Six months ago tornadoes tore through metropolitan Mobile. Luckily, University of Strops was largely unaffected, however after the disaster, the administration realized they needed to updat

You are the managing partner of a marketing consulting firm that specializes in athletics and sports management. Your firm includes the following departments: legal, public relations, accounting, management consulting, talent representation, and event management.

University of Strops Athletic Department

Location: Mobile, AL Enrollment: 10,000 with a 70% acceptance rate Male = 6,000, Female = 4,000 African-American = 75%, Caucasian = 20%, Other = 5% NCAA Division III member (no athletic scholarships) Conference: We Are Strops Universities & Schools (WASUS), which has 12 members Mascot: Dolphins Student-Athletes: 1,200 Male = 400, Female = 700 Sports: Male Female Basketball Basketball Golf Field Hockey Lacrosse Gymnastics Soccer Lacrosse Soccer Softball Volleyball Administrative Staff: Interim athletic director (female) Assistant athletic director (male) Administrative assistant (female) Sports information director (female) Athletic trainer (male) Compliance coordinator (male) Coaching Staff: All head coaches are full-time with part-time assistant coaches Men coach all men’s sports, women’s basketball, soccer, softball, & volleyball Women coach field hockey, gymnastics, & lacrosse There has been little turnover in the department, the newest coach (field hockey) was hired five years ago, and all staff members are relatively happy in their jobs. Granted they

would like to put more wins in the books, but they believe everything is cyclical, and they will start winning again soon. Budget Information: The previous athletic director felt each team should receive the same amount of money regardless of travel schedule, team size, officiating needs, equipment needs, etc. Facility and field maintenance costs are covered by the institutional budget. The department is allocated $500,000 annually, not including salaries. This must cover the following: equipment, officiating, team travel, department travel (meetings, etc.), team meals, recruiting, publicity, compliance, event management, conference fees, athletic training, post-season, conference fees, uniforms (four-year replacement cycle per team), and incidentals. Team Results/Records: Men’s and women’s basketball both finished within two games above or below .500 for the fifth straight year. Field hockey lost in the conference championship, and returns all starters from that team. Golf finished fourth in the conference and sent one golfer to the NCAA Championships. Men’s lacrosse finished one game above .500, their worst record in five years. Men’s soccer finished one game above .500, their best record in five years. Gymnastics won their third straight conference championship, and sent four gymnasts to the NCAA Championships. Women’s lacrosse finished .500, their best record in five years. Women’s soccer finished two games above .500, their worst record in five years. Softball finished third in the conference with a .750 record, improving on last year’s .500 finish, which was their first record of .500 or more in five years. Women’s volleyball went undefeated in conference play winning their first conference championship and advanced to the second round of the NCAA Tournament. This was their fifth straight winning season, and first trip to the NCAA Tournament. Your firm has been hired to represent the University of Strops athletic department.

Journal of Athletic Training 99

Journal of Athletic Training 2002;37(1):99–104 q by the National Athletic Trainers’ Association, Inc www.journalofathletictraining.org

National Athletic Trainers’ Association Position Statement: Emergency Planning in Athletics J. C. Andersen*; Ronald W. Courson†; Douglas M. Kleiner‡; Todd A. McLoda§

*Armstrong Atlantic State University, Savannah, GA; †University of Georgia, Athens, GA; ‡University of Florida, Health Science Center/Jacksonville, Jacksonville, FL; §Illinois State University, Normal, IL

J. C. Andersen, PhD, ATC, PT, SCS, contributed to conception and design; acquisition and analysis and interpretation of the data; and drafting, critical revision, and final approval of the article. Ronald W. Courson, ATC, PT, NREMT-I, CSCS, Douglas M. Kleiner, PhD, ATC, CSCS, NREMT, FACSM, and Todd A. McLoda, PhD, ATC, contributed to acquisition and analysis and interpretation of the data and drafting, critical revision, and final approval of the article. Address correspondence to National Athletic Trainers’ Association, Communications Department, 2952 Stemmons Freeway, Dallas, TX 75247.

Objectives: To educate athletic trainers and others about the need for emergency planning, to provide guidelines in the de- velopment of emergency plans, and to advocate documentation of emergency planning.

Background: Most injuries sustained during athletics or oth- er physical activity are relatively minor. However, potentially limb-threatening or life-threatening emergencies in athletics and physical activity are unpredictable and occur without warning. Proper management of these injuries is critical and should be carried out by trained health services personnel to minimize risk to the injured participant. The organization or institution and its personnel can be placed at risk by the lack of an emergency plan, which may be the foundation of a legal claim.

