Emergency Action Planning in School-Based Athletics: A Systematic Review

Introduction. A significant number of preventable catastrophic injuries occur in secondary school athletics. Compliance to Emergency Action Plan (EAP) recommendations is not well documented. The purpose of this systematic review was to identify compliance to EAP recommendations, access to an athletic trainer (AT) and automated external defibrillator (AED), and current legislative mandates in school-based athletics. Methods. Electronic databases were searched to identify articles that met criteria for inclusion. Studies in English that focused on adoption, implementation, or compliance with EAPs or other national guidelines pertaining to athlete health were eligible for inclusion. Quality and validity were examined in each article and data were grouped based on outcome measures. Results. Of 12,906 studies, 21 met the criteria for inclusion and full text review. Nine studies demonstrated EAP adoption rates ranging from 55% - 100%. Five studies found that EAPs were rehearsed and reviewed annually in 18.2% - 91.6% of schools that have an EAP. At total of 9.9% of schools were compliant with all 12 National Athletic Trainers Association (NATA) EAP guidelines. A total of 2.5% - 27.5% of schools followed NATA exertional heat illness guidelines and 50% - 81% of schools had access to an Athletic Trainer. In addition, 61% - 94.4% of schools had an AED available at their athletic venues. Four of 51 state high school athletic association member schools were required to meet best practice standards for EAP implementation, 7 of 51 for AED access, 8 of 51 for heat acclimation, and 3 of 51 for concussion management. Conclusions. There was a wide range of EAP adoption and a low rate of compliance to EAP guidelines in U.S. schools. Barriers to EAP adoption and compliance were not well documented and additional research should aim to identify impeding and facilitating factors.

Program Directors' Perception of the Importance of Soft Skills in Athletic Training

Context Soft skills have been reported to be a necessary aspect of athletic training education and clinical practice. However, almost no empirical research has explored the level of importance of soft skills or the frequency with which they are evaluated within athletic training education. Objective To delineate the perceived importance of soft skills within athletic training education and describe the frequency with which those soft skills are evaluated within athletic training programs. Patients or Other Participants Four hundred eight program directors (PDs) of Commission on Accreditation of Athletic Training Education–accredited athletic training programs were invited to patriciate; 122 responded and 108 of those responses (88.5%) were usable (64% PDs of baccalaureate programs, 28% PDs of professional masters, 8% did not disclose), yielding a 26.5% response rate. All 10 National Athletic Trainers' Association districts were represented, with the highest representation (26%) from District 4. A majority of respondents were female (57%). Most respondents (79%) had 11 or more years of experience (33% of those ≥21 years) as an athletic training educator, and 98% of respondents identified as white/non-Hispanic. Main Outcome Measure(s) Importance and frequency of soft-skill evaluation were measured using the Athletic Training Soft-Skills Assessment Instrument (ATSSAI). Data of perceived importance and frequency of evaluation were organized by various demographic variables and between scale dimensions. Results The ATSSAI psychometric analysis yielded satisfactory internal consistency and validity (α = .84 to .93). Paired-samples t test indicated significant differences between the ATSSAI Perceived Importance and Frequency of Evaluation scales (mean = 1.65 ± .47 versus mean = 3.29 ± 1.17, P = .000; Cohen d = 1.83). Pearson r correlation showed a positive relationship between perceived importance and frequency of evaluation, r = 0.81. Independent-samples t tests revealed female PDs perceived 2 soft skills (18%; observant and exact and prepared and adaptable) as more important (t99 = 2.12 and 2.18, P = .31 and .37) than did male PDs and evaluated 3 (27%; decisive and confident, prepared and adaptable, and observant and exact) more frequently (t99 = 2.35–2.50, P = .14–.21) than did male PDs. Conclusions All soft skills identified as necessary for inclusion in athletic training education were perceived to be very or extremely important by PDs. However, those same soft skills were not evaluated as often as their importance might suggest. Dependability and responsibility was the most important and most frequently evaluated soft skill (mean = 1.31 ± .51 and 2.21 ± 1.30, respectively). Female PDs generally perceived soft skills as more important and reported evaluating them more frequently. Soft-skill development is a tacit-based phenomenon that contributes to leadership effectiveness and clinical preparedness.

