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Standard
Standard

Athletes’ readiness to participate in activity is determined through a standardized pre-participation physical examination (PPE) screening process.

Narrative

For nearly four decades a number of medical organizations have formalized the pre-participation physical examination (PPE).4, 5, 6 This PPE is meant to identify areas of concern in the health of the athlete which could contribute to impaired function during participation in athletics. This formalization creates a base framework for all health care providers to work from. No matter who is performing the PPE, they should all be held to the same standard outlined by the document. The PPE should be performed early enough before participation to ensure that any areas of concern can be addressed prior to beginning participation. Pre-participation physical exams should be conducted in accordance with local and state guidelines.

Standard 1.1

Does the organization require each athlete to complete a standardized PPE screening process and be cleared by a QMP before participation in athletic activity?

Annotation:

The following best-practice recommendations should be considered supplementary to any state/local regulations. The physical exam should be conducted and clearance granted before any athletic participation including strength and conditioning sessions, try-out sessions, practices, or games. If another health care provider (physician assistant or nurse practitioner) performs the physical exam, the provider should be held to the same standards and expectations of a physician. Ideally, the physical exam should be conducted 4 to 6 weeks prior to athletic participation to allow proper time for follow up of any findings that require additional evaluation. A organizational representative should keep a copy of each athlete's PPE on file.

Supporting Documentation:

  • Organizational or governing body policy statement requiring each athlete complete a standardized PPE screening process.
  • Organizational or governing body policy statement on which QMP is given authority to clear a student for athletic activity.

Standard 1.2

Does the organization utilize standardized PPE screening instruments that are endorsed by the medical community?

Annotation:

The American Academy of Pediatrics PPE recommendations are an example of one adopted by many in the medical community. Several state interscholastic associations may have their own version of this form that member organizations are required to use.

Supporting Documentation:

  • PPE screening instruments used by the organization with their medical community reference(s).

Standard 1.3

Does the organization require a comprehensive medical and family history survey be completed by the athlete and parents as part of the PPE screening process?

Annotation:

Key areas to be included or addressed in the PPE:

  • Risk factors and symptoms of a cardiovascular disease (should be based on the current American Heart Association recommendations for pre-participation cardiovascular screening of competitive athletes).
  • Detection of any underlining musculoskeletal condition that might predispose an athlete to injury with special focus given to any areas that have been injured or undergone surgery.
  • History associated with heat acclimatization.
  • History of concussion.
  • Risk factors and symptoms of under-nutrition or obesity, and disordered eating.
  • Collect information that will assist in determining the mental health status of the athlete.

The medical and family history form should be completed by the parents prior to the PPE screening process.

Supporting Documentation:

  • Screening instruments used to survey medical and family history during the PPE screening process.

Standard 1.4

Does the organization require a medical physical examination be completed on each athlete by a QMP as part of the PPE screening process?

Annotation:

It should be noted that while it is ultimately the decision of the physician conducting the exam to provide a pre-participation physical exam he/she deems appropriate for medical clearance for sports participation, there is good evidence that following key areas to be included: vital signs (e.g. height, weight, and blood pressure); visual acuity testing; cardiovascular, neurologic, and general medical (e.g. pulmonary, abdominal, skin, genitalia [for males]) examination; and musculoskeletal examination. Additional examination may be warranted when the patient has a history of illness or injury reported on the health history portion of the PPE. An organization can encourage inclusion of these key areas by utilizing a PPE form that includes them.

Supporting Documentation:

  • Screening instrument used to do a general physical examination by a QMP.

Standard 1.5

Does the organization require a QMP to develop a management plan from areas of concern after the PPE screening process is completed with athlete and parent or guardian input?

Annotation:

Such a plan may involve additional screening or referral to the appropriate provider. Of particular concern are referral for appropriate tests and screenings for athletes who have a history of anemia, diabetes mellitus type 1 or 2, sickle cell trait, cardiovascular conditions or exercise-induced bronchospasms; or are female and have abnormal menstrual cycles. For athletes with such issues whose condition is currently being managed by a specialist, sharing of the providers recommendations for the management of the condition during athletic participation should be obtained and the care plan implemented.

Supporting Documentation:

  • Medical or injury management plan completed by the QMP, athlete and parent or guardian for any condition discovered during the PPE screening process that requires activity limitations, modifications or further testing/evaluation.

Standard 1.6

Does the organization include questions to assess the mental health status of the athlete during the PPE screening process along with a plan for referral and follow-up where appropriate?

Annotation:

The PPE is a great screening instrument to identify athletes at risk for many conditions, including mental health issues particularly those common to young athletes in this stage of life. The health history questions that include mental health will help the organization develop educational programs for coaches, parents and athletes. This information will help identify those at risk and establish action plans for at risk athletes with potential if left untreated could be catastrophic.

Supporting Documentation:

  • Questions or instruments utilized for screening athletes for psychological concerns.

  • Organizational plan for referring an athlete to the appropriate mental health professional and the how the follow-up process is completed.

Standard 1.7

Does the organization provide educational materials on selected health and safety issues to parents and athlete during the PPE screening process?

Annotation:

The PPE provides a good opportunity to educate athletes on the importance of proper hydration, nutrition, acclimatization, and the signs and symptoms of concussions, heat illness, sickle cell conditions and other injuries and illnesses. Such education materials can be attached to the forms required as a part of the pre-participation screening. These small steps can be helpful in prevention, recognition and care of these potentially life altering conditions.

Supporting Documentation:

  • Educational materials provided to athletes and parents during the PPE screening process that promotes health and safety issues.

Standard 1.8

Does the organization require written authorization from parent or guardian before sharing his/her child’s protected health and medical information with designated individuals such as coaches or other designated medical professionals?

Annotation:

Before the information gathered in the pre-participation screening can be shared with coaches and school officials, the parent or athlete must sign a consent form allowing the information to be released. The ability to share key medical information identified in the pre-participation screening that might predispose an athlete to injury/illness is an important component in providing appropriate medical care and an important strategy in preventing further injury or a catastrophic event.

Supporting Documentation:

  • Parental consent form that gives permission for the organization to share an athlete’s protected health and medical information with designated individuals such as a coach or other medical professionals.

  1. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations; Journal of Athletic Training 2013;48(4):546–553 https://www.nata.org/sites/default/files/preventing-sudden-death.pdf
  2. Advancing the Pre-participation Physical Evaluation: An ACSM and FIMS Joint Consensus Statement
  3. American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Academy of Pediatrics. PPE: Pre-participation Physical Evaluation. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010.  https://www.aap.org/en-us/about-the-aap/Councils/Council-on-Sports-Medicine-and-Fitness/Pages/Preparticipation-Physical-Evaluation.aspx
  4. BOC Guiding Principles for AT Policy and Procedures
  5. NATA Secondary School Value Model
  6. National Athletic Trainers' Association Position Statement: Preventing Sudden Death in Sports; Journal of Athletic Training 2012:47(1):96-118 http://natajournals.org/doi/pdf/10.4085/1062-6050-47.1.96
  7. National Athletic Trainers’ Association Position Statement: Pre-participation Physical Examinations and Disqualifying Conditions; Journal of Athletic Training 2014;49(1):102–120  https://www.ncaa.org/sites/default/files/NATA-Position-Statement-PPEs-and-Disqualifying-Conditions.pdf
  8. Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE.
  9. Screening for Sudden Cardiac Death Before Participation in High School and Collegiate Sports: American College of Preventive Medicine Position Statement on Preventive Practice
  10. Wingfield K, Matheson GO, Meeuwisse WH. Pre-participation evaluation: an evidence-based review. Clin J Sport Med. 2004;14(3):109–122. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3924614/
4: Conley KM, Bolin DJ, Carek PJ, Konin JG, Neal TL, Violette D. National Athletic Trainers' Association position statement: Preparticipation physical examinations and disqualifying conditions. J Athl Train. 2014;49(1):102-120.
5: Preparticipation Physical Evaluation Working Group. Preparticipation Physical Evaluation. Fourth ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
6: Casa DJ, Anderson SA, Baker L, et al. The inter-association task force for preventing sudden death in collegiate conditioning sessions: best practices recommendations. J Athl Train 2012;47(4):477-480.

Hill v. Slippery Rock University, 138 A.3d 673 (PA Super. Ct. 5/3/16), 332 Ed. Law Rep. 361

 

In September, 2011 Jack Hill, Jr. was participating in a late-night, high-intensity basketball practice for Division II Slippery Rock University when he complained of feeling ill, and collapsed to the floor, unresponsive.  Hill went into respiratory and cardiac arrest and passed away.  Hemoglobin electrophoresis disclosed Sickle Cell Trait (“SCT”).  The lawsuit alleged the negligence of Slippery Rock University, Slippery Rock University Health Center, and the nurse for not testing or requiring testing for SCT in pre-participation physical examinations.  Hill completed a pre-participation physical questionnaire, which asked if the student-athlete had Sickle Cell Anemia (“SCA”) or SCT.  Hill answered that he had neither SCA nor SCT, because he was unaware that he had SCT.

 

Although Division I schools required testing for SCT, Division II schools did not until 2012, and Division III schools until 2013.  Relying partly on the fact that the questionnaire asked about SCA or SCT, but did not test for the presence of either, the Superior Court of Pennsylvania stated, “the incomplete medical clearance may have led Mr. Hill to believe that he was physically fit for basketball.”  Finally, the Court held the lawsuit could proceed, as the plaintiffs sufficiently alleged that the medical and physical evaluations increased Mr. Hill’s risk of harm.

Standard
Standard

Practice, competition and athletic health care facilities as well as equipment used by athletes are safe and clean.

Narrative

Those engaged in organized athletic activities deserve the opportunity to play in a safe and hazard free environment. In the event of an injury or illness while participating in athletic activities, participants should be able to be cared for in an accessible, clean and well organized facility.7 This facility should promote privacy, care without risk of infection, and care with the designated QMP. Having a defined facility and hours of operation can also improve patient compliance and ensures a clean and safe environment to provide medical care.

Standard 2.1

Does the organization have written policies, procedures and protocols in place to ensure that practice, competition and athletic health care facilities as well as equipment used by athletes are cleaned and disinfected on a regular scheduled bases (e.g. Daily, weekly or monthly) in order to prevent the spread of infectious diseases?

Annotation:

Regular scheduled cleaning of athletic locker rooms and the athletic training facility can greatly reduce the chance of communicable skin conditions and illnesses. The organization’s policies and procedures should comply with State High School Activities Association or other governing organizations rules and guidelines. Policies should also follow current OSHA guidelines and current best practices.

Supporting Documentation:

  • Organizational policy, procedure and protocol statements on how to clean and disinfect practice, competition and athletic health care facilities to prevent the spread of infectious diseases.

  • Organizational policy, procedure and protocol statements on how to clean and disinfect equipment used by athletes to prevent the spread of infectious diseases.

  • Cleaning and disinfecting logs (dates, times and signatures) for both facilities and equipment.

  • At minimum, athletic training facilities should be cleaned daily, and locker rooms should be cleaned on a regular basis. (e.g. Daily, weekly and monthly.

Standard 2.2

Does the organization have an exposure control plan (ECP) to minimize occupational exposure to blood or other body fluids?

Annotation:

Proper handling, cleaning and disposal of all products and equipment that have been exposed to blood and other bodily fluids greatly reduces the chance of communicable conditions and illnesses. The organization’s ECP should comply with OSHA and any sponsoring organization (e.g. State High School Activities Association) guidelines. An ECP should be written specifically for each facility, reviewed and updated annually and readily available to all employees working directly with athletes.

Supporting Documentation:

  • ECP developed per OSHA guidelines.

Standard 2.3

Does the organization post guidelines and instructions for hand washing and hand sanitization?

Annotation:

Utilizing proper hand washing practices greatly reduces the chance of communicable conditions and illnesses. The organization should comply with OSHA and any sponsoring organization (e.g. State High School Activities Association) guidelines on proper hand washing and hand sanitization techniques. This practice has been shown to reduce infections for employees and their patients.

Supporting Documentation:

  • Posted guidelines and instructions for proper handwashing and hand sanitization.

  • Locations where hand sanitation and hand washing can occur.

Standard 2.4

Does the organization ensure locker and dressing rooms are cleaned and sanitized on a regular scheduled basis?

Annotation:

Regular scheduled cleaning of athletic locker and dressing rooms greatly reduces the chance of communicable skin conditions and illnesses. The organization should comply with OSHA and any sponsoring organization (e.g. State High School Activities Association) guidelines on proper athletic locker and dressing room cleaning and sanitation.

Supporting Documentation:

  • Organizational policy, procedure, and protocol statements on how to clean and disinfect locker and dressing rooms.

  • Cleaning and disinfecting logs (dates, times, and signatures) for locker and dressing rooms.

Standard 2.5

Does the organization ensure all athletic surfaces and equipment used by athletes are cleaned and sanitized on a regular basis (e.g. Daily, weekly and monthly?

Annotation:

The organization designates cleaning policies, procedures and protocols which outline frequency and personnel for appropriate cleaning of surfaces throughout the athletic department. This policy specifically addresses mats and other surfaces, both porous and non-porous, which come into contact with athletes and allow for transfer of contagious disease from one athlete to another.

Supporting Documentation:

  • Organizational policy, procedure, and protocol statements on how athletic surfaces and equipment used by athletes are cleaned and sanitized.

  • Cleaning and disinfecting logs (dates, times, and signatures) for athletic surfaces and equipment.

Standard 2.6

Does the organization ensure playing fields and courts are inspected for hazards before each use and on a regular basis?

Annotation:

Regular inspection of playing fields and courts for hazards and unsafe conditions will decrease the number of injuries seen by athletic teams. Taking just 5 minutes prior to the start of practices and workouts has the potential to significantly reduce the chance of injury to all participants.

Supporting Documentation:

  • Organizational policy, procedure, and protocol statements on how playing fields and courts are inspected before each event and on a regular basis.

  • Hazard inspection logs (dates, times, and signatures) for of playing fields and courts.

Standard 2.7

Does the organization provide a safe and clean area for the QMP to provide immediate treatment and care of injuries or illnesses?

Annotation:

A designated facility would provide a safe, secure, private and clean environment for a QMP to conduct do an evaluation as well as provide immediate treatment and care for injuries and illnesses.

Supporting Documentation:

  • A list of designated locations utilized by QMP to treat and care for injuries sustained during athletic events.

