Assessing Risks Related to the Sports Medicine and Athletics Training Programs

The following risk assessment article is excerpted from a prepublication manuscript:  Lopiano, D.A. and Zotos, C. (Publication 2013) The Athletics Director’s Handbook: A Comprehensive Practical Guide to the Management of Scholastic and Intercollegiate Athletics Programs. Champaign, IL: Human Kinetics.

The training room and all sports medicine and other policies, procedures, and actions related to treating injuries or ensuring the health and well-being of student-athletes is an area fraught with legal risk from the standpoint of negligence.  A good way to ensure an effective oversight process is to charge the staff member responsible for the athletics training program to annually complete a risk assessment checklist to identify deficiencies and to present a plan to remedy identified weaknesses. 

Authority, Policies, Staffing and Operations

1. Has a medical doctor been appointed as the “Team Physician” responsible for overall medical oversight of the athletics training program and staff?
2. Is the Team Physician available to the athletics trainers for consultation whenever needed?
3. Are the head and assistant athletics trainers National Association of Athletic Trainers (NATA) board certified and licensed athletics trainers in the state where the institution is located?  
4. Is the athletics training program responsible for maintaining complete documentation of student-athlete health care screening, medical history, the treatment of injuries (including symptoms, responses and progress), physician diagnosis, and consultation with specialists?
5. Does an athletics department policy exist regarding the student-athlete’s right to privacy and protection of confidential information unless obligated or allowed by law to disclose such information?
6. Are athletics trainers responsible for consultation with appropriate licensed medical practitioners in the design of treatment strategies?
7. Are athletics trainers mandated by policy to seek clarification of any instructions or treatment regimens that they have reason to believe to be inaccurate or contraindicated?
8. Do athletics department policies permit student-athletes to use the services of any physician at his/her own expense and without the approval of the team physician?
9. Have consulting physicians been appointed by the athletics department team physician in the areas of orthopedics, gynecology, dentistry, internal medicine, allergies and immunology, dermatology, cardiology, ophthalmology and other specialty areas as determined by student-athlete health care needs?
10. Does athletics department policy require that the employment and/or association on a paid or voluntary basis of allied health care professionals (i.e. chiropractors, massage therapists, nutritionists, etc.) be approved by the Team Physician and head athletics trainer according to established procedures.
11. Does athletics department policy require that coaches and athletic trainers ensure that allied health care personnel provide their services in professional settings (i.e., training room, locker room, etc.) as opposed to home, dormitory, or hotel rooms?
12. Does athletics department policy require that the work of allied health professional personnel be under the direct supervision of a full-time member of the coaching or athletics training staff?
13. Does athletics department policy require that allied health care professionals document all treatments rendered?
14. Does athletics department policy hold the head athletic trainer responsible for maintaining a state-of-the-art athletics training room that contains all required modalities for treatment, sufficient consumable supplies to meet the needs of the athletic training staff, and that such facility is operated with the highest standard of care and cleanliness that diminishes the possibility of contamination by blood-borne pathogens or infectious diseases?
15. Does athletics department policy require that all prescription and non-prescription drugs and supplements be kept in locked cabinets and that distribution and use procedures adequately control or supervise access?
16. Does an athletics department policy exist that establishes standards of dress for treatments and conduct of student-athletes in the training room and are the athletics training staff and coaches  charged with enforcing such standards to ensure the health and safety of training room occupants?

