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Sudden death and catastrophic injuries during sport can be attenuated with the implementation of evidence-based health and safety policies. However, the extent of the implementation of these policies within secondary school athletics is unknown.
To provide an assessment of the implementation of health and safety policies pertaining to the leading causes of sudden death and catastrophic injuries in sport within secondary school athletics in the United States.
Descriptive epidemiology study.
A rubric for evidence-based practices for preventing the leading causes of death and catastrophic injuries in sport was created. The rubric comprised 5 equally weighted sections for sudden cardiac arrest, head injuries, exertional heat stroke, appropriate medical coverage, and emergency preparedness. State high school athletic association (SHSAA) policies, enacted legislation, and Department of Education policies were extensively reviewed for all 50 states and the District of Columbia. States meeting the specific criteria in the rubric, which required policies to be mandated for all SHSAA member schools, were awarded credit; the weighted scores were tabulated to calculate an aggregate score. States were then ranked from 1 (best) to 51 (worst) based on the aggregate score achieved.
The median score on the rubric was 47.1% (range, 23.00%-78.75%). States ranked 1 through 10 (from 78.75% to 56.98%) were North Carolina, Kentucky, Massachusetts, New Jersey, South Dakota, Missouri, Washington, Hawaii, Wisconsin, and Georgia, respectively. States ranked 11 through 20 (from 56.03% to 50.55%) were Arkansas, New York, Mississippi, West Virginia, Oregon, Illinois, Tennessee, Arizona, Texas, and District of Columbia, respectively. States ranked 21 through 30 (from 49.40% to 44.00%) were Virginia, Pennsylvania, Florida, New Mexico, Alabama, Maine, Rhode Island, Indiana, Nevada, and Utah, respectively. States ranked 31 through 40 (from 43.93% to 39.80%) were Ohio, Delaware, Alaska, Vermont, Louisiana, Maryland, Oklahoma, Connecticut, Idaho, and South Carolina, respectively. States ranked 41 through 51 (from 38.73% to 23.00%) were Michigan, North Dakota, Nebraska, New Hampshire, Kansas, Wyoming, Minnesota, Montana, Iowa, California, and Colorado, respectively.
State scores ranged from 23.00% to 78.75% for the implementation of evidence-based best practices for preventing the leading causes of sudden death and catastrophic injuries (sudden cardiac arrest, traumatic head injuries, exertional heat stroke, and exertional sickling) in sport. Continued advocacy for the development and implementation of policies at the secondary school level surrounding sudden death and catastrophic injuries is warranted to optimize the health and safety of these student athletes.
With over 7.8 million secondary school student-athletes participating in sanctioned sports on an annual basis in the United States, it is prudent that their health and safety remain paramount to those overseeing secondary school athletics at all levels.28 When examining the total number of secondary school athletes sustaining fatal or catastrophic injuries from 1982 to 2015, there have been 735 fatalities (185 from direct causes, 550 from indirect causes) and 626 catastrophic injuries (613 from direct causes, 13 from indirect causes), with direct causes attributed to trauma (ie, athlete-to-athlete or athlete-to-object contact) and indirect causes being exertion based (ie, sudden cardiac arrest, exertional heat stroke, asthma).27 Furthermore, evidence shows that 90% of all sudden deaths during sport participation is accounted for by 4 conditions: sudden cardiac arrest, traumatic head injuries, exertional heat stroke, and exertional sickling.9,27 While the risk of mortality and morbidity exists to those participating in secondary school athletics, various steps can be taken to mitigate this risk and optimize emergency preparedness and care in this population.
The development and implementation of evidence-based best practices specific to factors responsible for sudden death in sport and physical activity have been shown to reduce the risk of morbidity and mortality.1,2,7,17,19,22 The National Collegiate Athletic Association (NCAA) has found success with the implementation of various health and safety policies, such as heat acclimatization in 2003 and the notification of sickle cell trait status in 2010.1 Similarly, evidence has shown that in states with mandated heat acclimatization for secondary school athletics programs, there have been zero exertional heat stroke–related deaths since implementation, whereas before implementation, these states had 50% (22/44) of all exertional heat stroke–related deaths from 1980 to 2015.7
While the implementation of health and safety policies at the NCAA level affects member schools across the United States, policy changes at the secondary school level are left to the individual states, as the National Federation of State High School Associations (NFHS) has no governing authority over the health and safety policies for secondary school athletics. States have continued to make progress in enhancing the health and safety of their student athletes1,3,4,20,30,31; however, the extent of mandated policies on topics related to the leading causes of sudden death and catastrophic injuries in sport is unknown. Therefore, the purpose of this study was to provide a graded assessment of the implementation of health and safety policies pertaining to the leading causes of sudden death and catastrophic injuries in sport at the state level for secondary school athletics programs.
