)
• Weight Scales (e.g., standing, chair, wheelchair, bed)
• Mobility Aids (e.g., cane, walker, crutches, wheelchair, scooter)
• Communication Aids (e.g., keyboard, mouse, screen, telephone, cell phone)

The survey asked two forced-choice questions and two open-ended questions about each of the 15 categories of medical equipment:

• Your experience with [name of category]:
  • None, Little, Moderate, Frequent, Extensive
• Your difficulty or discomfort with [category]:
  • None, Little, Moderate, Extreme, Impossible
• What difficulties did you have? (Please describe.)
• What changes might be made to improve the ease and/or comfort of using [category]? (Please describe.)

The second of the two RERC-AMI surveys was of people with disabilities from across the U.S. in the role of healthcare providers. The study incorporated an exploratory, cross-sectional design. It targeted for participation a diverse sample of professionals with a wide range of abilities/disabilities and medical specialties. Eligibility criteria included being at least 18 years of age, self-reporting at least one disability, having ability to understand English, and having had experience with medical devices. Data from people who reported cognitive disabilities were discarded because this population was excluded.

The primary methods of recruitment for the survey were messages posted to disability-related list-serves and Web sites, personal contacts, and distribution of an invitational postcard through the mail and at medical professional conferences and meetings. The survey took approximately 15 to 30 minutes to complete and it could be completed in one or multiple sessions. For participants with visual impairments, the survey was offered by phone.

The provider survey asked fewer demographic questions than the patient survey and allowed respondents to begin by selecting from the list of 15 types of medical equipment those with which they had professional experience. When participants completed the survey either online or with a researcher, they were asked questions only about the categories of equipment they had selected. For each category of equipment, the survey asked two forced-choice questions:

• Your experience with [name of category]:
  • None, Little, Moderate, Frequent, Extensive
• Your difficulty or discomfort with [category]:
  • None, Little, Moderate, Extreme, Impossible

In order to reduce the amount of time it would take to complete the survey, for each equipment category, the survey offered a list of difficulties that had been identified through the previous patient survey. For example, for examination tables, the provider survey listed these potential problems:

• Too high
• Too low
• Too narrow
• Too long
• Too short
• Too hard
• Too soft
• Problems with stirrups
• Problems with positioning
• Problems with transferring
• Problems with step
• Discomfort
• Unsafe
• Other

For each of the items checked, the survey provided a text box in which respondents could describe their own related experiences. The final, open-ended question asked:

• What changes might be made to improve the ease and/or comfort of using [name of category]? (Please describe.)

Regional Focus Group Methods

Following the two national surveys, the RERC-AMI conducted several regional focus groups in California and Wisconsin to explore some of the most problematic equipment in greater depth and detail.

The groups in Northern and Southern California focused on four categories of equipment with people with disabilities in the role of patients: examination tables, medical chairs, imaging equipment, and weight scales. The groups included participants with physical disabilities (four groups), people who were deaf and knew American Sign Language (one group), and people who were blind or had visual impairments (one group). Two additional California groups were composed of elder women and elder men, separately, and discussed home health equipment (home monitoring equipment and medication administration equipment) in addition to the other four equipment categories.

The groups in Wisconsin focused on three topics separately: dental equipment with dental patients (two groups) and dental care providers (dentists and dental hygienists, one group); ergometers (exercise bicycles) with elders who were involved in a regular exercise program and used ergometers (one group); and medical monitors with people with visual or hearing impairment who used monitoring devices in the home (one group).

Results by Study

National Patient Survey Results

A total of 457 individuals created accounts on the national patient survey Web site or completed the survey in an alternative format (Word form, printed on paper, printed in large print, over the telephone, or face-to-face interview). From this pool, the survey received 408 usable data sets. The respondents resided in all 50 states, and nearly equally in urban, suburban and rural areas. The majority of respondents were between the ages of 25 and 64 (86.0%), were female (66.1%), Caucasian (90.2%), had at least a bachelor’s degree (57.3%), worked full-time or part-time (36.0% and 20.9%, respectively), and used at least one form of assistive technology (98.0%). The respondents reported a wide variety of sensory and physical disabilities and medical diagnoses, particularly ambulatory impairments (74.5%) and visual impairments (31.9%).

