A Proposal for ECG’s in Pre-Participation Physical examinations (PPE) for college athletes

Washburn University School of NursingNU 670- Graduate Project  December 11, 2012

Tracy Hill, BSN, RN, MSN CandidateFamily Nurse Practitioner Student

Special Thanks

Shirley Dinkel, PhD., APRN Project Chair

Washburn University, School of Nursing

Karen Garrison, MA, ATC, LAT Clinical Education Coordinator/Asst. Athletic Trainer

Department of Kinesiology

Michael Messmer, D.O. CAQSM Sports Medicine Physician, St. Francis Hospital

Team Physician, Washburn University Ichabods

Team Physician, District 501

Team Physician, Topeka Golden Giants baseball

Sudden Cardiac Death (SCD)

Leading medical cause of death for student athletes (75%)

(Minneapolis Heart Institute Foundation, 2012, NCAA, 2012, Subasic, 2010).

Hypertrophic cardiomyopathy (HCM) is reported as the most common cause of unexplained SCD in young athletes

1 in 350 young people has an undetected heart condition

(AHA, 2012)

http://www.youtube.com/watch?v=TJyDmR-G3uM&feature=player_embedded

http://youtu.be/zsIIbTi6Oxw

SCD Defined:

Death resulting within minutes of an abrupt loss of heart function(AHA, 2012)

Death that is unexpected and non-traumatic and that occurs instantaneously or within a few minutes of an abrupt change in the person's previous clinical state (O’Connor, Kugler, & Oriscello, 1998).

Problem Statement

Washburn University (WU) does not have a guideline for performing ECGs as part of the PPE for student athletes and does not require routine ECG screenings as part of the PPE for

student athletes

Background of the Problem

No national standard for PPE

Poorly defined legislation

ECGs

Not required as part of PPE per NCAA, AHA

Many NCAA institutions provide anyway

No mandatory SCD registry

History & Physical (H & P)

AHA guidelines are minimum standards

Screening of athletes usually falls short of recommended guidelines (Subasic, 2010)

Electrocardiogram (ECG)

Viewed at the most cost-effective cardiovascular screening modality

In Europe, ECGs are performed on all college athletes and are heavily promoted as having reduced the incidence of SCD

(Subasic, 2012)

Personal History Family History Physical Examination

Exertional chest pain/discomfort

Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in 1 relative

Heart murmur

Unexplained syncope/near-syncope

Disability from heart disease in a close relative <50 years of age

Femoral pulses to exclude aortic coarctation.

Excessive exertional and unexplained dyspnea(shortness of breath)/fatigue, associated with exercise

Specific knowledge of certain cardiac conditions in family members*

Physical stigmata of Marfan syndrome

Prior recognition of a heart murmur

  Brachial artery blood pressure (sitting position, preferably in both arms)

Elevated systemic blood pressure

   

The 12-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive

Athletes

The 12-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive

Athletes

Implications for Student Athletes

African Americans have higher rates of SCD than Caucasians

Male athletes are at greater risk than females

Male basketball and football players having the highest rates of SCD overall

As many as 80% of patients with SCD are asymptomatic until sudden cardiac arrest occurs

Purpose of the Project

To examine the feasibility of adding ECG screening to the PPE to reduce the risk of SCD

in student athletes at WU

Project Objectives

1) Review of current practices at the WU Athletic Training Education Program and the Athletic Department for PPE and ECG screenings for student athletes

2) Review of literature to include current guidelines for the PPE and ECG screening and interpretation recommendations for student athletes

3) Explore funding sources for 12 Lead ECG equipment and supplies for WU Department of Kinesiology/Athletic Training Education Program

Project Objectives

4)Propose a guideline for the inclusion of ECGs in PPE for student athletes at WU

5)Educate WU Athletic Training Education Program faculty and staff in proper ECG placement and performance

6)Recommend a referral procedure for over-read of all ECG’s and follow-up of students determined to be at increased risk

Theoretical Framework OverviewShuler Nurse Practitioner

Practice Model

Holistic approach

4 conceptsBased on

nursing research and scientifically supported generalizations

NP

Person

Health

Nursing

Environment

Review of LiteratureKey findings

The rate of SCD in young athletes is higher than previous estimates (ACCF/AHA Task Force, 2011; Minneapolis Heart Institute Foundation, 2012; NCAA, 2012; O’Connor et al., 1998; Subasic, 2010)

Pre-Participation Screening of athletes in competitive sports usually falls short of recommended guidelines (Subasic,2010).

