Appropriate Medical Care Standards for Organizations Sponsoring Athletic Activity for the Secondary School–Aged Athlete: A Summary Statement

Standard 1: Athletes' Readiness to Participate in Activity Is Determined Through a Standardized Preparticipation Physical Examination Screening Process

For nearly 4 decades, a number of medical organizations have formalized the preparticipation physical examination (PPE).^5–7 The PPE is intended to identify areas of concern in the athlete's health that could contribute to impaired function during participation in sports. This formal process creates a base framework for the work of all health care providers. No matter who is performing the PPE, everyone should be held to the same standard outlined by the document. The PPE should be performed early enough to ensure that any areas of concern can be addressed before activity begins. Preparticipation physical examinations should be conducted in accordance with local and state guidelines and include appropriate education and documentation of the athlete's and parents' assumption of risk.

Does the organization require each athlete to complete a standardized PPE screening process and be cleared by a qualified medical professional (QMP) before participation in athletic activity? The American Medical Association defined the QMP as “an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.” (https://www.ismanet.org/pdf/education/QHP10-6-16.pdf)

Does the organization use standardized PPE screening instruments that are endorsed by the medical community?

Does the organization require that a comprehensive medical and family history survey be completed by the athlete and parents or guardians as part of the PPE screening process?

Does the organization require that a medical physical examination be completed on each athlete by a QMP as part of the PPE screening process?

Does the organization require a QMP to develop a management plan for areas of concern after the PPE screening process is completed with input from the athlete and parent or guardian?

Does the organization include questions to assess the athlete's mental health status during the PPE screening process along with a plan for referral and follow-up where appropriate?

Does the organization provide educational materials on selected health and safety concerns to the athlete and parent or guardian during the PPE screening process?

Does the organization require written authorization from the parent or guardian before sharing his or her child's protected health and medical information with designated individuals, such as coaches or other medical professionals?

Standard 2: Practice and Competition Equipment Used by Athletes and Athletic Health Care Facilities Is Safe and Clean

Those engaged in organized athletic activities deserve the opportunity to play in a safe and hazard-free environment. In the event of an injury or illness while participating in athletic activities, participants should be cared for in an accessible, clean, and well-organized facility.⁸ This facility should promote privacy, care without risk of infection, and care by the designated QMP. Having a designated facility and hours of operation can also improve patient compliance and ensure a clean and safe environment for providing medical care.

Does the organization have written policies, procedures, and protocols in place to ensure that practice, competition, and athletic health care facilities as well as equipment used by athletes are cleaned and disinfected on a regularly scheduled basis (eg, daily, weekly, or monthly) to prevent the spread of infectious diseases?

Does the organization have an exposure-control plan to minimize occupational exposure to blood or other bodily fluids?

Does the organization post guidelines and instructions for handwashing and hand sanitization?

Does the organization ensure that locker and dressing rooms are cleaned and sanitized on a regularly scheduled basis?

Does the organization ensure that all athletic surfaces and equipment used by athletes are cleaned and sanitized on a regular basis (eg, daily, weekly, and monthly?)

Does the organization ensure that playing fields and courts are inspected for hazards before each use and on a regular basis?

Does the organization supply a safe and clean area for the QMP to provide immediate treatment and care of athletes with injuries or illnesses?

Does the organization ensure that hydration equipment is cleaned and sanitized on a regular basis?

Standard 3: Equipment Worn by Athletes Is Properly Fitted and Maintained and Instructions for Safe and Appropriate Use Are Provided

Equipment used by athletes as part of any sport should conform, at minimum, to National Operating Committee Standards on Athletic Equipment and the American Society for Testing and Materials guidelines, even if the organization or participant provides the equipment. If the participant is allowed to use personally owned equipment, the organization must ensure that the equipment complies with all standards and guidelines, including recertification. Requiring equipment to conform with the National Operating Committee Standards on Athletic Equipment and the American Society for Testing and Materials standards provides assurance that minimal safety standards have been met. A review³ of case law showed that equipment that was not well maintained or was improperly fitted could contribute to, if not cause, injury to participants. In addition, the use of equipment that has not been approved by the appropriate certifying body exposes the athlete to the potential for injury and the sponsoring entity to liability and negligence.