Distribution of Drugs and Supplements

1. Non-medical employees, including coaches, are strictly prohibited, under all circumstances, from dispensing or recommending for the improvement of health or performance, any drug, medication, vitamin, nutritional or ergogenic aid, or other ingestible solid or liquid supplement purported to improve health or performance to any student-athlete. 
2. A policy exists specifying that the distribution of any drug, medication, vitamin, nutritional or ergogenic aid, or other ingestible solid or liquid supplement purported to improve health or performance to any student-athlete by non-medical personnel is grounds for immediate termination of employment.
3. A policy exists prohibiting non-medical employees from distributing to any student-athlete any prescription or over-the-counter medicines, including aspirins, cold medicines, etc.  
4. Athletics department policy specifically encourages coaches to promote the intake of water, Gatorade or other fluid replenishments provided by the athletic training staff and prohibits coaches from withholding or limiting fluid intake during any practice session.  
5. A policy exists specifying that only NATA board certified and state licensed athletics trainers are authorized to administer prescription drugs under the direction and supervision of a prescribing physician according to specific department procedures. 
6. A policy exists specifying that only a NATA board certified and state licensed athletics trainer is authorized to distribute over-the-counter drugs under written standing orders that specify specific circumstances or symptoms.   
7. A policy exists specifying that only NATA board certified and state licensed athletics trainers or a student trainer under his/her direct supervision is authorized to distribute iron, calcium and vitamin supplements according to recommended daily allowances (RDA) or in therapeutic dosages when documented and recommended by a physician.
8. A policy exists specifying that whenever a prescription, over-the-counter (OTC) drug or nutritional supplement is given to a student-athlete:  (a) a written record of the athlete’s name, indications for use, the medication, dosage, frequency and date dispensed must be recorded; (b) the athletics trainer administering the medication is expected to convey orally and in writing, information about the drug, indications for use, side effects, and interactions with other drugs or foods; (c)  the athletics trainer administering the drug shall assess the athlete’s understanding of compliance with the medication regimen; (d) if subsequent student-athlete self-administered dosages are specified, such medication shall be provided in a unit dose package or in an envelope or dispensing container marked with the athlete’s name, the dispensing date, the name of the drug, quantity and directions for use; and (e) minors shall not be provided with over-the-counter medications without parental consent, such consent and administration being recorded and that record kept on file.
9. A policy exists that specifies that prescription and non-prescription drugs used by the athletics training staff are required to be stored under lock and key in a location under the direct supervision of the athletics trainer.

Disordered Eating

1. Does an athletics department policy exist that prohibits the weighing of student-athletes in non-weight controlled sports, with the exception of weigh-ins related to high heat conditions and the loss of fluids?
2. Does part of the required athletics department pre-participation medical screening questionnaire specifically address nutrition and eating disorder screening questions?
3. Is a training session conducted at the beginning of the school year for coaches and athletic trainers on the identification, referral, and treatment of athletes with eating disorders?
4. Has an eating disorder treatment team been designated with the head athletics trainer serving as athletics department liaison to the team?
5. Does a comprehensive athletics department policy exist on the identification and treatment of eating disorders, including the right to restrict participation of medically unstable athletes?
6. Has a senior staff administrator been designated to work with the athletics training staff and external medical/psychological service providers regarding athletes with eating disorders and the enforcement of eating disorder policy guidelines?

Medical Screening

1. Does a policy exists that requires a pre-participation initial medical evaluation that includes a comprehensive health history, immunization history as defined by current Centers for Disease Control and Prevention (CDC) guidelines and a relevant physical exam, with strong emphasis on the cardiovascular, neurologic and musculoskeletal evaluation?
2. After the initial entry medical evaluation, does the athletics department require an updated history of the student-athlete's medical condition which is administered by an institutional medical staff member (e.g., sports medicine staff, team physician) to determine if additional examinations (e.g., physical, cardiovascular, neurological) are required?
3. Does the athletics department have a policy requiring pre-participation screening for the CDC recommended immunizations – MMR, hepatitis B, diphtheria, tetanus, and meningitis?   
4. Are follow-up examinations required for those student-athletes who have sustained a significant injury or illness during the sports season to re-establish medical clearance before resuming participation in their respective sports?
5. Does the institution screen for sickle cell trait?
6. Does the institution have a comprehensive concussion policy and return to play procedure?
7. Do all athletics staff members understand that the medical records it keeps are subject to federal and state law? Has the institution’s legal counsel been consulted and rendered an opinion regarding the confidentiality and content of student-athletes’ medical records?
8. Does the athletics department have clear written guidelines about the creation, maintenance and release of medical records and the information they contain and are all personnel who have access to student-athletes’ medical records familiar with such guidelines and informed of their role in maintaining the student-athlete’s right to privacy?
9. Does an athletics department policy exist requiring that each student-athlete annually sign a permission form that authorizes the release of medical information to others, specifying all persons authorized to receive such information, and the type of medical information that may be released?