ECG screening results in many false positives, yet overall cost per diagnosis of adding ECG screening is similar to that of H & P screening alone

AHA last PPE guideline review 2007- ECG optional

Sudden Death in Athletes U.S. Registry

Implementation of Best Practice Strategies

Analyzed PPE forms – recommend The American Medical Society for Sports Medicine (AMSSM) PPE form

Composed Curriculum Development Grant including development of a budget; identified additional funding sources

Developed and provided Educational tools

Course objectives (KN 492); Instructive posters; Educational videos; 12 Lead ECG competency checklist

Recommended a local cardiologist over-read ECGs

Proposed ECG Budget Expenses

ECG Equipment/Supplies Budget Actual Difference ($)

GE Mac 1200 ECG Machine (inlcudes ECG cable & Leads, Electrodes and Operations Manual)- recertified, preowned   1,850 1,850

ECG cart   300 300

ECG Recording Paper (Chart fan fold 216x280x150 Red); $7.52/pk; $75.26/case   75 75

*10pks/cs- Ref. 2009828-061- Graphic Controls-GE Healthcare Recording Paper      

ECG Electrodes: Red Dot Rest Tab Style - EKG 100/bag; 40 bags/case ($2.62/bag); $104.80/case   105 105

Freight/Material Shipping/Handling   85 85

Taxes (8.525%) x $2,415.00   206 206

Total Expenses Budget Actual Difference ($)

  $ - $ 2,621 $ 2,621

Washburn University Athletic Training Education Program

Adult 12 LEAD EKG COMPETENCY CHECKLIST

NAME_______________________________ DATE____________________

Competent Performance (Verbalization or Return Demonstration)

Adult 12-Lead EKG Performance Yes (V/D) No Validator Comments Check cable & lead wire for disconnected wires. Position patient and identify limb sites. Prepare skin for electrode placement to assure adequate

tracing as needed: Cleanse with soap & water, and/or Abrade skin using washcloth or 4x4, and/or Apply skin prep, and/or

Trim hair with clippers (no razor)

Apply electrodes to patient securely in appropriate position; fasten lead wires per 12-Lead ECG Procedure.

Leave limb electrodes in place. Place V leads per Right-Sided ECG Procedure:

V1 - 4th Intercostal Space (ICS), right sternal border V2 - 4th ICS, left sternal border V4 - 5th ICS left midclavicular line V3 - Equidistance between V2R and V4R V5 - horizontal level of V4R at the left anterior

axillary line V6 - horizontal level of V4R at the left midaxillary

line

Turn on ECG machine Demographic data should be entered at the top of the

ECG. Last Name First Name Gender Date of birth Age

Check for accuracy

Assess tracing quality by reviewing ECG monitor and printed ECG. Perform the following steps for troubleshooting:

Check for negative deflection in lead 1 which would indicate right and left arm lead reversal.

Review ECG for missing lead(s).

Acquire (print)ECG image Rev 12/12

Signature of Validator Initials

Implications for Advanced Practice

Nursing

Ample opportunity for multidisciplinary collaboration with SCD and future research possibilities

Potential for publication – increased by current attention/focus on topic

Opportunity to attend educational conferences and present the proposal on SCD

Change Agent – Legislation

Include APRNs as providers who can perform PPEs

Facilitate implementation of ECG screenings as part of PPEs - state and federal levels

Require mandatory reporting of SCD events

Discussion:Future work/tasks

Submission and approval of the Curriculum Development Grant

Approval of additional funds, as needed to support this project and the initial purchase of ECG equipment and supplies

Initiate contact with local cardiologists

Approval of Project by the Athletic Department/Athletic Training Education Program is pending final budget authorization

Discussion

KN 492 Core curriculum enhancements

Utilization of the new recommended PPE form

Implementation of ECG screening as part of PPE screening

Future MSN student to continue the implementation and evaluation piece of as their graduate project?

Consider working with the Diagnostic Medical Sonography Program at WU in the future to implement echocardiograms into the PPE screening.

Conclusion

At the end of the day, what’s a life really

cost?

Questions?

Complete list of references available upon request.