Best Practices for Emergency Action Planning and Implementation in Athletic Settings: Introduction

Ray Castle, PhD, LAT, ATC, NREMT; Ron Courson, ATC, PT, SCS, NRAEMT, CSCS; David Csillan, MS, LAT, ATC; Jim Ellis, MD, FACEP; Francis Feld, DNP, CRNA, LAT, NRP; Glenn R. Henry, MA, EMT-P; Jim Kyle, MD, FACSM, FAAFP; Robb Rehberg, PhD, ATC, NREMT; Samantha E. Scarneo-Miller, PhD, LAT, ATC; Chris Troyanos, ATC

Note from the co-lead authors: This paper, “Best Practices for Emergency Action Planning and Implementation in Athletic Settings,” represents a significant advancement in emergency preparedness within athletic environments.

Building upon the foundational recommendations set forth by the National Athletic Trainers’ Association in 2002, this paper expands the scope of best practices from 12 to 29. These updated guidelines aim to address the evolving complexities of emergency response in modern athletic settings.

Developed collaboratively over six years, this comprehensive guide incorporates the expertise of interdisciplinary professionals, including EMS experts, physicians representing various specialties, and athletic trainers. This collaborative effort ensures a robust interdisciplinary consensus, reflecting inputs from EMS and public safety personnel across various levels of expertise.

The primary audience for this paper includes EMS and public safety professionals, aiming to educate them on the nuances of creating efficient emergency responses tailored specifically to athletic settings. Furthermore, the paper provides clear, actionable instructions for both medical personnel (such as athletic trainers and physicians) and non-medical personnel (including coaches and administrators).

In addition to its detailed recommendations, the paper also features a comprehensive list of supplemental resources to support each section, enhancing its practical utility in real-world applications. Specifically, the paper outlines eight key components essential for developing an effective athletic-based Emergency Action Plan (EAP):

1. Preparation and Planning: Initial steps and assessments prior to emergencies.
2. Communication Protocols: Clear lines of communication and coordination.
3. Emergency Equipment: Availability and readiness of necessary medical equipment.
4. Personnel Responsibilities: Defined roles and responsibilities during emergencies.
5. Venue Specifics: Considerations tailored to the athletic venue.
6. Medical Considerations: Guidelines for immediate medical care and treatment.
7. Transportation Procedures: Protocols for transferring injured individuals.
8. Drills and Training: Regular practice and refinement of emergency procedures.

These components collectively contribute to a structured approach towards emergency preparedness, ensuring a swift and effective response to medical emergencies within athletic contexts.

Overall, the paper not only updates and expands existing guidelines but also serves as a pivotal resource for enhancing emergency preparedness practices across diverse athletic settings.

This is the introductory article in an eight-part series. Part 2 will be published on July 30, 2024.

Co-Lead Authors:

Ray Castle, PhD, LAT, ATC, NREMT

Ron Courson, ATC, PT, SCS, NRAEMT, CSCS

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Two recent and highly publicized sport-related sudden cardiac arrests (SCA) incidents provide worst- and best-case outcomes and reinforce the importance of the emergency action plan (EAP). In January 2023, a legal settlement was reached in the wrongful death case of Matthew Mangine, Jr. In June 2020, Mangine, a high school soccer player in Kentucky, suffered a sudden cardiac arrest during conditioning activities and later died.

What is unique to this case is that multiple automated electronic defibrillators (AED) were available at the school; however, none were utilized until EMS arrived 12 minutes later.⁸ Conversely, and illustrating the importance of the EAP, was Damar Hamlin (NFL defensive back for the Buffalo Bills) during the first quarter of a nationally televised football game on January 2, 2023. This athlete suffered and survived SCA during an event where this exact scenario was discussed as part of the EAP in the NFL pregame 60-Minute Medical Meeting (“Medical Time Out”).

Another critical aspect of the successful outcome of this incident was that the annually rehearsed scenario-based training was performed to practice and prepare for SCA and multiple other medical emergency situations common to American football. On April 19, 2023, the Buffalo Bills announced that Hamlin was cleared to resume full football activities without limitations.

