A Proposal for ECG’s in Pre-Participation Physical examinations (PPE) for college athletes Washburn University School of Nursing NU 670- Graduate Project December 11, 2012 Tracy Hill, BSN, RN, MSN Candidate Family 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=TJyDmRG3uM&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 nontraumatic 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) The 12-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes Personal History Exertional chest pain/discomfort Family History Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in 1 relative Unexplained syncope/nearDisability from heart syncope disease in a close relative <50 years of age Excessive exertional and Specific knowledge of unexplained dyspnea(shortness certain cardiac conditions of breath)/fatigue, associated in family members* with exercise Prior recognition of a heart murmur Elevated systemic blood pressure Physical Examination Heart murmur Femoral pulses to exclude aortic coarctation. Physical stigmata of Marfan syndrome Brachial artery blood pressure (sitting position, preferably in both arms) 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 Overview Shuler Nurse Practitioner Practice Model Holistic approach Person 4 concepts Based on nursing research and scientifically supported generalizations Environment NP Nursing Health Review of Literature Key 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 GE Mac 1200 ECG Machine (inlcudes ECG cable & Leads, Electrodes and Operations Manual)- recertified, preowned ECG cart ECG Recording Paper (Chart fan fold 216x280x150 Red); $7.52/pk; $75.26/case Actual Difference ($) 1,850 1,850 300 300 75 75 105 105 85 85 206 206 *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 Freight/Material Shipping/Handling Taxes (8.525%) x $2,415.00 Total Expenses Budget $ - Actual $ 2,621 Difference ($) $ 2,621 Washburn University Athletic Training Education Program Adult 12 LEAD EKG COMPETENCY CHECKLIST NAME_______________________________ DATE____________________ Competent Performance Adult 12-Lead EKG Performance 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 (Verbalization or Return Demonstration) Yes (V/D) No Validator Comments 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.