Running head: ECG ACQUISITION TIME AND MOTION STUDY

Wireless ECG Monitoring in Critical Care

The health care team’s time is invaluable to saving lives and “...the work productivity of those

nurses who remain at the bedside is just as important.” 1 Technology can enhance or hinder the time and

effort required by the critical care team to deliver emergent nursing care. Thus the need to save critical

nurse time by eliminating any unnecessary steps required to apply, remove and reapply ECG lead wires,

can be a significant and vital task. A wireless system affords this opportunity by “…eliminating the need to

detach and reattach lead wires in preparation for transport of patients as well as facilitating patient

mobility and ambulation.” 2 A wireless system also adds to patient comfort because the patient is not

“tethered to lead wires” and is free to move about without restriction. 2

In this study hospital, there are approximately 150 to 200 ECG’s performed daily with an average

of approximately 50,000-70,000 ECG’s acquired annually. Their use is vital to the assessment and correct

diagnosis of medical conditions in patients every day. Although it has been known for some time that

ECG wireless technology may prove to be a valuable asset, studies on the phenomenon and the overall

efficacy of this technology are few in the acute care setting.

Performing or “running” a standard hard wire 12-lead ECG takes seconds, but the time necessary

to prepare the patient for the hard wire 12-lead ECG is significantly longer. Most of the nurse’s or

technician’s time is spent removing existing limb leads, making sure the patients skin is clean and dry,

placing the precordial leads onto the chest and most importantly, providing a modest environment for the

patient. In addition, the caregiver must be aware of any chest hair or sensitive areas on the patient’s skin

affected by the application and removal of adhesive ECG electrodes and accompanying ECG leads. As

just illustrated, monitoring a patient’s ECG rhythm with a standard hard wire system as well as performing

the 12-lead ECG has required a certain amount of time and a number of specific repetitive steps.

Traditional hard wire systems for 12-lead ECG take time away from direct patient care and impact nursing

care when devices are antiquated and not 21st century or state of the art. Patient care is even further

delayed when patients are placed on traditional ECG hard wire devices for 12-lead ECG monitoring

during transport for off-unit testing.

Statement of the Problem

Running head: ECG ACQUISITION TIME AND MOTION STUDY
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The study hospital’s Critical Care Units (CVICU, CCU, ICU) Sub-ICU, Telemetry and the Stroke

Unit transitioned to wireless systems to benefit nurse efficiency, enhance patient comfort and service and

prevent the discomfort of needless touches. Initially, every in-patient telemetry monitored floor utilized the

wireless system to monitor ECG rhythms and acquire 12-Lead ECG’s when ordered. Since that time,

however, some of these original units have discontinued the use of the wireless system and have

converted back to the traditional hard wire system for telemetry monitoring and ECG acquisition. This

study is an effort to test and demonstrate the patient and nurse benefits of the wireless ECG system,

through research carried out in specific units currently utilizing the wireless ECG system. The study

design documents the time-motion savings and required number of patient touches when using wireless

ECG data acquisition as compared to traditional hard-wired ECG data acquisition.

Review of the Literature

Today, wireless technology provides the opportunity to markedly decrease ECG acquisition time

and decrease the number of times a patient is interrupted to perform an ECG, thereby increasing patient

rest intervals and the time that other vital care can be addressed. The use of wireless technology can also

decrease the number of times a patient is touched and then exposed, with the ever inherent risk of cross-

contamination to patient and equipment, while also providing continuous unencumbered monitoring of the

patient. “The use of a wireless monitoring system may be one method to improve the overall clinical

outcomes of monitored patients and enhance patient safety efforts within a hospital environment.” 3 Since

2002, a wireless single patient system has been cleared for use by the FDA 4, yet many hospitals and

clinics across the country have yet to incorporate this technology into their patient monitoring program.

In facilities where wireless ECG systems are currently being used, a review of the literature shows that

time-motion studies have not been documented to capture the actual savings of time and decrease in

number of touches and episodes of exposures to the patient.