Recommendations: The National Athletic Trainers’ Associ- ation recommends that each organization or institution that sponsors athletic activities or events develop and implement a written emergency plan. Emergency plans should be developed by organizational or institutional personnel in consultation with

the local emergency medical services. Components of the emergency plan include identification of the personnel involved, specification of the equipment needed to respond to the emer- gency, and establishment of a communication system to sum- mon emergency care. Additional components of the emergency plan are identification of the mode of emergency transport, specification of the venue or activity location, and incorporation of emergency service personnel into the development and im- plementation process. Emergency plans should be reviewed and rehearsed annually, with written documentation of any modifications. The plan should identify responsibility for docu- mentation of actions taken during the emergency, evaluation of the emergency response, institutional personnel training, and equipment maintenance. Further, training of the involved per- sonnel should include automatic external defibrillation, cardio- pulmonary resuscitation, first aid, and prevention of disease transmission.

Key Words: policies and procedures, athletics, planning, cat- astrophic

Although most injuries that occur in athletics are rela- tively minor, limb-threatening or life-threatening in- juries are unpredictable and can occur without warn-

ing.1 Because of the relatively low incidence rate of cata- strophic injuries, athletic program personnel may develop a false sense of security over time in the absence of such inju- ries.1–4 However, these injuries can occur during any physical activity and at any level of participation. Of additional concern is the heightened public awareness associated with the nature and management of such injuries. Medicolegal interests can lead to questions about the qualifications of the personnel in- volved, the preparedness of the organization for handling these situations, and the actions taken by program personnel.5

Proper emergency management of limb- or life-threatening injuries is critical and should be handled by trained medical and allied health personnel.1–4 Preparation for response to emergencies includes education and training, maintenance of emergency equipment and supplies, appropriate use of person-

nel, and the formation and implementation of an emergency plan. The emergency plan should be thought of as a blueprint for handling emergencies. A sound emergency plan is easily understood and establishes accountability for the management of emergencies. Furthermore, failure to have an emergency plan can be considered negligence.5

POSITION STATEMENT

Based on an extensive survey of the literature and expert review, the following is the position of the National Athletic Trainers’ Association (NATA):

1. Each institution or organization that sponsors athletic ac- tivities must have a written emergency plan. The emer- gency plan should be comprehensive and practical, yet flexible enough to adapt to any emergency situation.

2. Emergency plans must be written documents and should be distributed to certified athletic trainers, team and at-

100 Volume 37 • Number 1 • March 2002

tending physicians, athletic training students, institutional and organizational safety personnel, institutional and or- ganizational administrators, and coaches. The emergency plan should be developed in consultation with local emer- gency medical services personnel.

3. An emergency plan for athletics identifies the personnel involved in carrying out the emergency plan and outlines the qualifications of those executing the plan. Sports med- icine professionals, officials, and coaches should be trained in automatic external defibrillation, cardiopulmo- nary resuscitation, first aid, and prevention of disease transmission.

4. The emergency plan should specify the equipment needed to carry out the tasks required in the event of an emer- gency. In addition, the emergency plan should outline the location of the emergency equipment. Further, the equip- ment available should be appropriate to the level of train- ing of the personnel involved.

5. Establishment of a clear mechanism for communication to appropriate emergency care service providers and identi- fication of the mode of transportation for the injured par- ticipant are critical elements of an emergency plan.

6. The emergency plan should be specific to the activity ven- ue. That is, each activity site should have a defined emer- gency plan that is derived from the overall institutional or organizational policies on emergency planning.

7. Emergency plans should incorporate the emergency care facilities to which the injured individual will be taken. Emergency receiving facilities should be notified in ad- vance of scheduled events and contests. Personnel from the emergency receiving facilities should be included in the development of the emergency plan for the institution or organization.

8. The emergency plan specifies the necessary documenta- tion supporting the implementation and evaluation of the emergency plan. This documentation should identify re- sponsibility for documenting actions taken during the emergency, evaluation of the emergency response, and in- stitutional personnel training.

9. The emergency plan should be reviewed and rehearsed annually, although more frequent review and rehearsal may be necessary. The results of these reviews and re- hearsals should be documented and should indicate wheth- er the emergency plan was modified, with further docu- mentation reflecting how the plan was changed.

10. All personnel involved with the organization and spon- sorship of athletic activities share a professional respon- sibility to provide for the emergency care of an injured person, including the development and implementation of an emergency plan.

11. All personnel involved with the organization and spon- sorship of athletic activities share a legal duty to develop, implement, and evaluate an emergency plan for all spon- sored athletic activities.

12. The emergency plan should be reviewed by the adminis- tration and legal counsel of the sponsoring organization or institution.

