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Electrode Configuration for Continuous In-Hospital

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Electrode Configuration for Continuous In-Hospital Copyright (2014) Richard L. Fidler, PhD(c), MSN, MBA, CRNA, ANP ii Dedication and Acknowledgements I dedicate this dissertation to my father, God rest his soul, who supported and inspired me to have the ambition and desire to succeed in making a better life. After many hospitalizations, my father told me that if I wanted to do something meaningful in the hospital, “make these heart monitors better”. I also must acknowledge my mentor, Dr. Barbara Drew, for her inspiration and encouragement to do something meaningful with my career. For many years, I said that I would never get a PhD, especially in Nursing. Dr. Drew showed me that nurses make meaningful contributions to the science of patient care, not necessarily nursing science or medical science. To Dr. Claire Sommargren, who has continued to push me since day one to get through this program and stay on track, when many distractions were constantly presented to me. And Dr. Hu, I have the utmost of respect for an engineer joining the faculty in a school of nursing. Your and your team made my data analysis possible, and without you, I would not be finishing this research. My deepest appreciation to the family, friends, and co-workers who picked up my slack when I was too busy to even recognize that I was overloaded with a full-time career and full-time doctoral program. I could never have done this alone. iii Abstract Determining the Ideal Electrode Configuration for Continuous In-Hospital Electrocardiographic (ECG) Monitoring Richard L. Fidler, PhD(c), MSN, MBA, CRNA, ANP Significance: Hospital ECG-monitoring is done using the Mason-Likar electrode configuration with chest-mounted and newer technology allows the addition of precordial electrodes to the bedside monitor to acquire a 12-lead ECG. Mason-Likar limb electrodes need to move to the limbs for a standard 12-lead ECG; however, if this step is missed nonstandard and nonequivalent ECG is obtained. The Lund electrode configuration, with more distal limb electrodes was proposed as a solution, but it is unknown how Lund and Mason-Likar compare in signal quality, false lethal arrhythmia alarms, and patient comfort. Methods: One hundred patients from ICU and PCU were enrolled, and in addition to standard hospital monitoring equipment, each subject wore two Holter monitors, one in the Mason-Likar and the other in the Lund electrode configurations for a 24-hour period. Randomization to abrasive skin prep was conducted. ECG signals were sent for blinded analysis for signal quality using the Hook-Up Advisor® and arrhythmia analysis using EK-Pro®. Signal quality was rated as “green-yellow-red”, and lethal arrhythmia alarms were categorized as true or false by clinicians. Qualitative patient data regarding the monitoring experience was also gathered. iv Results: Subjects each provided a mean of 23.8-hours of data in both electrode configurations, and 45 subjects received abrasive skin preparation. Signal quality was compared between configurations using a paired t-test showing that the Mason-Likar configuration spent 8.2% more time in “green”. There was no difference between electrode configurations in the numbers of false lethal arrhythmia alarms. Abrasive skin preparation did not confer a benefit in signal quality or false lethal arrhythmia alarms. Patients prefer options to carry monitoring equipment. Hairy patients prefer to be shaved to reduce pain at electrode removal. Implications: There is a difference favoring the Mason-Likar configuration over Lund for mean ECG signal quality, and there is no difference in false lethal arrhythmia alarms. Mason-Likar should remain the choice for continuous in-hospital ECG monitoring. Skin preparation conferred no benefit in signal quality or false lethal arrhythmia detection. v Table of Contents CHAPTER 1: INTRODUCTION ................................................................................................................ 1 STATEMENT OF THE PROBLEM ........................................................................................................................ 1 PURPOSE OF THE STUDY ................................................................................................................................ 2 RESEARCH AIMS ........................................................................................................................................... 3 Hypotheses ........................................................................................................................................... 3 CONTRIBUTIONS OF THIS DISSERTATION RESEARCH ............................................................................................ 4 CHAPTER 2: REVIEW OF LITERATURE AND THEORETICAL FRAMEWORK ............................................... 5 REVIEW OF LITERATURE: INTRODUCTION ......................................................................................................... 5 DEVELOPMENT OF THE WILSON CENTRAL TERMINAL (WCT) ............................................................................... 7 CLINICAL USE OF THE ECG ............................................................................................................................. 8 ALTERNATIVE ELECTRODE PLACEMENT SCHEMES ................................................................................................ 9 IDEAL ELECTRODE CONFIGURATION EVALUATION TOOL .................................................................................... 11 COMPUTER SEARCH STRATEGIES ................................................................................................................... 12 MASON-LIKAR PLACEMENT OF ELECTRODES ................................................................................................... 13 ML CONFIGURATION COMPARED TO STANDARD DIAGNOSTIC 12-LEAD ECG ....................................................... 14 LUND ELECTRODE CONFIGURATION COMPARED TO MASON-LIKAR AND STANDARD ECG ........................................ 18 CURRENT LITERATURE REFLECTS INCONSISTENT AND POOR METHODOLOGY ......................................................... 21 INACCURATE PLACEMENT OF ELECTRODES IMPACTS INTERPRETATION AND SIGNAL QUALITY ................................... 23 ECG ARTIFACT CAUSES MISDIAGNOSIS AND INAPPROPRIATE TREATMENT ............................................................ 25 THE MONITOR AS A SOURCE OF ARTIFACT ...................................................................................................... 26 MEDICAL DEVICES AS SOURCES OF ECG ARTIFACT ........................................................................................... 27 ELECTRODE AND SKIN RELATED ISSUES IN ECG SIGNAL QUALITY ......................................................................... 27 RELATIONSHIP BETWEEN SIGNAL QUALITY AND ARRHYTHMIA INTERPRETATION .................................................... 31 PHYSIOLOGIC MONITORING ALARMS ............................................................................................................. 33 Alarm Fatigue Not Well Understood .................................................................................................. 34 Alarm Reductions Strategies .............................................................................................................. 34 Alarm delays ...................................................................................................................................... 35 Redundant measures ......................................................................................................................... 35 Impact of monitor watchers ............................................................................................................... 36 SUMMARY ................................................................................................................................................ 36 THEORETICAL PERSPECTIVES ......................................................................................................................... 38 CARDIAC ELECTROPHYSIOLOGY ..................................................................................................................... 40 Obtaining the Electrocardiogram ...................................................................................................... 40 Basic Cellular Cardiac Electrophysiology ............................................................................................ 41 Loss of Surface Voltage ...................................................................................................................... 42 OHM’S LAW AS THEORETICAL CONSTRUCT FOR ECG SIGNAL ACQUISITION ........................................................... 43 DEFINITIONS USED IN OHM’S LAW ................................................................................................................ 43 Voltage ............................................................................................................................................... 43 Current ............................................................................................................................................... 44 Resistance .......................................................................................................................................... 45 THE USE OF IMPEDANCE IN PHYSIOLOGIC MONITORING .................................................................................... 47 SUMMARY OF ELECTRICAL PHYSICS IN ECG MONITORING ................................................................................
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