Table 1 shows the percentages of respondents with various disabilities who reported they had difficulty with each of the 15 categories of medical equipment. Many respondents reported more than one disability; therefore, the rows of the table are not mutually exclusive. The percentages shown are valid percentages: data were used only from those respondents who had experience with that type of equipment.

Overall, a majority of the survey respondents reported having had experience and moderate, extreme, or impossible difficulty with four categories of medical equipment:

• Examination Tables (n=291) 75.0%
• X-ray Equipment (n=258) 68.0%
• Exercise and Rehabilitation Equip. (n=203) 55.3%
• Weight Scales (n=222) 53.1%

The categories of equipment with which 25-50% respondents had experience and moderate or greater difficulty were:

• Examination Chairs (n=262) 49.7%
• Mobility Aids (n=241) 48.5%
• Communication Aids (n=183) 40.5%
• Medication Administration (n=147) 40.2%
• Dental Equipment (n=235) 37.8%
• Eye Exam Equipment (n=238) 36.9%
• Cardiac Stress Test Equipment (n=91) 33.0%
• Monitoring Equipment (n=188) 27.6%
• Oxygen Equipment (n= 90) 26.7%

In general, the most prominent themes in the narrative data were:

• Safety issues
• Positioning and comfort issues
• Patient transfer issues
• Issues with visual displays and markings
• Issues with activities requiring fine motor movements

National Provider Survey Results

The national provider survey generated a total of 92 usable data sets. The respondents represented a wide range of medical professions, including physicians, physician’s assistants, nurse practitioners, nurses, occupational therapists, speech therapists, dentists and x-ray technicians. They also represented diverse areas of specialization, including general medicine, pediatrics, physical medicine/rehabilitation, orthopedics, and obstetrics/gynecology. The respondents were from 18 states, with slightly more than half working in urban medical facilities, most of the rest in suburban facilities, and a few in rural settings. A majority (59%) of the respondents worked full time, 20% of the respondents worked part-time, and 2% of the respondents reported being retired; the remaining 17% did not answer the question. Some of the respondents had disabilities, with vision being the most prevalent; a few respondents had hearing impairments, high blood pressure, arthritis or rheumatism, back and/or orthopedic conditions.

Below are the percentages of respondents from a variety of healthcare backgrounds who reported they had little or greater difficulty with the six categories of medical equipment that were reported as most problematic for patients.

• Exam tables (n=37) 40%
• Monitoring Equipment (n=15) 16%
• Weight Scales (n=14) 15%
• Imaging Equipment (n=11) 11%
• Exam Chairs (n=9) 9%
• Medication Administration (n=6) 6%

As with the national consumer survey, the most prominent themes in the narrative data of the provider survey were:

• Safety issues
• Positioning and comfort issues
• Patient transfer issues
• Issues with visual displays and markings
• Issues with activities requiring fine motor movements

Regional Focus Group Results

A total of 75 individuals participated in the 8 focus groups conducted in California. An attempt was made to recruit a racially and ethnically diverse sample, particularly because the patient survey sample had not been. Other inclusion criteria consisted of being at least 18 years of age, being able to understand English, self identifying as having a disability, and having experience with the types of medical devices that would be discussed at the sessions. Persons who reported cognitive disabilities were excluded. The focus group sessions were conducted at the facilities of community-based organizations, such as independent living centers and senior centers. Participants were recruited through the organizations using convenience and snowball sampling methods. Transportation was provided for participants who needed it. Participants were compensated $50 for their time, and a light meal was served before each session.

Each focus group session was audio recorded. The recordings of the first 6 group sessions were subsequently transcribed verbatim. For the final two groups with elder adult participants, a court reporter was utilized for simultaneous transcription (which saved time and improved accuracy).

Two investigators independently reviewed and categorized all the transcript data according to a set of five primary themes, and then met to achieve consensus in categorization. The themes were: equipment issues, environmental issues, healthcare provider issues, patient issues, and a cross-cutting theme of safety issues (see Table 2).