These two different cases emphasize the role that immediate response by athletic trainers, emergency physicians, first responders, and other personnel have in the early administration of CPR and AED/defibrillation, as well as the coordinated transfer of care to a local hospital on patient mortality.^2,4,5,12

The purpose of the EAP is to organize an appropriate and effective emergency medical response in the event of an athletic emergent injury or illness. The EAP for venues must incorporate an “all-hazards approach” to account for medical emergencies and environmental hazards both intentional (e.g., fires, active shooters, bombings, stabbings, and chemical) and unintentional (e.g., excessive heat/cold, tornadoes, hurricanes, floods, and lightning) that may occur during activities or functions.⁷ The use of terms such as “sports” and “athletic teams” is interchangeable with other athletic trainer practice settings.

It is essential that sports healthcare providers have an organized and well-communicated plan in place for emergency situations, and that the EAP is regularly reviewed and rehearsed. The document specifically addresses the implementation of the “Medical Time Out”⁹ for activities, which involves coaches, administrators, event management personnel, EMS and public safety, referees, and visiting team medical staff to address their respective roles in assisting during an emergency or for a collapsed athlete.^3,11

Healthcare professionals and other responders (e.g. coaches, administrators, etc.) must be trained and equipped with appropriate medical equipment and supplies to address emergency situations. Effective emergency response is multi-dimensional, and interdisciplinary, and requires stakeholder input, training, established lines of communication, regular stakeholder review and rehearsal, documentation, and coordinated response for post-event critical incident stress management.¹⁰

An effective emergency action plan is essential for the organization’s and its stakeholders’ continual preparedness and resiliency. It should be comprehensive, progressive, risk-driven, integrated, collaborative, coordinated, flexible, and professional.⁶

While it may not be possible to plan and train personnel for all types of emergency situations, the EAP must provide a determined coordinated response for the most common sports-specific emergencies and support best-case outcomes. The EAP should be written in a format that allows for an emergency response to any type of medical emergency and should be included as a part of the policies and procedures manual.

Minimum (Updated) Components of Emergency Action Plans for Athletic Settings

This document aims to present current evidence and best practices for developing and implementing emergency action plan policies and procedures in athletic settings. The 2002 NATA Position Statement on “Emergency Planning in Athletics”¹ presented a total of 12 recommendations. Alongside the initial recommendations, the authors incorporated 5 adjustments to the original recommendations along with 17 new recommendations.

The updated recommendations have been aligned into eight (8) key operational components that are essential to any Emergency Action Plan (EAP), regardless of the athletic setting. The following list contains the original 12 recommendations along with recommendation adjustments and new recommendations (BOLD HIGHLIGHTED). A detailed description of the 29 recommendations (with supporting references) is available in the Supplement document.