Physical Activity in Extreme Conditions of Heat or Cold

1. Does the athletics training staff produce team hydration protocols for each sport each season that (1) consider the uniqueness of each sport, (2) are approved by the team physician, and (3) transmitted to all coaches and the athletics training staff?
2. Does the athletics training staff conduct a thorough, physician-supervised, pre-participation medical screening before the season starts to identify student-athletes predisposed to heat illness on the basis of risk factors and those who have a history of exertional heat illness?  Are individual hydration protocols designed for each of these identified student-athletes, submitted to the team physician for approval, to the appropriate coaches and training staff, and explained at meetings with affected student-athletes?
3. Does the athletics department educate student-athletes on the effects of dehydration and the factors for risk via seasonally conducted health and awareness sessions implemented by coaches and training staff?
4. Does the athletics training staff provide informational postings at practice facilities and training rooms to maintain awareness of the importance of adequate hydration?
5. In conditions of extreme heat, are coaches instructing athletes to wear clothing at practice and competition that is lighter in color and/or fabric, regardless of school colors?
6. Does the athletics training staff transmit to all coaches, recommendations from national medical and athletics training associations regarding the identification of symptoms and procedures to lessen the risk and prevent the likelihood of heat-related illness occurring among its student-athletes?
7. Do certified athletic trainers and other health care providers attending practices or events have the authority to evaluate and examine any student-athlete who displays signs or symptoms of heat or cold related illness and restrict the student-athlete from participating if symptoms are present?
8. Do coaches and the athletics training staff work together to ensure that practice workloads are adapting student-athletes to exercise in the heat (acclimatization) gradually over 10 to 14 days?
9. Does the athletics training staff supervise a practice of weighing high-risk student-athletes and, in high-risk conditions, weighing all student-athletes, before and after practice to estimate the amount of body fluids lost during practice and to ensure a return to pre-practice weight before the next practice?
10. Are all of the following supplies available to the certified athletics training staff to use on the field, in the locker room, and at various other stations to meet heat-related concerns: (a) a supply of cool water or sports drinks or both; (b) ice for active cooling (ice bags, tub cooling) and to keep beverages and student-athletes cool during exercise; (c) rectal thermometer to assess body-core temperature; (d)  telephone or 2-way radio to communicate with medical personnel and to summon emergency medical transportation if necessary; and (e)  tub, wading pool, kiddy pool, or whirlpool to cool the trunk and extremities via immersion cooling therapy?
11. Does the athletics training staff conduct a thorough, physician-supervised, pre-participation medical screening before the season starts to identify student-athletes predisposed to cold-related illness on the basis of risk factors and those who have a history of cold-related illness?
12. Does the athletics training staff educate student-athletes and coaches concerning the prevention, recognition, and treatment of heat-related and cold-related injury and the risks associated with activity in high heat, high humidity or extremely cold environments?
13. Does the athletics training staff follow event and practice policies that ensure proper management of student-athletes participating in cold, windy, and wet conditions, including the use of wind-chill guidelines that consider the effect of wind speed on the influence of air temperature?
14. Does the athletics training staff work with coaches to ensure that student-athletes’ wear proper clothing when participating in cold, windy, and wet conditions (i.e., an internal layer that allows evaporation of sweat with minimal absorption, a middle layer that provides insulation, and a removable external layer that is wind and water resistant and allows for evaporation of moisture)?
15. In conditions of intense cold, are student-athletes instructed to re-warm, as needed, during and after activity using external heaters, a warm indoor environment, and/or the addition of clothing?
16. In conditions of intense cold, does the athletics training staff provide all of the following supplies on the field, in the locker room, or at convenient aid stations:  (a) a supply of water or sports drinks for rehydration purposes as well as warm fluids for possible re-warming purposes; (b) insulated containers for fluids that may freeze during events in subfreezing temperatures or procedures assuring intermittent replacement; (c) heat packs, blankets, additional clothing, and external heaters, if feasible, for active re-warming; (d) flexible rectal thermometer probe to assess core body temperature, which is a low-reading thermometer (i.e. capable of measuring temperatures below 956F [356C]); (e) telephone or 2-way radio to communicate with additional medical personnel and to summon emergency medical transportation; and (f) tub, wading pool, or whirlpool for immersion warming treatments (including a thermometer and additional warm water to maintain required temperatures)

Control of Blood-Borne Pathogens and Infectious Diseases.

1. Is an annual training session conducted at the beginning of the school year to review standard precautions and all policies related to blood-borne pathogens and infectious diseases with the coaching staff, athletics trainers, team managers, event management and facilities staff, and other appropriate support staff?  Has a specific employee been designated to conduct such standard precautions training and to review all policies with coaches or support staff that have been hired after the annual training has completed?
2. If wrestling is a sport within the athletics program, has a specific employee been designated to educate wrestling coaches on the NCAA guidelines regarding skin infections in wrestling?
3. Has an employee been designated as responsible for ensuring that all supplies and equipment are available to coaches for the proper care of contaminated environmental surfaces per OHSA Standard Precautions?
4. Has a specific employee has been designated to ensure a first aid kit has been distributed to all coaches and they have been instructed on how to initially control an athlete’s bleeding wound?
5. Is athletics department policy in full alignment and compliance with OSHA standards for blood-borne pathogens and NCAA Sports Medicine Handbook guidelines?
6. Does athletics department policy prohibit mandatory HIV testing or participation restrictions of individuals with HIV?