BACKGROUND FOR THIS POSITION STAND

Need for Emergency Plans Emergencies, accidents, and natural disasters are rarely pre-

dictable; however, when they do occur, rapid, controlled re-

sponse will likely make the difference between an effective and an ineffective emergency response. Response can be hin- dered by the chaotic actions and increased emotions of those who make attempts to help persons who are injured or in dan- ger. One method of control for these unpredictable events is an emergency plan that, if well designed and rehearsed, can provide responders with an organized approach to their reac- tion. The development of the emergency plan takes care and time to ensure that all necessary contingencies have been in- cluded. Lessons learned from major emergencies are also im- portant to consider when developing or revising an emergency plan.

Emergency plans are applicable to agencies of the govern- ment, such as law enforcement, fire and rescue, and federal emergency management teams. Furthermore, the use of emer- gency plans is directly applicable to sport and fitness activities due to the inherent possibility of ‘‘an untoward event’’ that requires access to emergency medical services.6 Of course, when developing an emergency plan for athletics, there is one notable difference from those used by local, state, and federal emergency management personnel. With few exceptions, typ- ically only one athlete, fan, or sideline participant is at risk at one time due to bleeding, internal injury, cardiac arrest, shock, or traumatic head or spine injury. However, emergency plan- ning in athletics should account for an untoward event involv- ing a game official, fan, or sideline participant as well as the participating athlete. Although triage in athletic emergency sit- uations may be rare, this does not minimize the risks involved and the need for carefully prepared emergency care plans. The need for emergency plans in athletics can be divided into 2 major categories: professional and legal.

Professional Need. The first category for consideration in determining the need for emergency plans in athletics is or- ganizational and professional responsibility. Certain governing bodies associated with athletic competition have stated that institutions and organizations must provide for access to emer- gency medical services if an emergency should occur during any aspect of athletic activity, including in-season and off- season activities.6 The National Collegiate Athletic Associa- tion (NCAA) has recommended that all member institutions develop an emergency plan for their athletic programs.7 The National Federation of State High School Associations has recommended the same at the secondary school level.8 The NCAA states, ‘‘Each scheduled practice or contest of an in- stitution-sponsored intercollegiate athletics event, as well as out-of-season practices and skills sessions, should include an emergency plan.’’6 The 1999–2000 NCAA Sports Medicine Handbook further outlines the key components of the emer- gency plan.6

Although the 1999–2000 NCAA Sports Medicine Handbook is a useful guide, a recent survey of NCAA member institu- tions revealed that at least 10% of the institutions do not main- tain any form of an emergency plan.7 In addition, more than one third of the institutions do not maintain emergency plans for the off-season strength and conditioning activities of the sports.

Personnel coverage at NCAA institutions was also found to be an issue. Nearly all schools provided personnel qualified to administer emergency care for high-risk contact sports, but fewer than two thirds of institutions provided adequate per- sonnel to sports such as cross-country and track.9 In a mem- orandum dated March 25, 1999, and sent to key personnel at

Journal of Athletic Training 101

all schools, the president of the NCAA reiterated the recom- mendations in the 1999–2000 NCAA Sports Medicine Hand- book to maintain emergency plans for all sport activities, in- cluding skill instruction, conditioning, and the nontraditional practice seasons.8

A need for emergency preparedness is further recognized by several national organizations concerned with the delivery of health care services to fitness and sport participants, in- cluding the NATA Education Council,10 NATA Board of Cer- tification, Inc,11 American College of Sports Medicine, Inter- national Health Racquet and Sports Club Association, American College of Cardiology, and Young Men’s Christian Association.12 The NATA-approved athletic training educa- tional competencies for athletic trainers include several refer- ences to emergency action plans.10 The knowledge of the key components of an emergency plan, the ability to recognize and appraise emergency plans, and the ability to develop emer- gency plans are all considered required tasks of the athletic trainer.11 These responsibilities justify the need for the athletic trainer to be involved in the development and application of emergency plans as a partial fulfillment of his or her profes- sional obligations.

In addition to the equipment and personnel involved in emergency response, the emergency plan must include consid- eration for the sport activity and rules of competition, the weather conditions, and the level of competition.13 The vari- ation in these factors makes venue-specific planning necessary because of the numerous contingencies that may occur. For example, many youth sport activities include both new partic- ipants of various sizes who may not know the rules of the activity and those who have participated for years. Also, out- door sport activities include the possibility of lightning strikes, excessive heat and humidity, and excessive cold, among other environmental concerns that may not be factors during indoor activities. Organizations in areas of the country in which snow may accumulate must consider provisions for ensuring that accessibility by emergency vehicles is not hampered. In ad- dition, the availability of safety equipment that is necessary for participation may be an issue for those in underserved areas. The burden of considering all the possible contingencies in light of the various situations must rest on the professionals, who are best trained to recognize the need for emergency plans and who can develop and implement the venue-specific plans.