Standard 2.8

Does the organization ensure hydration equipment is cleaned and sanitized on a regular basis?

Annotation:

Regular scheduled cleaning and sanitizing of hydration equipment greatly reduces the chance of communicable conditions and illnesses. The organization should comply with OSHA and any sponsoring organization (e.g. State High School Activities Association) guidelines on proper sanitation of hydration equipment.

Supporting Documentation:

  • Organizational policy, procedure, and protocol statements on how hydration equipment is cleaned and sanitized on a regular basis.

  • Cleaning logs (dates, times, and signatures) for any equipment used to hydrate athletes.

  1. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations; Journal of Athletic Training 2013;48(4):546–553 Appropriate Medical Care for Secondary School-Age Athlete Consensus Statement
  2. BOC Facility standards document
  3. Guiding Principles for AT Policy and Procedures
  4. National Athletic Trainers’ Association Position Statement: Emergency Planning in Athletics; Journal of Athletic Training 2002;37(1):99–104
  5. NATA Official Statement on Communicable Diseases in Secondary School Sports
  6. NATA Official Statement on Community-Acquired MRSA Infections
  7. NATA Official Statement on Communicable and Infectious Diseases in Secondary School Sports
  8. Practice Analysis, 7th ed. BOC@2015
  9. NATA Secondary School Value Model
  10. NATA Position Improvement Guide
7: Board of Certification. BOC Facility Principles. In: Board of Certification, ed.: http://www.bocatc.org/system/document_versions/versions/42/original/boc-facility-principles-20170615.pdf?1497543426; 2015.

In Ausmus by Ausmus v. Board of Education of City of Chicago, 155 Ill.App.3d 705, 508 N.E. 2d 298 (Appellate Court of Illinois, First District, Fifth Division, 4/16/1987), the Court cited cases from various jurisdictions enunciating the legal requirement of providing safe facilities and equipment, as follows:

 

Gerrity v. Beatty (1978), 71 Ill.2d 47, 15 Ill.Dec. 639, 373 N.E.2d 1323 for negligence in failing to furnish safe athletic equipment fit for the purpose intended. See also Hadley v. Witt Unit School District No. 66 (1984), 123 Ill.App.3d 19, 78 Ill.Dec. 758, 462 N.E.2d 877 (where, in addition to other allegations, a complaint alleges that school district was negligent in providing hazardous equipment it should not be barred as a matter of law because the school district has a duty to provide safe equipment); Nielsen v. Community Unit School District No. 3 (1980), 90 Ill.App.3d 243, 45 Ill.Dec. 595, 412 N.E.2d 1177 (Supreme Court Rule 308 (87 Ill.2d R. 308), interlocutory appeal holding that plaintiff's complaint alleging negligence by the school district in furnishing defective and dangerous equipment in a high school science class was not barred as a matter of law); Griffis v. Board of Education District No. 122, Oak Lawn (1979), 72 Ill.App.3d 784, 29 Ill.Dec. 188, 391 N.E.2d 451 (a reversal of the dismissal of a negligence action against the school district, wherein the court stated, “[l]ike the court in Gerrity, we are not anxious to relieve school boards from liability for acts which do not clearly fall within the doctrine of educational immunity * * *”); and Thomas v. Chicago Board of Education (1978), 60 Ill.App.3d 729, 17 Ill.Dec. 865, 377 N.E.2d 55, rev'd on other grounds, 77 Ill.2d 165, 32 Ill.Dec. 308, 395 N.E.2d 538 (complaint that school board was negligent in furnishing ill-fitting and obsolete football equipment was sufficient to state a cause of action under the holding in Gerrity v. Beatty (1978), 71 Ill.2d 47, 15 Ill.Dec. 639, 373 N.E.2d 1323).

 

Ausmus by Ausmus v. Bd. of Educ. of City of Chicago, 155 Ill. App. 3d 705, 709–10, 508 N.E.2d 298, 300–01 (1987)

 

Clean Equipment

In Zaffarese v. Iona College, 63 A.D. 3d 727 (New York Supreme Court, Appellate Division, Second Department, 06/02/2009), the Court dismissed plaintiff’s allegation that athletic facilities are required to be maintained in such a manner as to be free from the MRSA bacteria.  The Court also dismissed plaintiff’s allegation that athletic training personnel have the duty to routinely screed for the presence of MRSA, holding that requiring athletic personnel to screen for the presence of MRSA “far exceed[s] any legally cognizable duty on the part of the defendant.”  However, the Court allowed plaintiff’s claim that the defendant had actual or constructive notice of the presence of MRSA and notwithstanding such notice, failed to take proper precautionary measures.  Thus, this case stands for the proposition that facilities are not required to be free of MRSA, and athletic personnel are not required to screen for MRSA, but when athletic personnel know or should be aware that MRSA actually exists in the facility, the suit may proceed.

Standard
Standard

Equipment worn by athletes is properly fitted and maintained while instructions to use safely and appropriately are provided.

Narrative

Equipment used by athletes as part of any sport should conform, at minimum, to National Operating Committee Standards on Athletic Equipment (NOCSAE) and the American Society for Testing and Materials (ASTM) guidelines even if the organization or participant provides the equipment.  If the participant is allowed to use personally owned equipment it is imperative that the organization ensure the equipment complies with all standards and guidelines including recertification. Requiring standards by NOCSAE and ASTM provide assurance that equipment meets minimal safety standards.  A review of case law shows that equipment that is not well maintained or that is improperly fitted can contribute to, if not cause, injury to participants. In addition, the use of equipment that has not been approved by the appropriate certifying body exposes the athlete to injury and the sponsoring entity to liability and negligence.

Standard 3.1

Does the organization require employees who fit athletes with standard athletic equipment to document their professional education and training from qualified providers?

Annotation:

The organization's policy and procedure manual outlines that only qualified personnel fit athletic equipment using manufacturer’s guidelines. The equipment fitting procedures should be updated on an annual basis after reviewing changes by the manufacturer and the addition of new equipment.

Supporting Documentation:

  • Education and training materials (manufactures guidelines and best practices) with objectives and assessment methods to demonstrate competency.
  • Log (name, date and signatures) of the education and training session(s) on how to fit athletes with standard athletic equipment.

Standard 3.2

Does the organization have written policies, procedures and protocols on how to recondition, maintain, clean, and sanitize athletic equipment issued to athletes?

Annotation:

The organization's policy and procedure manual outline athletic equipment recertification according to manufacturer’s guidelines. The organization's equipment procedures should be updated on an annual basis after reviewing changes by the manufacturer and the addition of new equipment. Documenting the procedures will ensure compliance with manufacturer’s guidelines and make sure that equipment is reconditioned, deemed safe and provides protection to all athletes who use the equipment.

Supporting Documentation:

  • Organizational policy, procedure and protocol statements on how to recondition, maintain, clean and sanitize all equipment issued to athletes.
  • List of equipment issued to athletes with manufacture(s) recertifying the equipment. Dates of original purchase and recertifying dates per manufacture’s recommendations.

Standard 3.3

Does the organization require personnel to supervise athletes at all times when using athletic equipment?

Annotation:

The organization does not allow athletes to participate in activities using athletic equipment when not directly supervised by competent personnel. The organization should comply with the sponsoring organization (e.g. State High School Activities Association) rules and guidelines on proper supervision of athletes when using athletic equipment. At a minimum, supervising personnel should have current training in CPR, first aid, AED, sport specific coaching techniques, coaching fundamentals and be familiar with the venue EAP.

Supporting Documentation:

  • List of personnel responsible for supervising athletes when using athletic equipment is on file and include records of compliance. Example of a record of compliance could include a signed statement form supervising personnel indicating they supervise athletes at all times when they are using athletic equipment.

Standard 3.4

Does the organization require coaches to demonstrate competency in sport specific coaching techniques while instructing athletes using issued equipment?

Annotation:

The organization needs to maintain up to date records of compliance with all coaching education requirements for all activities. It is important that these records include paid, unpaid and volunteer members of the coaching staff. These requirements can vary from state to state and year to year as well as organization to organization. For these reasons, it is the responsibility of the administration that the coaches are aware of their responsibilities. Records should be updated annually and kept on file based on legal requirements.

Supporting Documentation:

  • Log (name, date and signatures) of the education and training session(s) on coaching techniques while instructing athletes using issued athletic equipment.
  • Education and training materials with objectives and assessment methods to demonstrate competency. If an online course is utilized, a copy of course objectives and a coach’s course completion certificate directly related to the sport the coach is instructing technique using athletic equipment.
  • Log of annual coaching education from state/national training licensing/clinics.
  1. National Athletic Trainers’ Association Position Statement: Preventing and Managing Sport-Related Dental and Oral Injuries: Journal of Athletic Training 2016;51(10):821–839 http://natajournals.org/doi/pdf/10.4085/1062-6050-58.01
  2. National Athletic Trainers’ Association Position Statement: Head-Down Contact and Spearing in Tackle Football; Journal of Athletic Training 2004;39(1):101–111 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC385269/
  3. Benson BW, Hamilton GM, Meeuwisse WH, McCrory P, Dvorak J. Is protective equipment useful in preventing concussion? A systematic review of the literature. Br. J. Sports Med. 2009;43(Suppl 1):i56-i67. http://dx.doi.org/10.1136/bjsm.2009.058271    
  4. Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players; Sports Health. vol. 8 • no. 3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4981070/
  5. Knapik JJ, Marshall SW, Lee RB, et al. Mouthguards in sport activities history, physical properties and injury prevention effectiveness. Sports Med. 2007;37(2):117-144. https://doi.org/10.2165/00007256-200737020-00003
  6. Mascarenhas AK. Mouthguards reduce orofacial injury during sport activities, but may not reduce concussion. J. Evid. Based Dent. Pract. 2012;12(2):90-91. https://doi.org/10.1016/j.jebdp.2012.03.021
  7. Moyer RF, Birmingham TB, Bryant DM, al. e. Valgus Bracing for Knee Osteoarthritis: A Meta-analysis of Randomized Trials. Arthritis Care Res. 2014 https://onlinelibrary.wiley.com/doi/full/10.1002/acr.22472
3: Almquist J, Valovich McLeod TC, Cavanna A, et al. Summary statement: appropriate medical care for the secondary school-aged athlete. J Athl Train. 2008;43(4):416-427.

In Palmer v. Mount Vernon TP. High School Dist. 201, 662 N.E.2d 1260 (Illinois Supreme Court, 1/18/86), the Illinois set the duty of school districts regarding safe equipment, as follows:

 

A school district has a duty to furnish reasonably necessary safety equipment to protect students from reasonably foreseeable serious injury; the school district cannot discharge this duty by simply warning the students to purchase such equipment themselves. (Lynch, 82 Ill.2d at 434–35, 45 Ill.Dec. 96, 412 N.E.2d 447.)

 

A school district should not be permitted to avoid its obligation to provide appropriate safety equipment by the expedient of advising students that they should purchase such equipment at their own expense. As this court stated in Lynch, a student's ability to engage in a school athletic activity while wearing the appropriate safety equipment should not be dependent upon the student's financial ability to obtain such equipment. Lynch, 82 Ill.2d at 434–35, 45 Ill.Dec. 96, 412 N.E.2d 447.

 

For an example of how the law varies from state to state, see e.g. Allen v. Dover Co-Recreational Softball League, 807 A.2d 1274 (Supreme Court of New Hampshire, 9/30/02) in which the Supreme Court of New Hampshire ruled that a recreational softball league had no duty to provide helmets for softball players, and no duty to protect player against risk of errant throw striking her in the head; as compared to the case of Tolar, et al. v.  The Amateur Softball Association of America, et al; No. 48,880 3rd Judicial District Court Lincoln Parish, Louisiana, a case worked by the author’s firm, in which a Louisiana Court ruled that the identical claim of a widow (errant softball throw striking her husband in the head resulting in his death) could proceed to trial on claims that the Amateur Softball Association of America had a duty to provide helmets for softball players.

Standard
Standard

Protective materials and products used to prevent athletic injuries are safely are appropriately applied.

Narrative

Application of taping, wrapping, padding, splinting and bracing materials or equipment are common practices in the athletic setting and most often used prophylactically. Applying supportive materials or equipment to an athlete is used to restrict the motion of an injured joint, compress soft tissues to reduce swelling, support anatomical structures involved in the injury, serve as a splint or secure a splint, secure dressing or bandages, protect the injured joint from re-injury, or protect the injured tissues during the healing process. It is also common for a QMP to fabricate or modify prophylactic materials (e.g. foam, felt, rigid or semi-rigid plastics) and apply them safely and effectively to minimize the risk of injury or re-injury. Preventive and protective materials (e.g. athletic tape, casting, splints, felts, foams, pads) and special protective/correction equipment (e.g. braces, durable medical equipment, orthotics, mouth guards) should only be applied by a QMP that has the fundamental knowledge (e.g. anatomy, physiology, biomechanics, physics, chemistry) and skills to do so.

Standard 4.1

Does the organization have a QMP who safely and appropriately applies preventive taping, wrapping, padding, splints and braces to athletes in order to prevent injury or re-injury?

Annotation:

The organization requires that anyone who fits braces, applies tape or other appropriate interventions and modalities be members of the athletic health care team, as an athletic trainer. Using trained personnel for appropriate use of all protective braces, athletic tape and other supportive equipment is a necessity. Improper use and application puts the athletes at risk for further injury and prolonged recovery time.

Supporting Documentation:

  • Credentials (e.g. licensure, certification, regulation) of the QMP applying preventative taping, wrapping, padding, splints and braces to athletes to prevent injuries are current, verifiable, and documented.
  • Written guidelines indicating what, how, and under what circumstances protective materials should be applied safely to athletes to prevent injury or re-injury.

Standard 4.2

Does the organization have a QMP to safely and appropriately fabricate or modify protective materials and apply them to athletes in order to prevent injury?

Annotation:

The organization should require that anyone who fits braces, applies tape or other appropriate interventions and modalities be a member of the athletic health care team, such as an athletic trainer. This will ensure that these interventions are applied correctly, follow a standard of care and have been proven to reduce the chance of injury. The QMP is responsible for having knowledge of rules and standards that govern the selection and fitting of protective equipment for all activities.