References: 

Binkley, H.M., Beckett, J., Casa, D.J., Kleiner, D.M, and Plummer, P.E. (2002)  National athletic trainers’ association position statement:  Exertional heat illnesses.  Journal of Athletic Training, 37 (3): 329-343.  Retrieved on September 2, 2011, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164365/

Casa, Douglas J., and Susan K. Hillman. 2000. "National Athletic Trainers' Association Position Statement: Fluid Replacement for Athletes." Journal of Athletic Training 35, no. 2: 212.

Centers for Disease Control and Prevention. (2011) Recommended immunization schedule for persons aged 7-18 years – United States – 2011.  Retrieved on September 1, 2011, from  http://www.cdc.gov/vaccines/recs/schedules/downloads/child/7-18yrs-schedule-bw.pdf.

Centers for Disease Control and Prevention. (2011)  Universal precautions for preventing transmission of bloodborne infections.  Retrieved on September 1, 2011, from http://www.cdc.gov/niosh/topics/bbp/universal.html

DeFranco, M.J., Baker, C.L., DaSilva, J.J., Piasecki, D.P, and Bach, B.R. (2008) Environmental issues for team physicians.  American Journal of Sports Medicine, 36(11).  Retrieved on September 2, 2011, from http://www.bachmd.com/Files/enviromental%20issues774.pdf

Guskiewicz, K.M., S.L. Bruce, R.C. Cantu, M.S. Ferrara, J.P. Kelly, M. McCrea, M. Putukian, T.C. Valovich McLeod.  (2004)  National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion.  Journal of Athletic Training, 2004; 39(3):280-297.  http://www.csmfoundation.org/NATA_Position_Statement.pdf

Inter-Association Task Force. (2003)  Consensus statement on exertional heat illness.  Retrieved on September 2, 2011, from http://www.the-aps.org/news/consensus.pdf

Joy, E. (2002)  Heat illness.  Gatorade Sports Science Institute Sports Medicine Tip Sheet.  Retrieved on September 2, 2011, from http://www.amssm.org/MemberFiles/Heatillness.pdf

National Athletic Trainers Association.  (2001)  Emergency medical plan.  Retrieved on September 2, 2011, from http://www.nata.org/emergency-medical-plan

National Athletic Trainers Association.  (2004)  National athletic trainers association position statement:  Management of sport related concussion.  Journal of Athletic Training.   2004 Jul-Sep; 39(3): 280–297.  Also available at:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC522153/

National Collegiate Athletics Association.  (2010)  Committee on competitive safeguards and medical aspects of sports memorandum:  Concussion management plan.  (April 29, 2010).  Retrieved on September 2, 2011, from
http://onbalance.com/news/downloads/NCM-NCAA_Memo.pdf

National Collegiate Athletics Association.  (2011)  2011-2012  NCAA sports medicine handbook.  Indianapolis, IN. (July, 2011), see p. 87 for sickle cell trait discussion.   Retrieved on September 2, 2011, from http://fs.ncaa.org/Docs/health_safety/2011_12_Sports_Medicine_Handbook.pdf.

Occupational Safety and Health Administration.  (2011) OSHA’s bloodborne pathogens standards.   Retrieved on September 2, 2011, from http://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf

Sadler, J.M. (2006)  Heat illness:  Avoidance and prevention.  Retrieved on August 30, 2011, from http://www.sadlersports.com/riskmanagement/sports-insurance-heatillness.html

University Interscholastic League.  (1999) Cold weather illness:  Recognition, management, and prevention of cold exposure.  Austin, TX.  Retrieved on September 2, 2011, from http://www.uiltexas.org/health/info/cold-weather-illness

University of Texas at Austin.  (1992)  Intercollegiate athletics for women policy manual.  Unpublished.  Austin, TX:  Department of Women’s Intercollegiate Athletics.

University of Texas at Austin.  (2010)  Intercollegiate athletics policy manual.  Austin, TX.  Retrieved on August 26, 2011, from http://www.longhornspolicymanual.com/.

Van Kampen, D.A., M.R. Lovell, J.E. Pardina, M.W. Collins, and F.H. Fu. (2006) The "value added" of neurocognitive testing after sports-related concussion. The American Journal of Sports Medicine 34:1630-1635 (2006)