Additionally, it is believed that standard hard wire 12-lead ECG data acquisition and transport devices

contribute to poor utilization of professional nursing hours and don’t support continuous patient

monitoring. It is important to identify any savings in nursing time so that it can be redirected to direct

patient care and promote increased efficiency and patient safety. Wireless ECG systems are designed to
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save critical nurse time by eliminating the need to detach and reattach lead wires when performing

ECG’s.2 These ECG’S are performed on patients who are not only stationary in bed, but are also being

prepared for monitored transport off their unit. As mentioned, the wireless system simultaneously

facilitates patient mobility and ambulation.2 A wireless ECG system provides the opportunity to redirect

nursing time to other valuable care measures which increase nurse satisfaction, enhance patient comfort

and reduce the risk of cross contamination due to repeated exposure to touches by health care personnel

and use of re-useable, improperly cleaned lead wires.1,2,3,5

Method & Materials

Population

The sample of participants was N=95 adult patients with an order from a physician or nurse

practitioner to undergo 12-lead ECG while in a Critical Care Unit, Sub-Intensive Care unit or Stroke Unit

and during transport from one unit of the hospital to another. In some instances a patient may have been

involved in more than one acquisition. This evaluation was conducted at one hospital located in Newport

Beach, California.

Design

This study is quantitative comparative evaluative design. The acquisitions included 30 ECG acquisitions

performed as follows; a) 30 ECG acquisitions performed using a wireless ECG system, b) 30 ECG

acquisitions performed using traditional hard wire ECG system, c) 30 ECG acquisitions performed using

the Wireless ECG system while a patient was prepared for transport and d) 30 ECG acquisitions using

traditional hardwire ECG monitoring while a patient was prepared for transport Instruments

Instruments

Reliability and Validity

Wireless system: A valid reliable wireless system was used in this study following hospital standards. The

product has FDA approval and was acknowledged by the Department of Health and Human Services on

August 5, 2003.

Procedure

Each subject had ECG electrodes connected to the wireless lead wear. A single patient use disposable

lead set was utilized to acquire the ECG data which was transmitted to the ECG monitor. Transmission
Running head: ECG ACQUISITION TIME AND MOTION STUDY
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was performed wirelessly via patient and monitor transceivers (radios) utilizing Bluetooth ® transmission

technology. Following hospital standards, a hard wire 12 lead ECG system was utilized to obtain a

traditional 12 lead ECG using reusable, multi patient use ECG lead wires.

1. Demographic instruments were not utilized as identifiers were not accessed or

maintained post consent, all data was held in confidence. Patients received copies

of their consents.

2. A tool for time motion was designed strictly to enter date, time of application of lead

wear and time of ECG acquisition with either the wireless or hard wire system.

Content validity of the tool was established by two data collectors during a “pilot

period” which encompassed the first ten measurements of data collection. A stop

watch, with calibration each day, was utilized to measure time and a hand counter

was used to count the number of touches to each patient during each measurement.

The percentage of agreement for content validity was 98.6%.

Procedure

After approval by the institutional review board (IRB), the investigative team began the

appropriate research procedures. Patients were invited to participate and were then consented for the

study. Personnel performing the observations were trained and their understanding and accountability

confirmed through feedback sessions. A convenient sample was initiated in order to screen patients with

orders for a 12 Lead ECG to be performed that day. The registered nurses receiving orders for ECG’s

played a key role in the study by communicating when ECG’s were expected to be performed on their

units. Two ECG data acquisition observers were trained by the vendor to record established intervals in

preparation for the study.

Inter-observer reliability was established by comparing the ECG data acquisition time

documented for 10 stationary patients and 10 patients prepared for transport with ECG monitoring, by

each observer. The independent observers performed the following measurements and recorded the total

duration of time and number of patient touches on the patient data flow sheets:
Running head: ECG ACQUISITION TIME AND MOTION STUDY
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1. The duration of time of each ECG data acquisition using the Wireless System or ECG

hard-wire system (including time to enter patient’s room, ECG machine prep time, set-up

of ECG Lead Wear on chest, ECG equipment operation time, electrode removal time,

time to leave patient’s room, and post procedure clean-up of the equipment).

2. The duration of time to apply ECG transport monitor (including time to connect adapter

from wireless system patient lead wear to transport monitor or hard wires from the

transport monitor to the patient).

3. The number of times a patient was touched in preparing and obtaining an ECG tracing

using both wireless and wired system.

