TROUBLESHOOTING TROUBLESHOOTING Arrhythmia Calls No matter how sophisticated an arrhythmia monitoring program may be, no real-time monitoring equipment recognizes the presence or absence of P-waves. Therefore, it is very important to remember that alarms will not sound for certain arrhythmias unless the heart rate exceeds the upper and lower limits for heart rate. Note: Close observation of the patient’s rhythm by a trained clinician is vital. Rhythms, such as Sinus Arrhythmia, will not be called.
TROUBLESHOOTING There are three general categories of questionable arrhythmia calls. 1. False Positive Calls result when the arrhythmia system signals an arrhythmia when there is none. It is important to understand how the algorithm analyzed the rhythm. 2. False Negative Calls result when the arrhythmia system fails to detect and signal an arrhythmia event when one is present. 3. Incorrect Analysis occurs when the system signals that an arrhythmia event occurred, but classifies it incorrectly.
TROUBLESHOOTING Examples Many of the types of false positive calls are related to electrode application and signal quality. Let’s consider several examples. Example 1 - False High PVC Alarm Problem High PVC alarm occurs but no PVCs are present. Fig. 93. Example 1 - False Positive Call Correction • Press the Re-learn button to discard the patient’s previous templates and replace them with the current templates. • Check for dry electrodes. It may be time to replace them.
TROUBLESHOOTING Fig. 94. Example 2 - False Positive Call Correction Persistent QRS variability in the patient’s dominant rhythm is a rather difficult problem for computerized arrhythmia detection. Only the trained caregiver can judge if a specific QRS morphology represents a variation in the patient’s basic QRS or if it is abnormal. However, in an attempt to reduce the number of alarms, you can perform the following steps: 1. Turn off all nonessential alarms 2.
TROUBLESHOOTING Example 3 - Missed Ventricular Tachycardia Problem Sometimes the arrhythmia system calls a ventricular arrhythmia differently than the clinicians would. Remember that the system has criteria which must be met. For example, V-TACH is called when the rate is greater than or equal to 100 BPM and 3 consecutive PVCs are detected. If the ventricular abnormal varies, then the system may mis-classify some of the beats as non-ventricular. Fig. 95.
TROUBLESHOOTING Example 4 - Excessive Artifact or Poor Signal Quality Problem Older analog systems made the differentiation between electrical and physical interference (artifact), and poor signal strength or antenna interference, difficult because they both showed up as artifact on the ECG signal. With newer digital systems, troubleshooting the causes of interference is much easier. Most interferences related to the antenna system will show up as gaps (drop outs) in the waveform.
TROUBLESHOOTING 2. Muscle Artifact Muscle artifact is also known as electromyographic signals (EMG) and are produced by the normal electrical activity associated with muscle movement. The only difference between the electrical muscle activity and the electrical heart activity is that cardiac voltage is generally consistent and muscle voltage is erratic. Because the bandwidth of muscle noise is so similar to the ECG signal, it cannot be totally eliminated by filtering.
TROUBLESHOOTING 3. Electrode Contact Noise If the path from the patient’s skin to the ECG transceiver is broken or disturbed, then it can cause noise that may completely obscure the ECG waveform. This is usually due to poor contact between the electrode and the patient’s skin (dangling electrodes), poor skin preparation, or dry electrode gel.
TROUBLESHOOTING Example 5 - Missed Supraventricular Tachycardia Problem The alarm was not called after a six-beat episode of SV-TACH. Fig. 101. Example 5 - SV-TACH Episode Alarm Correction For an alarm to be called for SV-TACH, the episode must consist of 8 Supraventricular ectopic beats at a rate of 150 BPM or greater. Remember the arrhythmia system does 6 beat averaging. PatientNet Operator’s Manual, v1.
TROUBLESHOOTING Example 6 - Repeated High PVC Alarms Problem PVCs are present and counted correctly, but the “High PVC” alarm keeps going off. Fig. 102. Example 6 - High PVC Alarm Correction Increase the number of PVCs per minute limit on the High PVC Alarm Configuration screen. Example 7 - PVCs Not Called Problem PVCs are present, but no counts are shown. Fig. 103. Example 7 - Present PVCs Not Counted Correction 1.
