The High School Athlete: Setting up a High School Sports Medicine Program




General Principles


Athletic Healthcare in High-Level Collegiate and Professional Sports





  • At the very highest levels of sports, organizations are much like corporations; they function to increase success of their shareholders by providing a product (a winning team) directly linked to profitability.



  • While there are ethical concerns with this model, it provides an environment of highly established care because the health of an athlete is directly linked to a team’s success.



  • Below are the characteristics of such models:




    • Remarkable financial resources



    • Well-defined roles and responsibilities



    • Risk management and loss control



    • Optimization of athletes’ health for on-field performance



    • High organizational control and attention to detail



    • Professional personnel secured in adequate quantity




      • Certified athletic trainers (ATCs)



      • Qualified team physicians (sports medicine fellowship-trained, primary care physicians, and orthopedists)



      • Other allied healthcare professionals including certified strength and conditioning coaches, nutritionists, psychologists, optometrists, dentists, exercise physiologists, and physical therapists




    • Compliance with Team Physician Consensus Statement (see Recommended Readings )



    • Policies delineated and enforced routinely




Differences in Athletic Healthcare for the High School Athlete





  • The effect of high-profile professional and collegiate sports has trickled down into secondary schools, with many school administrators, coaches, and parents looking for the same type of on-demand medical care.



  • However, most schools have the following concerns:




    • Lack of financial resources



    • Lack of leadership—just maintain status quo




      • Turnover of personnel (school board, superintendent, principal, athletic director, and coaches)



      • Not a priority—too many other issues




    • Lack of medical resources




      • No ATC or physician



      • Inadequate medical knowledge among coaches and athletic directors



      • Communication with medical community often poor



      • Results in incorrect or delayed care




    • Lack of policies/standards




      • No overall single system of care—each coach does his/her own thing



      • Assumed to be met by minimal standards and effort by external personnel or agencies, such as state-required preparticipation physical examinations, volunteer team physicians, or presence of ambulance at home varsity football games





Solution: Goals and Requirements





  • Goals: appropriate healthcare for athletes and minimal liability through a risk management (loss control) policy



  • Requirements: knowledge, organization, and commitment toward detailed planning



Approach to Optimal High School Athletic Healthcare


Key Elements


Four key elements of the approach: family, school, medical community, and ATCs


Family Involvement





  • Most high school athletes are minors and are dependent on their parent(s) or guardian(s)



  • School, ATC, and physician must focus on communication with parents/guardians of injured athletes



  • Parents/guardians:




    • Know the athlete’s medical history



    • Are usually more concerned with their children’s health and academics than sport



    • Are important resources regarding psychosocial dynamics




  • Financial concerns may prevent seeking appropriate care



School Commitment





  • School should assume responsibility for operating safe programs.




    • Obligations toward students and their families and commitment to meeting them; solutions must be internal as well as external



    • Qualifications and backgrounds of athletic directors and coaches



    • Should work as a unit, operating a single interscholastic athletic program and single athletic healthcare program




      • Institution of policies, guidelines, and procedures for daily use



      • Record-keeping system



      • Emergency action planning and first-aid/CPR training





  • Seek assistance from the medical community for all sports: preparticipation physical examinations as well as preseason fitness screening, weekly school visits, event coverage, and therapies and treatments




    • Know what is desired from physicians, physical therapists, and clinicians



    • Designate team physician(s)




  • Hire National Athletic Trainers’ Association (NATA)-certified athletic trainers (and licensed in state if available) as they are the most suitable professionals to coordinate and operate the athletic healthcare program




    • Cannot be present simultaneously at all athletic venues




      • Use of student athletic trainers and educated coaches for assistance




    • Requires a support system




      • Policies and procedures, including record-keeping, accountability, and quality assurance systems




    • Requires wireless communication and golf cart to meet obligations of daily coverage and emergency response during fall and spring seasons



    • Should insist on medical supervision and quality assurance system



    • Should have adequate budget



    • Reasonable schedule demands




      • Known high turnover rate for ATCs due to heavy workload



      • Consider second ATC in large high schools





Medical Involvement (Team Physicians)





  • A written contract is best.