Wet Bulb Globe Temperature Use in National Collegiate Athletic Association Football Bowl Subdivision Athletic Training Staffs

Heat illnesses present a risk for athletes, especially football players. The National Athletic Trainers’ Association established recommendations to prevent heat illnesses, which include measuring wet bulb globe temperature (WBGT). This study aimed to determine the prevalence of WBGT use among the 130 National Collegiate Athletic Association Football Bowl Subdivision athletic training staffs. Of 82 respondents, 59 use WBGT to assess heat stress. The majority of Football Bowl Subdivision training programs (72% of respondents) use the WBGT, but adherence to this National Athletic Trainers’ Association recommendation varies throughout the season (practice versus games) and is likely influenced by the geographical location of the university.

Patient Care Documentation in the Secondary School Setting: Unique Challenges and Needs

Context Athletic trainers (ATs) recognize patient care documentation as an important part of clinical practice. However, ATs using 1 electronic medical record (EMR) platform reported low accountability and lack of time as barriers to documentation. Whether ATs using paper, other EMRs, or a combined paper-electronic system exhibit similar behaviors or experience similar challenges is unclear. Objective To explore ATs' documentation behaviors and perceived challenges while using various systems to document patient care in the secondary school setting. Design Qualitative study. Setting Individual telephone interviews. Patients or Other Participants Twenty ATs (12 women, 8 men; age = 38 ± 14 years; clinical experience = 15 ± 13 years; from National Athletic Trainers' Association Districts 2, 3, 6, 7, 8, 9, and 10) were recruited via purposeful and snowball-sampling techniques. Data Collection and Analysis Two investigators conducted semistructured interviews, which were audio recorded and transcribed verbatim. Following the consensual qualitative research tradition, 3 researchers independently coded transcripts in 4 rounds using a codebook to confirm codes, themes, and data saturation. Multiple researchers, member checking, and peer reviewing were the methods used to triangulate data and enhance trustworthiness. Results The secondary school setting was central to 3 themes. The ATs identified challenges to documentation, including lack of time due to high patient volume and multiple providers or locations where care was provided. Oftentimes, these challenges affected their documentation behaviors, including the process of and criteria for whether to document or not, content documented, and location and timing of documentation. To enhance patient care documentation, ATs described the need for more professional development, including resources or specific guidelines and viewing how documentation has been used to improve clinical practice. Conclusions Challenges particular to the secondary school setting affected ATs' documentation behaviors, regardless of the system used to document care. Targeted professional development is needed to promote best practices in patient care documentation.

Athletic Trainers' Concussion-Assessment and Concussion-Management Practices: An Update

Context Athletic trainers (ATs) are often the first health care providers to conduct concussion assessments and carry out postinjury management. Best practices for concussion evaluation and management have changed rapidly in recent years, outdating previous reports of ATs' concussion practices. Objective To examine ATs' current concussion-assessment and -management techniques. Design Cross-sectional study. Setting Web-based survey. Patients or Other Participants A random convenience sample of 8777 ATs (response rate = 15.0% [n = 1307]; years certified = 15.0 ± 10.6) from the National Athletic Trainers' Association membership. Main Outcome Measure(s) Survey Web links were e-mailed to prospective participants, with 2 follow-up e-mails sent by the National Athletic Trainers' Association. The survey collected demographic information, the number of concussions assessed, the concussion-recovery patterns, and the assessment and return-to-participation (RTP) decision-making methods used. Results The ATs reported assessing a median of 12.0 (range = 0–218) concussions per year. A total of 95.3% (953/1000) ATs cited clinical examination as the most frequently used concussion-assessment tool, followed by symptom assessment (86.7%; 867/1000). A total of 52.7% (527/1000) ATs described a 3-domain minimum multidimensional concussion-assessment battery. Published RTP guidelines were the most common RTP decision-making tool (91.0%; 864/949), followed by clinical examination (88.2%; 837/949). The ATs with master's degrees were 1.36 times (95% confidence interval [CI] = 1.02, 1.81) more likely to use a 3-domain concussion-assessment battery than ATs with only bachelor's degrees (χ2 = 4.44, P = .05). Collegiate ATs were 2.12 (95% CI = 1.59, 2.84) and 1.63 (95% CI = 1.03, 2.59) times more likely to use a 3-domain concussion-assessment battery than high school and clinic-based ATs, respectively (χ2 = 26.29, P < .001). Conclusions Athletic trainers were using the clinical examination, standardized assessment tools, and a 3-domain concussion-assessment–battery approach more frequently in clinical practice than previously reported. However, despite practice improvements, nearly half of ATs were not using a 3-domain minimum concussion-assessment battery. Clinicians should strive to implement multidimensional concussion assessments in their practices to ensure optimal diagnosis and management.

