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T.HillA Proposal for ECG’s in pre-participation physical examinations (PPE) for college athletes

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A Proposal for ECG’s in pre-participationphysical examinations (PPE) for college athletes

Washburn UniversitySchool of Nursing

NU 670- Graduate Project

[Nov. 2, 2012]

Tracy Hill, BSN, RN, MSN CandidateShirley Dinkel, PhD., APRN - Instructor


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Implementing ECG’s as part of pre-participation physical examinations (PPE) for student athletesIntroduction

Athletes are seen as one of the healthiest segments of our society. About 400,000 students

between age 17 and 23 participate in National Collegiate Athletic Association (NCAA) sports

every year. However, each year, about one in 44,000 players in the NCAA has sudden cardiac

death (SCD) (Hendrick, 2011; Wong 2011). While still considered relatively rare, the rate of

SCD in young athletes is higher than previous estimates (American College of Cardiology

Foundation/American Heart Association Task Force [ACCF/AHA], 2011, Minneapolis Heart

Institute Foundation, 2012, NCAA, 2012, O’Connor et al., 1998, Subasic, 2010).The NCAA

reports that the incidences of sudden cardiac death have been more prevalent among African-

Americans (one in every 17,000 student-athletes per year) than Caucasians (one in 58,000).

Additionally, men have been shown to be at greater risk (one per 33,000) than women (one in

76,000) (NCAA, 2012). Fortunately, the incidence of sudden death in an athlete, especially a

young athlete, is a rare event, although the true incidence of SCD is unknown and probably

underestimated due to the absence of a mandatory reporting system (Casa et al., 2012, NCAA,

2012). The incidence of SCD could be as high as 110 deaths each year in young athletes or 1

death every three days in the United States (Casa et al., 2012).

Sudden cardiac death (SCD) in young athletes was first reported in the 1980s. SCD is

defined by the American Heart Association (AHA) as “death resulting within minutes of an

abrupt loss of heart function”, (Wong, 2011) or 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). SCD is the leading medical cause of

death for student athletes, accounting for 16 percent of college-athlete deaths (Subasic, 2010).

The overall prevalence of cardiac abnormalities responsible for SCD has been estimated to be


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0.3% (3 in 1000) in the general athlete population, and while actual incidence rates of SCD are

markedly lower, relatively few cardiac abnormalities lead to a fatal event in young athletes

(O’Connor & Knoblauch, 2010). The NCAA required screenings for student athletes currently

includes a comprehensive personal and family medical history, physical examination, and

appropriate additional diagnostic testing, if warranted. Many NCAA institutions also offer an

electrocardiogram (ECG) and/or echocardiogram as part of an athlete’s heart screen, although it

is not a requirement (NCAA, 2012).

A recent study by Wong (2011) report that while it is more expensive, researchers feel

that ECGs are necessary to properly screen athletes for heart conditions. The University of

Washington is one example of an institution that now requires ECGs on incoming freshman

athletes as a result of the study, because in 2002, a woman’s basketball player on the UW team

collapsed from heart failure and survived, and in 2006, the women’s basketball coach suffered a

cardiac arrest, too. Both the former player and coach are now advocates for requiring testing

nationwide, stating "The NCAA has an opportunity to take a stand in a positive way and mandate

testing, and at the end of the day, what's a life really cost?" (Wong, 2011)

According to a study led by Thomas DeBauche, MD, of Cypress Cardiology in Cypress,

Texas, cost issues should no longer keep electrocardiograms out of most schools' efforts to

screen student athletes for potentially fatal heart problems. Researchers reported that due to

recent declines in the price of ECG machines, students can be screened for a cost of less than $3

each after an initial investment of under $500 per school (Phend, 2009).

Problem Statement

Hypertrophic cardiomyopathy (HCM) is reported as the most common cause of

unexplained sudden cardiac death in young athletes (Minneapolis Heart Institute Foundation,


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2012, NCAA, 2012, Subasic, 2010). Prevention of SCD in athletes requires early recognition of

those conditions known to cause SCD (O’Connor & Knoblauch, 2010). Adequate screening and

evaluation are important to identify and counsel persons with underlying cardiovascular disease

before they begin exercising at moderate to vigorous levels (“AHA/ACSM Joint Position

Statement“, 1998).

The purpose of this project is to apply evidence-based practice (EBP) recommendations

to 1) Discuss current evidence available to support implementing ECG screenings as part of the

pre-participation physical examination (PPE) for student athletes at WU, 2)Enhance high quality

care that is safe to all athletes by early recognition and detection of cardiac problems that may

lead to SCD, 3) In collaboration with the Department of Kinesiology Athletic Training Education

Program, it is proposed that athletic training students be trained to properly perform ECGs as

part of enhancement to their core curriculum for KN 492: Clinical Experiences in Athletic

Training- General 4) Implement ECG screening as part of PPE for all student athletes at WU.

Included will be a proposal for funding to obtain the appropriate equipment and training

necessary to perform and interpret ECG’s for student-athletes as part of the PPE and

implementation of diagnostic tools. Currently, routine ECG’s are not performed as part of the

PPE at WU.

Significance to Nursing

Health care providers, including Advanced Practice Nurses (APNs), play an important

role in correctly performing and interpreting ECG’s, and appropriately identifying and referring

those with abnormal ECGs. In 1996, pre-participation sports screenings became a joint public

health initiative and are supported by the AHA. The guidelines are not mandated or presented as

a national standard, and their purpose is to identify risks and prevent injury in competitive


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athletes. They are routinely updated, widely accepted, and endorsed as standards of care by

numerous medical and sports related associations (Subasic, 2010).