TROUBLESHOOTING Example 8 - Alarms Turned Off Problem Rhythm not accompanied by an audio alarm. You can see on the full disclosure that the alarm is turned OFF. Fig. 104. Example 8 - Audio Alarm Not Activated PatientNet Operator’s Manual, v1.04, 10001001-00X, Draft All information contained herein is subject to the rights and restrictions on the title page.
TROUBLESHOOTING Example 9 - Asystole Alarm Not Called Problem There is a pause of 2.837 seconds, but the system did not call an Asystole alarm. The arrhythmia software algorithm detects asystole after a period of 3.0 seconds during which no QRS has been noted. This example is below that 3.0 second threshold. Fig. 105. Example 9 - No Asystole Alarm Called Example 10 - V-TACH Alarm Not Called Problem The patient had an episode of V-TACH, but the system did not call a V-TACH alarm.
TROUBLESHOOTING Example 11 - Possible Problems Related to Tall P and T-Waves Problem The algorithm is designed to selectively recognize the P and T waves and to emphasize detection of the R-wave, so as to prevent classifying the former as Beats. 1. Large P-waves may be detected and classified incorrectly as R-waves, causing the algorithm to generate incorrect high heart rate, or PVC related, false alarms. For example, you manually count 70 BPM, but the computer counts 140 BPM.
TROUBLESHOOTING Example 12 - False Asystole Alarm Problem Small R-Wave Voltage 1. When R-waves are small, the system might not see the signal. A false positive asystole call and alarm may occur. Fig. 108. Example 12 - Small R-Wave Voltage Correction 1. Resolve this by moving the electrodes to a different lead configuration, such as closer to the heart, to achieve a stronger signal. Increasing the size on the waveform display will not remedy this situation.
TROUBLESHOOTING spikes and display them in very short, regular intervals that are superimposed on the patient’s waveform. The actual pacemaker pulse voltage is typically a minimum of ten times the impedance pulse voltage. Repositioning the electrodes a minimum of three to four inches from the pacemaker will typically minimize the likelihood of the impedance pulse being deleted as a pacemaker spike.
TROUBLESHOOTING Example 14 - False Asystole Alarms with Paced Rhythms Problem False Asystole Alarms on Fused Beats The following figure demonstrates one situation with pacemaker rhythms which may result in a false positive asystole call. Note the absence of the N-beat annotations on the lower strip. Remember, the pacer filter is enabled when the Process is set to Pacer.
TROUBLESHOOTING Example 15 - High Heart Rates with Paced Rhythms Problem False High Rates Due to Detection of Beats on Pacer Artifact The following figure shows the opposite situation of the false Asystole calls. Here, the system is double counting and the false high rates are due to detection of beats on pacer artifact. When the system called false high rate alarms due to this situation (more than one annotation per beat), the pacer filter should be increased.
TROUBLESHOOTING Reporting If the problem persists, then please contact your technical support representative. When reporting a condition, please include the following information: • Pacemaker/AICD/PCD • Type • Make • Model Number • Manufacturer • Attach a pacer report if applicable Note: Please print and attach an annotated zoomed-in printout of the Full Disclosure with Leads I, II, and V. Ideally, start recording ten seconds prior to the event and continue through the event in question.
TROUBLESHOOTING Event Information Form 1. Date and time of event ____________________________________________________________________ 2. Event description _________________________________________________________________ ____________________________________________________________________ 3. SMART ALARM Yes___ No___ ALARM ON___ OFF___ Arrhythmia ON___ OFF___ Arrhythmia Lead Selection AUTO___ MANUAL___ 4.
TROUBLESHOOTING Zoomed-In Full Disclosure Fig. 113. Zoomed-In Full Disclosure Example 224 PatientNet Operator’s Manual, v1.04, 10001001-00X, Draft All information contained herein is subject to the rights and restrictions on the title page.
TROUBLESHOOTING 24-Hour Full Disclosure - 1 Hour Report Fig. 114. 24-Hour Full Disclosure Example PatientNet Operator’s Manual, v1.04, 10001001-00X, Draft All information contained herein is subject to the rights and restrictions on the title page.
