Indian J. Anaesth.

SAMADDAR, 2002; 46RAY

MAHAPATRA, (6) :: 437-440
INDIGENOUS ECG ELECTRODES 437

INDIGENOUS REUSABLE CHEST ELECTRODE

A COST EFFECTIVE ALTERNATIVE TO COMMERCIAL
DISPOSABLE ELECTRODE FOR E.C.G. MONITORING
Dr. D. P. Samaddar1 Dr. B. C. Mahapatra2 Dr. B. Ray3

SUMMARY
Objective : Indigenous modification of E.C.G. chest electrode, Design : Prospective, Settings : Operation theatres of Tata Main
Hospital (TMH), Intervention : Disposable E.C.G. electrodes are commonly used for E.C.G. monitoring. Recurring expenditure on
these electrode could be considerable in a large hospital. Indigenous reusable chest electrode can save this expenditure while ensuring
the quality of E.C.G. tracing.
Such cost effective indigenous chest electrodes were designed for repetitive use in the operation theatre complex of Tata Main Hospital.
Value Engineering steps were adopted for systematic approach to problem solving.
Main Result : Calculated annualized recurring saving following the indigenous electrode is Rs. 69,965/-. Quality of E.C.G. tracing
was comparable to conventional disposable chest electrode.
Keywords : E.C.G. electrode, E.C.G. monitoring, Value engineering, Cost-effectiveness.

Disposable E.C.G. electrodes, mandatory for knob like structure on the dorsal surface (Fig 1) to which
continuous monitoring of E.C.G. in operation theatres, a metallic prong (Fig.2) is fixed for monitoring the patient.
are expensive considering the large number of operations The prong has a long wire at its other end, which goes
performed in a busy operation theatre complex. Viridia to the monitors. “3 prongs for 3 chest electrodes and 3
Hewlett Packard (HP) monitors are routinely used in 5 of connecting wires” needed to monitor one patient, form a
the 11 operating rooms in the Tata Main Hospital for separate unit known as “E.C.G. leads set” (Fig. 2).
continuous monitoring of ECG.
These monitors were installed in July 1999. Three
disposable chest electrodes are necessary for ECG
monitoring for each patient. In the year 1999 – 2000 for
3921 major and intermediate operations those were
performed an expenditure of Rs. 88,222.50 was incurred
by the hospital for disposable chest electrodes (@ Rs.
22.50 for one patient). In order to minimise this cost, the
Value engineering team took up a project on how to
design an electrode which could be a good cost effective
replacement for the disposable electrode. The effort went
through the usual stage of a VE project.1-7
Fig. 1 Disposable Chest Electrode

a. Orientation Phase
Each disposable electrode has a central metallic
portion with flat ventral disc of 1 cm diameter and small
1. M.D. Sr. Specialist & Incharge ICU.
2. M.D., Specialist & Incharge O.T.
3. M.D., Sr. Specialist & HOD.
Dept. of Anaesthesiology & Critical Care,
Tata Main Hospital, Jamshedpur-831001.
Correspond to :
Dr. D. P. Samaddar
31, Dindli enclave, Kadma, Jamshedpur,
Bihar - 831005.
The lead sets are reusable components supplied
along with the monitors by the H.P. company. The chest
electrodes however being disposable item are procured
by the customer from time to time. Flat ventral surface
of chest electrode receives electrical signal when they are
placed firmly on patient’s chest (Fig 2). The electrical
signal from metallic portion of chest electrode is
transmitted to the prong, then connecting wire and finally
to the monitor for continuous display of E.C.G. on monitor
screen.
438 INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2002

on a disc which can withstand repeated use, then

expenditure on disposable chest electrode can be minimised.
Following ideas were generated to replace the papery disc
with a more durable disc (Table 2).