Currently, there is no standardized guideline for the performance and evaluation of ECGs

as part of student athlete physicals at Washburn University. Properly trained WU athletic

training students and faculty, along with medical providers, can increase overall safety during

athletic activities in those unknowingly vulnerable to SCD by: 1) Implementing diagnostic tools

such as ECG equipment, 2) Educating and training athletic training students to perform ECGs,

and 3) Utilizing ECG’s as part of pre-participation sports physicals for student-athletes at WU.

By increasing knowledge and awareness of evidence based guidelines and standards

about SCD and ECG’s in pre-participation sports physicals, WU is in a position to provide early

detection, recognition and treated of patients at risk for SCD. By implementing ECG screenings

for student athletes, the providers potentially improve health outcomes and potentially save lives

of student athletes, before SCD occurs. WU Department of Kinesiology Athletic Training

Education Program faculty and students, along with the WU Athletic Department and the

University have the potential to be at the forefront of implementing current European and

Olympic recommendations for ECG screenings for athletes and what may soon be “best

practice” nationally as well. It is vital that educators and practitioners recognize the need to have

a procedure to provide the most up to date evidence based care to improve patient outcomes.

This proposal, intended to reduce the potential risk of SCD in student athletes, provides the

opportunity for WU to enhance the comprehensiveness of services for student athletes and

promotes multidisciplinary collaboration in an effort to improve outcomes and facilitate prompt

recognition and treatment of patients at risk for SCD. ECGs as part of a PPE, if implemented,

could minimize cardiovascular risk associated with sports. Health care providers, including


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APRNs, play an important role in correctly performing and interpreting ECG’s, and

appropriately identifying and referring those with abnormal ECGs.

There is general consensus that within a benevolent society there is a responsibility on the

part of healthcare providers to initiate prudent efforts to identify life-threatening diseases in

athletes to minimize cardiovascular risk associated with sports (Maron et al., 1996). There also

appears to be an implied ethical and possibly legal obligation on the part of educational

institutions to implement cost-efficient strategies to ensure that their athletes are not subject to

unacceptable medical risks. ECGs as part of a PPE, if implemented, could minimize

cardiovascular risk associated with sports.

An ECG is universally acknowledged as more likely to identify serious cardiac problems,

and it has been adopted as an international standard for screening in much of the world. The

European Society of Cardiology and the International Olympic Committee have recommended

the addition of ECGs to pre-participation sports physicals for college athletes. An ECG is

required prior to sports participation in the International Olympics and is practiced by 92% of

professional sports teams in the United States (Subasic, 2010).

In collaboration with the Department of Kinesiology Athletic Training Education

Program at Washburn University, a guideline that includes ECG screening as part of the student-

athlete pre-participation sports physical is suggested. It is also suggested that the a local

cardiologist review all ECG’s and be consulted for any potential abnormal ECG’s to determine if

further testing is warranted. As forerunners in the initiative, WU has the opportunity to be among

the first to implement the already recommended international and Olympic standards for ECG

screenings in athletes, an initiative that may soon be “best practice” nationally as well.

Project Objectives


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Currently, the WU Athletic Training Education Program and the Athletic Department

does not have a guideline for including ECGs as part of the PPE. This proposal presents

implementing ECG screenings as part of the PPE for student athletes, necessary training for

athletic training faculty and students to effectively perform ECGs, and exploring funding sources

for a 12 lead ECG machine and necessary equipment and supplies. There are six objectives for

this project. They include:1) Review of literature to include current national guidelines for the

pre-participation physical examination (PPE) and ECG screening and interpretation

recommendations for student athletes; 2) Review of current practices at the WU Department of

Kinesiology Athletic Training Education Program and Athletic Department for PPE and ECG

screenings for student athletes 3) Propose a guideline for the inclusion of ECGs in PPE for

student athletes at Washburn University; 4) Educate WU athletic training faculty and staff in

proper ECG placement and performance and 5) Recommend a referral procedure for overread of

all ECG’s and follow-up of students determined to be at increased risk and 6) Explore funding

sources for 12 Lead ECG equipment and supplies for WU Department of Kinesiology Athletic

Training Education Program.

Background of the Problem

Current guidelines for pre-participation screening of competitive athletes in the US

include a comprehensive history and physical examination.

There were five objectives to this proposal, including 1)Determine the value of

electrocardiography (ECG) added to a PPE screening in college athletes, 2) Provide the

opportunity for Washburn University to be more active in preventing SCD in student athletes, 3)

Revise and enhance the course curriculum for KN 492: Clinical Experiences in Athletic

Training- General Medical to include education and training on performing ECGs, 4) Write a


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curriculum grant to help fund necessary ECG equipment and supplies for revised course,

including development of a budget, 5) Educate providers on current standards and recommend

assessment tools, including a new pre-participation physical examination (PPE) form.

Pre-participation cardiovascular screening is the systematic practice of medically

evaluating large, general populations of athletes before participation in sports for the purpose of

identifying, or raising suspicion of abnormalities that could provoke disease progression or

sudden death (American Heart Association [AHA], 2007, p. 1643). The American Heart

Association (AHA) has published guidelines for pre participation sports physicals. The

Hypertrophic Cardiomyopathy Association (HCMA) encourages each state to use these

guidelines when updating their requirements for participation in high schools and college level

programs. According to the WU Athletic Training Department, student PPEs does not currently

include an ECG.

