CENTRAL TELEMETRY SYSTEM, MODEL WEP-4200A SERIES

{0}------------------------------------------------ # SECTION 2 - 510(K) SUMMARY Name and Address of Applicant . Nihon Kohden America, Inc. 90 Icon St. Foothill Ranch, Ca 92610 Date: 05/19/2004 # JUN = 1 2004 K040395 p. 1 of 3 Phone: (949) 580-1555 Dial 9 and then Ext. 4401 Fax: (949) 580-1550 Attn: Serrah Namini, Regulatory Affairs Assoc. Dir. - Name of the device: WEP-4200A series Central Telemetry System . - Trade or proprietary name: WEP-4200A series Central Telemetry System . - The common or usual name: Central Telemetry System . - . The classification name: Physiological Patient Monitor with Arrhytmia Detection and Alarms per 21 CFR Part 870.1025, - The legally marketed equivalence: The predicate device is Nihon Kohden's Central . Telemetry system, WEP-8430A, 510K: K945944, dated 11/27/95. All features available with the new WEP-4200 are also available on Nihon Kohden BSM-4104A, 510K: K001693 - A description of the device: The system provides for monitoring ECG, ST levels, VPC rate, . arrhythmia events, SpO2, NIBP, temperature, respiration and apnea. The device will be offered with up to 5 multi-connectors and SpO2. The system is comprised of a receiver (WEP-4200A), and a transmitter (ZS-910P). WEP is a multi-parameter monitor consisting of a color LCD touch-screen to display waveforms and numerics of monitored parameters, multi-parameter receiver unit, visual alarm indicator, external communications port, and a removable battery pack for transmitter. Options include a thermal array recorder and a laser printer interface card. - A summary of the technological characteristics of the device compared to the . predicate device: The telemetry system is intended to monitor, record and display physiological data including ECG, blood oxygen saturation (SpO2), noninvasive blood pressure (NIBP), body temperature, respiration and apnea. These features are currently available in the legally marketed Nihon Kohden predicate devices, such as WEP-8430 and BSM-4100A series. The device acquires ECG signals through electrodes placed on the patient. The ECG signals are then amplified, filtered and displayed on a color LCD. Heart rate value is determined from the ECG signal or the pulse waveform and the device may sound an alarm when the heart rate falls outside preset upper and lower limits. These features are currently available in the legally marketed Nihon Kohden predicate devices, such as WEP-8430 and BSM-4100A series. The device monitors the ECG to detect arrhythmias. User selectable options are provided to control the alarm, storage and recording of arrhythmia events. The device is capable of generating an audible and visual alarm when an arrhythmia event is detected. The device incorporates the same multi-template arrhythmia detection and analysis of the predicate device WEP-8430 and BSM-4100A series. The device includes a pulse oximeter, which measures the blood oxygen saturation using finger, foot, ear, and multi-site probes and displays a numeric value and a pulse plethysmograph waveform. When the SpO2 value falls outside preset upper and lower limits, the alarm is activated. The device uses the same control software as the predicate device. The device includes a noninvasive blood pressure measurement system, which measures and displays the systolic, diastolic, and mean pressures through the use of pressure cuffs placed on the arm or leg. The NIBP measurement interval may be set to manual, continuous or selected time intervals. When NIBP measurements are set to time intervals, the user may also select an additional trigger method called PWTT as offered with the predicate device. An alarm may be generated when the systolic, diastolic or mean pressure values fall outside preset upper and lower limits. {1}------------------------------------------------ K040395 p 2 of 3 The device measures temperature through the use of the same commercially available temperature thermistors as the predicate device WEP-8430. Temperature thermistors measures temperature through the use of the same commercially available temperature thermistors as the predicate device. The control software for the temperature function is the same in both the new device and the predicate. The device measures respiration rate through impedance (picked up through the ECG electrodes), through the sensor or through the use of a thermistor respiration pickup transducer. Respiratory waveform is displayed on the monitor and respiration rate is calculated and displayed on the monitor. The device may generate an audible and visual alarm when the measured respiration value falls outside preset upper and lower limits. The software algorithm that determines the respiration rate count is the same in both the new device and the predicate. A thermal array recorder is available as an option to allow the printing of waveforms and alphanumeric data. Automatic alarm recording, manual recording, and timed recording are available. All system functions are operable from AC or battery power. A battery charging circuit is incorporated into each device. #### A summary of the technological differences between the device compared to the . predicate devices: The new device is an updated version of the WEP-8430A, eight patient telemetry, based on the same technology platform as the BSM-4104A bedside monitor. It uses features and capabilities from the predicate devices. The transmitting frequency of the new device is in the 608-614 MHz (WMTS) frequency band. The predicate device transmitted in the UHF frequency band. This change was made to meet FCC and FDA recommendations for WMTS. The new device has more storage memory, which is used to expand the storage of arrhythmia recall files and full disclosure. The basic functions of the arrhythmia recall and full disclosure remain unchanged. #### Indications for Use: . The device is intended to monitor, display and record physiological data to provide cardiac and vital signs monitoring. The device is intended to present a visual record of the electrical signals produced by the heart and monitor the electrocardiogram to generate visible and/or audible alarms when an arrhythmia exists. The device is also intended to monitor heart rate, pulse rate, blood oxygen saturation (SpO2), noninvasive blood pressure (NIBP), body temperature, respiration rate and apnea. The device may generate an audible and/or visual alarm when a measured rate falls outside preset limits. The system communicates in the new WMTS band as required by FCC. The device will be available for use by medical personnel on all patient populations within a medical facility, including ICU, CCU, recovery room and general