Supporting Documentation:

  • Credentials (e.g. licensure, certification, registration) of the QMP applying preventative taping, wrapping, padding, splints and braces to athletes to prevent injuries are current, verifiable, and documented. If not a state licensed or nationally certified athletic trainer, then evidence of training should be verified and documented based on the specific type of protective material utilized.
  • Written guidelines indicating what, how and under what circumstances fabricated or modified protective equipment or supplies should be safely applied to athletes to prevent injury or re-injury.
  1. Beam JW. Orthopedic Taping, Wrapping, Bracing, & Padding. 3rd ed. Philadelphia: FA Davis; 2017
  2. Lewis, M., Wright, Barker, S. and Deer, R. Cramer’s Comprehensive Manual of Taping, Wrapping and Protective Devices, 5th ed., 2017, Sagamore-Venture Publishing.
  3. Best, R., Mauch, F., Bohl, C., Huth, J., and Bruggerman, P. Residual Mechanical Effectiveness of External Ankle Tape Before and After Competitive Professional Soccer Performance., 2014, 24(1): 51-57.
  4. Ankle Bracing is Effective for Primary and Secondary Prevention of Acute Ankle Injuries in Athletes: A Systematic Review and Meta-Analyses. Barelds, I. Van den Broek, A, Huisstede, B, Sports Med, 2018.   
  5. Collins NJ, Barton CJ, van Middelkoop M, et al 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017 Br J Sports Med 2018;52:1170-1178.
  6. Callaghan MJ, McKie S, Richardson P, al. e. Effects of patellar taping on brain activity during knee joint proprioception tests using functional magnetic resonance imaging. PhysTher. 2012;92(6):821-830
  7. Gabriner ML, Braun BA, Houston MN, al. e. The Effectiveness of Foot Orthotics on Improving Postural Control in Individuals With Chronic Ankle Instability: A Critically Appraised Topic. J Sport Rehabil. 2015
  8. Montalvo AM, Cara EL, Myer GD. Effect of kinesiology taping on pain in individuals with musculoskeletal injuries: Systematic review and meta-analysis. PhysSportsmed. 2014;42(2):48-57.
  9. Moyer RF, Birmingham TB, Bryant DM, al. e. Valgus Bracing for Knee Osteoarthritis: A Meta-analysis of Randomized Trials. Arthritis Care Res. 2014
  10. Yeo BK, Donanno DR. The effect of foot orthoses and in-shoe wedges during cycling: a systematic review. J Foot Ankle Res. 2014;7:31

 

8: Lam KC, Valier AR, Anderson BE, McLeod TC. Athletic Training Services During Daily Patient Encounters: A Report From the Athletic Training Practice-Based Research Network. J Athl Train. 2016;51(6):435-441.
9: Kaminski TW, Hertel J, Amendola N, et al. National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013;48(4):528-545.
10: Yeo BK, Bonanno DR. The effect of foot orthoses and in-shoe wedges during cycling: a systematic review. J Foot Ankle Res. 2014;7:31.

See for example section B. 2-3 below, 46 La. Admin. Code Pt XLV,  5705, as follows:

 

A.         The Activities of an Athletic Trainer--the practice of prevention, emergency management, and physical rehabilitation of injuries and sports-related conditions incurred by patient/athletes. In carrying out these functions, the athletic trainer shall use whatever physical modalities are prescribed by a team physician or consulting physician, or both. The results of these activities should be recorded.

B.         Practice of Prevention--shall include, but is not limited to the following:

. . . .

3.         working cooperatively with supervisors, coaches, and a team physician or consulting physician in the selection and fitting of protective athletic equipment for each athlete and constantly monitoring that equipment for safety; and

 

Standard
Standard

Athletic participation in a safe environment is ensured or activity is modified or canceled based on established environmental policies.

Narrative

Monitoring environmental conditions and modifying and/or cancelling activity that may pose a threat to the health, and safety of the athlete is critical for the prevention of sudden death in sport. Sponsoring organizations of athletics programs have a duty to develop, adopt and implement comprehensive best-practice policies for preseason heat acclimatization, outdoor participation in both warm and cold weather, lightning and air quality18 based on accepted evidence-based techniques. To enhance implementation and promote clear lines of communication, the policies should include the designation of a representative whose responsibility it is to monitor changing environmental conditions and to suspend or resume activity when conditions are safe. To optimize communication and ensure a uniform message to the athletes, key members of the sponsoring organization must be provided with and educated on all environmental modification and cancellation policies. The organization should pay close attention to the routine preventative measures that must be put in place and be aware of the potential catastrophic injury or illness that can occur when modifications are not closely monitored and followed.

Standard 5.1

Does the organization have written policy, procedure and protocol statements on activity progressions for heat acclimatization?

Annotation:

The environmental conditions policy should be located within the organization’s policy and procedures manual and should be signed off and approved by organizational representatives. The development of the organization’s heat acclimatization guidelines should be based on the NATA Preventing Sudden Death in Sports, the pre-season heat acclimatization guidelines, and the NATA Heat Illness Position Statement. Other members influenced by this policy (e.g. coaches, school safety officials, school administration, school nurses, and local emergency services) should be educated on this policy. It is recommended that at minimum the organizational representatives review this document annually to make changes consistent with local state and national standards.

Supporting Documentation:

  • Organizational, governing body, local or state agency policy, procedure and protocol statements on activity progressions for heat acclimatization.
  • Evidence of at minimum an annual review by AHCT of the heat acclimatization policy, procedures and protocols and any quality improvement measures taken to improve are documented. Non-compliance reports are included in the review process.

Standard 5.2

Does the organization have policy, procedure and protocol statements to modify or cancel athletic activity due to hot and humid weather?

Annotation:

The environmental conditions policy should be located within the organization’s policy and procedures manual and should be signed off and approved by the organizational representatives. The development of a wet-bulb globe temperature (WBGT) based practice/play guidelines should be based on the work to rest ratio and modification guidelines published in the NATA Heat Illness Position Statement or the American College of Sports Medicine (ACSM) and the region specific WBGT data or regional category as determined by Grundstein et al. Other members influenced by this policy (e.g. coaches, safety officials, administration, and local emergency services) should be educated on this policy. It is recommended that at minimum the organizational representatives review this document annually to make changes consistent with local state and national standards.

Supporting Documentation:

  • Organizational, governing body, local or state agency policy, procedure and protocol statements to modify or cancel outdoor athletic activity due to hot and humid weather.
  • Evidence of at minimum an annual review by AHCT of the of the policy, procedures and protocols to modify or cancel outdoor activity due to hot and humid weather and any quality improvement measures taken to improve are documented. Non-compliance reports are included in the review process.

Standard 5.3

Does the organization have a policy to modify or cancel outdoor athletic activity due to cold weather?

Annotation:

The environmental conditions policy should be located within the organization’s policy and procedures manual and should be signed off and approved by the organizational representatives. The development of the organization’s wind chill practice/play guidelines should be based on the wind chill chart and the risk for frostbite exposure table and appropriate clothing guidelines published in the NATA Environmental Cold Injury Position Statement. Other members influenced by this policy (e.g. coaches, safety officials, administration, nurses, and local emergency services) should be educated on this policy. It is recommended that at minimum the organizational representatives review this document annually to make changes consistent with local state and national standards.

Supporting Documentation:

  • Organizational, governing body, local or state agency policy, procedure and protocol statements to modify or cancel outdoor athletic activity due cold weather.
  • Evidence of at minimum an annual review by AHCT of the of the policy, procedures and protocols to modify or cancel outdoor activity due to cold weather and any quality improvement measures taken to improve are documented. Non-compliance reports are included in the review process.

Standard 5.4

Does the organization have a policy to modify or cancel outdoor athletic activity due to lightning?

Annotation:

The environmental conditions policy should be located within the organization’s policy and procedures manual and should be signed off and approved by the organizational representatives. The development of the organization’s lightning guidelines should be based on the best practice guidelines set forth in the NATA paper on Preventing Sudden Death and the NATA position statement on lightning safety for athletics and recreation. It should include slogans enforced by the National Weather Service that activity be cancelled when thunder is heard and identify safe and appropriate structures. Other members influenced by this policy (e.g. coaches, safety officials, administration, nurses, and local emergency services) should be educated on this policy. It is recommended that at minimum the organizational representatives review this document annually to make changes consistent with local state and national

Supporting Documentation:

  • Organizational, governing body, local or state agency policy, procedure and protocol statements to modify or cancel outdoor athletic activity due to lightning.
  • Evidence of at minimum an annual review by AHCT of the of the policy, procedures and protocols to modify or cancel outdoor activity due to lighting and any quality improvement measures taken to improve are documented. Non-compliance reports are included in the review process.

Standard 5.5

Does the organization have a policy to modify or cancel outdoor athletic activity due to poor air quality?

Annotation:

The environmental conditions policy should be located within the organization’s policy and procedures manual and should be signed off and approved by the organizational representatives. The development of the organization’s air quality practice/play guidelines should be based on the United States Environmental Protection Agency(USEPA) air quality index air quality index (AQI) flag system and your local AQI can be checked on www.airnow.gov. Other members influenced by this policy (e.g. coaches, safety officials, administration, nurses, and local emergency services) should be educated on this policy. It is recommended that at minimum the organizational representatives review this document annually to make changes consistent with local state and national standards.

Supporting Documentation:

  • Organizational, governing body, local or state agency policy, procedure and protocol statements to modify or cancel outdoor athletic activity due to poor air quality.
  • Evidence of at minimum an annual review by AHCT of the of the policy, procedures and protocols to modify or cancel outdoor activity due to poor air quality and any quality improvement measures taken to improve are documented. Non-compliance reports are included in the review process.

Standard 5.6

Does the organization designate an individual to monitor the outdoor weather environment and make activity modifications for each athletic event?

Annotation:

The environmental conditions policies should be located within the organization’s policy and procedures manual and should be signed off and approved by the organizational representatives. The development of all environmental modification/cancellation guidelines should be based on the best practice evidence outlined within this document. Each policy should identify an individual who is responsible for executing/implementing each policy and gives that individual the authority to act to protect all individuals from the environmental threat. Other members influenced by this policy (e.g. coaches, school safety officials, school administration, school nurses, and local emergency services) should be educated on this policy. It is recommended that at minimum the organizational representatives review this document annually to make changes consistent with local state and national standards.

Supporting Documentation:

  • Designated weather monitors listed for each event and/or year per sport and venue with signature and date.

Standard 5.7

Does the organization educate and train all stakeholders on environmental policies, procedures, and protocols on an annual basis?

Annotation:

The environmental conditions policies should be located within the organization’s policy and procedures manual and should be signed off and approved by the organizational representatives. The development of all environmental modification/cancellation guidelines should be based on the best practice evidence outlined within this document. Each policy should be disseminated to all other members influenced by this policy. It is recommended that at minimum the organizational representatives review this document annually to make changes consistent with local state and national standards.

Supporting Documentation:

  • Signature page of the annual education and training of all stakeholders involved with implementing environmental policies, procedures, and protocols.
  • Education and training materials with objective and assessment methods to demonstrate competency.
  1. Armstrong et al ACSM Position Stand EHI during training and competition 2007
  2. Cappaert et al NATA Position Statement Environmental Cold Injuries  2008
  3. Casa et al IATF for Prevention of Sudden Death in Secondary School Athletics Programs 2013
  4. Casa et al Preseason Heat Acclimatization  Guidelines for Secondary School Athletics 2009
  5. Castellani et al ACSM Position Stand: Prevention of Cold Injuries During Exercise 2006
  6. Gratz J Lightning safety and large stadiums 2006
  7. Grundstein et al Regional Safety Thresholds For Athletics in the US 2014
  8. KSI Webpage Wet Bulb Globe Temperature Monitoring
  9. National Athletic Trainers’ Association Position Statement: Lightning Safety for Athletics and Recreation; Journal of Athletic Training 2013;48(2):258–270
  10. US EPA Technical Assistance for Reporting of Daily Air Quality the AQI 2016
6: Casa DJ, Anderson SA, Baker L, et al. The inter-association task force for preventing sudden death in collegiate conditioning sessions: best practices recommendations. J Athl Train 2012;47(4):477-480.
11: Casa DJ, Guskiewicz KM, Anderson SA, et al. National athletic trainers’ association position statement: Preventing sudden death in sports. Journal of athletic training. 2011;47(1):1-24.
12: Binkley HM, Beckett J, Casa DJ, Kleiner DM, Plummer PE. National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses. J Athl Train. 2002;37(3):329-343.
13: Kerr ZY, Marshall SW, Comstock RD, Casa DJ. Implementing exertional heat illness prevention strategies in US high school football. Med Sci Sports Exerc. 2014;46(1):124-130.
14: Cappaert TA, Stone JA, Castellani JW, et al. National Athletic Trainers' Association position statement: environmental cold injuries. J Athl Train. 2008;43(6):640-658.
15: American College of Sports M, Armstrong LE, Casa DJ, et al. American College of Sports Medicine position stand. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39(3):556-572.
16: Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine position stand: prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006;38(11):2012-2029.
17: Walsh KM, Bennett B, Cooper MA, Holle RL, Kithil R, Lopez RE. National Athletic Trainers' Association position statement: lightning safety for athletics and recreation. Journal of Athletic Training. 2000;35(4):471-477.
18: United States Environmental Protection Agency. Technical Assistance Document for the Reporting of Daily Air Quality – the Air Quality Index (AQI). https://www3epagov/airnow/aqi-technical-assistance-document-may2016pdf. 2016.
19: Casa DJ, Almquist J, Anderson SA, et al. The inter-association task force for preventing sudden death in secondary school athletics programs: best-practices recommendations. J Athl Train. 2013;48(4):546-553.

In Pichardo v. North Patchogue Medford Youth Athletic Association, Inc., 569 N.Y.S. 2d 186 (New York Supreme Court, Appellate Division, Second Department, 4/29/91), 172 A.D.2d 814, the New York Supreme Court dismissed the lawsuit of a participant in a summer league baseball game who was struck by lightning and killed.  The Court found that the player was not under inherent compulsion to play, and thus league officials were not negligent in allowing the game to continue when threatening weather became apparent. 

 

In Porter v. Grant County Board of Education, 219 W.Va. 282 (6/16/2006), 633 S.E.2d 38, the West Virginia Supreme Court ruled that the school board was not negligent in failing to cancel an athletic event due to snow and ice, despite the fact that academic classes were cancelled countywide, when the plaintiff fell on snow and ice on school grounds on the way to the athletic event.