Currently, all Big 12 Division 1 institutions, including Kansas State University and the

University of Kansas, both within 58 miles of Washburn University, include an ECG and

echocardiogram on all incoming athletes as part of their PPEs. For the purpose of collecting data

on ECG screenings from schools similar in size to Washburn, this author attempted to contact the

athletic training staff at each of the five Division II schools in Kansas. The Division II

Universities in Kansas include Emporia State University, Emporia, KS, Fort Hays State

University, Hays, KS, Newman University, Wichita, KS, Pittsburg State University, Pittsburg,

KS, and Washburn University in Topeka, KS. The athletic training staff at each of the

universities was contacted by email, asking whether or not these schools did routine ECG

screenings as part of their PPE for their student athletes. At the time of this proposal, Washburn

University’s athletic training staff was the only school to respond to the email. Currently,


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Washburn University does not conduct ECG’s on their student athletes as part of their PPE,

citing “it is very cost prohibitive to screen every athlete with the ECGs, although we do not

hesitate if it is warranted” (personal communication, Karen Garrison, MA, ATC, LAT, Clinical

Education Coordinator/Asst. Athletic Trainer, Washburn University, April 23, 2012). At this

time, the only time they order ECGs for their student athletes is if there is a family medical

history or something abnormal on their PPE (Appendix A). Officials in the athletic department

at WU also cite the National Athletic Trainers’ Association (NATA) Position Statement:

Preventing Sudden Death in Sports, quoting that "The pre-participation physical examination

(PPE) should include the completion of a standardized history form and attention to episodes of

exertional syncope or pre-syncope, chest pain, a personal or family history of sudden cardiac

arrest or a family history of sudden death, and exercise intolerance." (personal communication,

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

Washburn University, April 23, 2012), (Casa et al., 2012). It is noteworthy, however, that the

NATA also reports that pre-participation screening is one strategy available to prevent SCD, and

that the best protocol to screen athletes is highly debated, and some methods lack accuracy.

Additionally, the NATA Position Statement on preventing SCD in sports reports that “As many

as 80% of patients with SCD are asymptomatic until sudden cardiac arrest occurs, suggesting

that screening by history and physical examination alone may have limited sensitivity to identify

athletes with at-risk conditions.” (Casa et al., 2012).

Exercise-associated acute cardiac events generally occur in individuals with structural

cardiac disease. Hypertrophic cardiomyopathy (HCM) is a condition that is generally not

compatible with competitive athletics and therefore those with HCM should not participate in

most athletic programs. HCM has been proven to be the leading cardiovascular cause of SCD in


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the young athlete population, accounting for about one third of events (American College of

Cardiology Foundation/American Heart Association Task Force [ACCF/AHA], 2011,

Minneapolis Heart Institute Foundation, 2012, NCAA.com, 2012, O’Connor et al.,1998, Subasic,

2010).

Theoretical Framework

The Shuler Nurse Practitioner Practice Model was used as the theoretical framework for

developing this proposal. The Model presents a holistic approach to delivery of patient care and

to evaluation of services provided. The four concepts of person, health, nursing and

environment, along with the concept of the NP role, are intrinsic to the Shuler Nurse Practitioner

Practice Model (Shuler, 2000). It is based on nursing research and scientifically supported

generalizations that are relative to the NP practice areas.

School Based Health Centers (SBHC) are in a unique position to assist with development

of positive health behaviors by providing holistic services, including ECG screenings for student

athletes, as well as all patients who receive services at SBHC. To deliver holistic services, the

SBHC must have a multidisciplinary team comprised of health care providers, mental health

counselors, health educators, nutritionists, social workers, teachers and support staff (Shuler,

2000). WUSHS onsite team leader/manager is an Advanced Practice Registered Nurse (APRN)

responsible for the coordination of SBHC services delivered, provision of primary care, and

evaluation of services rendered.

As a result of the holistic treatment plan, patient problems related to unmet basic needs,

including underlying cardiac problems potentially uncovered by a routine ECG, can be

identified. The development and implementation of a holistic treatment plan should include

consultation and referral to multidisciplinary team members and other resource agencies. The


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Shuler Nurse Practitioner Practice Model was used as the theoretical basis for the proposal

because it presents a holistic approach to patient assessment, problem identification/diagnosis

determination, treatment, and evaluation.

Review of Literature

Overview

A systematic literature review and critical analysis of available articles was completed.

The literature review utilized the following databases: PubMed, ProQuest, UpToDate, SAGE,

Cochrane, Google scholar and CINAHL databases, as well as searches of websites of relevant

organizations (e.g. AHA, ACSM, NATA, and NCAA). Key words used included ECG, college

athletes, cardiovascular screening, guidelines, pre-participation physical examination, NCAA,

sudden cardiac death, screening, hypertrophic cardiomyopathy, prevalence, incidence and

genetic cardiovascular disease. Applicable articles were limited to English language sources,

and human studies. Articles published in the last 15 years were included. Bibliographies of all

relevant articles were visually searched to retrieve additional articles. Twenty-five applicable

articles were then reviewed in full for inclusion in this proposal.

In 1996, pre-participation sports screenings became a joint public health initiative

supported by the AHA. The guidelines are not mandated or presented as a national standard, and

their purpose is to identify risks and prevent injury in competitive athletes. They are routinely

updated, widely accepted, and endorsed as standards of care by numerous medical and sports

related associations (Subasic, 2010). The most recent update was in 2007. The moving force

behind the update was the age of the original recommendations, as well as a strong debate as to

whether a 12-lead ECG should be added to the recommended practice guidelines. The AHA

decided, despite continued debate, that an ECG was not recommended at that time due to limited


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resources, cost, and the potential for false-positive results; therefore, the utilization of an ECG

for sports physicals remains optional. However, an ECG is universally acknowledged as more

likely to identify serious cardiac problems, and it has been adopted as an international standard

for screening in much of the world. The ECG is viewed at the most cost-effective

cardiovascular screening modality (Subasic, 2010).

Subasic (2010), also reports that the screening of athletes prior to participation in

competitive sports usually falls short of recommended guidelines. Currently, the NCAA requires

all student-athletes beginning their initial season of eligibility and students who are trying out for

a team to undergo a medical examination before engaging in any physical activity with the team,

and each subsequent year, an updated medical history is administered (NCAAwebsite, 2012, p.

2). Currently, the NCAA does not require ECGs on student athletes as part of their PPE, it

remains optional.

