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)  G3uM&feature=player_embedded G3uM&feature=player_embedded 

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 HistoryFamily HistoryPhysical 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

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  4 concepts  Based on nursing research and scientifically supported generalizations NP PersonHealthNursingEnvironment

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 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/SuppliesBudgetActualDifference ($) GE Mac 1200 ECG Machine (inlcudes ECG cable & Leads, Electrodes and Operations Manual)- recertified, preowned 1,850 ECG cart 300 ECG Recording Paper (Chart fan fold 216x280x150 Red); $7.52/pk; $75.26/case 75 *10pks/cs- Ref 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 Freight/Material Shipping/Handling 85 Taxes (8.525%) x $2, Total ExpensesBudgetActualDifference ($) $ - $ 2,621

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.