Education and Assessment of Proper Electrocardiagram Lead Placement

Electrocardiogram lead placement – Implementation Paper

Executive Summary

Electrocardiography (ECG) is a diagnostic test that has been used for over a century.  ECGs are one of the most common diagnostic tools to assess for signs of cardiac disease.  With nearly 50 million ECGs performed annually worldwide, it is vital to ensure that this widely used tool interprets the medical data accurately.  Incorrect ECG lead placement can lead to misinterpretation, misdiagnosis and mistreatment.

ECGs are quick and easy to use, and inexpensive, however, careful attention to the placement of the electrodes is paramount to an accurate read.  ECGs are a simple non-invasive method of impacting diagnosis and can impact greatly the course of the treatment (Kania, Rix, Fereniec, Zavala-Fernandez, Janusek, Mroczka, Stix, Maniewski, 2014).  Grossi & Lynch (2016) state, “in spite of this, lead misplacements do occur which, if not recognized, may have disastrous consequences with patients receiving the wrong treatment or not being treated at all based on the features of an incorrectly acquired ECG” (p. 1).  Therefore, it is imperative that all health care professionals responsible for performing and interpreting ECGs are knowledgeable of the appropriate placement of these leads as these can alter the appearance of the interpretation radically (Lynch, 2014).

Misplacement of the leads is not an isolated issue only in the critical care setting.  Providers in other settings such as the acute care floors and step-down units, operating rooms and the emergency department who also routinely monitor and interpret ECGs are challenged with the task of appropriate lead placement.  It is the aim of this practice implementation to provide the proper tools to assist in the education and assessment of proper ECG lead placement.

Practice Recommendations

The American Association of Critical-Care Nurses (AACN) introduced two practice alerts regarding cardiac monitoring.  The first, in 2004 and a second practice alert in 2008.  The practice alert in 2004 emphasized detection and early intervention of myocardial ischemic events (Evenson & Farnsworth, 2010).  It also highlighted the appropriateness of lead selection in detecting such events.  The second practice alert was detection of serious dysrhythmias requiring treatment during bedside monitoring (Evenson & Farnsworth, 2010).  Evenson & Farnsworth (2010), also caution “if patients are not monitored by using the recommended lead for dysrhythmia interpretation, nurses and physicians correctly diagnose a wide QRS tachycardia only 34% of the time, and erroneous interpretation can lead to inappropriate treatment” (p.15).

As a practical factor, a wholistic methodology must be assumed in order to remedy this potentially devastating problem.  This implementation impacts a vast number of ancillary staff members within an acute care setting such as a hospital. These include bedside nurses, nurse educators, advanced practice providers, physicians and decision makers on the executive side.  Due to inadequate research on this subject matter, and the potential for devastating implications, it stands to benefit a course of action, such as education and training of proper lead placement.

Implementation Plan for Recommendation

For the purpose of this safety and change initiative implementation the Comprehensive Unit-Based Safety Program (CUSP) model will be utilized (White, Dudley-Brown, & Terhaar, 2016, p. 103).  There are five steps to CUSP that were defined by the Agency for Healthcare Research and Quality (AHRQ).  The steps are to 1) educate the audience on the science of safety, (2) identify potential defects in care, (3) assign leaders to a unit-level CUSP team, (4) learn a lesson from one defect a month and lastly, (5) implement tools such as teamwork and communication to improve and develop safety at work (White, Dudley-Brown, & Terhaar, 2016, p. 103).