In the June 2011 issue of The American Journal of Medicine, researchers collected

electrocardiograms and echocardiograms of 964 athletes at a single university and found that

distinct ECG abnormalities were present in 10% and were more common in males as well as

black athletes. Two athletes were subsequently excluded from competition (Elsevier, 2011)

Definition

Sudden cardiac death (SCD) is the leading cause of death in exercising young athletes

(Casa et al., 2012). SCD is defined by the AHA as “death resulting within minutes of an abrupt

loss of heart function”, and is the leading medical cause of death for student athletes, accounting

for 16 percent of college-athlete deaths (Wong, 2011). SCD is unexpected and non-traumatic and

occurs instantaneously or within a few minutes of an abrupt change in the person's previous

clinical state (O’Connor, Kugler, & Oriscello, 1998).The underlying cause of SCD is usually a


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structural cardiac abnormality. HCM and coronary artery anomalies are responsible for

approximately 25% and 14% of SCD, respectively, in the United States.

Hypertrophic cardiomyopathy (HCM) is characterized by a thickened left ventricular wall

that causes an enlarged heart and while many people with HCM live a normal life and do not

experience health-related problems, HCM is currently the most common genetic heart disease

and most frequent cardiovascular cause of sudden death in young athletes (AHA, 2007, NCAA,

2012). HCM is often detectable by ECG, and in the general population may occur in as many as

one in every 500 individuals. The clinical spectrum is broad and complex, encompassing the risk

for sudden cardiac death predominantly in the young and heart failure disability at any age

(Minneapolis Heart Institute Foundation, 2012).

Pathophysiology/Clinical Manifestations

Sudden Cardiac Death is a syndrome defined by its clinical presentation rather than by a

discrete pathophysiology. SCD is a sudden state of circulatory failure due to loss of cardiac

systolic function and is the result of 4 specific cardiac rhythm disturbances: ventricular

fibrillation (VF) and pulseless ventricular tachycardia (VT), pulseless electrical activity (PEA)

and asystole (Epocrates, 2012). SCD is instantaneous and most individuals become unconscious

within seconds to minutes as a result of insufficient cerebral blood flow. SCD can occur in

patients who have no previous history of heart disease. However, underlying heart disease is

present in the vast majority of patients with SCD and identification of the patient at risk for

sudden death or definition of the factors that result in the precipitation of the fatal arrhythmia

continues to represent a major challenge. In SCD, there are usually no predictive symptoms, but

if present, they are nonspecific and include chest discomfort, palpitations, shortness of breath and

weakness.


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The “athletic heart” describes a heart that has a structural change of the heart wall,

suggestive of HCM, and is often seen in athletes who train at high levels. The AHA reports that

The American College of Cardiology Bethesda Conference No. 36, as well as the European

Society of Cardiology guidelines indicate that risk for SCD is increased during intense

competitive sports and also suggests that the removal of those individuals with HCM from the

athletic arena can diminish their risk (ACCF/AHA, 2011). Causes of sudden cardiac death in

young competitive athletes that constitute the largest percentages associated with SCD in

student-athletes are included in Figure 1(Subasic, 2010).

Epidemiology of SCD in Athletes

Sudden cardiac death (SCD) most commonly occurs in male athletes, who have estimated

death rates nearly fivefold greater than the rates of female athletes. Congenital cardiovascular

disease is the leading cause of non-traumatic sudden athletic death, with HCM being the most

common cause (O’Connor et al., 1998). Adding other heart conditions known to cause sudden

cardiac death, the prevalence of serious underlying heart disorders may approach three in every

1,000 student-athletes. A study on sudden cardiac death conducted by Harmon, K, et al (2008),

in which researchers gathered data from the NCAA, along with news reports and insurance

claims, found that college athletes across the nation suffer from sudden cardiac death up to seven

times more frequently than previously reported (Wong, 2011). The study tracked deaths from

2004-2008, and reported that about 400,000 students between age 17 and 23 participate in

NCAA sports every year. The researchers reported that the total number of deaths from all

causes were 273, and 29%, or 80 of those athletes, died from medical causes and 56% of those

deaths were cardiovascular-related sudden deaths. Researchers have also found that among the

400,000 athletes who participate in NCAA sports every year, the incidences of SCD have been


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more prevalent among African-Americans, 1: 17,000 student-athletes per year, than Caucasians,

1:58,000. Male basketball players have the highest rate of sudden cardiac death and men have

been shown to be at greater risk than women (NCAA, 2012, Wong, 2011).

The design of a screening strategy must take into account the fact that sudden cardiac

death in athletes is an infrequent event and that only a small proportion of participants in

organized sports in the United States is at risk. There are approximately 4 million competitive

high school–age athletes in addition to 500,000 collegiate and 5,000 professional athletes (Maron

et al., 1996). According to the American Heart Association, 1 in every 350 young people has an

undetected heart condition, and sudden cardiac arrest happens among exercising youth once

every three days in the United States (AHA, 2012). According to the Washburn University

Department of Institutional Research (2011), in the fall of 2011, there were 7,303 students

enrolled at Washburn University, and of those, 271 were student athletes. Therefore, it is

possible, and maybe probable, that at least one student athlete at WU has an undetected heart

condition.

The NCAA points out that many schools require only that students fill out a family

history regarding cardiac problems and have a qualified provider listen to their hearts. They also

report that heart disorders are more common than might be expected in a population group that is

perceived to be healthy, such as student athletes. Due to its sudden and often unrecognized

nature, the epidemiologic characteristics of SCD are difficult to determine with precision,

nevertheless, estimates can be made. Survival is estimated at <20% for patients presenting out-

of-hospital with VF, and <10% overall for patients presenting with out-of-hospital SCD (Rhea,

Eisenberg, & Sinibaldi, 2004). An ECG can only detect 60% of those at risk for sudden cardiac


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death. There are some conditions that cannot be detected with an ECG. Until further testing is

available, ECG is the best and most cost-effective tool to detect those at risk.