Results by Category of Equipment

The following section aggregates the difficulties identified through the three studies (two surveys and focus group series ) for seven categories of medical equipment:

• Examination Tables
• Medical Chairs
• Weight Scales
• Imaging Equipment
• Monitoring Equipment
• Medication Administration Equipment
• Exercise Ergometers

Examination Tables

The primary findings about examination tables were the following:

• Safety issues:
  • The table may be unstable
  • Fear of physical harm:
  • Fear of falling
  • Concern for skin integrity
• Dimensions/geometry:
  • The table height may be too high
    • Especially for wheelchair users or patients (especially elderly) with hip or leg problems
  • The table width may be too narrow
    • Especially for patients to adjust their position or reposition their bodies
  • The table length may be too short
  • Especially for some types of medical exams
• Transfer issues:
  • The step that pulls out at the foot of the table may be too small
    • Especially for people with a wide stance
    • Especially for obese patients
  • The step may be unsteady
  • There may be nothing to hold on to for stability while transferring
  • Some individuals are unable to transfer independently
• Physical Positioning:
  • The table’s surface may be too hard
  • Patients may have nothing to lean on for support, especially if the table is placed in the middle of the room
  • Stirrups used for gynecological and urological exams may be uncomfortable and hard to use
• Emotional/psychological issues:
  • Fear of being left alone
  • The wait for the healthcare provider to arrive may be long
• Other difficulties:
  • The paper strip on the table’s surface:
    • The paper may be slippery for people with physical disabilities
    • If the color of the paper contrasts with the color of the table surface, it may help people with visual impairments see where to sit
    • Deaf people may find the paper handy for writing notes on to communicate with the healthcare provider

Medical Chairs

The primary findings about medical chairs were the following:

• Safety issues:
  • Fear of physical harm:
    • Fear of falling
  • Eye exam chairs were reported as particularly unsafe
  • The armrests and foot rests may be fixed in place and difficult to maneuver around
  • The eye exam equipment may be moveable but only within a limited range and because it is permanently attached it may be difficult to maneuver around
• Dimensions/geometry:
  • The chair may be too high to transfer into easily
• Transfer issues:
  • If the base of the chair extends out to the side beyond the edge of the seat, wheelchair users may not be able to maneuver themselves close alongside, making transfer across the gap and into the chair very difficult and potentially dangerous
  • The chair may not have arm rests
  • If the chair does have arm rests, sometimes they are too low to provide needed support
  • If the chair does have arm rests, sometimes they are too high and interfere with transfer
• Physical positioning:
  • The chair may be too narrow
    • Especially for post-operative hip patients
  • The leg support section of the chair may have a fixed knee angle, and that angle may be uncomfortable or unachievable for some users
  • Depending on the shape of the footrest, the user’s feet may be unsupported or may get tangled up in the footrest
  • The headrest may not be sufficiently adjustable for patient comfort
  • The chair’s padding may be too hard or otherwise uncomfortable

Weight Scales

The primary findings about weight scales were the following:

• Safety issues:
• Fear of physical harm
• Fear of falling
• Concern for the scale’s accuracy
  • Especially for larger patients
  • Especially for patients with balance limitations
  • Especially considering the importance of accurate weight measurement for appropriate medication dosing
  • Scale calibration may not always be maintained
• Concern for the scale’s capacity
  • Especially for obese patients
  • Especially for wheelchair users who are weighed in their chairs
  • Especially for individuals who are weighed by being carried by another person
• Dimensions/geometry:
  • The scale’s platform may not be big enough
• Transfer issues:
  • The scale’s platform may be unstable
  • The standing scale may have nothing to hold on to for support
  • The scale platform may be too high to step up onto easily
  • Especially for people with mobility impairments
• Visual displays:
  • Scale displays may be hard to read
  • Especially for people with visual impairments
  • Scale displays are not usable by people who are blind
• Personnel issues:
  • Some people, especially wheelchair users, do not know their weight because their healthcare providers do not have wheelchair scales; some people have not been weighed in many years
  • Among wheelchair users, it was reported as common for healthcare providers to ask them to guess or estimate their own weight