TROUBLESHOOTING Commonly Asked Questions 1. How much change in the shape of the QRS complex is tolerated by the algorithm? Subtle changes in the QRS will be tolerated by the algorithm if the new beat continues to match the stored template. The reference QRS is a snapshot of the dominant beat at the time the system was “learning.” If the patient’s ECG changes due to ischemia or infarction (the resultant ST, T-wave changes). then the system may look at the beat as an abnormal beat, resulting in false calls.
TROUBLESHOOTING 6. What are false positive calls? A false positive call is one where an event was labelled as an arrhythmia when it was not. It is most often seen when artifact appears to be an arrhythmia and is called such by the computerized detector. 7. What are false negative calls? A false negative call is one where the algorithm misses an actual arrhythmia event. 8.
TROUBLESHOOTING Error Messages General PatientNet System Error Messages The following table lists the possible error messages that may occur with the PatientNet System. Contact your service representative for additional information. Error Message 228 Cause Corrective Action Laser Off-Line The laser printer is not connected or is not responding. Make sure the printer is turned on, connected to the system, and that the On Line indicator is illuminated.
TROUBLESHOOTING Error Message Cause Corrective Action Page Queue Full There are too many paging requests currently pending. This condition should resolve itself in a few minutes as the pages are sent. If this situation continues, then contact your technical support representative. A Pager number must be entered prior to admitting a patient This is a configurable setting. When enabled behind the passcode screens, this feature forces the operator to enter a pager number.
TROUBLESHOOTING WMTS Specific Multiple Device Masters There is more than one Central Station configured to be a Device Master. Reconfigure the Central Stations so that there is exactly one Device Master. No Device Master There is no Central Station on the Network that is configured to act as the Device Master. Configure one of the Central Stations on the Network to be the Device Master. Access Point Error. An Access Point on the Network is using an incompatible version of the Access Point Firmware.
GLOSSARY OF TERMS GLOSSARY OF TERMS This glossary of terms includes clinical definitions of ECG monitoring terms, as well as definitions and features of the arrhythmia detection system. Clinical definitions may vary; however, these are presented as representative of generally accepted explanations in current practice. PatientNet specific terms will be denoted by (PN) after the definition.
GLOSSARY OF TERMS Atrial Fibrillation - an arrhythmia arising in numerous ectopic pacemakers in the atria characterized by very rapid atrial fibrillation waves, and an irregular, often rapid ventricular response. Atrial Flutter - an arrhythmia arising in an ectopic pacemaker in the atria characterized by abnormal atrial flutter waves with a sawtooth appearance and usually a regular ventricular response. Augmented Limb Leads - also called the frontal plane leads.
GLOSSARY OF TERMS Ectopic Beat - contraction that occurs from an impulse generated from a site other than the sinoatrial node. e.g. premature atrial contraction, premature junctional contraction, and premature ventricular contraction. Electrocardiogram (ECG) - the graphic display of the electrical activity of the heart generated by the depolarization and repolarization of the atria and ventricles.
GLOSSARY OF TERMS Learned Reference - the template of the patients “normal” or dominant ECG complex to which every incoming beat is compared. (PN) Modified Chest Lead MCL1 - the bipolar lead closely resembling lead V1, views the anteroseptal wall of the heart. Multifocal - (multiform) PVCs that have different QRS complexes as a result of their originating in different ectopic ventricular sites.
GLOSSARY OF TERMS Standard Limb Leads (bipolar) - these are the ECG Leads I, II, and III. Tachycardia - a heart rate exceeding 100 beats per minute. Template - a template stores information about the shape of a beat. Templates serve as a reference to which all incoming beats will be compared. Beats either match or do not match the reference beat. The algorithm determines if the patient has had that type of beat before, if it is occurring more frequently, or if the shape (morphology) has changed.
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OPTIONAL FEATURES AND EQUIPMENT OPTIONAL FEATURES AND EQUIPMENT Touch Screen The touch screen lets you select buttons and perform other functions by touching the screen directly with your finger rather than by clicking with the mouse.