This study utilized a descriptive observational design. Health and safety policies specific to the leading causes of sudden death and catastrophic injuries in sport and emergency preparedness were quantified for all 50 states and the District of Columbia. For the purposes of this study, only policies that were required or mandated to be followed by all state high school athletic association (SHSAA) member schools were used. Policies that were recommended or encouraged were not included, as it is implied that individual schools were left to decide whether to implement evidence-based best practices. The institutional review board at the University of Connecticut deemed that this study was exempt from approval, as human participants were not directly involved.
To provide an objective assessment as to where individual states ranked in terms of health and safety policies aimed at preventing the leading causes of sudden death and catastrophic injuries in sport, a grading rubric was created (Table 1). Utilizing current evidence-based best practices for preventing sudden death in sport within secondary school athletics11 and supplementary position statements, consensus statements, and Inter-Association Task Force statements endorsed by some of the leading medical organizations within the United States (Table 2),5,8,10,12–15,18,25,26 the grading rubric consisted of 5 equally weighted subsections: sudden cardiac arrest, exertional heat stroke, traumatic head injuries, appropriate health care coverage, and emergency preparedness. The weighting of the individual components within each subsection was derived from the number of components within each subsection.
Five experts in the areas of preventing sudden death and catastrophic injuries in sport independently reviewed the rubric to establish content validity. The 5 experts were board-certified athletic trainers with either a doctor of philosophy (PhD; n = 3) or master of science (MS; n = 2) degree in exercise science, with a combined 38 years of clinical experience and 78 published peer-reviewed articles on topics related to sudden death and catastrophic injuries in sport and physical activity and optimizing athletic performance. After a review of the rubric by the expert reviewers, all comments were tabulated, and changes in the content of the rubric were made when there was a majority consensus (≥3 of the 5 reviewers agreeing) or if the comment was substantiated by current evidence-based best practices.
Data on required health and safety policies for preventing sudden death and catastrophic injuries in sport were collected from state entities empowered to make statewide regulations for SHSAA member schools. SHSAA handbooks, bylaws, and constitutions for the 2016-2017 academic year were obtained in addition to any policies and procedures available via publicly accessible sources (ie, the SHSAA website). Relevant enacted legislation signed by the respective state’s governor as well as policies and procedures instilled by each state’s Department of Education policies were also obtained. For the purposes of this study, only publicly accessible data were obtained and reviewed from the aforementioned entities.
Two researchers (W.M.A. and S.E.S.) with a collective 8 years’ experience researching health and safety policies at the secondary school level, 14 years’ clinical experience as board-certified athletic trainers, and 27 peer-reviewed publications on topics related to preventing sudden death and catastrophic injuries in sport and physical activity and optimizing athletic performance independently reviewed the extent of policy implementation for each state based on the materials that were acquired from the aforementioned entities. States were given credit for each rubric-specific criterion met, and the associated weighted value for each criterion was summed to provide an overall score. After the independent review and grading, the 2 researchers met to compare their scores for each state. Any discrepancies within the grading of individual components of the rubric were discussed between the 2 researchers until a consensus was made. In the event the researchers were unable to arrive at a consensus, a third researcher (D.J.C.), who is a board-certified athletic trainer with 24 years of clinical experience and 205 peer-reviewed publications on the topics related to preventing sudden death and catastrophic injuries in sport and physical activity and optimizing athletic performance, was brought in to make a final decision.
After the final determination of each state’s individual score from the rubric, a round of quality assurance was completed. Each state’s rubric was sent to the executive director of that respective state’s SHSAA. In addition, the rubric was sent to the attendees of the 2017 Collaborative Solutions for Safety in Sport meeting, which consisted of representatives from each SHSAA and sports medicine advisory committee, as they were made aware of this project during the meeting held in March 2017 in Kansas City, Missouri. Persons receiving the rubric were given 30 calendar days to review and provide the researchers with any discrepancies from their perspective. If discrepancies existed, the reviewers were requested to provide a copy of the publicly available policy in question for assessment by the researchers. If the researchers confirmed that discrepancies existed, the rubric was updated to reflect the changes in the data provided by the representatives from the SHSAA. Fifteen states responded to emails within the 30-day period, with 8 states identifying discrepancies with the rubric scores. The 8 states that indicated discrepancies provided appropriate documentation as to where the policy was located for their state, which the researchers reviewed using the aforementioned steps; changes to the rubric were then made if warranted. For the states that did not respond within the 30-day period, it was assumed that the information listed was correct, and no further changes were made.