 

In the author’s opinion, Pichardo and Porter reflect the efforts of national lobbying to cloak States, political subdivisions, and insurance companies with “immunity” (see e.g. Governmental Tort Claims and Insurance Reform Act) and deny individuals access to courtrooms and our justice system.  As some states have been successful in limiting the efforts of insurance companies to push their tort reform agenda through state legislatures, these case results cannot be taken to infer that schools will escape liability for failure to monitor or cancel athletic events.

Standard
Standard

Education and counseling is provided for athletes on nutrition, hydration and dietary supplementation.

Narrative

Sports nutrition is a key factor in an athlete’s growth, development, and performance. Sponsoring organizations of athletic programs have a responsibility to provide a safe environment including, scientifically based information regarding nutrition, hydration, and supplements. Adolescents need education and counseling to make sound nutritional decisions in an age where fad diets and performance enhancement products are prevalent and marketed to their specific demographic. Members of the AHCT should be well versed in proper sports nutrition for the adolescent and have a basic knowledge of proper nutrition and eating habits and have access to a professional nutritionist or dietitian. Organizations should establish components of a comprehensive sports nutritional support system, based on current scientific facts, and should include specifics regarding healthy nutritional habits, appropriate hydration prior to, during, and after activity and supplement use. Lastly, athletes who participate in sports that use weight classification systems may be at higher risk for disordered eating and unsafe weight gain or loss practices. Organizations need to educate and monitor athletes in these sports using recommended practices for monitoring and aiding in weight management.

Standard 6.1

Does the organization provide a QMP that educates and counsels athletes on how to meet their dietary goals and unique nutritional needs?

Annotation:

The nutritional needs for each athlete vary, depending on gender, age, body composition, training regimen, and daily activities. All athletes should have a basic understanding of their personal nutritional goals and how to select an eating strategy to meet those goals. Basic nutrition is important for growth, health, scholastic achievement, energy, and improving sports performance. The organization should have access to individuals trained in nutrition education and counseling to assist athletes in meeting their nutritional goals. These individuals may include, but are not limited to, an athletic trainer, registered dietitian, physician, director of food service, nurse, counselor, administrator, strength and conditioning specialist or, coach with appropriate training. The organization should ensure that these individuals know their limitations when counseling a minor on their nutritional and weight management goals and always include parental awareness and participation. Individuals in the organization that are involved in nutrition education and counseling of athletes should communicate with each other on a regular basis especially on nutrition education initiatives within the organization. Nutrition education should be available to athletes in a variety of formats (e.g. posters, flyers, presentations, handouts, brochures, appropriate digital media, and guest speakers) and guide them on how to develop a healthy eating strategy to meet their goals. In addition, information should be available to parents and athletes on how to seek professional nutritional counseling within the organization or identified community resources.

Supporting Documentation:

  • Credentials (e.g. licensure, registration or certification) of the QMP educating and counseling athletes on how to meet their dietary goals and unique nutritional needs are current, verifiable, and documented.
  • List of educational materials and resources provided to athletes and parents on how athletes can meet their dietary goals and unique nutritional needs and evidence of how it is communicated to athletes and parents is available.

Standard 6.2

Does the organization provide a QMP that educates and counsel athletes on how to stay properly hydrated utilizing the parameters of a hydration protocol?

Annotation:

A lack of adequate fluid replacement (hypohydration) and excessive intake (hyperhydration) can compromise athletic performance and increase health risks. During physical activity, athletes need access to water to prevent hypohydration, but must be aware of the risks of overdrinking and exercise-associated hyponatremia (EAH) caused by excessive consumption of fluids (including sports drinks). The organization should establish a hydration protocol for athletes, including a rehydration strategy that considers the athlete’s sweat rate, sport dynamics (e.g., rest breaks, fluid access), environmental factors, acclimatization state, exercise duration, exercise intensity, and individual preferences. Individuals overseeing athletic activity should monitor hydration and signs/symptoms of dehydration or overhydration. Implementing a hydration protocol for athletes will only succeed if athletes, coaches, athletic trainers, and team physicians realize the importance of maintaining proper hydration status and the steps required to accomplish this goal. Hydration education should be available to athletes in a variety of formats (e.g. posters, flyers, presentations, handouts, brochures, and appropriate digital media) and guide them on how to develop a hydration plan to meet their health and performance goals.

Supporting Documentation:

  • Credentials (e.g. licensure, certification) of the QMP educating and counseling athletes on how to stay properly hydrated utilizing the parameters of a hydration protocol are current, verifiable, and documented.
  • Hydration protocol should address these parameters:
    • WBGT
    • Sweat Rate
    • Acclimatized
    • Length of Activity
    • Intensity
    • Properly pre-hydrated
    • Individual container
    • Type of beverage
    • Assess hydration status
    • Available breaks
    • Amount given
    • End hydration status
    • Hydrated body weight
  • List of educational materials and resources provided to athletes and parents on how athletes should stay properly hydrated and evidence of how it is communicated to athletes and parents is available.

Standard 6.3

Does the organization provide a QMP that educates and counsels athletes on the safety and efficacy of dietary supplements?

Annotation:

To achieve improved performance and overall health, athletes should be educated on diet modification and proper nutrition before considering dietary supplements. When an athlete is considering use of a dietary supplement, several questions should be asked and investigated: is it safe, is it legal, and is it effective? Since supplements are not regulated by the Federal Drug Administration (FDA), the organization has the responsibility to educate athletes regarding the efficacy, safety, and legal issues associated with the use of supplements. Supplement education should be available to athletes in a variety of formats (e.g. posters, flyers, presentations, handouts, brochures, appropriate digital media, and guest speakers). In addition, information should be available to parents and athletes on how to seek professional guidance and referral within the organization or identified community resources on supplement efficacy, safety and legal issues. Referral to registered dietitians or other professionals with expertise in nutrition and supplement use should be considered to assist athletes and parents in making safe decisions.

Supporting Documentation:

  • Credentials (e.g. licensure, certification) of the QMP educating and counseling athletes on the safety and efficacy of dietary supplements are current, verifiable, and documented.
  • List of educational materials and resources provided to athletes and parents on the safety and efficacy of dietary supplements.
  • Resource guide on how athletes can access specialized counseling services (e.g. dietitian, sports dietitian) on the safety and efficacy of dietary supplements and evidence of communication to athletes and parents is documented.

Standard 6.4

Does the organization have a policy, procedures and protocols for the assessment and management of weight classification athletes?

Annotation:

Unsafe weight management practices can compromise athletic performance and negatively affect health. Athletes often attempt to lose weight by not eating, limiting caloric or specific nutrients from the diet, engaging in pathogenic weight control behaviors, and restricting fluids. If the organization sponsors sports that classify athletes by weight (e.g. youth football, boxing, rowing, wrestling, crew) the organization should have a plan to assess and provide support for athletes engaged in these sports. Best practices for weight management should be followed. Body composition assessments when required should be done in the most scientifically appropriate manner possible and follow current guidelines. Reasonable and individualized weight and body composition goals should be identified by appropriately trained health care personnel (e.g., athletic trainers, registered dietitians, physicians). All personnel should follow current guidelines that support safe and effective weight loss and weight management practices and techniques. A safe and healthy dietary plan that supplies sufficient energy and nutrients should be maintained throughout the year and athletes should refrain from taking dietary or other nutritional supplements without guidance from appropriately trained health care professionals and parent awareness and approval.

Supporting Documentation:

  • Management plan that addresses the assessment, education, and management of athletes participating in sports that require weight classifications.  Athletes in weight classification sports should have individual monitoring plans with assessments at least once per month in the off-season and at regular intervals in-season, not to exceed once per week, to monitor for weight fluctuations.
  • Individual athlete’s weight management plan is provided to athletes and parents and how it is communicated is evident.
  1. American Dietetic Association, Dietitians of Canada, American College of Sports Medicine, Rodriguez NR, Di Marco NM, Langley S. American College of Sports Medicine position stand: nutrition and athletic performance. Med Sci Sports Exerc. 2009;41(3):709–731.
  2. Berning J, Manore MM, Meyer NL, eds. Nutrition and athletic performance before, during and after exercise: adapting the joint position statement into practical guidelines. Barrington, IL: Gatorade Sports Science Institute; 2010.
  3. Bonci CM, Bonci LJ, Granger LR, et al. National Athletic Trainers’ Association position statement: preventing, detecting, and managing disordered eating in athletes. J Athl Train. 2008;43(1):80–108.
  4. https://www.nfhs.org/media/1014751/nfhs_smac_hydration_position_statement_october_2014.pdf 
  5. https://www.nfhs.org/media/1015652/dietary-supplements-position-statement-2015.pdf
  6. International Olympic Committee Consensus Statement on Youth Athletic Development
  7. National Athletic Trainers' Association Position Statement: Safe Weight Loss and Maintenance Practices in Sport and Exercise; Journal of Athletic Training 2011:46(3):322-336
  8. National Athletic Trainers’ Association Position Statement: Anabolic-Androgenic Steroids; Journal of Athletic Training 2012;47(5):567–588
  9. National Athletic Trainers’ Association Position Statement: Evaluation of Dietary Supplements for Performance Nutrition; Journal of Athletic Training 2013;48(1):124–136
  10. Selected Issues for Nutrition and the Athlete: a Team Physician Consensus Statement
22: Casa DJ, Armstrong LE, Hillman SK, et al. National Athletic Trainers' Association Position Statement: fluid replacement for athletes. J Ath Train. 2000;25(2):212-224.
23: Bonci CM, Bonci LJ, Granger LR, et al. National athletic trainers' association position statement: preventing, detecting, and managing disordered eating in athletes. J Athl Train. 2008;43(1):80-108.
24: Turocy PS, DePalma BF, Horswill CA, et al. National Athletic Trainers' Association position statement: safe weight loss and maintenance practices in sport and exercise. J Athl Train. 2011;46(3):322-336.
25: Buell JL, Franks R, Ransone J, et al. National Athletic Trainers' Association position statement: evaluation of dietary supplements for performance nutrition. J Athl Train. 2013;48(1):124-136.

See for example See for example section B. 2-3 below, 46 La. Admin. Code Pt XLV,  5705, as follows:

A.         The Activities of an Athletic Trainer--the practice of prevention, emergency management, and physical rehabilitation of injuries and sports-related conditions incurred by patient/athletes. In carrying out these functions, the athletic trainer shall use whatever physical modalities are prescribed by a team physician or consulting physician, or both. The results of these activities should be recorded.

B.         Practice of Prevention--shall include, but is not limited to the following:

            ….

4.         counseling and advising supervisors, coaches, and patient/athletes on physical conditioning and training, such as diet, flexibility, rest, and reconditioning.

 

46 La. Admin. Code Pt XLV,  5705

Standard
Standard

Wellness programs promote a safe progression of physical fitness and improve long-term health across an athlete’s lifespan.

Narrative

Participation in sports and physical activity provides the opportunity for many physical and psychosocial benefits to student athletes. In addition, it provides an opportunity for on-site qualified medical providers and others in the sports medicine community to serve as leaders in aiding adolescents to benefit from a physically active lifestyle and the benefits of sports participation. Several professional organizations have developed statements to ensure the safe development of young individuals into healthy, active adults in a manner that promotes general physical fitness and sampling in a variety of sports. To help achieve optimal wellness and sports performance, organizations should ensure they have the ability to design safe and effective training programs that include athlete monitoring. The organization should ensure whole person health care through the collection of patient-report outcomes to guide injury or illness management. Attention should be paid to behavioral health concerns, including the abuse of prescription and over the counter medications, supplements, and performing enhancing substances.

Standard 7.1

Does the organization provide a QMP who uses appropriate assessment instruments, equipment and protocols to measure fitness, body composition, posture, flexibility, muscular strength, power, speed, agility and endurance?

Annotation:

For the welfare and well-being of youth, long-term training prescription should be complimented with appropriate monitoring and assessment tools. In the absence of careful monitoring, youth may be at an increased risk of excessively demanding training loads, insufficient opportunities for rest and regeneration, or contraindicating training methods. Administering tests to assess for movement dysfunction and readiness for physical activity is an important aspect of overall wellness, sports performance, and injury prevention. A QMP should use monitoring and assessment tools to determine training for effectiveness, to aid in program design, determining mechanisms of adaptation, to instill motivation within the athlete, or to obtain further knowledge and understanding about the physiological demands of a sport or physical activity. Although a wealth of monitoring and assessment tools are available for practitioners, the number and sophistication of tools included within any long-term athletic development program should be dependent on the efficacy and relevance of the tests, their associated measurement error, the availability of time, equipment, and facilities, and the degree of the practitioner’s expertise. Importantly, practitioners should select tests that are accurate, reliable, valid, and provide meaningful data. It is essential that practitioners adhere to the ethics of pediatric testing, clearly explain all protocols to both athletes and parents, and collect both parental consent and participant assent before any testing.

Supporting Documentation:

  • Credentials (e.g. licensure, certification) of the QMP assessing athlete’s fitness and body composition are current, verifiable and documented.
  • Organizational policy, procedure and protocol statements on how to conduct fitness (posture, flexibility, muscular strength, power, speed, agility and endurance) and body composition assessments. List of test administered and what is done with the results of the assessments.
  • Parental consent form that gives permission for the QMP to conduct fitness and body composition tests.

Standard 7.2

Does the organization provide a QMP who designs and implements safe and effective flexibility, strength training and cardiovascular conditioning programs that include expected outcomes, safety precautions, hazard inspections and instruction/supervision of proper techniques?

Annotation:

The organization should adopt a progressive, individualized, and integrated approach to the programming of flexibility, strength training and cardiovascular conditioning programs and those programs be implemented and supervised by qualified professionals. All equipment should be specific for the developmental level and size of the individuals to ensure appropriate techniques are implemented. Specific emphasis should be made to ensure equipment is size appropriate and athletes should progress from body weight exercises to free weights, and eventually to a full exercise program. Equipment and facilities should be inspected, regularly cleaned and free of hazards to ensure a safe training environment. Young athletes should be supervised by an adult with training in pediatric strength and conditioning, such as an athletic trainer or strength coach (with credentialing), to ensure proper techniques and spotting. A staged approach using criteria from the National Strength and Conditioning Association’s (NSCA) long-term athlete development program can assist with programmatic development.

Supporting Documentation:

  • Written guidelines for the implementation of fitness programs that include expected outcomes, safety precautions, hazard inspections and expected techniques for safe participation. Utilizing of any patient-report outcome measures of health-related quality of life should use the framework of a disablement model. A QMP possesses (a) an appropriate understanding of pediatric exercise science, exercise prescription, technique evaluation, and testing methods, (b) relevant coaching experience and a strong pedagogical background, and (c) a recognized strength and conditioning qualification, for example, the Certified Strength and Conditioning Specialist (CSCS) certification or a Certified Athletic Trainer (AT).
  • Safety precautions and rules clearly posted in all training and workout facilities.