OPTIONAL FEATURES AND EQUIPMENT Paging Alarm Paging The optional paging system allows system operators to page caregivers, groups of caregivers or paging devices when an alarm occurs. The Central Station sends the room number, the text of the alarm, and the time to the paging device. Patient alarms must be enabled for paging (see page 239). When an alarm enabled for paging occurs, the operator is prompted either to send the page to the pager number(s) associated with the patient or to cancel the page.
OPTIONAL FEATURES AND EQUIPMENT Assigning a Pager Number to a Patient To assign a pager number or telephone extension to a patient for notification in case of alarms: 1. Press Pager # on the Patient Settings screen to bring up the on-line numeric keypad. 2. Enter the pager number or telephone extension (maximum 7 characters) to be assigned to this patient and press Enter. 3. If the patient belongs to a zone (a group of up to ten different pager numbers), enter Z and then the zone number.
OPTIONAL FEATURES AND EQUIPMENT Testing the Paging System To ensure that pages are sent by the page popup unit and that the pagers configured on the system are receiving the information correctly, perform a paging system test, typically once per shift. When this test is performed, all persons with pagers should call in to confirm that they have received the page. This test can only be performed from the page popup unit. 1. Press System on the Main screen. 2.
Multi-Mouse movement directions and pointer reactions for a Pod Configuration Lower Right Lower Middle Lower Left Right Left Upper Right Upper Middle Upper Left Remains on this Screen Remains on this Screen Remains on this Screen Remains on this Screen Moves to (9-16) Moves to (25-32) Moves to (25-32) Moves to (33-40) Remains on this Screen Remains on this Screen Remains on this Screen Moves to (1-8) Moves to (17-24) Moves to (25-32) Moves to (33-40) Moves to (41-48) Remains on this Screen Remain
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SYSTEM COMPLIANCE SYSTEM COMPLIANCE Compliance Statement Table 22 Device UL and FCC Compliance Device UL Compliance FCC Compliance Other Central Station, Remote UL 544, UL 1950 Viewing Station Part 15 CISPR 11 Class A and IEC 802-2, 802-3, 802-4, 802-5 DT-4500 Ambulatory Transceiver UL 2601-1 Part 15.242, Part 95 IPX7 Compliant/CISPR 11/ Subpart H (WMTS) EN60601-1-2 DT-7000/7001 Instrument Transceiver UL 2601-1 Part 15.
SYSTEM COMPLIANCE DT-4500 Ambulatory Transceiver UL Classification DT-4500 WITH RESPECT TO ELECTRIC SHOCK, FIRE, AND MECHANICAL HAZARDS ONLY IN ACCORDANCE WITH UL2601-1/CAN/CSA C22.2 NO. 601.1 4P41 The DT-4500 transceiver is classified in accordance with UL 2601-1, Type BF with Defibrillator Proof (5000V per AAMI EC-13-1992), and IPX7 (according to IEC 5291989). The DT-4500 has been designed to withstand the effects of EMI and meets the EMC requirements of EN60601-1-2 (April 1993) and CISPR 11.
SYSTEM COMPLIANCE DR-10000 Access Point UL Classification The DR-10000 Access Point is classified in accordance with UL 1950, Information Technology Equipment (including Electrical Business Equipment), and CAN/CSA C22.2 No. 950-95 (Third Edition). FCC Compliance in the 174-216 MHz and 608-614 MHz bands 1. The marketing and operation of intentional radiators, under the provisions of 15.242 of the FCC rules, is restricted to biomedical telemetry devices that are employed on health care facilities premises.
SYSTEM COMPLIANCE 3. The user and the installer of a biomedical telemetry device that is operating within the frequency range 608-614 MHz, and that will be located within 32 km of the very long baseline array (VLBA) stations or within 80 km of any of the other radio astronomy observatories noted in footnote US311 of 2.106 of this chapter, must coordinate with, and obtain the written concurrence of, the director of the affected radio astronomy observatory before the equipment can be installed or operated.
SPECIFICATIONS SPECIFICATIONS Specifications are provided to help you determine the space, ventilation, air conditioning, and power requirements to ensure proper operation of your monitoring system.To provide adequate cooling of the equipment, you must maintain at least two inches of air space at the top, rear, and both sides of computers and display monitors. Ensure that the PatientNet Central Station is kept free of fumes, dirt, and electrical interference.