The scores for each state’s rubric were tabulated to obtain an aggregate score, which was based on a total score of 100. The scores were then transformed to a percentage, and each state was ranked from 1 (state with the greatest number of health and safety policies required of their member schools) to 51 (state with the lowest number of health and safety policies required of their member schools). The rubric scores are also presented as medians and percentiles.
Table 3 depicts the rank of all 50 states and the District of Columbia pertaining to the implementation of evidence-based best practices for preventing the leading causes of death and catastrophic injuries in sport. Of the 50 states and the District of Columbia, the median score on the rubric was 47.1%. States scoring in the top 10%, with a score of ≥60.46% on the rubric, were North Carolina, Kentucky, Massachusetts, New Jersey, and South Dakota. Conversely, states scoring in the bottom 10%, with a score of ≤33.68% on the rubric, were Minnesota, Montana, Iowa, California, and Colorado. Individual state scoring is depicted in the Appendix (available at http://journals.sagepub.com/doi/suppl/10.1177/2325967117727262).
The purpose of this study was to objectively grade each of the 50 states and the District of Columbia on the implementation of evidence-based best practice policies for preventing the leading causes of sudden death and catastrophic injuries in sport at the secondary school level. To our knowledge, this is the first time that an objective assessment and ranking of each state’s implementation of health and safety policies specific to the leading causes of sudden death and catastrophic injuries in sport has been calculated. We found that the scores that states received ranged from 23.00% to 78.75%, with a median score of 47.1%. In addition, we found that the state with the greatest number of evidence-based best practice health and safety policies on this topic was North Carolina, compared to Colorado, which had the least number of policies required of its SHSAA member schools.
After a review of each state’s policies, a large degree of variability was observed, which was reflected in the subsequent scores and ranking for each state. States that tended to score higher on the rubric had policies in place that covered evidence-based best practices in all 5 subsections of the rubric. Conversely, states that tended to score lower on the rubric were lacking policies in 1 or more subsection altogether.
Examining the evidence-based best practices that all states required of their SHSAA member schools to implement focused on the management of a suspected concussion; if a concussion is suspected, the athlete is removed from play and not permitted to return until cleared by a health care professional. Collectively, the only evidence-based best practices that were not readily met across the United States pertained to the regulation of off-season strength and conditioning sessions. This is alarming, as secondary school student athletes have continued to die during strength and conditioning sessions, and data from the collegiate level have shown that off-season strength and conditioning sessions were responsible for the greatest number of NCAA Division I football athlete deaths from 2000 to 2016.6
The large variability in policy implementation at the state level can be attributed to the differences between each state’s procedures for developing and implementing health and safety policies at the secondary school level. Within secondary school athletics, each state has the autonomy to develop and implement health and safety policies, which is voted on by each state’s high school athletic association after receiving recommendations from its sports medicine advisory committee or enacted through state legislation. While each state’s sports medicine advisory committee, composed of licensed health care professionals, may put forth proposed health and safety policies, the final decision on the adoption and implementation of such proposed policies is typically the responsibility of the SHSAA executive committee, which often does not have any medical expertise. Likewise, at the legislative level, unless there is engagement from all stakeholders involved (ie, sports medicine professionals, secondary school administrators, and legislators), health and safety policies for secondary school athletics may lack essential components of evidence-based best practices.
Notwithstanding, most SHSAAs maintain positive professional relationships with their sports medicine advisory committees (A.M. Pike et al, unpublished data, 2017) and have made continued progress in developing programs and policies to better protect their student athletes. Ultimately, to optimize the health and safety of secondary school student athletes in the United States, policies and procedures to minimize the risk of sudden death and catastrophic injuries need to be created, implemented, evaluated, and refined by the sports medicine advisory committee in each state and not the high school athletic association. This would ensure that those with the most knowledge of serious potential medical consequences are the decision makers for the implementation of best practices of these issues.