Imaging Equipment

Imaging equipment has many of the same obstacles as exam tables. In addition, the issues unique to imaging equipment were:

• Safety issues:
  • Fear of physical harm:
    • Fear of falling
    • Concern for skin integrity, especially when platform has no pad
• Dimensions/geometry:
• The scanning bore may not be big enough to accommodate obese patients or patient with unusual body geometries
• Transfer issues:
  • The patient support surface may have no pad and it may be slippery
  • Because patients can’t take metal mobility aids (e.g., a wheelchair or cane) into the MRI room, they may have to be transported into the room on a gurney
  • Because patients may have to be transported into the MRI room on a gurney, they must do a double transfer between the gurney and the MRI platform both before and after the scan
  • Because they can’t take metal into the MRI room, patients with metallic implants may not be able to receive this type of scan at all
• Physical positioning:
  • The imaging platform may be uncomfortable
  • The platform may have no pad and it may be cold
  • The platform may have no padding and/or pillows to support patients in sometimes-awkward positions
• Other difficulties:
  • The equipment may be close to the patient and may cause claustrophobia
    • Especially MRI machines
  • Communication with the healthcare provider is critical so that patients know what to expect and how to behave
    • Communication is particularly problematic for deaf patients with whom communication must be visual, which sometimes requires the healthcare provider to enter the room each time they need to communicate with the patient

Monitoring Equipment

Monitoring equipment includes blood pressure cuffs, blood glucose meters, thermometers, and other similar equipment. The issues identified were:

• Safety issues:
  • Fear of physical harm:
    • Fear of misreading markings and consequently misdosing
  • Concern for accuracy of equipment
• Dimensions/geometry:
  • The tubing on the blood pressure cuff may be too short
    • Especially for patients in wheelchairs or beds
• Physical positioning:
• The blood pressure cuff may not fit well
• Automated blood pressure cuffs may get too tight
• The Velcro may be of poor quality and not attach sufficiently
• Fine motor movements:
  • Alarms may be difficult to set or disarm
  • The buttons may be too small
  • The touch screen may be hard to use
    • Especially for people with limited manual dexterity
    • Especially for people with visual impairments
  • Lancets may be difficult to manipulate
  • It may be difficult to get blood onto glucose meter test strips accurately
    • Especially for people with limited manual dexterity
    • Especially for people with visual impairments
  • It may be difficult to get a good seal on an ear thermometer, which makes it hard to obtain an accurate reading
  • The packaging may be hard to open
  • The device may be hard to plug into an electrical outlet
  • The batteries may be hard to change
• Visual displays:
  • The message may disappear too quickly
  • The print and other markings may be too small to read easily
    • Especially for people with visual impairments
  • The message may not be provided in audible format
• Audible alarms:
  • The alarms may be difficult to hear
    • Especially for deaf individuals
  • The alarms may not be distinguishable from others nearby
• Cognitive issues:
  • The layout of the machine may be confusing
  • The use procedures may be too complicated
  • Calibration may be difficult to maintain
• Other difficulties:
  • Some medical patients and healthcare providers are sensitive to latex, which may be present in the device but not recognized

Medication Dosing and Dispensing Equipment

Medication dosing and dispensing equipment includes pill bottles, pill splitters, pill organizer boxes, blood glucose meters, lancets, syringe-loading devices, and syringes.