1. Writing the Emergency Action Plan
   1. Each institution or organization that sponsors athletic activities must have a written EAP.
   2. The EAP developed should be comprehensive and practical, yet flexible enough to adapt to any emergency situation. The EAP should consider the possibility of multiple injuries as well as address the acute care of unintentional (e.g., inclement weather, sudden cardiac arrest, spectator-related heat illnesses, etc.) as well as intentional acts (e.g., active shooter situation, vehicular damage, cyberterrorism, etc.).
   3. The EAP should be written in collaboration with all local public safety agencies (EMS, Fire, Police, and maybe even Emergency Management).
2. Personnel Identification, Feedback, Qualifications, and Roles Within the EAP
   1. The EAP should: 1) identify all non-medical and medical personnel involved in carrying out the EAP, 2) delineate personnel level of training, qualifications, roles, and responsibilities to utilize designated equipment available at each venue, and 3) outline each personnel’s function within a designated chain of command.
3. Stakeholder Feedback, Scheduled Rehearsals, and Review
   1. EAPs should be distributed and reviewed with athletic trainers, team and attending physicians, athletic training students, institutional and organizational safety personnel, institutional and organizational administrators, and coaches. Additional external reviews include visiting the team’s athletic training/medical staff (as part of the “Medical Time Out”) and primary receiving facility emergency department.
   2. The written plan should integrate with local EMS, fire, law enforcement, hospital, and health care coalition preparedness/response plans.
   3. The EAP should be reviewed, rehearsed, and updated annually (at a minimum), although more frequent review and rehearsal may be necessary. Immediate updates are warranted if there have been significant changes in the venue, personnel, and/or an after-action report/evaluation which would trigger an immediate update. The results of these reviews and rehearsals should be documented and should indicate whether the EAP was modified, with further documentation reflecting how the plan was changed.
   4. The EAP should be rehearsed with all internal organizational staff (including but not limited to: healthcare professionals, coaches, etc.) on a regular and planned basis as determined by the organization or agency.
   5. The EAP should include a mechanism for performance and assessment of annual competencies and readiness drills conducted to maintain readiness for potential catastrophic injuries/illnesses.
   6. EAPs should be distributed to public safety agencies that may respond to emergency situations at the organization’s activities/functions.
   7. The EAP should be rehearsed with all pre-hospital (e.g., emergency medical services, police, fire) and hospital staff (e.g. emergency department physicians, nurses, etc.).
4. Contemporary Equipment and Supplies
   1. The EAP should specify the equipment needed to carry out the tasks required in the event of an emergency. In addition, the EAP should outline the location and availability of all emergency equipment for use by medical and non-medical personnel at each venue.
   2. Equipment/supplies should be: 1) clearly labeled/identifiable in conspicuous locations, and 2) accessible at all times; this includes events/activities off-school premises or conducted outside normal business hours of the organization.
5. Communications
   1. The EAP should establish a clear mechanism for communication to appropriate emergency care service providers and identify the mode of transportation (ambulance; or air flight) for the injured participant.
   2. The communication plan should be redundant with a designated and deliberate backup plan (landline, mobile phone; hand signals; mobile transmitter/receivers) if the initial communication method fails.
   3. Each venue-specific EAP should provide minimum information that must be communicated to emergency medical services (EMS). The EAP should incorporate information on the emergency care facilities to which the injured individual will be transported to based on state or regional medical response network (e.g. ST-elevated myocardial infarction, or STEMI; spine; stroke; trauma) facility capabilities. The organizing/host organization should consider notifying emergency-receiving facilities regarding upcoming/scheduled events and contests. Additional consideration should also be given to including incorporating personnel from the emergency receiving facilities in the development of the EAP for the institution or organization.
6. Venue Implementation and Response
   1. The EAP should be specific to the activity venue. That is, each activity site must have a defined EAP that is derived from the overall institutional or organizational policies on emergency action planning. The EAP should address games/events, practices, conditioning activities, and other activities.
   2. A copy of the EAP specific to each venue should be posted and readily available to all medical team members. The EAP should be shared and readily available to the visiting team, ideally, before an event.^1,11
   3. The Medical Time Out (which may also be referred to as a pre-event medical meeting) should be conducted before athletic events and practices to enhance communication and coordination with respective team medical staff members, coaches, EMS, game officials, venue administrators, and public safety.
7. Documentation
   1. The EAP specifies the necessary documentation supporting the implementation and evaluation of the EAP. This documentation should identify responsibility for documenting actions taken during the emergency, evaluation of the emergency response, and institutional personnel training.
   2. Documentation of care rendered before EMS arrives is crucial to the continuum of care. Patient care reports (PCRs) should contain information on patient assessment, treatment, patient history, etc. This can be completed post-incident and transmitted to the receiving facility electronically.
   3. The EAP should be rehearsed at each venue site where there is a specific plan. The plan must have a documented process of when the reviews occur.
   4. A debriefing of any actual emergency incident and/or transfer to a hospital should take place to identify compliance with the EAP and areas for improvement.
   5. An after-action report/evaluation should be conducted for more serious events (defined by the organization) as a quality assurance program and should address any recommended adjustments to the EAP if a similar occurrence happened in the future.
   6. Every emergency response (e.g. game, tournament) and rehearsal should have a debriefing. The debriefing should include all personnel directly involved in the event or rehearsal. The EAP documentation should be updated after each debriefing to record the debrief meetings. If nothing is changed, the plan should indicate such.
   7. Documentation of annual reviews, drills, and regularly planned training/in-service sessions should be on file and signed by appropriate designated officials. The documentation should include attendance rosters and dates of all activities.
   8. All personnel involved with the organization and sponsorship of athletic activities share a professional and legal responsibility to provide for the emergency care of an injured or ill person, including the development, implementation, and evaluation of the EAP for all sponsored activities.
   9. The EAP should be reviewed and approved by the administration of the sponsoring organization or institution.
8. Post-Event Critical Incident Stress Management
   1. The health and safety of all persons involved in critical incidents should be addressed through a comprehensive post-event critical incident stress management plan.

Acknowledgements

We want to thank Dr. Richard C. Hunt, MD, FACEP – Senior Medical Advisor, Office of Health Care Readiness, ASPR, U.S. Department of Health and Human Services (HHS) for his time and expertise guidance in the development of this manuscript.

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