Barriers to obtaining a high quality ECG recording

Barriers to obtaining a good quality ECG. Obtaining an accurate, good-quality ECG, with a sharp, flat baseline and distinct wave forms, is crucial for enabling correct interpretation. Barriers to achieving this include inaccurately placed electrodes or leads, electrical interference from other devices, skeletal muscle activity, and poor conduction of the current somewhere along its path from the skin to the monitor. Electrode or lead misplacement is a common problem which can cause profound changes to the shape of the wave forms, leading to significant errors in diagnosis. For this reason, we spent a lot of time in week one looking at the correct location of the electrodes and attachments to the leads.

An example of a very common mistake is reversal of the left and the right arm leads, so that the left arm lead is placed on the right arm, and vice versa. If we look at the waveforms on a normal ECG, you can see that they’re predominantly upright in lead II and pointing downwards in aVR. However, when the left and right arm leads are switched, the waveform directions in this example are reversed. To help avoid this kind of error, it is good practice to check for the normal, predominantly upright waveforms in lead II and downwards facing waveforms in aVR immediately following the procedure. Electrical interference can be due to alternating current which supplies electrical wall outlets.

This can be caused by electrical wires in the walls and other equipment in the room. And it’s identified on an ECG as a thick, fuzzy baseline. Ways of addressing this include unplugging equipment which is not in continuous use or moving the ECG and the patient away from the equipment. Skeletal muscles also generate electrical impulses, which can be detected by an ECG. Causes include muscle tension, which may arise when someone is not relaxed or comfortably positioned, or muscle tremor from, for example, shivering, anxiety, or a condition such as Parkinson’s disease. Movement of the patient on the bed or talking can also cause this problem. The muscle activity is represented on the ECG as a bumpy or spiky baseline.

To minimise the issue, it’s important the patient feels warm, comfortable and relaxed. And they are asked to remain as still as possible and not to speak during the procedure. A wandering baseline is undulating rather than flat, making the ECG difficult to interpret. It is linked to the movement of the chest wall during breathing. But it can also have other causes, such as poor skin to electrode contact. In stable patients, asking the person to hold their breath during the procedure may be helpful.

Poor conduction of the electrical signal is a frequent problem, which can rise due to inadequate skin preparation, which is necessary to remove oils, sweat, hair, and buildup of dead cells from the skin, to facilitate a good skin to electrode contact. Dry electrodes which may have reached their expiry date, been inappropriately stored, or been left on the body for a period of time, may also not have enough gel to provide a good contact. Other possible causes of poor conduction are tension on the cables, which may cause the electrodes to peel off the skin, and breaks or cracks in the cable or lead wires.

Where conduction from the skin to monitor has not taken place, you will see a missing lead with just a dotted baseline, as shown on the screen. Strategies for ensuring good conduction, including skin preparation, had been explained in week one.