Data Analysis

There were 120 acquisitions of ECG’s, for the sample of N=95. An analysis of the average time

to perform an ECG for all four ECG data acquisition cohorts, both wireless and traditional hard-wire ECG,

demonstrated that the time for ECG was decreased using wireless ECG technology. This analysis utilized

a standard average time measurement that calculated P values using a t-test. During observation, an

incidental count of the number of times the nursing staff touched the patient while using the wired system

was 62 touches as compared to 19 touches when staff used the wireless system. Descriptive statistics,

using SPSS (Statistical Package for the Social Sciences) and t-test inferential statistical analyses
were used between the groups. The t-test determined significant differences between the two ECG data

acquisition methods in terms of duration of time and the number of times the patient was touched.

Results

Table 1 summarizes mean ECG acquisition times and total number of touches to the patient for

wireless and traditional 12-lead ECG monitoring systems. Statistically significant differences (p<0.0001) in

the amount of time required for ECG acquisition, both while a patient was stationary and during transport,

were observed between the wireless monitoring system and traditional hardwire 12-lead ECG monitoring.

The mean (SD) stationary ECG acquisition time using the wireless system was 123 (46.0) seconds
Running head: ECG ACQUISITION TIME AND MOTION STUDY
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compared with 298 (99.6) seconds using a hardwire 12-lead ECG system and the mean (SD) number of

touches during ECG acquisition while a patient was stationary was 13 (7.6) touches compared with 43

(9.1) touches using traditional 12-lead ECG monitoring.

Significant differences (p<0.0001) in mean ECG acquisition times and mean number of touches

were also observed for patients who were prepared for transport to other departments within the hospital.

The mean (SD) ECG acquisition times for patients prepared for transport were 16.1 (8.7) seconds for the

wireless system as compared with 58.7 (19.5) seconds when traditional 12-lead ECG monitoring system

was used. Mean (SD) number of touches to the patient were considerably less, 6 (2.2) for the wireless

ECG acquisitions as compared to 19 (6.4) when using traditional hardwire 12-lead ECG monitoring.

Figure 1 illustrates graphically the mean time required for ECG acquisition, and the mean number

of touches to the patient for both the wireless monitoring system, and the traditional hardwire 12-lead

ECG monitoring when the ECG is performed on patients who are stationary at the bedside. Figure 2

illustrates the mean ECG acquisition time and mean number of touches required for ECG data acquisition

while a patient is being prepared for transport.

Discussion

The data obtained during this study indicate significant decreases in the amount of time and the

number of touches to the patient when 12 lead ECG tracings are obtained, using wireless ECG
Running head: ECG ACQUISITION TIME AND MOTION STUDY
7
monitoring as compared with ECG acquisition using a traditional hardwire ECG system. This

improvement in the efficiency of ECG data acquisition is attributed to several factors, including time saved

when the disposable leads and wires used do not have to be cleaned 6, time saved when lead wires do

not need to be continually reconnected and reapplied to the patient’s chest, and time saved when there is

no need to remove and reattach lead wires each time the patient is moved and/or transported. By

eliminating trunk cables and lead wires, a wireless system allows the patient to move about more freely

and ambulate (up to 30 feet away) from the monitor without risk of tripping or falling over cable wires, or

disconnecting from the cardiac monitor, resulting in an unsafe situation. The hygienic benefits of a single

use wireless ECG system cannot be understated when addressing the universal hospital concern to

decrease hospital acquired infections (HAI’s) through the decrease and elimination of cross contamination

between patients.6 In a “Benefits Analysis of Wireless ECG” performed by the Lewin Group, potential

savings in nursing time was estimated at close to 3 hours per acute myocardial infarction and coronary

artery bypass graft patient stay. 4

Clinical Significance

Of clinical significance in the use of wireless ECG technology is the absence of loss of ECG history and

subsequent disclosure. Wireless lead wear is not removed from the patient and at no time is the patient

disconnected from the ECG monitoring system. Such a system can offer enhanced

“signal quality by eliminating interference and by maintaining excellent electrode contact. This results in

potential reductions in nuisance alarms and unscheduled time off monitor. 5 “More accurate alarms can

improve the quality of care and reduce the risk of adverse events by improving the vigilance of care

givers.” 5 As important, is that the risk of losing relevant ECG activity (disclosure) is significantly reduced

and virtually abated from the overall process. One more aspect of clinical significance, though not

measured in this study, is the decrease in variability of ECG lead wear placement on the patient’s chest.

This decrease in variability is very advantageous in that the transmission of consistent ECG waveforms

important for monitoring and ongoing diagnosis and treatment of the patient is consistent and reliable.