• Safety issues:
  • Fear of physical harm:
    • Fear of misreading markings and consequently misdosing
      • Especially for people with visual impairments
    • Fear of poking oneself with a needle when loading a syringe
      • Especially for people with visual impairments
    • Fear of cutting a finger on a pill splitter’s razor blade
  • Pill splitters may cut pills in half inaccurately, causing misdosing
  • Patients may miss medication doses because they do not remember to take them or if they already took them
  • Some medical professionals advise their patients not to use home health equipment because the accuracy of the results is unreliable
• Fine motor movements:
  • The packaging may be difficult to open
    • Especially for people with limited manual dexterity
    • Especially bottles that require a pinch grip
  • The device may be difficult to manipulate
    • Sorting pills into organizer boxes may be too difficult or too much trouble
    • Syringes may be difficult to operate
      • Especially for people with limited manual dexterity
      • Especially to inject with one hand
    • The touch screen may be difficult to use
      • Especially for people with limited manual dexterity
      • Especially for people with visual impairments
    • The device (e.g., a pill organizer) may require significant force to open but provide small surface areas against which to push
    • It may be difficult to align the pill in a pill splitter
    • Syringes may be difficult to operate
      • Especially for people with limited manual dexterity
      • Especially to inject with one hand
    • The touch screen may be difficult to use
      • Especially for people with limited manual dexterity
      • Especially for people with visual impairments
• Visual displays:
  • The print and other markings may be too small to read easily
    • Especially for people with visual impairments
• Cognitive issues:
  • The patient may have difficulty remembering to take medication, or whether a medication was taken and/or when it was taken
  • The mechanism for opening a pill bottle may be difficult to understand
  • Especially the Target bottle whose upright orientation is cap-down
  • Especially bottles that require the user to pinch and turn simultaneously

Exercise Ergometers

The primary findings about exercise ergometers were the following:

• Transfer issues:
  • The machine may be too tall
  • It may be difficult to approach the machine with assistive devices, including a wheelchair or walker
  • There may not be enough clearance for easy transfer
• Positioning issues:
  • The machine may be difficult to adjust once the user is on it
  • The machine may not offer enough support to keep user stable
  • The machine may not have straps to secure the user’s feet to the pedals
    • The seat may be uncomfortable
  • The seat may be too hard
  • The seat may be too small
  • The machine may not be sufficiently adjustable to accommodate a person of short stature
• Visual displays and controls:
  • The controls may be hard to find
  • The visual display may be hard to read
    • Especially for people with visual impairments
  • The messages may not be provided in audible format
• Capacity:
  • The machine may not accommodate obese users

Personnel Issues

Personnel issues came up repeatedly in the survey responses and during the focus group discussions, for participants with all types of disabilities.

• The anatomy or biomechanics of some patients with disabilities may be unfamiliar and unexpected for some healthcare providers.
• Focus group participants described procedures that were customized for their situations, such as receiving healthcare (including chest x-rays) while remaining in the wheelchair rather than transferring out of the chair. This caused concern that healthcare providers may “cut corners” at the expense of the patients, which, some worried, may result in a lower level of care.
• Participants described some healthcare providers as being impatient with patients who have disabilities. Some providers were perceived as rude or disrespectful.
• Focus group participants described incidents of inappropriate patient handling. They also described inappropriate handling of assistive technologies, even while the patient was using the technology, and even after being asked not to do so.

Communication issues with medical staff were particularly critical for patients with sensory disabilities.

• Sign language interpreters may not be available during medical visits, especially visits to emergency departments. Patients may be forced to rely on family members, which is not always appropriate or desirable.
• Interpreters may not be gender-matched, which may cause patient comfort and adversely affect communication.
• Interpreters may not be trained in medical terminology, which may be unfamiliar to the patient, as well, which may adversely affect communication.
• Sometimes healthcare providers do not explain procedures and expectations of patients beforehand, which may result in inappropriate behavior of the patient and compromise quality of care.

General Conclusions

Project staff drew several conclusions from the results of the national surveys and regional focus groups.

• Some people with disabilities avoid seeking medical care, for a variety of reasons including inaccessibility of medical equipment.
• Inaccessibility of medical equipment may prevent people from getting appropriate medical services.
• Even if accessible medical equipment exists, it isn’t always available: either it is not purchased or it is not located where healthcare providers can use it.
• Even if accessible medical equipment is available, it isn’t always used by healthcare providers.
• The RERC on AMI needs to address the policies and procedures related to use of the medical equipment, including device procurement, installation, and availability, as well as personnel issues (with particular attention to strategies for communicating with patients who have sensory disabilities).