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.