The information on appropriate ECG electrode placement particularly in the acute and critical care setting as well as the pre and post-op care units will be provided through discussion on relevance of proper lead placement, reinforcement on the recommendations of the American Heart Association (AHA) and American College of Cardiology (ACC) along with the AACN guidelines included in a poster board presentation.  Included as part of the education, will be a blank diagram of a human ribcage (see Appendix A) with clear visible anatomical landmarks with options to, mark or write in the appropriate site(s) of correct placement of the limb leads and precordial leads on the diagram.  The diagrams will then be assessed as part of a “pre-test” for accuracy of electrode placement and labeling of the leads by the staff members.  After the completion of the “pre-test”, respective staff members will be educated on the AHA/ACC and AACN guidelines.  Visual aids such as colored brochures with detailed information on the placement of leads with accurate landmarks to check or palpate prior to electrode placement will be disseminated.  As part of this “pre-test” there will also be a three-question multiple choice quiz (see Appendix B).  The questions will assess the knowledge and understanding of the devastating outcome of lead reversals or misplacement.  It is expected that a minimum of 25-50% of the staff will display an improvement in knowledge of labeling the diagram compared to the “pre-test”.  Staff will demonstrate an understanding of the detrimental effects of lead reversal or misplacement by answering three multiple choice questions with an expectation of a perfect score on the quiz.

A follow up visit to the unit after two weeks, will consist of a reassessment of knowledge with another blank diagram of the ribcage and the staff will be instructed to mark the appropriate spot for electrode placement and the three-question quiz will be re-administered.  This will provide knowledge growth after implementation of the educational project and information disseminated from the prior visit to the unit.  An assessment of the staff’s placement of the ECG electrodes in the recommended areas as per the AHA and ACC guidelines will be calculated from the second set of ribcage diagrams.  On the five-lead ECG, which are used most commonly, it is crucial the staff know the proper landmarks for electrode placement because the precordial lead is utilized for arrhythmia detection, by placing it in the spot similar to any of the V1-V6 leads on a 12-lead ECG, this can help in detecting bundle branch blocks and pacemaker rhythms along with wide QRS complex tachycardias (Francis, 2016).

The key stakeholders impacted from this implementation project are first and foremost the nursing staff.  Nurses have a vested interest in this issue as lead placement is a result of translating theory (academic knowledge of how to place leads) to action.  It is not only important for nurses to recognize dysrhythmias on an ECG, but it is crucial they comprehend the appropriate method on the application of this diagnostic aid on the patient.

Another group of stakeholders identified are the physician and advance practice providers.  Misplacement of ECG leads has a direct impact on this group particularly from a legal standpoint.  Providers stand to lose the most compared to any other group due to the fact they would misdiagnose and mistreat the wrongly placed leads.  The providers who order and interpret ECGs must learn to discern the subtle differences on the tracings within the different views while these leads are potentially misplaced.

The leadership or executive heads also play a key role in the implementation.  Whether it’s a general or specialty hospital, a large teaching medical center or a small community hospital, irrespective of size, this venue provides care for patients who may have either a life-threatening injury or a chronic debilitating condition.  With over 5,500 registered hospitals and upwards of 35 million total admissions in 2016 in the United States according to the American Hospital Association (2018), now more than ever, saving lives and restoring health is the number one objective.  However, these facilities have also been shouldered with the responsibility of improving the health and well-being of the communities.

From a quality of care perspective patient safety and quality of care are an important criterion for this group.  Performances are evaluated and publicized, and often scrutinized through different agencies.  The facilities with the higher-ranking performances are rewarded with larger reimbursements.  Substandard performances are often penalized, financially and through poor performance ratings.  Misplacement of ECG leads contributing to misdiagnosis and mistreatment not only raises awareness to standards of care but can pose financial implications to an acute care unit or hospital.  Therefore, it is imperative for the acute care facility and its leadership to proactively look at the policy of change in proper ECG placement.

Outcome Measures

The implementation of this practice change as stated previously will require a concerted effort from all actors, such as the staff nurses, advanced practice providers as well as physicians and most importantly it will need the green light from the leadership executives such as the unit manager and Chief Nursing Officer.  Upon completion of the initial surveys/quizzes and education and information dissemination on a unit, it will be the ultimate goal of the project to bring about a companywide change in practice.  Some potential avenues of promoting this implementation would be to utilize poster boards, employee identification (ID) badge pocket reference cards, annual reviews or competencies check and online modules.  Each of these options comes with its share of advantages and disadvantages.