    • Delineates responsibilities and expectations



    • Helps ensure that the school has given careful thought to its obligations



    • Good communication leads to good working relationships




  • Monetary compensation—yes or no?




    • If compensated, may nullify “Good Samaritan” immunity



    • Amount offered is frequently meager compared to earnings in office




      • True value of assistance provided?





  • Responsibilities (enumerated in Team Physician Consensus Statement)



  • Jurisdiction: Are your decisions final?



  • Medicolegal (liability) concerns




    • Good Samaritan Law immunity may cover team physician in certain states




      • Team physician is not really a Good Samaritan under strict definition—“someone without obligation who steps forward to render emergency care”



      • Has clearly defined responsibilities toward athletes, school, and athletic program



      • Event coverage is evidence of that responsibility



      • May be covered by “good intent, no compensation” concern



      • Good Samaritan immunity extends only to “emergency care” rendered during event coverage; protection does not extend to preparticipation physical examinations, weekly injury clinics at school, and return-to-play clearance examinations




    • Potential responsibility and liability for ATC’s actions




      • Need to clarify issue with school district



      • ATCs generally function “under direct medical supervision of a physician”



      • In states that have not specifically defined the “scope of practice” for ATCs through licensure, certification, or registration, the team physician needs to assess implications and responsibilities of “direct medical supervision.” An analogous supervisory situation may be the physician–physician’s assistant relationship.



      • Written standing orders for the ATC and emergency action plans (EAPs) are essential requisites for limiting any liability risks




    • Malpractice insurance and liability coverage




      • Incorporated into your personal or clinic policy (already existing or a new rider clause to be added)



      • Through school district insurance policy





  • Medical privacy concerns (HIPAA and FERPA)




    • Health Insurance Portability and Accountability Act (HIPAA) of 1996 and Family Education Rights and Privacy Act (FERPA) in 1974 were developed to regulate “protected health information”



    • FERPA regulations prevail within the domain of public schools.




      • FERPA governs school nurses, school physicians, coaches, and ATCs.




    • HIPAA Privacy Rule allows release of medical information without authorization for “treatment, consulting with other providers, referring the patient to other providers, and notifying a patient’s family”




      • Athletes who consult at medical facilities outside of school will most likely fall under purview of HIPAA.




    • Eligibility decisions regarding “cleared” or “not cleared” on preparticipation physical examinations can be provided to coaches and school administrators (without inclusion of other medical information) without signed consent.



    • For group preparticipation physical examinations conducted at the school, must ensure confidential storage of forms, with information pertaining to restrictions shared only with those who have “need to know”




      • Need to know—always includes ATC, school nurse, and school physician (team physician)




        • Variable for coach and administration depending on circumstances because the athlete’s well-being may require one to have an understanding of his/her limitations or signs/symptoms





    • Coaches and administrators, as well as school nurses and ATCs, must be made aware of FERPA and HIPAA regulations and constraints regarding privacy of healthcare information.




  • Degree of involvement




    • Set overall medical policy with athletic director and ATC



    • Strongly consider forming a medical advisory board with school district



    • Provide medical advice to the interscholastic athletic program



    • Provide medical coverage at games. Ideal goal—to see every team member at least once during the season—may require division of coverage among several physicians, possibly by sport or on a rotational basis




      • Football team: home varsity coverage (mandatory); away varsity and home junior varsity coverage (recommended)



      • Wrestling team: preseason weight class recommendations, midseason weight certification, assessment of skin for communicable diseases, and coverage of home matches (recommended)



      • Coverage of all tournaments at home school



      • Soccer team (boys and girls): coverage of events as schedule permits



      • Basketball team (boys and girls): coverage of events as schedule permits



      • Other sports as schedule permits




    • Develop an emergency contact plan and emergency action plan, including use of automated external defibrillator (AED) for sudden cardiac arrest



    • Develop a concussion action plan, including return to sports and academics



    • Conduct preparticipation physical examinations



    • Visit school/athletes regularly



    • Educate coaches and ATCs



    • Provide support for ATC’s authority




      • Medicolegal supervisor of the ATC



      • Assess knowledge, skills, and experience of the ATC and mutually develop an appropriate set of standing orders with cumulative working relationship and legal scope of practice for ATCs in their jurisdiction



