ECG PROCEDURE AND LEAD PLACEMENT GUIDE:

PEDIATRICS

PURPOSE
To provide Registered Nurses (RN), Registered Psychiatric Nurses (RPN), Registered Respiratory
Therapists (RRT) and Physicians (Staff, Residents and Fellows) with guidelines for Electrocardiogram
(ECG) lead placement consistent with the standards established by the BC Children’s Heart Centre.
SCOPE
This procedure applies to all Registered Nurses (RN), Registered Psychiatric Nurses (RPN), Registered
Respiratory Therapists (RRT) and physicians (staff, residents and fellow).
In order to perform an Electrocardiogram (ECG) the Registered Nurse (RN), Registered Psychiatric Nurses
(RPN), Registered Respiratory Therapist (RRT) or Physician (Resident, Physician or Staff) must
demonstrate knowledge of:
 Proper lead placement for infant, child and teen/adult body habitus
 Infection control procedures (routine infection control practices)
 Communication and informed consent
 Proper pre and post test documentation in the patient record consistent with each specific clinical
area.

RATIONALE
To ensure consistent application of ECG lead placement the Trained Health Care Provider will perform
ECGs utilizing techniques taught by a Certified Cardiology Technologist consistent with the standards
established by the BC Children’s Heart Centre.
Accuracy of lead placement ensures correct test interpretation and repeatability should subsequent testing
be required.
Correct entry of patient demographic fields is essential to allow results to be viewed and reported on MUSE
and accurately attach ECG results to the online Cerner PowerChart patient record.
SITE APPLICABILITY
BC Children’s Hospital
BC Women’s Hospital – Neonatal Care
PRACTICE LEVEL/COMPETENCIES
Relevant competencies will be developed through education, preceptorship and clinical practice.
EduQuick sessions are provided throughout the hospital at various regular intervals. Contact the
Cardiology Technologist/ECG Trainer (7114) for EduQuick schedule, troubleshooting of lead placement
and general questions.
If the equipment requires servicing please place a Biomed Service Request and include the system’s
PHSA Asset Number.
EQUIPMENT
GE Heathcare MAC 5500 HD
Kendall Electrode ECG Resting Q-Trace 5400 (ePro 315807, Item ID 3677)
GE ECG 150 mm Recording Paper (ePro 2009828-024, Item ID 17032)
Vermed Pediatric Leads, (ePro 6502930v, Item ID 92076)
Cavi Wipes