The Sudden Death in Athletes U.S. Registry is maintained by Dr. Barry Maron of the

Minneapolis Heart Institute Foundation. The data compiled in this important registry helps to

clearly define the causes of sudden death in U.S. Athletes. It has been proven through this

registry that the leading cause of sudden cardiac arrest and death in this population remains

HCM (Hypertrophic Cardiomyopathy Association [HCMA], 2009). The registry includes 1,866

US athletes between the ages of 8 and 39 who participated in 38 different sports and who died

suddenly or survived cardiac arrest. Of the deaths, 56% were due to cardiovascular disease.

HCM in the general population may occur in as many as one in every 500 individuals. According

to Maron (HCMA, 2009), among the 1,049 deaths due to cardiovascular disease, the highest

number of events in a single year was 76, with an average of 66 events per year during the last

six years of data collection for the registry.

Current Recommendations

Although routinely practiced in Europe, promoted by the International Olympic

Committee, and mandated in Italy, pre-participation screening including 12-lead ECG is not

commonly performed in competitive collegiate athletes in the US. Current recommendations for

cardiovascular screening call for a careful history and physical examination performed by a

knowledgeable health care provider. According to Subasic (2010), screening of athletes prior to

participation in competitive sports usually falls short of recommended guidelines. Many schools

require only that a student fill out a family history regarding cardiac problems and have a

physician listen to their hearts. Poorly defined legislation and the absence of a national standard

for sports physicals have contributed to the inadequate health screenings of athletes. Currently,


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the NCAA requires all student-athletes beginning their initial season of eligibility and students

who are trying out for a team to undergo a medical examination before engaging in any physical

activity with the team, and each subsequent year, an updated medical history is administered

(NCAA, 2012). The NCAA required screenings for student athletes currently includes a

comprehensive personal and family medical history, physical examination, and appropriate

additional diagnostic testing, if warranted. Many NCAA institutions also offer an

electrocardiogram (ECG) and/or echocardiogram as part of an athlete’s heart screen, although it

is not a requirement (NCAA, 2012).

Issues related to the methodology and justification for pre-participation screening,

including use of the 12-lead electrocardiogram (ECG), has become a complex area of debate.

Traditionally, member institutions of the NCAA have been independently responsible for their

own pre-participation evaluation process and the design of the institutional screening history and

physical examination (AHA, 2007, p. 7). Currently, the AHA panel does not believe it to be

either prudent or practical to recommend the routine use of tests such as 12-lead ECG or

echocardiography in the context of mass, universal screening (AHA, 2007). Clearly, the role of

routine ECG screening in the United States to prevent SCD is not settled and will require more

data and debate.

Effectiveness of ECG in Prevention

Broad-scale ECG screening has not been tested or implemented in the United States,

although some US studies have suggested that ECG screening may be cost-effective on the basis

of estimated cost per year of lives saved. According to Phend (2009), the addition of a 12-lead

ECG screening would cost just $300 per year of life saved. Another study by Magalski, et al.

(2011) reported that recent data in high school and college athletes demonstrated that ECG is


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associated with 2.1 life-years saved per 1000 athletes, an incremental cost of $89 per athlete, and

a cost-effectiveness ratio of $42,900 per life-year saved. Compared with no screening, use of

ECG with history and physical examination also was associated with 2.6 life-years saved per

athlete, an incremental cost of $199, and a cost-effectiveness ratio of $76,100 per life-year saved

(Magalski, 2011).

The sensitivity of ECG among elite and professional athletic populations is estimated to

range from 51% to 70%, and specificity is reported in the range of 62% to 98%. Additionally,

mandatory screening of Japanese schoolchildren since 1973 has demonstrated a greater

sensitivity of ECG versus history and physical examination. (O’Connor & Knoblauch, 2010).

Lawless, the team doctor for U.S. Figure Skating and a cardiology consultant to Major

League Soccer (MLS), said that taking a regular history and physicals of athletes may only detect

a disease such as HCM two to six percent of the time, while the ECG can pick it up 50 to 80

percent of the time (Subasic, 2010). Lawless also reports that ECG readings are abnormal in 95%

of patients with HCM and provide the ability to suspect other cardiac abnormalities associated

with sudden death. In Europe, and particularly Italy, universal ECGs are performed on athletes

and are heavily promoted as having reduced the incidence of sudden death (Subasic, 2012). Italy

pioneered nationwide screening of athletes with ECG in the late 1990s, and subsequently

revealed a 90% drop in sudden cardiac events after the screening program began (Isaacson, 2010,

Phend, 2009). Competitive Italian athletes undergo required PPE and ECG, with ECG reportedly

demonstrating 77% greater power to detect HCM than history and physical examination alone

(O’Connor & Knoblauch, 2010).

The European Society of Cardiology and the International Olympic Committee have

recommended the addition of ECGs to pre-participation sports physicals for college athletes. An


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ECG is required prior to sports participation in the International Olympics and is practiced by

92% of professional sports teams in the United States (Subasic, 2010,). In 2004, the International

Olympic Medical Committee issued a screening protocol including ECG for Olympic athletes

(American Academy of Pediatrics [AAP], 2012). In 2005, the European Society of Cardiology

(ESC) issued a consensus statement on cardiovascular pre-participation screening of all young

competitive athletes younger than 35 years, recommending a 12-lead ECG in addition to focused

history and physical examination (AAP, 2012, Malhotra et al., 2011). The AHA recommends

only history and physical without ECG (AHA, 2007, Malhotra et al., 2011).