Does the organization require employees who fit athletes with standard athletic equipment to document their professional education and training from qualified providers?

Does the organization have written policies, procedures, and protocols on how to recondition, maintain, clean, and sanitize the athletic equipment issued to athletes?

Does the organization require personnel to supervise athletes at all times when using athletic equipment?

Does the organization require coaches to demonstrate competence in sport-specific coaching techniques while instructing athletes on the use of issued equipment?

Standard 4: Protective Materials and Products Used to Prevent Athletic Injuries Are Safely and Appropriately Applied

Taping, wrapping, padding, splinting, and bracing materials or equipment are commonly applied in the athletic setting and are most often used prophylactically.^9,10 Application of supportive materials or equipment to an athlete is intended to restrict the motion of an injured joint, compress soft tissues to reduce swelling, support anatomical structures involved in an injury, serve as or secure a splint, secure a dressing or bandages, protect the injured joint from reinjury, or protect the injured tissues during the healing process. It is also common for a QMP to fabricate or modify prophylactic materials (eg, foam, felt, rigid or semirigid plastics) and apply them safely and effectively to minimize the risk of injury or reinjury.¹¹ Preventive and protective materials (eg, athletic tape, casting, splints, felts, foams, pads) and special protective or corrective equipment (eg, braces, durable medical equipment, orthotics, mouth guards) should only be applied by a QMP who has the fundamental knowledge (eg, anatomy, physiology, biomechanics, physics, chemistry) and skills to do so. Furthermore, the use of any protective equipment should be in compliance with governing-body rules and regulations for use during competition.

Does the organization have a QMP who can safely and appropriately apply preventive taping, wrapping, padding, splints, and braces to athletes to prevent injury or reinjury?

Does the organization have a QMP to safely and appropriately fabricate or modify protective materials and apply them to athletes to prevent injury?

Standard 5: Athletic Participation in a Safe Environment Is Ensured or Activity Is Modified or Canceled Based on Established Environmental Policies

Monitoring environmental conditions and modifying or canceling (or both) activity that may pose a threat to the health and safety of the athlete is critical for preventing sudden death among athletes.^7,12 Sponsoring organizations of athletics programs have duties to develop, adopt, and implement comprehensive best-practice policies for preseason heat acclimatization,^13,14 outdoor participation in both warm and cold weather,^13,15–17 lightning,¹⁸ and air quality¹⁹ according to accepted evidence-based techniques. To enhance implementation and promote clear lines of communication, the policies should designate a representative with the responsibility of monitoring changing environmental conditions and suspending activity when warranted or resuming activity when conditions are safe. To optimize communication and ensure a uniform message to the athletes, key members of the sponsoring organization must be provided with and educated on all environmental-modification and cancellation policies.^7,12 The organization should pay close attention to the routine preventive measures that must be put in place and be aware of the potential catastrophic injuries or illnesses that can occur when modifications are not closely monitored and followed.

Does the organization have written policy, procedures, and protocol statements on activity progressions for heat acclimatization?

Does the organization have written policy, procedures, and protocol statements on modifying or canceling athletic activity due to hot and humid weather?

Does the organization have a written policy for modifying or canceling outdoor athletic activity due to cold weather?

Does the organization have a written policy for modifying or canceling outdoor athletic activity due to lightning?

Does the organization have a written policy for modifying or canceling outdoor athletic activity due to poor air quality?

Does the organization designate an individual to monitor the outdoor weather environment and modify activity for each athletic event?

Does the organization educate and train all stakeholders on environmental policies, procedures, and protocols on an annual basis?