      • Role in creating a job description



      • Role in interviewing and hiring



      • Role in job evaluation



      • Role in quality assurance of care rendered by ATC




        • Frequent and regular communication



        • Chart review and case studies as needed






  • Role of a team physician in school without an ATC




    • Understand history and culture of the school



    • Assess strengths and weaknesses of how athletic care is and was provided



    • Greater challenge to meet responsibilities



    • Possible institution of athletic healthcare system (AHCS; see the following section)



    • Encourage school to recognize need for ATC




  • Role of a new team physician in a school with an established ATC




    • The team physician should understand the methods and culture of the existing system.



    • ATC may welcome an active, involved, “hands-on” team physician or prefer a more distant consultant model if he or she is comfortable as the central focus of the AHCS and confident of his/her abilities and skills.



    • Team physician should develop appropriate relationship with ATC.




Athletic Trainer





  • Hiring considerations and working conditions (team physician should help school in the hiring process)



  • Scenario—getting a job is not easy (but it is getting easier!). ATC submits resume and NATA pamphlets as to why certified ATC is necessary.



  • ATC may be perceived as a salesman.




    • Identifying “a problem I didn’t know existed”



    • Offering solution to the problem




  • Funding is a factor—ATC is usually a low-paying, entry-level job



  • If ATC is hired, under what conditions?



  • Full- or part-time ATC?



  • Teacher and ATC? How many classes?



  • How many working hours per week, including games?



  • How many working days per year?




    • ATC needs more days than regular school calendar.



    • If general contract calls for same number of days as teachers, it must take into account preseason football days, weekends, and holiday tournament days.




      • Possible solution: part-time substitute ATC, who works 1 day per week throughout school year (40 days); this schedule decreases the risk of burnout for the full-time ATC (from not having time off) and allows ATC to work same number of days as teachers



      • Part-time ATC can service several schools each week, if more work is desired.





  • Medical backup and supervision




    • Head team physician should be specifically recognized as the medical supervisor of the ATC.



    • Degree and frequency of communication should be clearly established.



    • Whose decision is final regarding return to play?




  • Adequate budget for equipment and supplies, professional fees, books, and continuing education



  • Quality of training room



  • Written job description



  • Job performance (accountability and quality assurance)




    • Evaluated by team physician and others (e.g., athletic director, school nurse, coaches, principal, and athletes)




  • Potential for career advancement





Athletic HealthCare System


Generic Model System





  • The AHCS was initially developed by adapting college and professional sports medicine programs to high school level.



  • This can be installed at any school, large or small sized, and at any school location, rural or urban.



  • The AHCS should be tailored to each school and adhere to accepted standards of practice.




    • Effectiveness of the AHCS is greatly improved with an ATC and a sports medicine-trained team physician.




Model System





  • The AHCS was developed under strict guidelines of the US Department of Education from 1978 to 1982 and validated in 1982, 1987, and 1995.



  • The AHCS was nationally disseminated in the 1980s and 1990s by grants through the National Diffusion Network.




    • This consortium was well known by schools with a track record for proven, cost-effective programs that worked.




  • In 2002, NATA developed a consensus statement with recommendations and guidelines for secondary school sports.




    • In 2004, the consensus statement was augmented by an updated, science-based document.




Key Elements of the Athletic Healthcare System



Assessment





  • Complete evaluation of existing programs



  • Standards for care delineated



  • Areas of assessment




    • Identify AHCS team members that have a diverse skill set



    • Athletic facilities—safe practice and competition venues



    • Athletic equipment—selection, fit, and maintenance



    • Emergency action plan—development and implementation



    • Treatment facilities/athletic training room



    • Provision of athletic healthcare services



    • Documentation strategies and injury surveillance




  • Self-assessment initially followed by external evaluation




    • Concept and methodology similar to assessments by the Joint Commission on Accreditation of Health Organizations (JCAHO) and educational assessments