College Athletic Trainers’ Perceptions of Rest and Physical Activity When Managing Athletes With a Sport-Related Concussion

Context: Cognitive and physical rest are commonly utilized when managing a sport-related concussion (SRC); however, emerging research now suggests that excessive rest may negatively impact recovery. Despite current research recommendations, athletic trainers (ATs) may be behind in implementing this emerging research into clinical practice. Objective: To assess college ATs’ perceptions and implementation of an emerging SRC management approach (cognitive and physical rest and activity). Design: Cross-sectional study. Setting: Survey. Participants: A total of 122 (11.8%) ATs (53.3% female; 10.8 [9.8] y experience; 8.7 [6.9] SRCs managed annually) responded to the survey, which was randomly distributed to 1000 members of the National Athletic Trainers’ Association, as well as 31 additional ATs from varying universities. Main Outcome Measures: A 5-point Likert scale assessed the ATs’ perceptions and clinical practices as they relate to specific athlete behaviors (ie, texting, sleeping). The ATs were asked about their willingness to incorporate physical activity into clinical practice. Results: Playing video games (95.9%) and practicing (93.4%) were the activities most perceived to extend SRC recovery. However, sleeping more than usual (7.4%) and increased time in a dark environment (11.5%) were viewed as less likely to extend recovery. ATs restricted practicing (98.4%) and working out (91.8%) for athletes with SRC, while sleeping more than usual (6.6%) and increased time in a dark environment (13.1%) were less restricted. About 71% of the ATs would implement light physical activity for athletes with a symptom score of 1 to 5, 31% with scores of 6 to 10, and 15% with scores of 11 to 20. About 43%, 74%, and 97% believe that light, moderate, and vigorous physical activity, while symptomatic, will extend recovery, respectively. Conclusions: The ATs were receptive to including light physical activity into their SRC management, although only in certain situations. However, most ATs’ beliefs and clinical practices did not completely align with emerging research recommendations for the management of SRCs.

Athletic Trainer Services in the Secondary School Setting: The Athletic Training Locations and Services Project

Context Previous research from a sample of US secondary schools (n = 10 553) indicated that 67% of schools had access to an athletic trainer (AT; 35% full time [FT], 30% part time [PT], and 2% per diem). However, the population-based statistic in all secondary schools with athletic programs (n = approximately 20 000) is yet to be determined. Objective To determine the level of AT services and employment status in US secondary schools with athletics by National Athletic Trainers' Association district. Design Cross-sectional study. Setting Public and private secondary schools with athletics. Patients or Other Participants Data from all 20 272 US public and private secondary schools were obtained. Main Outcome Measure(s) Data were collected from September 2015 to April 2018 by phone or e-mail communication with school administrators or ATs and by online surveys of secondary school ATs. Employment categories were school district, school district with teaching, medical or university facility, and independent contractor. Data are presented as total number and percentage of ATs. Descriptive statistics were calculated for FT, PT, and no AT services data for public, private, public + private, and employment type by state and by National Athletic Trainers' Association district. Results Of the 20 272 secondary schools, 66% (n = 13 473) had access to AT services, while 34% (n = 6799) had no access. Of those schools with AT services, 53% (n = 7119) received FT services, while 47% (n = 6354) received PT services. Public schools (n = 16 076) received 37%, 32%, and 31%, whereas private schools (n = 4196) received 27%, 28%, and 45%, for FT, PT, and no AT services, respectively. Most of the Athletic Training Locations and Services Survey participants (n = 6754, 57%) were employed by a medical or university facility, followed by a school district, school district with teaching, and independent contractor. Combined, 38% of AT employment was via the school district. Conclusions The percentages of US schools with AT access and FT and PT services were similar to those noted in previous research. One-third of secondary schools had no access to AT services. The majority of AT employment was via medical or university facilities. These data depict the largest and most updated representation of AT services in secondary schools.