Standard 6: Education and Counseling Are Provided for Athletes on Nutrition, Hydration, and Dietary Supplementation

Sports nutrition is a key factor in an athlete's growth, development, and performance. Sponsoring organizations of athletic programs have a responsibility to provide a safe environment, including scientifically based information regarding nutrition, hydration, and supplements.^20–22 Adolescents need education and counseling to make sound nutritional decisions in an age when fad diets and performance-enhancement products are prevalent and marketed to their specific demographic. Members of the athletic health care team (AHCT), the group of QMPs designated by the organization to provide athletic health care services, should be well versed in proper sports nutrition for the adolescent, have a basic knowledge of proper nutrition and eating habits, and have access to a professional nutritionist or dietitian. Organizations should establish components of a comprehensive sports nutrition support system that is based on current scientific facts and should include specific information regarding healthy nutritional habits; appropriate hydration before, during, and after activity; and supplement use.²³ Last, athletes who participate in sports that use weight-classification systems may be at a higher risk for disordered eating and unsafe weight-gain or weight-loss practices. Organizations need to educate and monitor athletes in these sports using recommended practices for monitoring and aiding in weight management.^21,22

Does the organization provide a QMP who educates and counsels athletes on how to meet their dietary goals and unique nutritional needs?

Does the organization provide a QMP who educates and counsels athletes on how to stay properly hydrated by using the parameters of a hydration protocol?

Does the organization provide a QMP who educates and counsels athletes on the safety and efficacy of dietary supplements?

Does the organization have written policies, procedures, and protocols for the assessment and management of athletes who participate in weight-classification sports?

Standard 7: Wellness Programs Promote a Safe Progression of Physical Fitness and Improve Long-Term Health Across an Athlete's Lifespan

Participation in sports and physical activity provides the opportunity for many physical and psychosocial benefits to student-athletes. In addition, it offers an opportunity for on-site QMPs and others in the sports medicine community to serve as leaders in aiding adolescents in benefiting from a physically active lifestyle and sports participation.²⁴ Several professional organizations^25–27 have developed statements to ensure the safe development of young individuals into healthy, active adults in a manner that promotes general physical fitness and sampling in a variety of sports. To help achieve optimal wellness and sport performance, organizations should ensure they can design safe and effective training programs that include athlete monitoring. The organization should ensure whole-person health care through the collection of patient-reported outcomes to guide injury or illness management.^28,29 Attention should be paid to behavioral health concerns, including the abuse of prescription and over-the-counter medications, supplements, and performance-enhancing substances.³⁰

Does the organization provide a QMP who uses appropriate assessment instruments, equipment, and protocols to measure fitness, body composition, posture, flexibility, muscular strength, power, speed, agility, and endurance?

Does the organization provide a QMP who designs and implements safe and effective flexibility, strength-training, and cardiovascular-conditioning programs that include safety precautions, hazard inspections, instruction in and supervision of proper techniques. and expected outcomes?

Does the organization provide a QMP who develops and implements wellness strategies to mitigate the risk for long-term health conditions across an athlete's life span?

Does the organization provide a QMP who educates athletes on the effects, consequences, and risks of alcohol, performance-enhancing drugs, over-the-counter medications, prescription medications, and recreational drugs?

Standard 8: Comprehensive Athletic Emergency Action Plan Is Established and Integrated With Local Emergency Medical Services per Athletic Venue

Participation in athletic activities can carry an inherent risk of serious injury. As such, members of the AHCT, along with coaches and administrators, need to be prepared for emergency situations by developing and implementing a comprehensive athletic emergency action plan (EAP).³¹ The need for an EAP has been well documented in the literature^31–33 and supported in case law.³⁴ The sponsoring organization should have a comprehensive athletic EAP to ensure that appropriate care can be provided in a timely manner, even in the absence of on-site medical providers. However, the development of an athletic EAP requires the input of the QMPs, administrators of the sponsoring organization, legal counsel or risk managers, coaches, and facility managers, along with parents and members of the local emergency response community. The athletic EAP should be specific to each venue (practice or game), be reviewed annually with all involved personnel, have legal approval before implementation, and include a mechanism for a responsible adult to advocate on behalf of an injured minor in situations when parents or guardians are not present.