    • Formal written report issued



    • Develop action plan based on weaknesses and deficiencies



    • Assessment frequency—every 3–5 years





Education


Coaches





  • Know rules and expectations for coach education in your state or league



  • Coaching education and standards provided by the National Federation of State High School Associations (NFHS), the National Association for Sport and Physical Education, and various other groups




    • Basic life support (BLS)



    • First aid, health, and safety



    • Concussion education



    • Nutrition and hydration



    • Mental health and sports psychology



    • Behavior and engagement of athletes and parents



    • Injury prevention and injury management




  • Education on the culture of sport




    • Encourage an environment of honesty in reporting injuries without repercussions



    • Recognize injury, treat and completely rehabilitate to allow pain-free participation




      • No longer fall back on “no pain, no gain” philosophy





  • Education on how to most effectively partner with ATCs and team physicians




    • Share responsibilities



    • Defer to knowledge of objective healthcare providers



    • Work with AHCS team to install injury reduction programs




High School Student Athletic Trainers





  • Assist coaches and ATCs in daily tasks



  • Courses in summer and/or during school year



  • May be funded through vocational education monies



  • Provides career opportunities in the healthcare field



Athletic Directors and Other Administrative Personnel





  • Athletic administration courses through national associa­tions like the NFHS and the National Interscholastic Athletic Admin­istrators Association



  • Regional and state conferences




    • Focus on organizational management and implementation of a safe athletic program



    • Safety and liability issues



    • Strategies to interact with coaches, sports medicine team, and state associations





Athletic Training Room/Treatment Facilities





  • Recommendations




    • Should have privacy for evaluation of student-athletes



    • Should be accessible for both male and female athletes



    • Should not be a conditioning center or a weight room



    • Often used as a rehabilitation room



    • Ensure appropriate disposal of biohazard waste



    • Have a plan for equipment and supply inventory, stocking and storage



    • Location: ideally close to locker rooms and athletic fields



    • Adequate plumbing and drainage for ice machine and tubs



    • Ensure appropriate heating, ventilation, and lighting



    • Ensure layout of room allows smooth flow of traffic



    • Educational resources for student-athletes: books, posters, and manuals



    • Ensure safety and security is assessed





Standard Procedures


Preparticipation Evaluation





  • Coordinate with medical community, ATC, and coaches




    • See preparticipation evaluation chapter for additional details



    • Identify athletes with medical conditions (e.g., diabetes, asthma, seizures, or anaphylaxis) and develop emergency and preventative management plans




Preseason Screening





  • Create off-season fitness plan for athletes of every sport




    • Develop injury and illness prevention plans



    • Provide sound nutritional counseling and education




  • Physical assessment




    • Flexibility



    • Strength and endurance



    • Aerobic capacity



    • Body composition




  • Education and culture




    • Create an environment for appropriate reporting of injuries



    • Develop “mental toughness”—psychological and emotional makeup



    • Educate on playing within rules



    • Emphasize sportsmanship



    • Educate on appropriate nutrition and hydration




      • Discussion on safe weight gain and weight loss



      • Educate on avoiding supplements and performance-enhancing substances




    • Review common adolescent high-risk behaviors (e.g., substance abuse, use of seat belts and bike helmets, internet and social media safety, or bullying)




Treatment Protocols and Guidelines





  • Should be shared with athletes, coaches, and parents



  • Should be created in conjunction with the team physician



  • Identify local experts for referral of injuries, psychosocial pathology (e.g., eating disorders or depression), and medical illness



  • PRICES




    • P rotection—brace/splint use



    • R est



    • I ce



    • C ompression



    • E levation



    • S upport—crutch use




  • Use of OTC medications—if allowed



  • Educational handouts for athletes and families on injuries



  • Steps of rehabilitation




    • Control pain and swelling



    • Restore range of motion



    • Restore strength



    • Restore stability




      • Taping, bracing, and rehabilitation exercises




    • Restore general functioning




      • Aerobic capacity



      • Core stability



      • Neuromuscular function



      • Balance




    • Restore sport-specific functioning




Return-to-Play Policy





  • Create in conjunction with the AHCS team, particularly the team physician




    • To reduce the risk of inappropriate clearance by an external physician, establish which provider has the final say on medical clearance—should ideally be the team physician




  • Should be shared with parents, coaches, and athletes during preseason meetings




    • Set expectations for when an injured athlete can resume play




  • Concussion-specific




    • Should comply with state legislation




      • Written medical clearance




    • Follow a step-wise return-to-play progression




      • Concussion in Sport Group, Zurich Guidelines, 2014




    • Before beginning the program, an injured athlete should have fully resumed academics and must be asymptomatic and off the medications used for symptomatic treatment.