CC.03.47 BCCH Child & Youth Health Policy and Procedure Manual Effective Date: 23-JAN-2018
Reviewed: 23-JAN-2021
Refer to online version – Print copy may not be current – Discard after use Page 1 of 6
 ECG PROCEDURE AND LEAD PLACEMENT GUIDE:
PROCEDURE
Obtaining Cart and Entering Patient Information
OBTAIN device from designated storage location
and bring to patient bedside.
PERFORM hand hygiene.
TURN device on by depressing the on/off button
located on the keyboard.
IDENTIFY patient using two patient identifiers.
EXPLAIN procedure to patient and/or family.
POPULATE all the fields on the patient
demographic screen manually. Pay special care to
use the correctly spelled, wristband verified:
- First Name
- Last Name
- Date of Birth
- MRN (Not PHN)
- Referring Physician (First initial, Last name)
- Reason for Test
- Nurse/RRT/MD (First initial, Last name)
Preparing Patient and Lead Placement
PROMOTE relaxation. Patient must be
cooperative and non-restrained during the
procedure.
PATIENT POSITIONING
- PLACE patient in the supine or semi-
fowlers position.
- ENSURE arms are placed down along both
sides of patient
- ENSURE patient’s legs and hips are
relaxed, not crossed or tilted
PREPARE skin for lead placement.
- DRY diaphoretic skin using a sterile gauze
- ENSURE skin is free of oils using a gauze
and sterile water. Alcohol swabs may be
used if necessary.
- SEPARATE skin hairs if applicable
ATTACH leads to the patient using the appropriate
Lead Placement Guide (see appendices).
CC.03.47 BCCH Child & Youth Health Policy and Procedure Manual
Refer to online version – Print copy may not be current – Discard after use
PEDIATRICS
Rationale
Routine Infection Control Practices reduces
transmission of microorganisms.
Turning the device on and off between patients
prevents the previous patient’s information from
being attached to the current patient
Failure to correctly identify patient prior to
procedures may result in error.
Reduces patient’s and/or family’s anxiety which
promotes relaxation and improves ECG quality
Accurate patient demographics ensures the ECG
results are correctly transferred to the Cerner
PowerChart patient record.
Including the first initial and last name of the person
conducting the test allows the Cardiology
Technologist to follow-up with data remediation
questions and helps with infection control inquiries.
Encouraging family involvement may facilitate
relaxation.
The use of “facilitating tucking” by family or health
care provider is recommended.
Only touch after patient or caregiver permission
granted or saying ‘excuse my touch’.
This is facilitated by nurses and/or parents
depending upon the age of the patient.
This reduces muscle tremor artifact by relaxing
muscles in the arms, shoulders and neck.
Ensures leads will adhere to the skin throughout the
test.
Leads will adhere better if hair is “pushed” to either
side. Shaving the skin free of hair may be
necessary in rare circumstances.
Effective Date: 23-JAN-2018
Reviewed: 23-JAN-2021
Page 2 of 6
 ECG PROCEDURE AND LEAD PLACEMENT GUIDE:
Performing the Test
INFORM patient that testing is about to start.
OBSERVE the acquisition screen tracing for
normal/abnormal readings for 30 – 60 seconds.
PRESS ECG located on the right side of the
keyboard. The captured tracing will be displayed
for review.
REVIEW captured tracing and ASSESS for signal
quality and presence of signal artifact.
SELECT CONTINUE if the displayed tracing is
sufficient to provide to the ordering physician.
OR
SELECT CANCEL if the displayed tracing is
insufficient to provide to the ordering physician.
The displayed tracing will revert to the real time
acquisition screen. Restart the acquisition process
at OBSERVE above.
REMOVE ECG wires from electrode stickers and
ECG stickers from patient.
TURN device off by depressing the on/off button
located on the keyboard.
PROVIDE printed ECG to Ordering Physician for
interpretation of findings.
DISCUSS plan for patient care.
PAGE On Call Cardiologist/Cardiology Fellow for a
second opinion if needed.
CLEAN acquisition module, cables, alligator clips
and keyboard using Cavi Wipes.
PLACE acquisition module onto the arm located on
the right hand side of the machine.
ENSURE cables and lead wires are hanging freely
and not coiled around the device.
RETURN device to its designated storage location.
REFERENCES
BC Children’s Hospital Heart Centre: Cardiology Technologist/Trainer, Zsanett Banati; 4480 Oak Street,
Vancouver, BC, V6H 3V4, Experience ongoing.
MAC 5500/MAC 5500HD Operator’s Manual,
www3.gehealthcare.com/en/Support/Support_Documentation_Library
CC.03.47 BCCH Child & Youth Health Policy and Procedure Manual
Refer to online version – Print copy may not be current – Discard after use
PEDIATRICS
Remind patient that the test will not hurt. Ask the
patient to breathe normally, lie still and not to talk.
ECG systems show heart rhythms in 10 second
tracing increments. Waiting 30-60 seconds allows
the user to see abnormal heart rhythms and more
effectively use the ECG as a risk screening tool.
Effort and time should be taken to capture tracings
with heart beat irregularities. If no irregularities are
noted a normal, artifact free tracing should be
captured.
IMPORTANT: Only Select CONTINUE for ECGs
that are of sufficient quality to provide to the
Ordering Physician and include in the Patient
Health Record.
Additional ECGs should only be attained if there is a
value added, clinical need to capture multiple time-
points (eg. sudden change in rhythm, arrhythmia
detection, physician request, etc.)
Always remove stickers gently (possibly using an
adhesive remover for dry skin) to ensure the patient
is not left with a negative experience.
Ask older patients if they would prefer to take the
stickers off themselves.
Turning the device on and off between patients
prevents the previous patient’s information from
being attached to the current patient
Physicians are trained to identify abnormal heart
function. RN/RPN/RTT’s collaborates with
physicians to ensure that any care plan changes
are made in a timely manner. Every ECG must be
given to a physician for interpretation of
findings.
NEVER EMERSE ANY PART OF THE
EQUIPMENT IN ANY LIQUID.
Coiling will damage the lead wires.
Ensure unit is turned off, screen is folded down and
system is plugged into outlet.
Effective Date: 23-JAN-2018
Reviewed: 23-JAN-2021
Page 3 of 6
 ECG PROCEDURE AND LEAD PLACEMENT GUIDE:
PEDIATRICS