Table - 2 : Suggestion for durable disc in place of papery

disc.
Suggestions Diameter of disc

1. Metallic disc (of steel plate) 5 cm

2. Foam leather disc 5 cm
3. Teflon disc 5 cm
4. Teflon disc 2.5 cm

This metallic portion has a surrounding soft disc of

approximately 5 cm diameter made of thick paper like
substance. This papery ring has adhesive surface ventrally
and non-adhesive surface dorsally. Adhesive surface
remains covered with a thin plastic cover which protects
the adhesive coat until it is removed just before fixing the
chest electrode to the patient’s chest.
d. Evaluation phase1,8
The team then selected the attributes of an ideal
chest electrodes (Table 3) and compared these attributes in
the evaluation matrix (Table 4) to find the score of each
attribute. Attributes were then arranged as per the score
in descending order (Table 5).

b. Function phase1,8 Table - 3 : Attributes of an ideal chest electrode

During functional analysis (Table-1), the team
S.No Attributes
reached to following conclusion:
A Durability
1. The metallic portion of the chest electrode is the B Quality of transmission
most important component for monitoring E.C.G. C Maintains good body contact
D Mouldable to body contour
2. The surrounding papery disc with it’s adhesive surface E Ease of fixation
only helps to keep the metallic portion of the electrode F Ease of implementation
in firm contact with patient’s body and maintains the G Aesthetics
H Cost
same position of electrode; thus facilitates transmission
I Acceptability
of electrical signal.
J Ease of cleaning
3. Papery disc can not be used repeatedly as it is fragile
and cannot be cleaned for reuse.
Table - 4 : Evaluation matrix
Table - 1 : Functional analysis of chest electrode A B C D E F G H I J Score Total

Components Function Type of

A B3 C2 D0 A1 A2 A3 A1 I1 A2 8+1 9
Verb Noun function
B B2 B2 B2 B3 B3 B2 B2 B2 21+1 22
1. Metallic portion
C D0 C1 C2 C2 C2 C2 C1 12+1 13
– Ventral flat disc receives electrical signal Basic
– Dorsal knob anchors prong Basic D E2 E1 D1 H2 E1 E0 1+1 2
2. Papery Disc holds metallic disc Basic
E E2 E2 H2 E1 E0 7+1 8
maintains body contact Basic
facilitates transmission Secondary F F2 H2 FI J2 4+1 8
moulds to body contour Secondary
G H2 I1 J2 0+1 1
3. Plastic cover protects adhesive surface Basic
H H2 H2 12+1 13
c. Creativity phase 1,8
I J1 3+1 4
It was appreciated by the VE team that if by some
J 6+1 7
means the metallic portion of the chest electrode is mounted
SAMADDAR, MAHAPATRA, RAY : INDIGENOUS ECG ELECTRODES 439

Table - 5 : Score and Rank of attr Table - 7 : Expenditure on indigenous electrode

Identity Attributes Total score Rank Type of electrode No. procured Unit cost Total cost
(Rs.)
B Quality of transmission 22 1
C Maintains good body contour 13 2 5 cm disc 9 100 900
H Cost 13 3
2.5 cm disc 10 75 750
A Durability 9 5
E Ease of fixation 8 4
Total expenditure 1650
J Ease of cleaning 7 6
F Ease of implementation 5 7
I Acceptability 4 8 ii) Use of chest electrode : Since chest electrodes are
D Mouldability 2 9 being reused the surface coming in contact with
G Aesthetics 1 10 patient’s skin is being cleaned with spirit after each
use. Electrodes are fixed to patient’s body with the
Metallic assembly similar to disposable electrode help of ordinary sticking plaster as the modified
was procured from local market and fixed in 4 variety of chest electrodes did not have sticky surface (unlike
suggested disc (Table 2). These indigenous electrodes in disposable) for self fixation.
were then studied on patients against the preselected
attributes (Table 3). Based on the experience gathered the Observation & result
4 suggestions were compared with each other on decision Modified chest electrodes are being regularly used
matrix (Table 6). since April 2000. Fig. 3 shows the dorsal view of
disposable (commercial) and indigenous electrodes for
Table - 6 : Decision Matrix comparison of external appearance. Further performance
evaluation was done during their use in six month period
and estimation of saving was done after six months in
September 2000, which was annualized to find out the
annual saving (Table 8,9).