Legal Need. Also of significance is the legal basis for the development and application of an emergency plan. It is well known that organizational medical personnel, including certi- fied athletic trainers, have a legal duty as reasonable and pru- dent professionals to ensure high-quality care of the partici- pants. Of further legal precedence is the accepted standard of care by which allied health professionals are measured.14 This standard of care provides necessary accountability for the ac- tions of both the practitioners and the governing body that oversees those practitioners. The emergency plan has been cat- egorized as a written document that defines the standard of care required during an emergency situation.15 Herbert16 em- phasized that well-formulated, adequately written, and peri- odically rehearsed emergency response protocols are absolute- ly required by sports medicine programs. Herbert16 further stated that the absence of an emergency plan frequently is the basis for claim and suit based on negligence.

One key indicator for the need for an emergency action plan is the concept of foreseeability. The organization administra- tors and the members of the sports medicine team must ques-

tion whether a particular emergency situation has a reasonable possibility of occurring during the sport activity in ques- tion.14,15,17 For example, if it is reasonably possible that a catastrophic event such as a head injury, spine injury, or other severe trauma may occur during practice, conditioning, or competition in a sport, a previously prepared emergency plan must be in place. The medical and allied health care personnel must constantly be on guard for potential injuries, and al- though the occurrence of limb-threatening or life-threatening emergencies is not common, the potential exists. Therefore, prepared emergency responders must have planned in advance for the action to be taken in the event of such an emergency.

Several legal claims and suits have indicated or alluded to the need for emergency plans. In Gathers v Loyola Marymount University,18 the state court settlement included a statement that care was delayed for the injured athlete, and the plaintiffs further alleged that the defendants acted negligently and care- lessly in not providing appropriate emergency response. These observations strongly support the need to have clear emergen- cy plans in place, rehearsed, and carried out. In several addi- tional cases,19–21 the courts have stated that proper care was delayed, and it can be reasoned that these delays could have been avoided with the application of a well-prepared emer- gency plan.

Perhaps the most significant case bearing on the need for emergency planning is Kleinknecht v Gettysburg College, which came before the appellate court in 1993.5,17 In a portion of the decision, the court stated that the college owed a duty to the athletes who are recruited to be athletes at the institution. Further, as a part of that duty, the college must provide ‘‘prompt and adequate emergency services while engaged in the school-sponsored intercollegiate athletic activity for which the athlete had been recruited.’’17 The same court further ruled that reasonable measures must be ensured and in place to pro- vide prompt treatment of emergency situations. One can con- clude from these rulings that planning is critical to ensure prompt and proper emergency medical care, further validating the need for an emergency plan.5

Based on the review of the legal and professional literature, there is no doubt regarding the need for organizations at all levels that sponsor athletic activities to maintain an up-to-date, thorough, and regularly rehearsed emergency plan. Further- more, members of the sports medicine team have both legal and professional obligations to perform this duty to protect the interests of both the participating athletes and the organization or institution. At best, failure to do so will inevitably result in inefficient athlete care, whereas at worst, gross negligence and potential life-threatening ramifications for the injured athlete or organizational personnel are likely.

Components of Emergency Plans

Organizations that sponsor athletic activities have a duty to develop an emergency plan that can be implemented im- mediately and to provide appropriate standards of health care to all sports participants.5,14,15,17 Athletic injuries may occur at any time and during any activity. The sports medicine team must be prepared through the formulation of an emergency plan, proper coverage of events, maintenance of appropriate emergency equipment and supplies, use of appropriate emer- gency medical personnel, and continuing education in the area of emergency medicine. Some potential emergencies may be averted through careful preparticipation physical

102 Volume 37 • Number 1 • March 2002

Sample Venue-Specific Emergency Protocol

University Sports Medicine Football Emergency Protocol

1. Call 911 or other emergency number consistent with organizational policies 2. Instruct emergency medical services (EMS) personnel to ‘‘report to and meet at as we have an

injured student-athlete in need of emergency medical treatment.’’ University Football Practice Complex: Street entrance (gate across street from ) cross street: Street University Stadium: Gate entrance off Road

3. Provide necessary information to EMS personnel: ● name, address, telephone number of caller ● number of victims; condition of victims ● first-aid treatment initiated ● specific directions as needed to locate scene ● other information as requested by dispatcher