Poster boards can be large print, colorful and visually pleasing.  It is one of the most ideal methods of disseminating information.  Typical costs for a poster board range from $70 to $85 for a 22-inch x 28-inch, or 24-inch x 36-inch respectively.  An ideal poster board would consist of a QRS complex with normal ranges of ST segments, QRS complex, QT interval and an oversized rib cage with detailed description of the landmarks and location of where precordial leads and limb leads must be placed.  There will also be a section on the description of potential dysrhythmias detected by misplacement of these leads.

Additionally, ID badge reference cards, would be simple to implement as the cards can be clipped onto an employee’s ID badge.  It would be a useful and convenient resource readily available as each staff member is required to carry and display a badge at all times.  These cards are also very cost effective as they are approximately $1.99 to make but can be obtained more inexpensively through a bulk rate.  After obtaining permission from the Chief Medical Officer (CMO) and Chief Nursing Officer (CNO) these cards can be distributed by the unit managers to their employees.

Annual review and online modules are a simple solution to educating the staff through review and hands-on demonstration of placing ECG leads appropriately on a mannequin to assess skills and competencies.  One major drawback to this option is its infrequency of method to introduce this policy and re-evaluate on an annual basis.  These options can not only provide a valuable educational experience but can also provide the user with continued education units.  Furthermore, online modules can be administered to the nursing and physician staff during hospital orientation as a new hire and subsequently during an annual review competency check.


Abnormal ECGs will always lead to further diagnostic testing.  Additional cardiovascular functional tests such as laboratory blood tests, echocardiogram, a transesophageal echocardiography (TEE) or even an invasive exam such as a cardiac catherization procedure can be performed to rule out abnormalities in the functionality of the human heart.  Noble, Hillis, Rothbaum (1990) stated that, “while it is true that the ECG may be normal despite an abnormal heart, or abnormal with a normal heart, it is equally true that the ECG often provides an important indication of cardiac abnormality, and even allows a fairly accurate appraisal of the anatomic and physiologic significance of that abnormality.  Furthermore, the ECG is by far the best method of analysis of disturbances of the cardiac rhythm” (p. 164).  Through the education and guidelines along with the evidence based research it is the aim of this implementation project to assist the staff of the acute or critical-care unit to avoid misplacement, misinterpretation and misdiagnosis of ECGs while caring for their patients.


  • American Hospital Association.  (February 2018).  Fast facts on U.S. hospitals.  Retrieved from
  • Evenson, L., & Farnsworth, M.  (October 2010).  Skilled cardiac monitoring at the bedside: an algorithm for success.

    Critical Care Nurse, 30(5), 14-22

    .  Retrieved from
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    Indian Pacing and Electrophysiology Journal,

  • Grossi, I. & Lynch R.M. (2016).  ECG Lead Misplacement -Fool Me Once Shame on You, Fool Me Twice Shame on Me.

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    2(4): 1025.
  • Kania M, Rix H, Fereniec M, Zavala‐Fernandez H, Janusek D, Mroczka T, Stix G, Maniewski
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  • Lynch, R. (2014).  ECG lead placement: A brief review of limb lead placement.

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  • Noble, R.J., Hillis, J.S., Rothbaum, D.A., Walker, H.K., Hall, W.D., Hurst, J.W., editors.  Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 33. Available from:
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    Translation of evidence into nursing and health care

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Appendix A

Please label diagram with appropriate Five-lead ECG electrode placement. You may draw an arrow, circle or mark with an ‘X’.

Appendix B

Please chose the best answer for each question below. You must answer all



  1. Switching or reversing RA and LL leads will produce an inversion of all frontal plane leads that mimics ____________________.

    1. Asystole
    2. Normal sinus rhythm
    3. Myocardial infarction
    4. Ventricular tachycardia
  2. The voltage produced from a reversal of the RA lead with the RL lead and the LA lead with the LL lead will produce what type of misinterpretation/diagnosis?

    1. Pulmonary embolus
    2. Right axis deviation
    3. Col pulmonale
    4. Pericardial effusion
  3. Misplaced electrodes can be diagnosed with ventricular tachycardia. What documented interventions have patients received from this misdiagnosis?

    1. Cardiac catherization
    2. IV administration of antiarrhythmics
    3. Placement of ICD or pacemaker
    4. All of the above

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