An ECG may show QT interval, ST-segment or T-wave changes, conduction

abnormalities and ventricular hypertrophy. Lawless (2010) presented research to the AHA

supporting the AHA's belief that universal ECG tests may result in a high rate of false-positive

results, prompting unnecessary follow-up tests (Isaacson, 2010). Though ECGs are not as

thorough as imaging tests like an echocardiogram, which shows a 3-D view of the heart, they are

cheaper and easier to conduct on a wider basis.

A recent study found that although ECG screening results in many false positives

resulting in additional tests, the overall cost per diagnosis of adding ECG screening is similar to

that of history and physical screening alone (Malhotra et al., 2011). The study at the University

of Virginia, conducted over 5 years, included all 1,473 of their competitive athletes, and each

athlete was screened with a history, physical and with ECGs using European Society of

Cardiology (ESC) guidelines with follow-up testing as dictated by clinical symptoms and ECG

findings. The authors demonstrated that adding ECGs to an athletic screening program

discovered significant pathology in college athletes (Malhotra et al., 2011). In the study, history

and physical alone uncovered five significant cardiac abnormalities. Additional testing with


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ECGs confirmed eight significant cardiac abnormalities that were not found by history and

physical alone (Malhotra et al., 2011).

Consideration must also be given to the interpretation of ECGs. Computer-generated

interpretations of ECG’s are often inaccurate and can result in inappropriate treatment (Anh,

Krishnan, & Bogun, 2006) Accurate provider over-reading is necessary to avoid such errors.

Over-reading of 12 lead ECG’s is required to circumvent errors of computerized ECG

interpretation. Cardiologists as primary readers more often corrected the misinterpreted ECGs as

compared with internists, emergency physicians, or other specialists (94% vs. 71%, P < .001)

(Anh, Krishnan, & Bogun, 2006). Not only should the cardiologist review the ECG, but should

also have access to any relevant clinical information to assist in interpretation.

Recent data collection from a local hospital revealed it costs $17-$20 for a 12 lead ECG

with interpretation from a cardiologist and report (CPT 93000); the ECG charge was $44.25,

reimbursement from Medicare was $17.70, and was $20 from commercial insurance carriers

(personal communication, Sheryle D’Amico, MHA, VP Physician Division, Lawrence Memorial

Hospital, June 5, 2012). Additionally, college students are required to carry health insurance, so

the cost for the university and the student athlete could be minimal, as many insurers will cover

80 to 100 percent of the costs.

Finally, the goal of any screening effort is to identify individuals at risk; unaffected or

low-risk individuals should be cleared, and conversely, those affected should be appropriately

restricted, counseled, and treated. No screening protocol has yet proven to be effective in their

role or validated as highly effective. The AHA has documented a 12-element recommendation

for pre-participation screening of competitive athletes (Table 1). This process will minimize

unnecessary variation.


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Implementation Plan

There are many options to explore to incorporate ECG screenings as part of PPE for

student athletes at WU. The primary goal of this project will be obtaining an ECG machine and

necessary equipment to properly screen current and future student athletes as part of their PPE.

Initially, I plan to collaborate with the Washburn University Department of Kinesiology Athletic

Training Education Program to review proposed guidelines and formulate a clinical guideline

that can be applied to WU. Statistics for student athletes show that in the fall of 2011 there were

271 student athletes at WU. If WU decided to implement ECG screenings for all new or transfer

athletes, that would be about 68 athletes per year. Collaboration with the WU Athletic Training

Education Program, and other community resources such as a local hospital, and/or the medical

director for WU Athletic Department will help meet project goals. This collective effort will

facilitate establishment of a collaborative agreement for over-read of ECGs, and referrals for

those at higher risk.

Solicitation of funds for EKG equipment and necessary supplies could include a proposal

that the Washburn University Athletic Department purchase all necessary ECG equipment

necessary for initiating and implementing, as well as continuation of ECG screenings as part of

the PPE for student athletes. Another option would be to collaborate with WU Department of

Kinesiology Athletic Training Program and the WU Athletic Department, along with other

community resources such as local hospitals, to explore the possibility of a community outreach

program with Washburn University that would include a donation of the necessary ECG

equipment and to absorb the cost of ECG screening and interpretation by their contracted

clinicians as part of community outreach endeavors. Other potential options for funding,

including, but not limited to: a Curriculum Development Grant, WU Alumni donation, WU


22

Endowment Association donation, WUSON alumni donation, WU Athletic Department

donation, Stormont Vail HealthCare and/or St. Francis Health Center Endowment Association

donation, personal donations, fundraising efforts, etc. Additionally, securing a donation of ECG

equipment and materials as part of a community outreach project collaboration with WU Athletic

Department could ensure screening all student athletes with an ECG as part of their PPE, and

could help reduce the risk of SCD in student athletes.

This proposal also recommends that all providers in the WU Athletic Training Education

Program obtain education and training on proper ECG placement. It is recommended that

continuing education for providers include courses related to cardiovascular issues in student

athletes. It is suggested that the WU Athletic Training Education Program students could be

required to spend at least 2 hours in the WU Athletic Training facility doing ECGs during

physical exam screenings for student- athletes. A simplified algorithm could be used, and may

help clinicians correctly identify both suspected electrode misplacements and artifacts

(Baranchuk et al., 2009, p. 67). Basic ECG interpretation course for all medical providers at WU

should be required. I have included an example of an ECG competency checklist as a potential

checklist to utilize for the WU Athletic Training Education Program course curriculum. Once

approval is given by the WU Athletic Training Education Department director, education and

training will begin for the staff on the clinical practice guidelines and associated ECG

competency training utilizing the 12 lead ECG competency check-list as a guide. WU Athletic

Training Education Program staff and students will watch two provided videos on ECG

placement and performance (Appendix D), and will have the opportunity to practice their skills

prior to ECG competency skills check-off. A 12 lead ECG instructive poster will be placed in all

exam rooms for reference (Appendix E, cardiacscience.com, 2012).