Standard 7.3

Does the organization provide a QMP who develops and implements wellness strategies to mitigate the risk for long-term health conditions across an athlete’s lifespan?

Annotation:

The organization should focus on whole-person health care and wellness (e.g., social, emotional, spiritual, environmental, occupational, intellectual, physical) for all athletes. General principles of health maintenance including skin care, dental hygiene, sanitation, immunizations, diet, rest, exercise, avoidance of infectious and contagious diseases, and weight control are just a few areas of focus. The goal is to create an environment of wellness within the athletic setting in order to prevent or limit the development of lifespan conditions like osteoarthritis, cardiovascular disease, neurocognitive disease, obesity and diabetes. Wellness strategies could include but not be limited to (e.g. posters, flyers, presentations, handouts, brochures, appropriate digital media, and guest speakers) in order to educate and promote general wellness to all athletes. In addition, information should be available to parents and athletes on how to seek professional guidance and referral within the organization or identified community resources for any general health or wellness condition. This may also include addressing care through a patient-centered approach, utilizing patient-report outcome measures of health-related quality of life using the framework of a disablement model.

Supporting Documentation:

  • Wellness materials or programs for athletes should be listed and evidence of communication to athletes and parents documented.  Utilizing of any patient-report outcome measures of health-related quality of life should use the framework of a disablement model.
  • Resource guide on how athletes can access specialized health care services is provided and evidence of how it is communicated to athletes and parents is available.

Standard 7.4

Does the organization provide a QMP who educates athletes on the effects, consequences, and risks of alcohol, performance-enhancing drugs (PED), over-the-counter (OTC) medications, prescription medications, and recreational drugs?

Annotation:

Athletes often take performance enhancing (PED), recreational, over-the-counter (OTC) and prescription drugs to improve their physical performance, physique, body image, gain an additional performance edge, health benefit or for pleasure, by modifying their perceptions, feelings, and emotions. Conversely, when abused, may lead to negative health effects on the central nervous, cardiovascular, hepatic, reproductive, musculoskeletal, immune, integumentary, and nephritic systems and possibly others. Athletes can be vulnerable to misinformation in terms of the safety, legality, and efficacy of these products. The organization has the responsibility to educate athletes on the dangers of these products. In addition, the organization has the responsibility of educating the professionals working with athletes on how to identify substance use and abuse and make proper referrals to qualified professionals.

Supporting Documentation:

  • Substance use and abuse education materials and programs for athletes should be listed and evidence of communication to athletes and parents documented. Utilizing of any patient-report outcome measures of health-related quality of life should use the framework of a disablement model.
  • Resource guide (e.g. flyers, posters, brochures) on how athletes can access specialized health care services relative to substance abuse or misuse is provided and evidence of how it is communicated to athletes and parents is available.
  1. https://journals.lww.com/nsca-jscr/Abstract/2016/06000/National_Strength_and_Conditioning_Association.1.aspx 
  2. AAP policy statement strength training in children: http://pediatrics.aappublications.org/content/121/4/835
  3. DiFiori, JP, Benjamin, HJ, Brenner, J, Gregory, A, Jayanthi, N, Landry, GL, and Luke, A. Overuse injuries and burnout in youth sports: A position statement from the American Medical Society for Sports Medicine. Clin J Sport Med 24: 3–20, 2014.
  4. https://www.nsca.com/long-term_athletic_development_position_statement/
  5. Lloyd, RS, Oliver, JL, Meyers, RW, Moody, JA, and Stone, MH. Long-term athletic development and its application to youth weightlifting. Strength Cond J 34: 55–66, 2012.
  6. NATA statement dietary supplements: http://natajournals.org/doi/pdf/10.4085/1062-6050-48.1.16?code=nata-site
  7. Oliver, JL, Brady, A, and Lloyd, RS. Well-being of youth athletes. In: Strength and Conditioning for Young Athletes: Science and Application. R.S. Lloyd and J.L. Oliver, eds. Oxon: Routledge, 2013. pp. 213–225. https://www.routledge.com/Strength-and-Conditioning-for-Young-Athletes-Science-and-application/Lloyd-Oliver/p/book/9780415694896
  8. Position statement on youth resistance training: the 2014 International Consensus https://www.ncbi.nlm.nih.gov/pubmed/24055781
  9. The Team Physician and Strength and Conditioning of Athletes for Sports: A Consensus Statement    (https://www.sportsmed.org/AOSSMIMIS/members/downloads/education/ConsensusStatements/Conditioning.pdf
26: Stovitz SD. The pyramid of sports medicine and child health. British journal of sports medicine. 2010;44(1):4-7.
27: Lloyd RS, Cronin JB, Faigenbaum AD, et al. National Strength and Conditioning Association Position Statement on Long-Term Athletic Development. J Strength Cond Res. 2016;30(6):1491-1509.
28: Valovich McLeod TC, Decoster LC, Loud KJ, et al. National Athletic Trainers' Association position statement: prevention of pediatric overuse injuries. J Athl Train. 2011;46(2):206-220.
29: Brenner JS, Council On Sports M, Fitness. Sports Specialization and Intensive Training in Young Athletes. Pediatrics. 2016;138(3).
30: Snyder AR, Parsons JT, Valovich McLeod TC, Curtis Bay R, Michener LA, Sauers EL. Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part I: disablement models. J Athl Train. 2008;43(4):428-436.
31: Valovich McLeod TC, Snyder AR, Parsons JT, Curtis Bay R, Michener LA, Sauers EL. Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part II: clinical outcomes assessment. J Athl Train. 2008;43(4):437-445.
32: Neal TL, Diamond AB, Goldman S, et al. Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement. J Athl Train. 2015;50(3):231-249.

In perhaps the most extensive opinion seen regarding the duty of an institution to care for its patient/athletes, the Commonwealth Court of Pennsylvania provided the following lengthy discussion in a lawsuit against the Pennsylvania Interscholastic Athletic Association (PIAA).  Although the case arose due to high school patients/athletes who suffered long term, severe concussion symptoms, the court requires an overarching duty of care with regard to the long-term health as highlighted:

 

[The] PIAA was in a superior position to know of student-athletes' concussion-injury rates and the long-term medical consequences. [The] PIAA and its members breached the duty to provide a ‘safe environment’ and by failing to provide long-term and/or complete medical or financial aid for student-athletes who suffered concussion(s) while playing PIAA sports.

[The] PIAA's conduct is particularly egregious in light of the fact that its policies and procedures—or lack thereof—leave student athletes like Plaintiffs ... inadequately protected from sustaining, monitoring, and recovering from brain injuries at a particularly early and vulnerable point in their lives. Unlike professional athletes, who at least have resources to pay for medical care necessitated by head injuries caused during their professional careers, youth athletes range in age from 12–18. For such PIAA student athletes, including Plaintiffs ... these injuries may have long-term, debilitating effects, ranging from an inability to finish their education, to loss of memory, physical impairments in hearing and sight, depression, and early-onset dementia.

 

[The] PIAA was aware of the health risks associated with blows producing sub-concussive and concussive results and was further aware that members of the PIAA athlete population were at significant risk of developing brain damage and cognitive decline as a result. Despite its knowledge and controlling role in governing member schools, coaches, trainers, and student player conduct, the PIAA failed to timely and adequately impose safety regulations and post-concussion protocols governing this health and safety problem.

Standard
Standard

Comprehensive athletic emergency action plan (EAP) is established and integrated with local EMS per athletic venue.

Narrative

Participation in athletic activities can carry an inherent risk of serious injury. As such, members of the AHCT, along with coaches and administrators, need to be prepared for emergency situations through the development and implementation of a comprehensive Emergency Action Plan (EAP). The need for an EAP has been well documented in literature and supported in case law. The sponsoring organization should have a comprehensive EAP to ensure that the appropriate care can be provided in a timely manner, even in the absence of on-site medical providers. The development of an EAP however, requires the input of the QMPs, administrators of the sponsoring organization, legal counsel or risk managers, coaches, and facility managers, along with parents and members the local emergency response community. The EAP should be specific to each venue (practice/game), reviewed annually with all involved personnel, should have legal approval prior to implementation, and include a mechanism for a responsible adult to advocate on behalf of an injured minor in situations when parents or guardians are not present.

Standard 8.1

Does your organization have a venue specific athletic emergency action plan (EAP) with input from internal and external partners that goes through a formal review and approval process?

Annotation:

The development of the EAP should include input from internal and external partners, (e.g. local EMS agencies, public safety officials, on-site first responders, administrators, athletic trainers, nurses, parents, team and consulting physicians.) An organization should develop a formal EAP Review Committee that provides input on the development and refinement of the EAP, at least on an annual basis. The EAP Review Committee is a sub-committee of the AHCT. The EAP should be developed to accommodate each specific venue utilized for athletic activity at that organization. The initial venue-specific EAP should go through a review and approval process that includes physician oversight and administration approval.

Supporting Documentation:

  • List of all AHCT and EAP Review Committee members by name, title and credentials in the EAP.
  • Signature page (signature, date, and time) in the EAP with name, credentials, title and date of the individuals giving institution oversight and approval (e.g. physician, administration, legal counsel, and risk management).
  • After initial EAP approval, documentation of any EAP edits along with organization oversight and approval should be evident.

Standard 8.2

Does the organization have a designated coordinator (QMP) responsible for developing, training, implementing, distributing and at minimum an annual review of the EAP?

Annotation:

At least one person in the organization should coordinate the implementation of the EAP. An EAP coordinator allows the organization to streamline the management of all activities related to EAP implementation. All communication, documentation, and training should be managed by a designated coordinator. The coordinator is often the chair of the EAP Review Committee and a QMP. At minimum the EAP should undergo an annual review lead by the designated coordinator and members of the EAP Review Committee.

Supporting Documentation:

  • Credentials (e.g. licensure, certification) of the QMP serving as the designated coordinator are current, verifiable, and documented.
  • Name, credentials, title and duties of the designated EAP coordinator (QMP) should be evident in the EAP.

Standard 8.3

Does the organization have a list of emergency personnel along with their described roles in the EAP?

Annotation:

An EAP should include a list of all emergency personnel (e.g. physician, athletic trainer, coach, local EMS) responsible for its implementation with their roles and responsibilities clearly identified and described. At minimum, all emergency personnel should maintain current certification/training in CPR/AED, first aid, prevention of disease transmission as well as education in EAP implementation.

Supporting Documentation:

  • List of emergency personnel with name, title and credentials (e.g. licensure, certification) in the EAP.
  • Scope of care for all emergency personnel with their roles and responsibilities clearly described during an emergency incident.
  • Credentials (e.g. licensure, certification) of all emergency personnel listed in the EAP are current, verifiable, and documented.

Standard 8.4

Does the organization have a list of emergency equipment and its location per venue in the EAP?

Annotation:

Emergency equipment is a key part of an effective EAP and should be listed by location for each venue. Equipment should be clearly identified by the scope of care for emergency personnel. Not all emergency personnel may be trained to use all of the emergency equipment, therefore, physician oversight along with local, state and federal laws will dictate the scope of care and related equipment to be included in an EAP. Equipment readiness is also a key factor in an effective EAP. A designated individual with a prescribed schedule should be responsible for ensuring that all emergency equipment is ready for use at all times.

Supporting Documentation:

  • List of available equipment should be listed by venue and scope of care per emergency personnel in the EAP. Appendix B provides an example listingof emergency equipment.
  • A checklist for equipment readiness, which person is responsible and their schedule for checking are in the EAP.

Standard 8.5

Does the organization have emergency care protocols outlined and developed in the EAP?

Annotation:

An important part of an emergency health care plan is the development, practice, and implementation of emergency care protocols, which defines the scope of care to be implemented within the EAP. Physician oversight guides this process and gives each emergency personnel member of the EAP guidance and direction on how to perform each of the emergency management skills listed in the EAP's scope of care. Emergency care protocols should reflect evidence-based standards of practice and should be practiced, reviewed, and rehearsed at least once a year, if not more often. State medical practice acts and local medical direction should impact the exact protocols that should be followed within each organization’s EAP. The protocols should be clearly outlined and described so that emergency personnel have a clear understanding on how to implement them during an emergency incident.

Supporting Documentation:

  • Emergency care protocols listed, outlined and described. Common emergency care protocols may include, but are not limited to: CPR, AED, BVM, airway obstruction techniques, severe bleeding (tourniquet application), emergency medication (e.g. MDI, epi pen, aspirin), oxygen (non-rebreather & nasal cannula) and airway adjuncts (oral and nasal), cervical collar, spinal restriction techniques, cold water immersion, splints, vital signs, blood glucose, pulse oximetry, and auscultation of lung sounds.
  • Logs of training are documented (signatures, date, and time) and available for annual review by EAP Review Committee.

Standard 8.6

Does the organization have guidelines to test and utilize internal and external communication systems in the EAP?

Annotation:

Prior to an event or practice emergency personnel members should ensure they can properly communicate internally with other members identified in the EAP using specified communication systems (e.g. walkie talkies, cell phones). Systems should be tested and in place prior to each practice or event. Each team member should ensure they can receive cell phone service from their location on or off campus in order to access local EMS services if needed as well as the location of available fixed telephones lines. In addition, guidelines on how to communicate internally and externally should be clearly outlined. Communication with EMS is critical and guidelines on how to properly do so should be integrated into the EAP.

Supporting Documentation:

  • Guidelines to describe which communication systems will be utilized per event or venue. Guidelines should include who will test the communication systems, when it should be tested and how often? A primary and backup communication system should be in place.

Standard 8.7

Does the organization ensure the designated EAP coordinator (QMP) provides education and training on the implementation of the EAP?

Annotation:

The EAP should be rehearsed at minimum annually although more frequent reviews and rehearsals might be necessary. The rehearsal or training should be conducted with all parties involved in the EAP (e.g. emergency personnel, local EMS, hospital staff). Rehearsal could include scenario-based training and/or practice sessions integrated with local EMS agencies. All rehearsal or training sessions should be documented and available for the EAP review committee.