Does the organization have a venue-specific athletic EAP with input from internal and external partners that goes through a formal review and approval process?

Does the organization have a designated coordinator (QMP or member of the AHCT) responsible for developing, training, implementing, distributing, and at minimum, annually reviewing the EAP?

Does the organization have a list of emergency personnel and their described roles in the EAP?

Does the organization have a list of emergency equipment and locations for each venue in the EAP?

Does the organization have emergency care protocols outlined and developed in the EAP?

Does the organization have guidelines for testing and using internal and external communication systems in the EAP?

Does the organization ensure that the designated EAP coordinator (QMP or member of AHCT) provides education and training on the implementation of the EAP?

Does the organization require listing of all emergency personnel referenced in the EAP, including all coaches, and obtain documentation that each maintains current certification in cardiopulmonary resuscitation and the use of an automated external defibrillator?

Does the organization require documentation that all emergency personnel listed in the EAP, including all coaches, maintain a minimum of current first-aid certification?

Does the organization ensure that the designated EAP coordinator (QMP or member of the AHCT) communicates and posts the EAP and shares the document with all appropriate stakeholders?

Does the organization have a quality improvement process that includes a review by the EAP review committee for each incident that requires the activation of the EAP?

Does the organization have guidelines on who will advocate for a minor in the event of an emergency incident when the parent or guardian is absent?

Standard 9: On-Site Prevention, Recognition, Evaluation, and Immediate Care of Athletic Injuries and Illnesses Are Provided With Appropriate Medical Referrals

On-site recognition, evaluation, treatment, and appropriate referral should be available, if warranted, to all participants in all activities. Each patient with an athletic injury needs immediate appropriate treatment and care to prevent further risk and to promote proper healing while reducing the risk of reinjury. It is in the best interest of the athlete that the person making medical decisions be a QMP.^35,36 This allows for sound medical judgment that is not based on the player's importance or the significance of the contest but on the signs and symptoms that the athlete shares with and presents to the QMP.³⁶ Relationships established by a QMP with other health care professionals will assist in referral to the appropriate medical provider.

Does the organization require a QMP to be on-site depending on the risk and rate of injury and illness in the activity?

Does the organization have a management plan with a focus on sudden death in sports that includes the prevention, recognition, evaluation, assessment, referral, treatment, and immediate care of asthma, catastrophic brain injury, cervical spine injuries, diabetes, exertional heat stroke, exertional hyponatremia, exertional sickling, head-down contact in football, lightning injuries, and sudden cardiac arrest?

Does the organization ensure that a QMP tracks and reports on injury and illness trends and develops strategies to mitigate modifiable risk factors based on the data?

Does the organization have guidelines for when, where, how, and by whom patients with athletic injuries or illnesses should be referred to outside medical providers?

Does the organization have a QMP who develops accommodation plans for athletes with congenital and acquired abnormalities, disabilities, and diseases to allow safe participation in athletic activities?

Does the organization have a written policy on the decision-making authority of all QMPs and coaches that includes the roles and responsibilities of each in determining the athlete's participation status for any health reason?

Standard 10: On-Site Therapeutic Intervention (Presurgical, Postsurgical, and Nonsurgical Conditions) Outcomes Are Optimized by Developing, Evaluating, and Updating a Plan of Care for Athletes in Coordination or Collaboration With Members of the AHCT

Rehabilitation is the process of regaining full function after injury and involves restoring strength, flexibility, endurance, and power.³⁷ The main goal is to return an injured player to training or competition without putting that individual or others at undue risk of injury or illness. This process is criteria driven (not time driven). Certain levels of physical ability and criteria must be achieved before further progression through the stages. Rehabilitation should start as early as possible after an injury and form a continuum that includes other therapeutic interventions. It can also start before or immediately after surgery when an injury requires operative intervention. In developing the rehabilitation plan, the clinician must consider that the athlete's objective is to return to the preinjury levels of activity and competence and the environment in which the injury occurred. Functional capacity after rehabilitation should be the same, if not better, than before the injury. The organization should also identify manufacturer, institutional, state, and federal standards that influence the approval, operation, inspection, maintenance, and safe application of therapeutic modalities and rehabilitation equipment.