Table - 8 : Expenditure on disposable electrode

No. of major and intermediate operations done

(April – Sept 2000) = 1597
No. of cases (Annualized data) X 2 = 3194
Suggestion No. 4 Teflon disc with smaller diameter No. of disposable electrodes required
(2.5cm) came out the best during clinical trial. This also (No. of cases X 3 elect. / Pt.) = 9582
scored the highest in decision matrix (Table 6) as it was
closest to the attributes of ideal chest electrode and it was Anticipated expenditure
cost effective as well. The group finally recommended (No. of elect. X cost of 1 electrode) = Rs. 71865/-
this for implementation in all operation theatres having i.e. 9582 X 7.50/-
Hewlett Packard monitor for major and intermediate
operations.
Table - 9 : Calculation of saving
e. Implementation phase1,8
i). Material used and cost for modification : Locally Expenditure on disposable = Rs. 71865
available raw materials were used for the reusable Expend. on indigenous electrodes (Table 7) = Rs. 1650
chest electrodes. In the initial phase of trial Teflon Calculated saving = Rs. 70215
chest electrodes with 5 cm diameter were made but
subsequently chest electrodes with 2.5 cm diameter The leads were found to be durable, easy to use
were found suitable due to ease of fixation. Cost of and clean. Aesthetic did not suffer and quality of
2.5 cm diameter disc was also lesser (Table No 7). E.C.G. tracing was good. Though the initial cost of
Metallic portion of the disc (available in local market) the indigenous leads was higher but due to reuse and
was fixed in the Teflon disc. A local supplier helped durability these leads were ultimately proved to be cost
in fabricating the material for us as per the effective. Anaesthesiologist working in the hospital were
specification. satisfied with the performance of modified electrodes. A
440 INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2002

this project and permitting publication of this article. All

operation theatre staff deserve thanks for their co-operation.
Special thanks to Mr. Riaz Ali (O.T.technician) and Mr.
D.P.Mahato (I/c O.T.technician) for their active
participation and Dr. Sampath Kumar for helping in
preparation of manuscript.

(Fig 3)
feed-back was also taken from them on the above
mentioned parameters.
Conclusion
Indigenous modification of high value consumables
can lead to significant reduction in expenditure without
compromising the quality. Modification of E.C.G.
electrode was one such exercise. Value Engineering steps
can help us in achieving these objectives in a systematic
manner through team effort.
Acknowledgement :- The authors are obliged to
Dr. G.K.Lath, FRCS, FICS, General Manager Medical
Services, Tata Main Hospital for allowing us to carry out
References
1. Samaddar DP et al Indigenous improvisation in the use of
E.C.G. leads in a multidisciplinary ICU – A value engineering
Indian Jour. of Crit. Care Med. Vol. 3(1) 1999 P 8-14.
2. B. Ray, Value engineering – A practical approach to managing
cost in Crit. Care. Indian Journal of Criticare Med. Vol 3(1)
1999 P4-7.
3. Arthur E. Mudge, Value Engineering – A systematic approach.
J POHL. Associates. 1806, Berteweed Drive. Pittsburg, PA
15243, 1989.
4. Larry W Zimmerman, Glen D Hart, Value Engineering – A
practical approach for owners, designers and contractors. CBS
publisher and distributors 485, Delhi 110 032, 1st ed. 1998.
5. S.S.Iyer, Value Engineering. New Age International (P) Limited.
483524, New Delhi 110-002, 1996.
6. James Brown, Value Engineering – A Blue Print Industrial
Press Inc., NY 10016-4078, 1992.
7. K. R.Chari, Value Engineering – An Introduction to concept
and application. National productivity council, 1993.
8. G. Jagannathan, Getting more at less cost – The value
engineering way. Tata McGraw Hill publishing company Ltd,
New Delhi 1992.

REVIEW OF CD-ROM ON PERIPHERAL NERVE BLOCKS

Edited by :
Dr. P.Kumar, Prof. & Head,
Dr. Anump Chandnani,
Dept. of Anaesthesiology,
M P Shah Medical College,
Jam Nagar – 361 008.
GUJARAT
This Video CD has been compiled from proceedings of the recently held the CME workshop at M.P.Shah Medical
College, Jamnagar wherein Senior faculty in the field from allover India have precisely demonstrated various nerve blocks
on live human patients with the help of ‘C’ arm X-ray gadget.
The various nerve blocks have been classified under subheadings as Head & Neck, UL, LL, Thorax and Abdomen.
In each of the sections an appropriate explanatory text along with illustrations, and vivid descriptions on the cadeveric
specimen is presented. After the viewer gets familiarised with the technique the block proper is actually demonstrated
on the live patients with the help of X-ray C arm etc.
Every effort has been made to present the blocks in a simple and understandable way. This effort and the beginning
of something new and indigenous has to be congratulated and appreciated. Probably the editors of the CDS have plans
to add the explanations and discussions on indications, contraindication, complications, etc in the next phase.
However, the CD can be very advantageous when made use of to learn and teach various nerve blocks.

Editor, IJA.