Supporting Documentation:

  • Logs of training are documented (signatures, date, and time) and available at minimum annual review by the EAP Review Committee.
  • Education and training materials with objectives and assessment methods to demonstrate competency are developed. If an online course is utilized in any aspect of training, a copy of course objectives and course completion certificate is available.

Standard 8.8

Does the organization require documentation of all emergency personnel listed in the EAP including all coaches and each maintains a current CPR/AED certification?

Annotation:

An important component of an effective EAP is the education of emergency personnel as listed in the EAP including all coaches on CPR/AED per emergency cardiac care (ECC) guidelines. 

ECC guidelines include:

  • Adult CPR
  • Pediatric CPR
  • Second Rescuer CPR
  • AED
  • Airway Obstruction
  • Barrier Devices (e.g. pocket mask, bag valve mask)

Acceptable ECC providers are those adhering to the most current International Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care. Examples of courses that provide the above requirements include, but are not limited to:

  • CPR/AED for the Professional Rescuer through the American Red Cross
  • BLS Health Care Provider through the American Red Cross
  • BLS Health Care Provider through the American Heart Association

ECC certification must be current each year. Depending on the ECC provider, ECC recertification may not be required each year. To be compliant with Occupational Safety and Health Administration (OSHA) standards, hands-on instruction and evaluation are required for certification.

Supporting Documentation:

  • List of certified personnel with dates of CPR/AED certification in the EAP.
  • Copy of each individual's CPR/AED certification card kept on file and available for at minimum annual review by the AHCT and the EAP Review Committee.

Standard 8.9

Does the organization require documentation of all emergency personnel listed in the EAP including all coaches maintain a minimum of current first aid certification?

Annotation:

An important component of an effective EAP is the education of emergency personnel as listed in the EAP including all coaches to a minimum of a first aid certification. The certification should adhere to the American Heart Association (AHA) and American Red Cross (ARC) jointly co-authored First Aid guidelines (current guidelines, 2010, 2015). Recommended courses that meet these guidelines include:

  1. AHA Heartsaver First Aid
  2. ARC First Aid
  3. National Federation of High School Sports (NFHS), First Aid, Health and Safety

Supporting Documentation:

  • List of certified personnel with dates of First Aid certification in the EAP.
  • Copy of each individual's First Aid certification card kept on file and available for review by the EAP Review Committee.

Standard 8.10

Does the organization ensure that the designated EAP coordinator (QMP) communicates, posts, and shares the EAP to all appropriate stakeholders?

Annotation:

Key aspects of an organization’s EAP such as venue access routes with directions, facility address, EMS tier services, area hospital and specialized medical services, global positioning for Air Med, and emergency contact information should be shared with opposing team's medical staff and coaches prior to an event (e.g. Medical Time Out). The EAP should also be posted in visible areas such dugouts, locker rooms, near telephones etc. The EAP should be communicated and shared with all internal and external partners (local EMS agencies, public safety officials, on-site first responders, administrators, athletic trainers, nurses, parents, team and consulting physicians). Does your organization participate in a pre-event medical meeting with officials and representatives from both teams to ensure there is an EAP and personnel are available should an emergency occur?

Supporting Documentation:

  • All relevant information of the EAP to be shared with opposing team’s staff prior to an event is clearly described.
  • All relevant information (e.g. phone numbers, physical address, medical resources) should be posted in each venue.

Standard 8.11

Does the organization have a quality improvement process that includes a review by the EAP Review Committee for each incident that requires the activation of the EAP?

Annotation:

Anytime the EAP is activated with an emergency incident, the organization should conduct a post-incident review and debriefing process. The process should include any documentation related to the event, as well as a documented review process of the EAP implementation. All documentation of the EAP implementation for each incident should be included in an EAP Review Committee meeting for feedback and refinement through established quality improvement processes.

Supporting Documentation:

  • Incident report review document and a log for each incident under review is in the EAP.
  • At minimum an annual review by EAP Review Committee after each incident and measures taken if any to improve the EAP is documented

Standard 8.12

Does the organization have guidelines on who will advocate for a minor in the absence of their parent or guardian in the event of an emergency incident in the EAP?

Annotation:

Accessing medical history and emergency contact information on minor athletes during an emergency incident in the absence of their parents is an important part of emergency preparedness. Collecting and accessing this information can vary from institution to institution but the method of quick and easy access is fundamental to providing quality emergency health care. In addition, the EAP should provide guidelines on who will be the athlete's legal advocate until the athlete's parents arrive. The decision on who will be the advocate for the athlete should be decided prior to each event or practice.

Supporting Documentation:

  • Guidelines on how athlete emergency information (major medical and parent or guardian contact information) is easily accessible (e.g. emergency pocket cards, binders, online) to all identified emergency personnel.
  • Guidelines on who will be the legal advocate for the athlete upon their parents or guardians absence if transported to a hospital are located in the EAP.
  1. Athletic Training Services: An Overview of Skills and Services Performed by Certified Athletic Trainers
  2. BOC Facility Principles, 2013.
  3. https://www.nata.org/sites/default/files/white-paper-Emergency-Action-Plan.pdf
  4. Inter-Association Task Force Recommendations on Emergency Preparedness and Management of Sudden Cardiac Arrest in High School and College Athletic Programs: A Consensus Statement; Journal of Athletic Training 2007;42(1):143–158
  5. NATA Secondary School Value Model
  6. The Inter-Association Task Force Document on Emergency Health and Safety: Best-Practice Recommendations for Youth Sports Leagues 2017:52(4): 384-400.
  7. National Athletic Trainers' Association Position Statement: Preventing Sudden Death in Sports; Journal of Athletic Training 2012:47(1):96-118
  8. National Athletic Trainers’ Association Official Statement on Athletic Health Care Provider “Time Outs” Before Athletic Events, 2012
  9. National Athletic Trainers’ Association Position Statement: Acute Management of the Cervical Spine–Injured Athlete; Journal of Athletic Training 2009;44(3):306–331
  10. National Athletic Trainers’ Association Position Statement: Emergency Planning in Athletics; Journal of Athletic Training 2002;37(1):99–104
19: Casa DJ, Almquist J, Anderson SA, et al. The inter-association task force for preventing sudden death in secondary school athletics programs: best-practices recommendations. J Athl Train. 2013;48(4):546-553.
33: Andersen J, Courson RW, Kleiner DM, McLoda TA. National Athletic Trainers' Association Position Statement: Emergency Planning in Athletics. J Athl Train. 2002;37(1):99-104.
34: Wasilko SM, Lisle DK. Automated External Defibrillators and Emergency Planning for Sudden Cardiac Arrest in Vermont High Schools: A Rural State's Perspective. Sports Health. 2013;5(6):548-552.
35: Cotton D, Wilde TJ. Sports Law. Iowa: Kendall Hunt; 1997.

See, for example, in Kentucky KRS § 160.445 “Sports safety course required for high school athletics coaches; training and education on symptoms, treatment, and risks of concussion; venue-specific emergency action plans” as follows:

 

  1. (a) The Kentucky Board of Education or organization or agency designated by the board to manage interscholastic athletics shall require each interscholastic coach to complete a sports safety course consisting of training on how to prevent common injuries. The content of the course shall include but not be limited to emergency planning, heat and cold illnesses, emergency recognition, head injuries including concussions, neck injuries, facial injuries, and principles of first aid. The course shall also be focused on safety education and shall not include coaching principles

(b) The state board or its agency shall:

 

. . . .

 

  1. Be responsible for ensuring that an approved course is taught by qualified professionals who shall either be athletic trainers, registered nurses, physicians, or physician's assistants licensed to practice in Kentucky;
Standard
Standard

On-site prevention, recognition, evaluation and immediate care of athletic injuries and illnesses are provided with appropriate medical referrals.

Narrative

On site recognition, evaluation, treatment and appropriate referral should be available, if warranted, to all participants of all activities. Each athletic injury needs to have immediate appropriate treatment and care to prevent further risk as well as promote proper healing while reducing the risk of re-injury. It is in the best interest of the athlete that the person making medical decisions be a QMP. This allows for sound medical judgment that is not based on the players importance or the significance of the contest but based on the signs and symptoms that the athlete shares and are presented to the QMP. Relationships established by a QMP with other health care professionals will assist in referral to the appropriate medical provider.

Standard 9.1

Does the organization designate that a QMP is onsite based on the risk and rate of injury and illness?

Annotation:

The organization is responsible for coordinating the level of care for all athletes. It will save the organizations’ and parents’ money on emergency department visits, unnecessary physician appointments and provide a consistent level of care. This in turn should translate into reduced liability of the organization, decreased health insurance claims and a safer, more positive experience for all athletes. Furthermore, a QMP will be making decisions about the health and safety of athletes or injuries and illnesses of athletes.

Supporting Documentation:

  • List of any QMP responsible for on-site recognition, evaluation and immediate treatment of injuries and illnesses (medical care and coverage).
  • Medical care and coverage policy should be based on risk of injuries and illnesses within all offered sports of the organization.
  • Calendar of QMP assignments are published (e.g. event, facility, sport) with evidence of administration approval.

Standard 9.2

Does the organization have a management plan with a focus on sudden death in sports that includes prevention, recognition, evaluation, assessment, referral, treatment, and immediate care of asthma, catastrophic brain injury, cervical spine injuries, diabetes, exertional heat stroke, exertional hyponatremia, exertional sickling, head down contact in football, lightning injuries and sudden cardiac arrest?

Annotation:

Cardiac conditions, head injuries, neck injuries, exertional heat stroke, exertional sickling, asthma, and other factors (e.g., lightning, diabetes) are the most common causes of death in athletes. For the athlete to have the best possible outcome, correct and prompt care is critical; delaying care until the ambulance arrives may result in permanent disability or death. A management plan is intended to assist in the development and implementation of policies, procedures and protocols to manage the risk of death and dying in sports. The annual self-evaluation process and plan for improvement is intended to be a guide to develop and refine organizational policies, procedures and protocols needed to prevent and manage sudden death in sports.

Supporting Documentation:

  • Comprehensive sudden death in sports management plan should include a self-evaluation process identifying the strengths and weaknesses of the organization and a specific plan for improvement.
  • List of the AHCT members along with their titles, credentials and specialty areas contributing in the self-evaluation process and plan for improvement.
  • At minimum an annual review by AHCT of the sudden death in sports management plan and any quality improvement measures taken to improve the plan are documented.   

Standard 9.3

Does the organization ensure that a QMP tracks and reports on injury and illness trends and includes strategies to mitigate modifiable risk factors based on the data?

Annotation:

Appropriate documentation of injuries and illness by the QMP sets the foundation for tracking trends and developing injury prevention strategies. The organization should have guidelines in place for medical documentation that would enable the organization to use current best practices to identify injury prevention strategies. Collaboration could include all members of the AHCT with the addition of physical fitness experts and dieticians. Injury prevention standards and education should be shared with all coaches, parents and athletes on a regular basis.

Supporting Documentation:

  • At minimum an annual report to AHCT of injuries and illnesses sustained by athletes that include strategies to prevent injuries and illnesses based on data trends.

Standard 9.4

Does the organization have guidelines for when, where, how and by whom athletic injuries and illness should be referred to outside medical providers?

Annotation:

The organization should have a plan and resources to direct athletes to the proper health care provider to ensure that the injury or illness is properly evaluated, diagnosed and treated. Proper referral for injuries can help prevent further injury and potentially decrease recovery time. Collaborative patient care using a team approach allows for the provision of a patient-centered approach to health care.

Supporting Documentation:

  • Directory listing of appropriate medical specialties and their contact information is available.
  • Guidelines on when, how and by whom athletic injuries and illnesses should be referred to other medical providers.

Standard 9.5

Does the organization have a QMP that develops accommodation plans for athletes with congenital and acquired abnormalities, disabilities and diseases in order to allow safe participate in athletic activities?

Annotation:

The organization should have a plan for accommodation and modifying activity under the direction of a QMP for all persons regardless of common congenital and acquired abnormalities, disabilities or disease. Emphasis should be placed on allowing all athletes to be active in activities in order to improve self-esteem, confidence, overall health and well-being.

Supporting Documentation:

  • Individualized management plans should be outlined and described for accommodations per local, state or national guidelines.
  • Evidence that individualized management plans have medical direction and parent or guardian approval.

Standard 9.6

Does the organization have a policy on decision-making authority of all QMP and coaches that includes the roles and responsibilities of each in determining participation status of athletic activity for any health reason?

Annotation:

Designating a QMP to oversee the medical services within your organization will provide consistency and improve safety for all student athletes. A variety of models exist for sports medicine administration. Regardless of the model used, responsibilities should be clearly delineated, particularly in cases where the QMP may have responsibilities other than medical care (e.g. administrative and academic). This delineation should also define the supervisory relationships for each area of responsibility so that potential role conflicts are minimized and medical care is not sacrificed. Personnel charged with supervising the QMPs various roles must recognize the roles and responsibilities they share with the QMPs. Deliberate attention must be given to avoid providing conflicting directions to the QMP. All involved should realize that quality medical care must supersede other responsibilities in times of conflict. Clear delineation of responsibilities and supervisory roles should be documented in advance of employment and shared routinely as part of the hiring and selection process, with subsequent documentation becoming part of the employment contract.

Supporting Documentation:

  • Documentation of clearly delineated responsibilities and roles for decision making authority for any health or medical reason is in place specifically for all QMPs and coaches.
  1. Interassociation Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges.  Journal of Athletic Training .  2014;49(1):128-137 https://www.nata.org/sites/default/files/SportsMedicineManagement.pdf
  2. National Athletic Trainers’ Association Position Statement: Prevention of Pediatric Overuse Injuries; Journal of Athletic Training 2011;46(2):206–220 https://www.ncbi.nlm.nih.gov/pubmed/21391806
  3. Osteoarthritis Action Alliance’s Consensus Opinion for Best Practice Features of Lower Limb Injury Prevention Programs https://oaaction.unc.edu/files/2018/08/FINAL_Consensus-Opinion_LLI-Prevention-Programs-Trojian-kra1.pdf
  4. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs:  Best-Practices Recommendations.  Journal of Athletic Training.  2013;48(4):546-553 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718357/
  5. National Athletic Trainers’ Association Position Statement: Management of Sport Concussion; Journal of Athletic Training 2014;49(2):245–265 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975780/
  6. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 https://bjsm.bmj.com/content/51/11/838
  7. Preventing Sudden Death in Sport, 2012 (pdf)
  8. Emergency Planning in Athletics, 2002 (pdf)
  9. Emergency Preparedness and Management of SCA in High School and College Programs, 2007
  10. National Athletic Trainers’ Association Position Statement: Acute Management of the Cervical Spine–Injured Athlete; Journal of Athletic Training 2009;44(3):306–331 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681208/
36: American Medical Association. H-470.995 Athletic (Sports) Medicine 1998:Accessed July 17, 2016. https://www.nata.org/sites/default/files/ama_support.pdf
37: Courson R, Goldenberg M, Adams KG, et al. Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges. J Athl Train. 2014;49(1):128-137.