Does the organization have a QMP responsible for implementing on-site physical rehabilitation and reconditioning programs during designated times for athletes?

Does the organization provide adequate facilities to implement on-site physical rehabilitation and reconditioning programs for athletes?

Does the organization provide adequate therapeutic modalities and rehabilitation equipment to facilitate physical rehabilitation and reconditioning programs for athletes?

Does the organization provide up-to-date and pertinent educational materials to optimize treatment, rehabilitation, and reconditioning outcomes?

Standard 11: Comprehensive Management Plan for At-Risk Athletes With Psychological Concerns

As with other medical emergencies, illnesses, and injuries, organizations should plan and be prepared to address psychosocial conditions.³⁰ These conditions include but are not limited to anxiety, depression, teen suicide, concussion; substance, alcohol, and physical abuse; eating disorders, bullying, and hazing; and the effects of attention-deficit/hyperactivity disorder. Members of the AHCT should rehearse and be able to identify and appropriately manage acute crisis situations and referral of patients with such conditions. Organizations should identify local experts with specialty training in working with at-risk athletes who can serve as resources for referral as needed. Members with this specialty training should be part of the AHCT.

Does the organization provide education and training for the AHCT, coaches, and staff members (eg, nurse, counselor, and administrator) on the identification and referral of athletes with psychological concerns?

Does the organization have a QMP responsible for providing education on stress-management strategies and referral services to help athletes better manage stressors and improve their ability to function?

Does the organization have a plan for recognizing and referring an athlete with psychological concerns to the appropriate mental health professional?

Does the organization have a collaborative and comprehensive EAP for addressing a mental health incident (eg, attempted harm to oneself or others) or catastrophic incident (eg, suicide, homicide, permanent disability)?

Does the organization offer professional counseling services for athletes and other personnel after a mental health or catastrophic incident, such as a posttragedy action plan?

Standard 12: Comprehensive Athletic Health Care Administration System Is Established to Ensure That Appropriate Medical Care Is Provided

Organizations sponsoring athletic programs for secondary school–aged individuals should establish a comprehensive athletic health care administration system that ensures the provision of appropriate medical care to all participants.^3,36 To supply appropriate medical care, organizations must create an AHCT that functions in a coherent, coordinated, and efficient manner with the coaches and administrators of sponsoring organizations and adheres to commonly accepted standards of good clinical practice. Specifically, the system should address the following: documentation, policies, procedures, job descriptions, job evaluations, job supervisory structure, directing physician, medical-direction documents, and written standing orders.

Does the organization have an AHCT consisting of QMPs with roles identified for each?

Does the organization designate a team or directing physician (MD or DO) who establishes the relationship and services provided?

Does the organization have a designated QMP to coordinate athletic health care and serve as a liaison to the medical community?

Does the organization ensure that a QMP properly documents athletes' medical records according to professional and legal standards?

Does the organization publish and make available its policy, procedures, and protocol manual to all stakeholders?

Does the organization ensure that medical devices are maintained and calibrated according to manufacturer guidelines and government regulations?

Does the organization provide appropriate storage of and security for medical records and require documented training for anyone accessing such records?

Does the organization provide the necessary resources for a member of the AHCT to communicate professionally with athletes, parents, coaches, administrators, and the medical community?

Does the organization provide adequate funds for the supplies and equipment needed for a comprehensive athletic health care program?

Does the organization provide adequate and equitable staffing of QMPs to implement a comprehensive athletic health care program?