ward. ### Non-clinical tests: The device does not directly contact patients. Accessories that contact patients, such as probes and thermistors, are the same accessories as used with other legally marketed products or are comprised of the same component materials as the predicate accessories. Therefore, good laboratory practice studies were not required per 21 CFR Part 58. The device is in compliance with the FDA Special Controls for arrhythmia detector and alarm system. The device complies with IEC 601-1 sub-clause 56.3(c) implemented by 21 CFR Part 898 Performance Standard for Electrode Lead Wires and Patient Cables. The device is also in compliance with applicable sections of IEC standard as listed in this application. ### The device is not sterile. The device was subjected to electromagnetic, environmental, safety and performance testing procedures. These tests verified the operation of the device. Design validation confirmed the operation of the software functions as well as hardware of the device. {2}------------------------------------------------ p. 3 . F 3 Therefore, Nihon Kohden believes that the device is substantially equivalent to the Nihon Kohden predicate devices as indicated. : : 1-040395 {3}------------------------------------------------ Image /page/3/Picture/11 description: The image shows the seal for the Department of Health & Human Services - USA. The seal is circular and contains the text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" around the perimeter. Inside the circle is an abstract image of an eagle. Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850 JUN - 1 2004 ___ Nihon Kohden America c/o Ms. Serrah Namini RA Assoc. Dir. 90 Icon Street Foothill Ranch, CA 92610 Re: K040395 K040579 Trade Name: WEP-4200A Series Central Telemetry System Regulation Number: 21 CFR 870.1025 Regulation Name: Arrhythmia Detector and Alarm Regulatory Class: II (two) Product Code: MHX Dated: May 25, 2004 Received: May 25, 2004 # Dear Ms. Namini: We have reviewed your Section 510(k) premarket notification of intent to market the device we have reviewed your Section 310(x) premained is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate for use stated in the encrosule) to regarly manation province Amendments, or to commence prior to May 20, 1976, are exactions of the Federal Food, Drug, devices that have occh rechasined in assere approval of a premarket approval application (PMA). and Cosment ACT (Act) that do not require approvine controls provisions of the Act. The You may, therefore, market the devices, sologie requirements for annual registration, listing of general controls provisions of the fiel labeling, and prohibitions against misbranding and adulteration. If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it If your device is classified (500 a0070) ins . Existing major regulations affecting your device can thay be subject to subli dualities, Title 21, Parts 800 to 898. In addition, FDA may be found in the Outs acements concerning your device in the Federal Register. {4}------------------------------------------------ Page 2 - Ms. Serrah Namini Please be advised that FDA's issuance of a substantial equivalence determination does not mean I lease of advised that I DTT Unstance or our deviee complies with other requirements of the Act mar I Dri has made a sond regulations administered by other Federal agencies. You must or any I catal statutes and equirements, including, but not limited to: registration and listing (21 Comply with an the 110 - 21 CFR Part 801); good manufacturing practice requirements as set OI IT at 0077, idocime (21 OFF earlation (21 CFR Part 820); and if applicable, the electronic forth in the quality byevelisions (Sections 531-542 of the Act); 21 CFR 1000-1050. product radiation comi or to begin marketing your device as described in your Section 510(k) I ms letter will anow you'le cogni maining of substantial equivalence of your device to a legally premailed predicate device results in a classification for your device and thus, permits your device to proceed to the market. If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please If you desire specific acriously 3 at (301) 594-4648. Also, please note the regulation entitled, Connect the Office of Comments to premarket notification" (21CFR Part 807.97). You may obtain other general information on your responsibilities under the Act from the Division of Small other general micrinational and Consumer Assistance at its toll-free number (800) 638-2041 or (301) 443-6597 or at its Internet address http://www.fda.gov/cdrh/dsma/dsmamain.html Sincerely yours, Neil R.P. Ogden Bram D. Zuckerman, M.D. ナレ Director Division of Cardiovascular Devices Office of Device Evaluation Center for Devices and Radiological Health Enclosure {5}------------------------------------------------ # NIHON KOHDEN AMERICA, INC. 510(k) NOTIFICATION Central Telemetry System G. Indications for Use Statement 510(k) Number (if known): KOYO39S S Device Name: WEP-4200A Series Telemetry system ## Indications for Use: The device is comprised of transmitters and a receiver communicated via WMTS radio frequency. The series of device are intended to monitor, display and record physiological data to provide cardiac and vital signs monitoring within a medical facility. The device is intended to produce a visual record of the electrical signals produced by the heart and monitor the electrocardiogram to generate audible and/or clookida organization produced by the novice is also intended to monitor patients' physiological data including heart rate, pulse rate, blood oxygen saturation (SpO2) noninvasive blood pressure (NIBP), body temperature respiratory rate and apnea. The device may generate an audible and/or visual alarm body temperature roopiratory no and limits. This device receives physiological signals via radio when a motor the transmitters. The device has the capability of communicating with external devices, such as personal computers. Vital sign data can be sent to a central monitor through the network via network card. The device will be available for use by medical personnel on patients within a medical facility including adults, children and infants. n for BDZ | (Division Sign-Off) | | |------------------------------------|---------| | Division of Cardiovascular Devices | | | 510(k) Number | K040398 | | Prescription Use (Part 21 CFR 801 Subpart D) | X | |----------------------------------------------|---------------------------------------------| | AND/OR | Over-The-Counter Use (21 CFR 807 Subpart C) | (PLEASE DO NOT WRITE BELOW THIS LINE-CONTINUE ON ANOTHER PAGE IF NEEDED) Concurrence of CDRH, Office of Device Evaluation (ODE) Page 1 of 1