In Williams v. Board of Supervisors of the University of Louisiana System, 135 So.3d 1352 (La. 2 Cir. 2/26/14) the Louisiana Second Circuit Court of Appeal upheld a jury verdict of nearly $2,000,000.00 to the minor child of Henry White, III a Grambling basketball player who collapsed while on an outdoor team run, and later died as a result of heat stroke complications.  No athletic trainers were present during the run.  When Mr. White collapsed, it took 15 – 20 minutes for a “trainer” to respond.  The “trainer” who finally arrived had failed her boards and was uncertified.  Expert testimony provided by Douglas Casa, Ph.D. established that Mr. White would have survived had the “trainer” been on-site, recognized the signs of heat stroke, and immersed White in an ice bath within 10 – 15 minutes.  The jury found Grambling and its staff 100% negligent, and the Louisiana Second Circuit Court of Appeals upheld the verdict. 

Standard
Standard

On-site therapeutic intervention (pre-, post-, and non-surgical conditions) outcomes are optimized by developing, evaluating and updating a plan of care for athletes.

Narrative

Rehabilitation is the process to regain full function following injury and involves restoring strength, flexibility, endurance and power. It is achieved through various exercises and drills. Rehabilitation is as important as treatment following an injury. The main goal is to return an injured player to training or competition without putting the individual or others at undue risk of injury or illness. This process is criteria driven (not time driven). Certain levels of physical ability, and criteria, must be achieved before further progression through the stages. The process of rehabilitation should start as early as possible after an injury and form a continuum with other therapeutic interventions. It can also start before or immediately after surgery when an injury requires a surgical intervention. The rehabilitation plan must take into account the fact that the objective of the athlete is to return to the same activity, level of competence, and environment in which the injury occurred. Functional capacity after rehabilitation should be the same, if not better, then before injury.

Standard 10.1

Does the organization have a QMP responsible for implementing on-site physical rehabilitation and reconditioning programs during designated times for athletes?

Annotation:

Providing rehabilitation and reconditioning services on-site can tremendously reduce lost instructional time for the student athlete. Decrease in absenteeism can also result in retention of state funding for public schools as well as result in increased classroom learning. It can also reduce lost work time by parents driving their child to physician and rehabilitation appointments.  The goal is to aid recovery to optimal function by a QMP by using appropriate procedures to provide therapeutic exercises, devices and manual techniques for athletes. Physicians and parents appreciate the fact that someone is on staff, and on site that will have contact with the injured athlete on a daily basis. QMP for rehabilitation and reconditioning programs possesses an adequate knowledge on interventions (for pre-, post-, and non-surgical conditions) designed to address an athlete’s identified impairments, activity limitations, and participation restrictions.

Interventions include but are not limited to:

  • Therapeutic and corrective exercise                                                                                              
  • Joint mobilization
  • Soft tissue techniques
  • Movement training (including gait training)
  • Motor control / proprioceptive activities
  • Task-specific functional training
  • Therapeutic modalities
  • Home care to include self-treatment and exercise
  • Cardiovascular training
  • Pharmacological agents and pharmokinetic agents

Supporting Documentation:

  • Guidelines for the implementation of rehabilitation and reconditioning programs that include expected outcomes, safety precautions and hazard inspections.
  • Credentials (e.g. licensure, certification) of all QMPs providing on-site physical rehabilitation and reconditioning programs are current, verifiable, and documented.
  • Schedule of QMP availability for rehabilitation and reconditioning is published for all stakeholders.

Standard 10.2

Does the organization provide adequate facilities to implement physical rehabilitation and reconditioning programs on-site for athletes?

Annotation:

While initial start-up costs for the athletic health care facility can be a substantial expense for providing on-site rehabilitation and reconditioning programs it actually can reduce the cost of athletic health care for student athletes. Costs can be reduced by providing athletic health care services free-of-charge on-site that previously were done for a fee off campus. The size of the athletic health care facility should be proportional to the number of athletes being serviced with a suggested minimum of 1000 sq. ft. At a minimum the following are areas to implement in regards to rehabilitation and reconditioning services:

  • Locked file cabinet for medical records
  • Office space available for medical personnel to have private conversations
  • Space allocation for rehabilitation and reconditioning equipment and exercises
  • Storage for exercise equipment and consumable supplies, (approx. 50sq. ft. min.)
  • Telephone access
  • Computer and Internet access
  • Office furniture and supplies (desk, printer)
  • Equal access for male and female athletes
  • Separate environmental control system for facility
  • OSHA complaint receptacle (with OSHA-complaint removal plan)
  • Access to water (hot, cold, drain). 
  • Electrical outlets and GFI protection
  • Ice machine
  • Hydrotherapy area

Supporting Documentation:

  • Floor plan for the athletic training facility should include but not be limited to: office space, equal access entrances for boys and girls, hydrotherapy area with access to cold/hot water, ice machine area and designated space for rehabilitation and reconditioning exercises and equipment.

Standard 10.3

Does the organization provide adequate therapeutic modalities and rehabilitation equipment to facilitate physical rehabilitation and reconditioning programs for athletes?

Annotation:

Adequate facilities are just one part of the equation for providing quality on-site athletic health care. The organization should supply the facility with the necessary equipment to provide a comprehensive rehabilitation and reconditioning program.   Common therapeutic interventions that require equipment include but not limited to:

  • Therapeutic modalities or exercise equipment to:
    • limit edema.
    • reduce pain.
    • restore joint mobility.
    • restore muscle extensibility.
    • restore neuromuscular function.
  • Exercise equipment to:
    • improve strength, endurance, speed, and power.
    • improve balance, neuromuscular control, coordination, and agility.
    • improve gait, posture, and body mechanics.
    • improve cardiorespiratory fitness.
    • restore functional exercises (e.g. sports- or activity-specific).
  • Exercise equipment to help implement a home-based program.

The organization should also identify manufacturer, institutional, state, and/or federal standards that influence approval, operation, inspection, maintenance and safe application of therapeutic modalities and rehabilitation equipment.

Supporting Documentation:

  • Inventory list of all common therapeutic modalities and exercise equipment owned by the organization that is available for rehabilitation and reconditioning.

Standard 10.4

Does the organization provide up to date and pertinent educational materials to optimize treatment, rehabilitation, and reconditioning outcomes?

Annotation:

A broad range of interventions, methods, techniques, equipment, activities using body movement are incorporated into a rehabilitation and reconditioning program. These interventions are designed to enhance function by identifying, remediating, and preventing impairments and activity restrictions (functional limitations) to maximize participation. Rehabilitation and reconditioning educational materials should be available to athletes and parents in a variety of formats (e.g. posters, flyers, presentations, handouts, brochures, appropriate digital media). In addition, information should be available to parents and athletes on how to seek professional guidance and referral within the organization or identified community rehabilitation resources. The organization should also use the International Classification of Functioning, Disability, and Health (ICF) framework for delivery of and communication about patient care to athletes, coaches and parents.30

Supporting Documentation:

  • List of rehabilitation and reconditioning educational materials or programs provided by the organization or QMP and evidence of communication to athletes and parents documented.
  • Treatment, rehabilitation and reconditioning outcome measures are outlined and described with an emphasis on steps and strategies for quality improvement.
  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1322922/
  2. https://www.nata.org/sites/default/files/secondary-school-position-proposal-guide.pdf
  3. https://www.nata.org/sites/default/files/secondary-school-position-improvement-guide.pdf
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293517/
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4741258/
  6. https://www.nata.org/sites/default/files/SportsMedicineManagement.pdf
  7. http://www.csm-institute.com/BOC_Facility_Safety.pdf
  8. https://www.nata.org/sites/default/files/best-practice-guidelines-for-athletic-training-documentation.pdf
  9. https://www.nfhs.org/articles/the-value-of-the-secondary-school-athletic-trainer/
  10. https://ksi.uconn.edu/nata-atlas/
  11. https://www.nata.org/professional-interests/job-settings/secondary-school
  12. https://www.athleticbusiness.com/high-school/understanding-the-roll-of-athletic-trainers-in-high-school-athletics.html
30: Snyder AR, Parsons JT, Valovich McLeod TC, Curtis Bay R, Michener LA, Sauers EL. Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part I: disablement models. J Athl Train. 2008;43(4):428-436.
38: Houglum PH. Therapeutic Exercise for Athletic Injuries. Champaign: Human Kinetics; 2001.

Many states require physician direction/supervision of licensed athletic trainers, but not all.  Athletic Trainers and organizations should be aware of state laws and requirements and ensure compliance.  State law takes precedence over documents produced by non-regulatory organizations such as NATA and State Athletic Training Associations.

 

In states where state law requires physician direction see, for example N.J. Admin. Code § 13:35-10.5  “Plan of care guidelines”

 

 (a) Every licensed athletic trainer shall enter into a written plan of care with a supervising physician, which sets forth the practices in which a licensed athletic trainer shall engage in while providing physical treatment modalities to athletes in an interscholastic, intercollegiate, intramural or professional athletic setting and all athletic training services, including physical treatment modalities, provided outside of these settings. The plan of care shall be signed and dated by both the licensed athletic trainer and the supervising physician.

(b) A licensed athletic trainer and his or her supervising physician shall meet at least once a year to review the plan of care and revise it as necessary.

(c) A supervising physician shall be available, either in person or through voice communication, whenever a licensed athletic trainer is practicing athletic training.

(d) A licensed athletic trainer shall make a plan of care available to the Board upon request.

Standard
Standard

Comprehensive management plan for at-risk athletes with psychological concerns.

Narrative

As with other medical emergencies, illness and injuries, organizations should plan and be prepare to address psychosocial conditions. These conditions include but are not limited to anxiety, depression, effects of concussion; substance, alcohol, and physical abuse; eating disorders, bullying and hazing; and effects of ADHD, teen suicide. Members of the AHCT should rehearse and be capable of identifying and appropriately referring such conditions. Organizations should identify local experts with specialty training in working with at-risk athletes who can serve as resources for referral as needed. Members with this specialty training should be included on the AHCT.

Standard 11.1

Does the organization provide education and training for the AHCT, coaches and staff members (e.g. nurse, counselor, and administrator) on the identification and referral of athletes with psychological concerns?

Annotation:

The education should include, but not limited to, anxiety, depression, effects of concussion; substance, alcohol, and physical abuse; eating disorders, bullying and hazing; and effects of ADHD, teen suicide.

Supporting Documentation:

  • Education and training materials with objectives and assessment methods to demonstrate competency are developed. If an online course is utilized in any aspect of training, a copy of course objectives and course completion certificate is available.
  • Logs of training are documented (signatures, date, time) and available for annual review by the AHCT.

Standard 11.2

Does the organization have a QMP responsible for providing education on stress-management strategies and referral services to help athletes better manage stressors and improve their ability to function?

Annotation:

Education and an understanding of techniques to manage stress are an important component of wellness and mental health. Athletes are more likely to utilize services provides if they are aware of their options. The organization should be aware that many student athletes define themselves and their identities through participation. When that identity is threatened the athlete may face psychological issues. Triggers can include performance issues, career-ending injuries, relationship challenges, academic pressure, an eating disorder or bullying or hazing, among other concerns.32,39As we find mental illnesses increasingly being reported in adolescents and young adults, it is important that psychological and mental health issues are considered by the organization.32This age group is identified as having higher incidence rates for sleep disturbances, loss of appetite, mood disturbances, short tempers, decreased interest in training and competition, decreased self-confidence, and inability to concentrate. Demands and stressors on the student athlete can be physical (e.g. physical conditioning, injuries, environmental conditions), mental (e.g. game strategy, meeting coaches’ expectations, attention from media and fellow students, time spent in sport, community-service requirements, and less personal and family time), and academic (e.g. classes, study time, projects, papers, examinations, attaining and maintaining the required grade point average to remain on the team, and earning and maintaining a collegiate or academic scholarship). These stressors place numerous expectations on a student athlete. Because the organization is certain to encounter athletes with these issues a collaborative team of sports medicine professionals and mental health experts should be identified.

Supporting Documentation:

  • Education and training materials with objectives and assessment methods to demonstrate competency are developed. If an online course is utilized in any aspect of training, a copy of course objectives and course completion certificate is available.
  • Logs of training are documented (signatures, date, and time) and available for annual review by the AHCT.
  • Resource guide on how athletes can access specialized counseling services to deal with stress management and life balance issues and evidence of communication to athletes and parents is documented.

Standard 11.3

Does the organization have a plan for recognition and referral of an athlete with psychological concerns to the appropriate mental health professional?

Annotation:

The team approach for recognition should include involvement of professionals such as the athletic trainer, nurse, counselor, and physician. The plan for recognition and referral should be shared with all relevant team members. The appropriate mental health professionals for referral might be clinical psychologist, psychiatrist, or a licensed social worker. The plan should address education on mental disorders in young adults, stressors unique to being a student athlete at the secondary school level, recognition of behaviors to monitor, special circumstances faced by student athletes that may affect their psychological health. Collaboration with other professionals to assist student athletes with psychological concerns and discuss legal considerations is encouraged. Any plan should be sure to follow the rules associated with HIPAA and FERPA regarding the individuals who should be involved in or knowledgeable of a certain patient case. In addition, the organization should have a plan to educate athletes, coaches and parents on the resources available for proper recognition and referral of athletes with psychological concerns.

Supporting Documentation:

  • Guidelines on identification of procedures for recognition and referral and appropriate mental health professionals to whom athletes may be referred is provided to all stakeholders and evidence of communication documented.

Standard 11.4

Does the organization have a collaborative and comprehensive emergency action plan (EAP) for a mental health incident (attempted harm to oneself or others) or catastrophic incident (suicide, homicide, permanent disability)?

Annotation:

The EAP for Mental Health Emergencies and Catastrophic Incidents should include the course of action that would be taken in an emergent mental health emergency response plan. The following guidelines are recommended for inclusion in the plan: respond with empathy and support; enact the organization crisis plan; notify the student crisis team; identify the level of intervention required; ensure safety and err on the side of safety; collaborate with colleagues; mobilize student's support system (family); connect immediately with appropriate resources; and follow up on the referral.