Lead Placement Guide, Infant

Tips/Troubleshooting
- ATTACH labelled clips to appropriate leads by depressing and
releasing the clip button. Ensure the clip button is facing up.
- USE Vermed TinyTab electrodes or CUT Kendall 5400 electrodes in
half vertically with scissors. Trim edges if necessary to ensure leads
do not touch each other.
- ENSURE leads do not touch and there is no gel migration between
them.
- LEAVE leads off if they cannot be positioned correctly. Results will
be more accurate with an absent ECG lead field rather than a
misplaced lead.
- COMMUNICATE with the nursing staff to temporarily remove or
reposition bandages, devices or vital sign electrodes to facilitate
correct lead placement when possible.

CC.03.47 BCCH Child & Youth Health Policy and Procedure Manual Effective Date: 23-JAN-2018
Reviewed: 23-JAN-2021
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 ECG PROCEDURE AND LEAD PLACEMENT GUIDE:
PEDIATRICS

Lead Placement Guide, Child

Tips/Troubleshooting
- ATTACH labelled clips to appropriate leads by depressing and releasing
the clip button. Ensure the clip button is facing up.
- CUT Kendall 5400 electrodes in half vertically with scissors. Trim edges if
necessary to ensure leads do not touch each other.
- ENSURE stickers do not touch and there is no gel migration between
them.
- LEAVE leads off if they cannot be positioned correctly. Results will be
more accurate with an absent ECG lead field rather than a misplaced lead.
- COMMUNICATE with the nursing staff to temporarily remove or reposition
bandages, devices or vital sign electrodes to facilitate correct lead
placement when possible.

CC.03.47 BCCH Child & Youth Health Policy and Procedure Manual Effective Date: 23-JAN-2018
Reviewed: 23-JAN-2021
Refer to online version – Print copy may not be current – Discard after use Page 5 of 6
 ECG PROCEDURE AND LEAD PLACEMENT GUIDE:
PEDIATRICS

Lead Placement Guide, Teen / Adult

Tips/Troubleshooting
- ATTACH labelled clips to appropriate leads by depressing and releasing
the clip button. Ensure the clip button is facing up.
- USE Kendall 5400 electrodes.
- PLACE (for patients with breasts) V4 on the chest wall under the breast in
line with the nipple.
- ENSURE stickers do not touch and there is no gel migration between
them.
- LEAVE leads off if they cannot be positioned correctly. Results will be
more accurate with an absent ECG lead field rather than a misplaced lead.
- COMMUNICATE with the nursing staff to temporarily remove or reposition
bandages, devices or vital sign electrodes to facilitate correct lead
placement when possible.

CC.03.47 BCCH Child & Youth Health Policy and Procedure Manual Effective Date: 23-JAN-2018
Reviewed: 23-JAN-2021
Refer to online version – Print copy may not be current – Discard after use Page 6 of 6