Conclusion

This research indicates that Critical Care Nurses’, ECG technicians’ and Respiratory Care

Practitioners’ (RCP’s) time can be saved with the use of wireless ECG technology. The technology is
Running head: ECG ACQUISITION TIME AND MOTION STUDY
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easy to use, reliable and consistent. Our physicians are satisfied with the quality of the wireless

technology and have come to accept it as a standard of care. Most importantly, patients are happy to

have a comfortable ECG system which monitors their cardiac activity in a safe and reliable manner

without encumbering their movements and holding them “hostage” to the monitor. 7,8 Staff are major

advocates for this system because of the system’s ease of use and overall time savings allowing for more

focus on direct patient care.

The data also supports the wireless ECG system since it saves valuable nursing, ECG and

respiratory staff time by decreasing the amount of touches to the patient, which in turn, decreases

patients’ exposure to cross contamination increasing their satisfaction and overall comfort (less touches

and exposure). “A single patient, disposable, wireless ECG system eliminates the possibility of cross

contamination from reusable ECG wires” 5, thereby decreasing the risk of infection and cross

contamination amongst multiple patients admitted to monitored units throughout our facility.

The practice of RN’s, ECG technicians and Respiratory Care Practitioners performing both

wireless and hard wire ECG’s currently remain the same for this hospital. The critical care team is acutely

aware of the benefits of the wireless systems and supports the continued use of the wireless product in

their units for their interests as well as the well being of their patients.

Strategies used to test the advantages of a disposable, wireless ECG system in this research

study provided significant evidence to support the continued use of wireless ECG monitoring systems in

both the in-patient and out-patient setting. Wireless, single use, disposable ECG technology supports not

only a safe and consistent cardiac monitoring environment for patients, but also provides a means to

decrease possible cross contamination and infection rates amongst the critically ill population. Further

studies are recommended to test wireless systems in various settings. “The use of disposable pads and

wireless lead wires is a measure that should become a standard of care.” 9

A study conducted by the Lewin Group to assess the burden of lead wire management on health care

providers concluded that nurses spend 40 minutes per day, per patient, dealing with lead wires. This

included responding to false alarms, untangling lead wires, and attaching and detaching lead wires to

patients. When asked what other duties they would perform with potential time savings offered by a

wireless system, nurses indicated they would provide more patient care, complete chart work, spend
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more time tracking administered medications, perform more patient education, and spend more time

talking to families.10

Lessons Learned and Suggestions for Future Studies:

Many more opportunities exist for continued study and measurement. Suggestions for future studies

include the measurement of patient satisfaction with wireless ECG systems as compared to traditional

hardwire ECG systems; an analysis of the degree of overall nursing satisfaction with wireless ECG

systems in daily practice (bedside use, maintenance, cost etc.); a study of the ease of use of the wireless

ECG system as compared to traditional ECG hard-wire system (at the bedside as well as upon transfer

and transport); and, a formal evaluation of measures which demonstrate a decrease in cross

contamination and subsequent hospital acquired infection rates when utilizing a wireless ECG system

(single patient use) as opposed to a wired ECG system (multi-patient use).

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ECG ACQUISITION TIME AND MOTION STUDY

References

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reduce healthcare-associated infections. Emergency Medicine & Critical Care, 10, 49-50.

4. The Lewin Group. The Potential Benefits of a Wireless Electrocardiogram System for Inpatient
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Cable Replacement System Reduces Artifacts and Increases ECG Alarm Accuracy, 2005.

6. Fensli R, Dale JG, O’Reilly P, et al; Towards improved healthcare performance: examining
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7. Sneha, S, Varshney U. A wireless ECG monitoring system for pervasive healthcare. Int J Electron
Healthc. 2007;3(1):32-50, accessed November 15, 2010.

8. Borrower S, Rodriguez-Sanchez C, Machado F, et al; A reconfigurable, wearable, wireless ECG

system. Conf Proc IEEE Eng Med Biol Soc. 2007;2007:1659-62 , accessed November 15, 2010.

9. Todd E. Barnett , The not-so-hidden costs of surgical site infections, Implementing a wireless ECG
lead wire system; AORN Journal, August 2007, Voll 86, N0 2, 255-256.

10. LifeSync® Disposable Leadwear®; LifeSync Corporation, Wireless ECG and Wireless EKG,
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2008; Accessed March 19, 2011.