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Project Outputs

The first project output will be providing a training packet and guidelines for WU

Athletic Training Education Program faculty and students. The guidelines will include an

updated health history and physical exam form, and ECG screening and referral

recommendations.

Next, funding options for ECG equipment and supplies will be explored. Funding

requests would include ECG equipment and supplies. A proposed budget has been prepared and

it is projected that the funds would cover necessary equipment and supplies for 2 years expenses

for training athletic training students on proper ECG placement and performance, and

performing ECGs for student athletes for their PPE. (Appendix G). This information, including

the prosed budge, will be submitted with a curriculum development grant for the 2012-2013

academic year.

If approved, and funding is secured to purchase ECG equipment and supplies, WU

students enrolled in KN 492: Clinical Experiences in Athletic Training- General Medical, will be

educated on the guideline and trained on proper ECG placement and performance, with a

mandatory competency implemented. An example of an ECG placement and performance

competency is included in Appendix F; it will need slight modification for WU Athletic Training

Education Program specifics. WU Athletic Training Education Program staff will submit the

ECGs to Dr. Messmer or other appropriate clinician for final review and further

recommendation. It will be suggested that Dr. Messmer, the medical director for the WU

Athletic Department, be up to date and comfortable with 12 lead ECG interpretation prior to

implementing ECG screenings as part of the PPEs for student athletes, so that proper 12 lead

ECG interpretations can be attempted. The services of a local cardiologist should be secured in


24

order to provide accurate over-read of all ECGs to determine those individuals at higher risk and

in need of follow-up.

Conclusion

The knowledge and research about SCD and ECG screenings in student athletes remains

controversial due to cost containment limitations, and thus will warrant further research on cost-

effectiveness in smaller university settings before widespread implementation is initiated. This

project should help guide future research and optimally aid in the implementation of ECG

screenings for all student athletes at the college level. ECG screening of U.S. college athletes can

uncover significant cardiac pathology not discovered by history and physical alone. Although

ECG screening also results in many false positives resulting in additional tests, the overall cost

per diagnosis of adding ECG screening is similar to that of history and physical screening alone.

Early detection of clinically significant cardiovascular disease through pre-participation

screening permits timely therapeutic interventions that may prolong life. While the results of an

ECG may require additional evaluation and testing by a medical provider, this author believes

that the benefit of this potentially life-saving screening outweighs this concern. Endorsement of

required ECG screenings in college athletes is pertinent and come from organizations such as the

AHA, ACSM, NATA, and NCAA in order for collegiate institutions to implement ECGs

nationally.


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Dissemination Plan

Project defense presentation to the WU School of Nursing Faculty is planned for

December 11, 2012. In addition, if funding is secured to begin this project, a presentation will be

planned in Fall 2013 to a group of WU Athletic Training Education Program staff and students

regarding ECG screenings as part of pre-participation physical examinations for college athletes.

Discussion will include the need for further research and consideration by university institutions

to implement ECGs for SCD screening as part of PPE in all college athletes. Discussions will

also include whether the endorsement of required ECG screenings in college athletes should

come from organizations such as the AHA, ACSM, NATA, and NCAA in order for collegiate

institutions to implement ECGs nationally. Final project results with be shared with the WU

Department of Kinesiology Athletic Training Education Program, the WU Athletic Department,

and the WU School of Nursing.


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References

AHA/ACSM Joint Position Statement: Recommendations for Cardiovascular Screening,

Staffing, and Emergency Policies at Health/Fitness Facilities. (1998, June). Medicine &

Science in Sports & Exercise, 30, 1009-1018. Retrieved from

http://www.acsm.org/access-public-information/position-stands

American Academy of Pediatrics. (2012). Pediatric Sudden Cardiac Arrest. Retrieved from

http://pediatrics.aappublications.org/content/early/2012/03/21/peds.2012-

0144.full.pdf+html

American College of Cardiology Foundation/American Heart Association Task Force . (2011).

2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic

Cardiomyopathy: Executive Summary. A Report of the American College of Cardiology

Foundation/American Heart Association Task Force on Practice Guidelines. Retrieved

from http://circ.ahajournals.org/content/124/24/2761.full

American Heart Association. (2007). Recommendations and Considerations Related to Pre-

participation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007

Update. A Scientific Statement from the American Heart Association Council on

Nutrition, Physical Activity, and Metabolism (Scientific Statement). Retrieved from

Hypertrophic Cardiomyopathy Association: http://www.4hcm.org

American Medical Society for Sports Medicine. (2010). Pre-participation Physical Evaluation

Form. Retrieved from http://www.amssm.org/Publications.html

American Nurses Association. (2001). Code of Ethics. In Code of Ethics for Nurses. Retrieved

from http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/

EthicsStandards/CodeofEthics.aspx


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Anh, D., Krishnan, S., & Bogun, F. (2006). Accuracy of electrocardiogram interpretation by

cardiologists in the setting of incorrect computer analysis. Journal of Electrocardiology,

39, 343-345. doi:

http://0dx.doi.org.topekalibraries.info/10.1016/j.jelectrocard.2006.02.002

Associated Press. (2012). D. Venkatesh collapses, dies. Retrieved from

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collapsing-field

Associated Press. (2012). Fabrice Muamba facing long recovery. Retrieved March 23, 2012,

from http://espn.go.com/sports/soccer/story/_/id/7726903/bolton-fabrice-muamba-said-

face-long-period-recovery

Baranchuk, A., Shaw, C., Alanazi, H., Campbell, D., Bally, K., Redfearn, D. P., Simpson, C. S.,

& Abdollah, H. (2009, February). Electrocardiography Pitfalls and Artifacts: The 10

Commandments. Critical Care Nurse, 29(1), 67-73. doi: 10.4037/ccn2009607

Casa, D. J., Guskiewicz, K. M., Anderson, S. A., Courson, R. W., Heck, J. F., Jimenez, C. C.,

McDermott, B. P., ... Walsh, K. M. (2012, February). National Athletic Trainers’

Association Position Statement: Preventing Sudden Death in Sports. Journal of Athletic

Training, 47, 96-118. Retrieved from http://www.nata.org/position-statements

Hendrick, B. (2011). Heart-Related Deaths in College Athletes: How Common? Each Year,

About One in 44,000 Collegiate Athletes Has Sudden Cardiac Death, Study Finds.