SPECIFICATIONS Intel Pentium III Relative Humidity Table 26 90% maximum @ 35° C (non-condensing) Regulations Intel Pentium III Safety UL 544 listed CSA certified to CSA 22.2, no. 125 Meets CISPR II Class A and IEC 802-2, 802-3, 802-4, 802-5 EMC Table 27 Power Intel Pentium III AC Input Power Power Consumption Measured Current Draw @ 115 V, amps RMS VA @ 115 V BTU/hr. 248 115 V/60 Hz or 230 V/50 Hz switchable 135 W 1.07 123 299 PatientNet Operator’s Manual, v1.
SPECIFICATIONS CRT and LCD Displays Table 28 Display Specifications Part Number Dimensions Type Glass Surface Weight Table 29 19” (Color CRT) Z40903 Non-Touch Z40309 Touch Screen 14.7 x 14.2 x 15.4 in. 374 x 360 390 mm 15 in. (14 in. diagonal viewable area) 0.27 mm dot pitch, 90 deflection tint (TM=46%) ARAG screen treatments 26.4 lb. (12 kg) net Z40902 Non-Touch Z40308 Touch Screen 18.1 x 18.2 x 18.8 in 460 x 461 x 475 mm 48.2 cm/19 in. (18 in. viewable area) diagonal 0.
SPECIFICATIONS System Components WMTS Transceivers DT-4500 The DT-4500 is an internally powered device and is suitable for continuous operation.
SPECIFICATIONS DT-7000 and DT-7001 The DT-7000 is an externally powered Class 1 device and is suitable for continuous operation. The DT-7001 is an externally and internally powered Class 1 device and is suitable for continuous operation. Both devices are intended for non-patient connection use.
SPECIFICATIONS Uninterruptible Power System and Power Conditioning Systems Note: It is recommended that you charge the battery before the first use of your UPS. You may use the UPS without charging the battery first, but the backup time may be less than the rating. The UPS charges the battery automatically when it is turned on and AC power is available.
CLINICAL REFERENCE TOOLS CLINICAL REFERENCE TOOLS Central Station Quick Reference Admit a Patient 1. 2. 3. 4. 5. Touch1 Setup at top of screen. On top half of screen, touch patient’s waveform box. Touch Admit on lower half of screen. Touch Patient Data, enter patient name, etc., using onscreen keyboard. Touch Exit (at bottom) to return to main screen. Record a Real-Time Strip 1. 2. 3. Touch Strip to right of patient information box. Recording will stop automatically.
CLINICAL REFERENCE TOOLS Central Station Clinical Calculations Heart Rate Accuracy Ambulatory Patients The heart rate is based on a tracked six-beat average. New heart rate = (current rate - current rate/6) + (instantaneous rate/6) PVC Count The PVC count is the number of PVCs (arrhythmia V calls) in the last 60 seconds. Central Station Beat Annotations PatientNet Arrhythmia Software V1.
CLINICAL REFERENCE TOOLS PatientNet Arrhythmia Analysis Software V1.05 Alarm Label Rhythm Description MUSCLE ASYSTOLE CHKSIGNAL NO SIGNAL V-FIB V-TACH Muscle Asystole Check Signal No Signal Ventricular Fibrillation Ventricula r Tachycardia Muscle Artifact No QRS Detected for 3.0 Sec Intermittent no signal detected No QRS Detected for 9.0 Sec Rapid disorganized Ventricular Impulses, no QRS’s Configurable.
CLINICAL REFERENCE TOOLS PatientNet Viewer Quick Reference Place a Patient on the Screen 1. Touch1 Network at top of screen. (If 16 channels, select First 8 or Last 8 button at top to get to desired channel). 2. On top half of screen, select desired viewing position by touching that waveform box. 3. On lower half of screen, sort list of patients by selecting CH, Patient Name, Room, Physician, or Pager #. 4. Select patient by touching desired Patient Name. 5. Touch Select. 6.