From a national level, the NFHS oversees the rules of 16 secondary school sports, which cover an estimated 7.8 million student athletes.29 Rules passed down to each state from the NFHS focus on maintaining fair play and sportsmanship, minimizing risk, preserving the traditions of the sport, and providing an even balance between offense and defense.29 These rules are specific to each individual sport and involve topics such as playing field, sport-specific equipment, and personal protective equipment. While sport-specific rules for minimizing the risk of injuries exist, such as wearing helmets, mouth guards, and ear and eye protection to help prevent traumatic face, skull, brain, and neck injuries,16,21,23,32,33 the NFHS does not currently have any rules pertaining to indirect causes of sudden death such as sudden cardiac arrest or exertional heat stroke.
Identifying strategies to prevent sudden death in sport and physical activity has led to the development of evidence-based best practices to guide patient care on topics such as sudden cardiac arrest, exertional heat stroke, traumatic brain injuries, and overall emergency preparedness. The implementation of policies related to the prevention and management of the leading causes of sudden death in sport has proven successful in reducing the number of fatalities previously observed at both the collegiate and secondary school level.1,2,7,19 Aside from reducing the number of fatalities associated with the leading causes of sudden death during sport, the implementation of heat acclimatization and environmental-based activity modification policies has been shown to significantly reduce the incidence of exertional heat illness as a whole (E.R. Cooper et al, unpublished data, 2017). Despite supporting evidence showing the effectiveness of the aforementioned policies, many states have yet to fully adopt and implement these life-saving policies within secondary school athletics, as observed from our findings.
While the purpose of the current study was to evaluate policy implementation at the state level, we did not capture policy implementation for all secondary schools within the United States. Private and/or boarding secondary schools are often regulated by independent league organizations and therefore are only obligated to abide by legislative mandates rather than policies in place by each SHSAA. The current study also only examined policies required and/or mandated within the 2016-2017 academic year, which may not reflect the positive changes that states have made leading up to the academic year in which data were collected. While data suggest that most SHSAAs maintain positive professional relationships with their sports medicine advisory committees in driving policy changes, these data are currently unpublished. Given prior literature investigating the effectiveness of mandated versus recommended policies from a broader public health issue,24 future research is needed to investigate the effectiveness of mandated versus recommended policies within secondary school athletics on reducing the incidence of sudden death in this setting. The current study only examined the implementation of mandated policies, as they require all SHSAA member schools to follow the written policies, versus a recommended policy in which individual schools/school districts are at the discretion of deciding what policies to put in place for their school. Additionally, while this study identified the current policy requirements for secondary schools across the United States, future research should investigate the local implementation of these policies in secondary schools.
When assessing health and safety policies pertaining to the leading causes of sudden death at the state level for secondary school athletics, states only met 23.00% to 78.75% of evidence-based best practice recommendations. Continued efforts by all entities (NFHS, SHSAAs, state sports medicine advisory committees, state departments of education, state legislatures, etc) overseeing secondary athletics within the United States are warranted to better enhance the health and safety of our young student athletes.
The authors acknowledge the following people for their assistance with this study: Rebecca L. Stearns, PhD, ATC, Robert A. Huggins, PhD, ATC, Yuri Hosokawa, PhD, ATC, Luke N. Belval, MS, ATC, and Miwako Suzuki, BA.
One or more of the authors has declared the following potential conflict of interest or source of funding: W.M.A. is a consultant for Clif Bar & Company, the Gatorade Sports Science Institute, BSX Athletics, and Nobo Inc; has received an honorarium from the National Athletic Trainers’ Association, Connecticut Athletic Trainers’ Association, and Wolters Kluwer Health; and serves on the technical advisory board of Body Biolytics. D.J.C. previously served on the board of advisors for Quest Diagnostics–Blueprint for Athletes; has provided expert testimony on many legal cases related to sudden death in sport; was compensated to serve on the medical and science advisory boards of Clif Bar & Company, the National Football League, and Sports Innovation Lab; receives honoriariums for talks given for Gatorade; and receives royalties from Jones & Bartlett Learning, UpToDate, Springer, and Lippincott Williams & Wilkins. The Korey Stringer Institute is a not-for-profit organization housed at the University of Connecticut; corporate partners include Gatorade, the National Football League, Kestrel, HeartSmart.com, Mission, CamelBak, Eagle Pharmaceuticals, and the University of Connecticut.
Ethical approval for this study was waived by the University of Connecticut.