  • Musculoskeletal injury




    • Little to no swelling



    • Little to no tenderness on palpation



    • Full, pain-free range of motion



    • Full, pain-free strength through range of motion



    • Pain-free joint stability—through rehabilitation, taping, bracing, or surgery



    • Full, pain-free general functional activities



    • Full, pain-free or minimal discomfort during sport-specific activities




  • Medical disorders/issues




    • Should have written medical clearance delineating activities allowed and any follow-up care or considerations necessary




Communication





  • List of key people and contact information disseminated among the AHCS




    • Should include hospitals, clinics, and physicians in the region




  • All AHCS personnel should possess individual cell phones in case of emergency.




    • If cell phones do not have reception, alternative modes of communication should be established (e.g., walkie talkies).




  • Information cards for every athlete




    • Medical conditions



    • Emergency contacts





Emergency Preparedness


Emergency Action Plan





  • Emergency information cards for every athlete



  • Written emergency action plan should be designed for every practice and competition location




    • Annual practice at every location with staff and the team



    • Attention to location of AEDs



    • Checklist for first-aid kit



    • Identify the procedure for alerting emergency medical services (EMS)/911




      • Map for route to athletic facility and fields



      • Sports medicine staff can call ahead to inform the hospital facility




    • Identify procedures for transfer of care from the AHCS to the EMS team



    • Ensure parents, guardians, and caregivers of the injured athlete are notified




Practice and Playing Field/Facility Safety





  • Safety inspections at the start of the year and the season



  • Daily inspection of playing surface and surroundings



Evaluation Procedure for Acute “On-the-Field” Injuries





  • Triage severity of injury to first rule out “worst-case injuries”




    • Life-threatening injuries/unresponsive or unconscious athletes




      • Begin BLS with focus on airway, breathing, and circulation (ABC)



      • Activate EMS




    • Unstable athlete—if left unattended, would the athlete deteriorate?




      • Begin BLS and activate EMS




    • Examples of potentially life-threatening, limb-threatening, or unstable injuries




      • Airway obstruction



      • Acute bleeding (internal or external hemorrhage)



      • Anaphylaxis



      • Cardiovascular collapse



      • Heat illness



      • Neurologic impairment/head injury



      • Severe fractures



      • Dislocations



      • Eye trauma





  • Have a plan to address common athletic injuries that may not require activation of EMS




    • Initial triage and determination if it is safe to move the athlete off the playing surface



    • Complete evaluation of injury on the sideline



    • Follow-up injury evaluation to ensure the athlete is not decompensating



    • Communication with coaches regarding the athlete’s status



    • Communication with the athlete’s parent, guardian, or care giver





Documentation and Injury Surveillance





  • Always document every evaluation and care provided



  • Reduces liability



  • Allows review for quality improvement and accountability



Record Keeping





  • Paper or electronic



  • Athlete emergency information card



  • Daily report of attendance and injuries




    • Note the absent athletes to assess injuries or illnesses before return to play




  • Keep athletic training room treatment log




    • Documentation on all treated athletes should include diagnosis, treatment(s), progress, and limitations.



    • May need to pass on treatment notes of the injured athletes to families or medical care providers




  • Maintain a file for correspondence from medical care providers



  • Maintain a master list of injured athletes for each team




    • Daily review with coaches to determine full, limited, or no participation




Injury Surveillance



Jul 19, 2019 | Posted by in SPORT MEDICINE | Comments Off on The High School Athlete: Setting up a High School Sports Medicine Program
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