Tracy Hill, BSN, RN, MSN Candidate Family Nurse Practitioner Student
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Transcript of Tracy Hill, BSN, RN, MSN Candidate Family Nurse Practitioner Student
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.