4. Provide appropriate emergency care until arrival of EMS personnel: on arrival of EMS personnel, provide pertinent information (method of injury, vital signs, treatment rendered, medical history) and assist with emergency care as needed

Note:

● sports medicine staff member should accompany student-athlete to hospital ● notify other sports medicine staff immediately ● parents should be contacted by sports medicine staff ● inform coach(es) and administration ● obtain medical history and insurance information ● appropriate injury reports should be completed

Emergency Telephone Numbers Hospital – Emergency Department –

University Health Center – Campus Police –

Emergency Signals

Physician: arm extended overhead with clenched first Paramedics: point to location in end zone by home locker room and wave onto field Spine board: arms held horizontally Stretcher: supinated hands in front of body or waist level Splints: hand to lower leg or thigh

screenings, adequate medical coverage, safe practice and training techniques, and other safety measures.1,22 However, accidents and injuries are inherent with sports participation, and proper preparation on the part of the sports medicine team will enable each emergency situation to be managed appropriately.

The goal of the sports medicine team is the delivery of the highest possible quality health care to the athlete. Management of the emergency situation that occurs during athletic activities may involve certified athletic trainers and students, emergency medical personnel, physicians, and coaches working together. Just as with an athletic team, the sports medicine team must work together as an efficient unit to accomplish its goals.22 In an emergency situation, the team concept becomes even more critical, because time is crucial and seconds may mean the difference among life, death, and permanent disability. The sharing of information, training, and skills among the various emergency medical care providers helps reach the goal.22,23

Implementation. Once the importance of the emergency plan is realized and the plan has been developed, the plan must be implemented. Implementation of the emergency plan re- quires 3 basic steps.23

First, the plan must be committed to writing (Table) to pro- vide a clear response mechanism and to allow for continuity among emergency team members.14,16 This can be accom- plished by using a flow sheet or an organizational chart. It is also important to have a separate plan or to modify the plan

for different athletic venues and for practices and games. Emergency team members, such as the team physician, who are present at games may not necessarily be present at prac- tices. Moreover, the location and type of equipment and com- munication devices may differ among sports, venues, and ac- tivity levels.

The second step is education.23 It is important to educate all the members of the emergency team regarding the emer- gency plan. All personnel should be familiar with the emer- gency medical services system that will provide coverage to their venues and include their input in the emergency plan. Each team member, as well as institution or organization ad- ministrators, should have a written copy of the emergency plan that provides documentation of his or her roles and responsi- bilities in emergency situations. A copy of the emergency plan specific to each venue should be posted prominently by the available telephone.

Third, the emergency plan and procedures have to be re- hearsed.16 This provides team members a chance to maintain their emergency skills at a high level of competency. It also provides an opportunity for athletic trainers and emergency medical personnel to communicate regarding specific policies and procedures in their particular region of practice.22 This rehearsal can be accomplished through an annual in-service meeting, preferably before the highest-risk sports season (eg, football, ice hockey, lacrosse). Reviews should be undertaken as needed throughout the sports season, because emergency medical procedures and personnel may change.

Journal of Athletic Training 103

Personnel. In an athletic environment, the first person who responds to an emergency situation may vary widely22,24; it may be a coach or a game official, a certified athletic trainer, an emergency medical technician, or a physician. This varia- tion in the first responder makes it imperative that an emer- gency plan be in place and rehearsed. With a plan in place and rehearsed, these differently trained individuals will be able to work together as an effective team when responding to emergency situations.

The plan should also outline who is responsible for sum- moning help and clearing the uninjured from the area.

In addition, all personnel associated with practices, com- petitions, skills instruction, and strength and conditioning ac- tivities should have training in automatic external defibrillation and current certification in cardiopulmonary resuscitation, first aid, and the prevention of disease transmission.5,7

Equipment. All necessary supplemental equipment should be at the site and quickly accessible.13,25 Equipment should be in good operating condition, and personnel must be trained in advance to use it properly. Improvements in technology and emergency training require personnel to become familiar with the use of automatic external defibrillators, oxygen, and ad- vanced airways.

It is imperative that health professionals and organizational administrators recognize that recent guidelines published by the American Heart Association call for the availability and use of automatic external defibrillators and that defibrillation is considered a component of basic life support.26 In addition, these guidelines emphasize use of the bag-valve mask in emer- gency resuscitation and the use of emergency oxygen and ad- vanced airways in emergency care. Personnel should consider receiving appropriate training for these devices and should limit use to devices for which they have been trained.

To ensure that emergency equipment is in working order, all equipment should be checked on a regular basis. Also, the use of equipment should be regularly rehearsed by emergency personnel, and the emergency equipment that is available should be appropriate for the level of training of the emergen- cy medical provi

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