Commentary on International Experience Opportunities for Athletic Training Students: A Perspective from the National Athletic Trainers' Association International Committee

Context International experiences (eg, study abroad, international service projects) have many benefits, including increasing cultural sensitivity, that can enhance athletic training student development. However, international experiences directly related to athletic training may be limited or hard to identify. Objective To outline current and upcoming resources available through the work of the National Athletic Trainers' Association International Committee (IC) related to athletic training international experience opportunities. Background The IC collaborated with the Commission on Accreditation of Athletic Training Education to ask about international experiences available in accredited programs in the 2016–2017 annual report. Synthesis Data were analyzed from all accredited programs (N = 410). Results Data indicated that athletic training–specific international experiences are available at a lower rate (0%–10.6% of programs) than general university-sponsored international experiences (15.4%–84.4% of programs). Information on athletic training student and faculty involvement is limited; at least 1 student participated in 39.5% to 61.5% of programs, and at least 1 faculty member participated in 15.4% to 23.4% of programs. Recommendation(s) Future research should identify and describe current international experience opportunities, as well as identify strengths, challenges, and priorities for developing and expanding international opportunities for athletic training students. Conclusion(s) With the globalization of athletic training, emphasis on providing culturally competent care, and undergraduate opportunities created by the degree transition, it seems an opportune time to encourage international experiences for athletic training students. Current and future IC resources aim to provide guidance to students and faculty interested in international experiences.

Preventing catastrophic injury and death in collegiate athletes: interassociation recommendations endorsed by 13 medical and sports medicine organisations

The following organisations endorsed this document: American Association of Neurological Surgeons, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine, College Athletic Trainers’ Society, Collegiate Strength and Conditioning Coaches Association, Congress of Neurological Surgeons, Korey Stringer Institute, National Athletic Trainers’ Association, National Strength and Conditioning Association, National Operating Committee for Standards on Athletic Equipment, Sports Neuropsychology Society. The following organisation has affirmed the value of this document: American Academy of Neurology.The Second Safety in College Football Summit resulted in interassociation consensus recommendations for three paramount safety issues in collegiate athletics: (1) independent medical care for collegiate athletes; (2) diagnosis and management of sport-related concussion; and (3) year-round football practice contact for collegiate athletes. This document, the fourth arising from the 2016 event, addresses the prevention of catastrophic injury, including traumatic and non-traumatic death, in collegiate athletes. The final recommendations in this document are the result of presentations and discussions on key items that occurred at the summit. After those presentations and discussions, endorsing organisation representatives agreed on 18 foundational statements that became the basis for this consensus paper that has been subsequently reviewed by relevant stakeholders and endorsing organisations. This is the final endorsed document for preventing catastrophic injury and death in collegiate athletes. This document is divided into the following components. (1) Background—this section provides an overview of catastrophic injury and death in collegiate athletes. (2) Interassociation recommendations: preventing catastrophic injury and death in collegiate athletes—this section provides the final recommendations of the medical organisations for preventing catastrophic injuries in collegiate athletes. (3) Interassociation recommendations: checklist—this section provides a checklist for each member school. The checklist statements stem from foundational statements voted on by representatives of medical organisations during the summit, and they serve as the primary vehicle for each member school to implement the prevention recommendations. (4) References—this section provides the relevant references for this document. (5) Appendices—this section lists the foundational statements, agenda, summit attendees and medical organisations that endorsed this document.

Exploring Athletic Trainers' Self-Confidence for Interpreting Results from Concussion Assessments

Purpose To explore athletic trainers' self-confidence for interpreting results from concussion assessments. Methods An online survey was administered via the National Athletic Trainers’ Association (NATA) membership listserv to a cross-sectional sample of 10,000 certified athletic trainers (ATCs) employed in high school and collegiate settings. The survey included: 1) ATC demographics (i.e., age, sex, years of experience); 2) ATC concussion management practices (i.e., previous concussion training, continuing education received on concussion, concussion assessments administered); and 3) a 4-point Likert scale (1=no confidence, 4=high confidence) assessing ATC self-confidence for interpreting results from concussion assessments. A total of 725 ATCs completed the survey yielding a response rate of 7.25%; 114 were excluded for missing data and 611 ATCs were included in final analyses. Sample demographics, ATC concussion management practices, and ATC self-confidence scores were examined with demographic statistics (i.e., means, standard deviations, frequencies, percentages) for 16 commonly used concussion assessments. Results The sample of ATCs (mean age 38.97±14.89 years) was predominately female (59.2%) and reported an average of 10.08±7.58 years of clinical experience. Clinical examinations (63.2%) and symptom scales (61.4%) were among the most frequent assessments with high ATC self-confidence for interpretation. Vestibular/oculomotor measures (27.2%) and computerized neurocognitive testing (26.2%) were among the most frequent assessments with low ATC self-confidence for interpretation. Conclusion Low ATC self-confidence scores for interpreting results from vestibular/oculomotor measures and computerized neurocognitive testing highlight the importance of incorporating a multi-disciplinary team approach and including sport neuropsychologists for the proper management of concussion.