CLINICAL REFERENCE TOOLS Interactive-PatientNet Viewer Quick Reference Place a Patient on the Screen 1. 2. 3. 4. 5. 6. Touch1 Network at top of screen. (If 16 channels, select First 8 or Last 8 button at top to get to desired channel). On top half of screen, select desired viewing position by touching that waveform box. On lower half of screen, sort list of patients by selecting CH, Patient Name, Room, Physician, or Pager #. Select patient by touching desired Patient Name. Touch Select.
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SUPPORTED BEDSIDE MONITORS AND DEVICES SUPPORTED BEDSIDE MONITORS AND DEVICES Refer to the current Customer Release Notes, Part Number 10001022, for a list of the supported bedside monitors and devices. PatientNet Operator’s Manual, v1.04, 10001001-00X, Draft All information contained herein is subject to the rights and restrictions on the title page.
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SELECTED REFERENCES SELECTED REFERENCES Computerized Arrhythmia Detection American national standard for cardiac monitor, heart rate meters, and alarms. Arlington, VA.: AAMI:1993; ANSI/AAMI EC13—1992 (Revision of ANSI/AAMI EC13-1983). Recommended practice for testing and reporting performance results of ventricular arrhythmia detection algorithms (ECAR). In: AAMI Standards and Recommended Practices. Arlington, VA; Association for the Advancement of Medical Instrumentation, 1987; 1993; 2:649-672. Arnold, J.
SELECTED REFERENCES Ford, J. H.2d et al. Centralized telemetry monitoring: implementation and management. Journal of the Society for Health Systems 3(2):52-68, 1991. Funk, M. Ask the experts: are dedicated monitor watchers necessary on the telemetry unit? Critical Care Nurse 16(5): 102-105, October 1996. Stukshis, I. et al. Accuracy of detection of clinically important dysrhythmias with and without a dedicated monitor watcher. American Journal of Critical Care 6(4): 312-317, July 1997. Funk, M. et al.
INDEX INDEX Numerics 72 Hour Full Disclosure 147 A A/P key 163 abort, patient transfers 93 adding comment labels 138 adding event labels 138 After key 165 AICD 90 alarm ??SOURCE 73, 82 Edit 142 High PVC 114 source see alarm source Alarm Config key 89 enabling alarms 110 ALARM OFF 37, 109 alarm source 116–117 alarm triggered event print 133 alarms 89, 105–128 16 channel option 175 ambulatory patient physiological 118 ambulatory patient technical 119 arrhythmia 117 automatic printing 113 bedside arrhythmia 1
INDEX continuous recording 132 D data loss 157 Default key 42 Depr key 170 Device key 82 Device popup 82 device types 83 disclosure modes 147 disclosure see full disclosure Display key 129, 150 Display Wave key 87 Display Wave popup 129 E ECG key 42 Edit alarm 142 Elev key 170 Erase key 142, 180 Event Information Form 222 Event key History screen 143, 180 Expand key 140 F First 8 key 175 Full Disclosure 72 Hour 147 full disclosure 147–156 24-hour disclosure report 155 24-hour summary report 156 disclosure
INDEX Patient Data key 74, 76, 87 Patient Data Report 77 patient information 74 modifying 76 viewing 75 patient information block 36, 109 alarms 106 main block 36 ventilator patient 37 patient settings 81 implants 90 patient transfers 91–93 PatientNet 15 PatientNet Viewers 29 IRVS 29 RVS 29 patients classification 82 selecting on the Main screen 81 PCD 90 pod 31, 177 Pod Configuration 33 Position key 129, 150 P-R measurement 140 Prev Alarm key 152 Print popups 143 printing 131–134 alarm triggered events 11
INDEX 24-Hour summary report 156 24Hr Summary key 162 24 Hr key 147 U Up To key 165 V ventilator data printing tagged reports 143 ventilator patients history data storage 135 history review 139 monitored parameters 84 printing tagged ventilator data 143 view screen 130 View Data screen 76 View key 129, 159 View screen 129 clinical information window 131 viewing history event 135 266 vital statistics 139 Vitals key 152 Volume Control screen RVS/IRVS 179 Volume key 40 V-Pak 183 W Warnings 19 electrical 19