Retrieved from http://www.webmd.com/heart-disease/news/20110404/heart-related-

deaths-in-college-athletes-how-common


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Hypertrophic Cardiomyopathy Association. (2009). Sudden Death in Athletes Registry.

Retrieved from http://www.4hcm.org/hcma-outreach-events/sudden-cardiac-arrest-in-

athletes/40256-sudden-death-in-athletes-registry.html

Isaacson, M. (2010). Sometimes, there are no answers; Adams’ death raises issue of medical

testing. Retrieved from http://sports.espn.go.com/chicago/nfl/columns/story?

columnist=isaacson_melissa&id=4837804

Magalski, A., McCoy, M., Zabel, M., Magee, L.M., Goeke, J., Main, M., Bunten, L., Reid, K., &

Ramza, B. (2011, June). Cardiovascular Screening with Electrocardiography and

Echocardiography in Collegiate Athletes. The American Journal of Medicine, 124, 511-

518. DOI: 10.1016/j.amjmed.2011.01.009

Malhotra, R., West, J., Dent, J., Luna, M., Kramer, C. M., Mounsey, J. P., Battle, R., ...

Mahapatra, S. (2011, May). Cost and yield of adding electrocardiography to history and

physical in screening Division I intercollegiate athletes: A 5-year experience. Heart

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Maron, B. J., Thompson, P. D., Puffer, J. C., McGrew, C. A., Strong, W. B., Douglas, P. S.,

Clark, L. T., ... Epstein, A. E. (1996). Cardiovascular Preparticipation Screening of

Competitive Athletes: A Statement for Health Professionals from the Sudden Death

Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee

(Cardiovascular Disease in the Young), American Heart Association. Circulation, 94,

850-856. doi: 10.1161/01.CIR.94.4.850

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O’Connor, D. P., & Knoblauch, M. A. (2010). Electrocardiogram Testing During Athletic

Preparticipation Physical Examinations. Journal of Athletic Training, 45 (3), 265-272.

O’Connor, F. G., Kugler, J. P., & Oriscello, R. G. (1998). Sudden Death in Young Athletes:

Screening for the Needle in a Haystack. Retrieved from

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Phend, C. (2009). AHA: ECG Cost-Effective for Screening Student Athletes. Retrieved from

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Rhea, T. D., Eisenberg, M. S., & Sinibaldi, G. (2004, October). Incidence of EMS-treated out-of-

hospital cardiac arrest in the United States. Resuscitation, 63(1), 17-24.

Shuler, P. A. (2000, October). Evaluating Student Services Provided by School-Based Health

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Table 1

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

Personal History Family History Physical ExaminationExertional 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 pressureNote: In addition the HCMA suggests that children and young adults who have been adopted or are in any way unsure about their family history be viewed as potentially at risk and follow up with a comprehensive cardiac evaluation.*Hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias. At the discretion of the examiner, a positive response or finding in any 1 or more of the 12 items may be judged sufficient to trigger a referral for cardiovascular evaluation.**Cardiovascular screening should include ECG, echocardiogram, possible stress test, possible cardiac MRI and follow up plan as needed. In the opinion of the HCMA, these tests should be conducted by a cardiac professional, not a general practitioner or pediatrician (HCMA, 2009).


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Figure 1

Figure 1. Causes of sudden cardiac death in young competitive athletes (median age 17), based on systematic tracking of 158 athletes in the United States, primarily from 1985 to 1995. Ao indicates aorta; LAD, left anterior descending coronary artery; AS, aortic stenosis; C-M, cardiomyopathy; ARVD, arrhythmogenic right ventricular dysplasia; MVP, mitral valve prolapse; CAD, coronary artery disease; HCM, hypertrophic cardiomyopathy; ↑, increased. Adapted from Maron et al with permission of the American Medical Association.


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Appendix A


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Appendix B


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Appendix CThe American Medical Society for Sports Medicine (AMSSM) PPE


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Appendix D

12 Lead ECG Placement Part I

http://www.youtube.com/watch?feature=player_detailpage&v=eA5HmQSMGHE

12 Lead ECG Placement Part II

http://www.youtube.com/watch?feature=player_detailpage&v=TFcyiCKyaZ4


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Appendix E


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Appendix FWashburn University

Department of Kinesiology Adult 12 LEAD ECG 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


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Appendix G

Proposed ECG Expense Budget [Fall 2012]

ECG Equipment/ Supplies Budget Actual Difference ($) Difference (%)GE Mac 1200 ECG Machine (inlcudes ECG cable & Leads, Electrodes and Operations Manual)- recertified, preowned 1,850 1,850 undefinedECG cart 300 300 undefinedECG Recording Paper (Chart fan fold 216x280x150 Red); $7.52/pk; $75.26/case 75 75 undefined *10pks/cs- Ref. 2009828-061- Graphic Controls-GE Healthcare Recording PaperECG Electrodes: Red Dot Rest Tab Style - EKG 100/bag; 40 bags/case ($2.62/bag); $104.80/case 105 105 undefinedFreight/Material Shipping/Handling 85 85 undefinedTaxes (8.525%) x $2,415.00 206 206 undefinedTotal Expenses Budget Actual Difference ($) Difference (%)

-$ 2,621$ 2,621$ undefined

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