Supporting Documentation:

  • Evidence of organizational policy, procedures and protocols on the EAP for Mental Health Emergencies.

Standard 11.5

Does the organization offer professional counseling services for athletes and other personnel after a mental health or catastrophic incident?

Annotation:

The crisis counseling could be appropriate in events such as death of friends or family, exposure to suicide or violence, traumatic injury, or other incidents that may cause stress and psychological concerns. The organization should have a plan in place that would provide counseling services for athletes and other stakeholders in the event of a catastrophic incident.

Supporting Documentation:

  • Evidence that crisis counseling services are available to athletes and other personnel after a mental health or catastrophic incident.
  1. Emergency Action Plan Guidelines: Mental Health Emergency in Secondary School Athletes www.nata.org/sites/default/files/mental_health_eap_guidelines.pdf
  2. Everly GS, Jr, Welzant V, Jacobson JM. Resistance and resilience: the final frontier in the traumatic stress management. Int J EmergMent Health. 2008;10(4):26-270.   www.ncbi.nlm.nih.gov/pubmed/19278142
  3. Interassociation Consensus Document: Understanding and Supporting Student-Athlete Mental Health  Best Practices www.ncaa.org/sites/default/files/SSI_MentalHealthBestPractices_Web_20170921.pdf
  4. Interassociation Recommendations for Developing a Plan to Recognize and Refer Student-Athletes With Psychological Concerns at the Secondary School Level: A Consensus Statement    www.ncbi.nlm.nih.gov/pmc/articles/PMC4477918/
  5. NATA webpage Mental Health Resources   www.nata.org/practice-patient-care/health-issues/mental-health
  6. National Athletic Trainers’ Association Position Statement: Preventing, Detecting, and Managing Disordered Eating in Athletes; Journal of Athletic Training 2008;43(1):80–108.  www.ncbi.nlm.nih.gov/pubmed/18335017
  7. Psychological Issues Related to Illness and Injury in Athletes and the Team Physician: A Consensus Statement-2016 Update.  https://journals.lww.com/acsm-csmr/Fulltext/2017/05000/Psychological_Issues_Related_to_Illness_and_Injury.18.aspx
  8. Special Issue focused on mental health: Athletic Training & Sports Health Care 2017;9(6)
32: Neal TL, Diamond AB, Goldman S, et al. Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement. J Athl Train. 2015;50(3):231-249.
39: Valovich McLeod TC, Bay RC, Parsons JT, Sauers EL, Snyder AR. Recent injury and health-related quality of life in adolescent athletes. J Athl Train. 2009;44(6):603-610.

At the time of publication, no case law was found on this standard.

Standard
Standard

Comprehensive athletic health care administration system is established to ensure appropriate medical care is provided.

Narrative

Organizations sponsoring athletic programs for secondary school-aged individuals should establish a comprehensive athletic health care administrative system that ensures that appropriate medical care is provided for all participants. To provide appropriate medical care, organizations must create an AHCT that must function in a coherent, coordinated, and efficient manner with coaches and administrators of sponsoring organizations and must adhere to commonly accepted standards of good clinical practice. Specifically, the system should address the following: documentation, policies and procedures, job descriptions, job evaluations, job supervisory structure, supervising physician medical direction documents, and written standing orders.

Standard 12.1

Does the organization have an AHCT consisting of QMPs with roles identified for each?

Annotation:

The AHCT is the group of qualified medical professionals designated by the organization to provide athletic health care for its athletes. The primary team is usually composed of the athletic trainer(s) and the team physician. The secondary team includes a network of QMPs that might play secondary roles based on specific circumstances. These QMPs might include (and are not limited to) the school nurse, an athlete's primary care physician, physician/surgical specialists, physical therapist, EMS personnel, counselor, psychologists, dentist, registered dietitian, strength and conditioning coaches and others. Communication between these team members is vital for continuity of care for the athlete, particularly if QMPs come from different networks/practices. While it is recognized that a secondary school-aged athlete is a minor and the selection of medical providers is ultimately the choice of the parent, an organization should work to establish affiliated QMPs willing to be part of the AHCT to provide appropriate and efficient comprehensive athletic health care.

Supporting Documentation:

  • Evidence of the existence of an AHCT such as contracts, written agreements, or position descriptions.
  • Name, credentials, title, roles and responsibilities of AHCT members are listed and described.

Standard 12.2

Does the organization have a designated team physician (MD or DO) under agreement that establishes the relationship and services provided?

Annotation:

Expectations clearly identifying the role of the team physician should be established to prevent misunderstandings with other providers, such as the athletes’ primary care physician and other physicians affiliated with the school. In some cases, an organization may have an agreement with one physician/physician group to provide care for orthopedic injuries/conditions and another for non-orthopedic injuries and general medical conditions, head injuries, etc. These arrangements should be established as written agreements to establish each physician’s role. Expectations regarding physician services that require reimbursement and those which do not should be clearly identified in the agreement for physician services. Whether a team physician is volunteering or employed by the school district, he or she should be approved annually by the school district’s board of education.

Supporting Documentation:

  • Contract or agreement that establishes the relationship between the team physician and services provided. Includes signature page with name, credentials, title and date of the individuals giving institution oversight and approval (e.g. administration, legal counsel, and risk management) of contract or agreement.
  • Team physician license to practice medicine is documented in the state of the organization.

Standard 12.3

Does the organization have a designated QMP to coordinate athletic health care and serve as a liaison to the medical community?

Annotation:

The organization should employ or contract with a QMP that has the knowledge and skills to develop, administer and manage a health care facility. The coordination of care by the QMP should be well organized, paying careful attention to the details of record keeping, assisting with referrals, insurance claims, developing and maintaining Emergency Action Plans, operating procedures, supply inventory, facility maintenance and OSHA/FERPA/HIPAA compliance. Purchasing supplies and equipment required for the provision of care and communication with other providers, coaches, administrators, and parents are key components of coordinating care.

Supporting Documentation:

  • Job description of QMP coordinating and/or providing health care for athletes.
  • Licensure and/or certificates of qualifications are clearly displayed to the public in the athletic training facility.

Standard 12.4

Does the organization ensure that a QMP properly documents athlete medical records according to professional and legal standards?

Annotation:

Documentation should meet medical industry standards and statutory regulations of record-keeping. Proper documentation serves to provide a complete, accurate and timely record of a patient’s complete medical history and may serve to minimize the risk of in the event of litigation. Proper recordkeeping facilitates communication and help to ensure a consistent level of care among and within multiple caregivers across various settings.

Supporting Documentation:

  • Guidelines on expected documentation procedures of services provided with at minimum, an annual review by the AHCT.
  • List all medical records utilized by the organization and description of how each is utilized in day-to-day operations of the organization.

Standard 12.5

Does the organization publish and make available its policy, procedure and protocol manual for all stakeholders?

Annotation:

Written policies and procedures are essential to the success of any organization. They serve has the “road map” for the organization and those who work within it. With appropriate written policies and procedures, the organization is helping to assure accountability.  A policy is a guiding principle used to set direction of an organization. It can be a course of action to guide and influence decisions. A procedure is a particular way of accomplishing something. It should be designed as a series of steps to be followed as a consistent and repetitive approach to accomplish an end result.

Examples of key policies and procedures:

  • Regulations governing the provision of athletic health care in your state
  • Position descriptions for QMP employed or contacted by the organization and performance evaluation procedures
  • Team physician roles, responsibilities and standing orders
  • Description of the QMP medical service at athletic events and practices
  • Use of the athletic health care facility
  • Athletic Emergency Action Plans for injured/ill athlete
  • Communication/notifying of parents or guardians of injured/ill athletes
  • Transportation of injured/ill students
  • Pre-participation physical exams
  • Return to play criteria
  • Documentation and record-keeping procedures
  • Managing budget and inventory
  • Purchasing equipment and supplies
  • Documentation of maintenance on modalities and AED
  • Catastrophic injury or death of an athlete
  • Inclement weather and thunder/lightning safety
  • Athletic participation during extreme heat or cold
  • Management of conditions such as asthma, diabetes, severe food, drug, or insect allergies (anaphylaxis), skin conditions, or epilepsy
  • Use of therapeutic modalities
  • Use of medication
  • Blood borne pathogens and infectious diseases
  • Safe Shelter in place policy

Supporting Documentation:

  • Policy, procedure and protocols manual is published for all stakeholders to easily access (e.g. organization web site, parents meeting).

Standard 12.6

Does the organization ensure medical devices are maintained and calibrated according to manufacturer guidelines and governmental regulations?

Annotation:

Medical devices should be maintained and calibrated according to manufacturer guidelines and governmental regulations.

Supporting Documentation:

  • List of medical devices (e.g. AED, ultrasound, electrical stimulation units) that require calibration or regular maintenance checks according to manufacture guidelines and governmental regulations.
  • A log (signatures, date and time) of medical devices checked, person responsible and schedule of validating calibration or maintenance. Stickers indicating the date on which a device was safety checked/calibrated should be located on the device as appropriate.

Standard 12.7

Does the organization provide appropriate storage and security of medical records and require documented training for anyone accessing such records?

Annotation:

It is critical that all medical records are stored and maintained according to legal standards. The legal standard is determined by state law requirement, in addition to HIPAA and FERPA laws. It is important to know the standards that your facility is required to follow. A policy and procedure on medical record storage and retention should be developed. Formal and documented training should be required for anyone who needs to access such records. These policies and procedures should include: 

  • Who has access to medical records and what functions are they allowed to perform? This should include non-medical providers such as administrators and information technology personnel. All those who have access should be bound by confidentially agreements. Function or reasons for access can include the ability to create and review medical record for medical care; the ability to review medical record for limited purpose such as billing or record request; and, the ability to have access to medical record system for computer maintenance and security only.
  • The system by which medical records are secured.
  • A procedure for when medical records are requested and produced for patient or others when a legal request is made.
  • A determination of who is the custodian of the medical records.
  • A notification plan if medical record security is breached
  • A determination for how long medical records are retained and where they well be retained.
  • A plan to determine how medical records are transferred, when applicable.

Supporting Documentation:

  • Evidence of policy, procedures and protocols on storage and security of medical records including training of anyone accessing such records.
  • Education and training materials with objectives and assessment methods to demonstrate competency are developed. If an online course is utilized in any aspect of training, a copy of course objectives and course completion certificate is available.

Standard 12.8

Does the organization provide the necessary resources for a member of the AHCT to communicate professionally with athletes, parents, coaches, administrators and medical community?

Annotation:

Communication is a critical aspect in the provision of appropriate medical care and the organization must maintain an open line of communication with athletes, parents, administrators, coaches, team physician, and all those who are a part of the school’s athletic health care network. The QMP hired/contracted by the organization to coordinate medical care must be sure to engage in verbal communication such as telephone calls to parents, consultations with physicians, and meetings with administrators and coaches on a regular basis. Relaying information from the AHCT to coaches via injury reports is important to insure players return to participation only when ready and that participation recommendations and restrictions are followed. Written communication between health care providers is critical for continuity of care. Short presentations to booster clubs or at parent meetings and creation/distribution of a pre-participation packet with the required PPE form including information about policies and procedures, educational information on important health and safety issues.

Supporting Documentation:

  • Communications tools and resources such as but not limited to: cell phones, portable radios, computers (e.g. desktop, tablets, iPad), printers, phone logs, injury management systems/software, printed materials, bulletin board supplies, flyers, posters or organization sponsored web sites should be made available to all QMPs and AHCT members

Standard 12.9

Does the organization provide adequate funds for supplies and equipment needed for a comprehensive athletic health care program?

Annotation:

The organization should allow input from a member of the ACHT in the annual budgeting for sports medicine supplies and equipment. The budget for sports medicine supplies and equipment should be commensurate with the funding required to carry out the elements of appropriate medical care for secondary school aged athletes as identified in these recommendations for your organization. It should be noted that schools with annual sports medicine supply and equipment budgets greater than $3500 have been reported to provide statistically significant higher level of medical care even when a variety of factors such as percentage of free/reduced lunch qualifiers in a school, school size, school setting, and proximity to a medical center.40

Supporting Documentation:

  • Evidence of an annual budget request prior to formulation of the organization's overall budget should be submitted to support the services under the supervision of the AHCT. Request for capital equipment may involved a separate proposal based on the organizations budget process.
  • Evidence of a budget request for capital equipment to support the services under the supervision of the AHCT.
  • Evidence that funds designated for equipment and supplies should be indicated as a line item in the organization’s overall budget.

Standard 12.10

Does the organization provide adequate and equitable staffing of QMPs to implement a comprehensive athletic health care program?

Annotation:

Supporting Documentation:

  1. Interassociation Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges
  2. NATA Appropriate Medical Coverage of Intercollegiate Athletics
  3. NATA Best Practices Guidelines in Athletic Training Documentation
  4. NATA Position Improvement Guide
  5. NATA Position Proposal Guide for Certified Athletic Trainers in Secondary School Athletics Programs
  6. NATA: Guidelines for Developing a Team Physician Services Agreement
  7. Wham GS, Saunders R, Mensch J. Key factors for providing appropriate medical care in secondary school athletics: athletic training services and budget. J Athl Train. 2010; 45 1: 75– 86.
3: Almquist J, Valovich McLeod TC, Cavanna A, et al. Summary statement: appropriate medical care for the secondary school-aged athlete. J Athl Train. 2008;43(4):416-427.
37: Courson R, Goldenberg M, Adams KG, et al. Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges. J Athl Train. 2014;49(1):128-137.
40: Wham GS, Jr., Saunders R, Mensch J. Key factors for providing appropriate medical care in secondary school athletics: Athletic training services and budget. Journal of athletic training. 2010;45(1):75-86.

While there is growing case law in this area, we would be unable to list all relevant cases.  Athletic trainers and organizations must be aware of state laws and ensure compliance.

 

See discussion regarding Standard 7, as cited from Hites v. Pennsylvania Interscholastic Athletic Ass'n, Inc., No. 8 C.D. 2017, 2017 WL 4507367, at *5–6 (Pa. Commw. Ct. Oct. 10, 2017).  Again, although the plaintiffs in the Hites case brought claims for inadequate care following concussions, the Court does an excellent job of stating the overarching duty of the PIAA regarding health care administration and ensuring appropriate medical care is provided.