Exertional Heat Illness: Adoption of Policies and Influencing Contextual Factors as Reported by Athletic Administrators

Scarneo-Miller SE, Adams WM, Coleman KA, Lopez RM. Sports Health. 2023 Mar 5:19417381231155107. doi: 10.1177/19417381231155107. Epub ahead of print. PMID: 36872595.


Take-Home Message

Most high school athletic administrators reported adopting a written exertional heat illness policy, but they often missed key components. The presence of an athletic trainer helped facilitate having a written policy that included more components.


Athletic administrators play an important role in policy adoption. Policies like those handling emergency exertional heat illnesses are vital since improper management could lead to poor outcomes. Unfortunately, we know little about the facilitators and barriers to adopting exertional heat illness policies.

Study Goal

The authors surveyed high school athletic administrators in the United States to describe the adoption of exertional heat illness policies and explore factors that influence the adoption of these policies.


During the 2018-2019 academic school year, the study team emailed almost 7,000 athletic administrators to invite them to complete a questionnaire that asked about 1) demographics, 2) exertional health illness policies, 3) oversight and modification of written policy, and 4) facilitators and barriers to policy development. The investigators used the precaution adoption process model to assess an athletic administrator’s readiness to adopt policies. The adoption model is based on 8 stages, from being unaware to maintaining a written policy for over 6 months.


Among the 466 athletic administrators (~48 years of age, 82% male, 77% worked in the field for over 15 years), 78% reported adopting a written policy on exertional heat illness prevention and treatment. Only 6% adopted all 11 essential elements of an exertional heat illness policy. Almost half of the administrators reported adopting less than 5 essential elements.

Older athletic administrators, those who previously treated an exertional heat illness, or those with an athletic trainer on staff were more likely to have a written policy. Furthermore, state mandates and having a medical professional were the most commonly reported facilitators for adopting a policy on exertional health illness prevention and using a rectal thermometer. Similarly, the most commonly reported barrier to a comprehensive exertional heat illness policy was lack of a full-time athletic trainer (11). Administrators also acknowledged budget restrictions that limited the use of a cold water immersion tub (23%), and key barriers to using a rectal thermometer were discomfort using the thermometer (32%), resistance from parents/guardians (30%), resistance from coaches (30%), and liability concerns (27%).


Nearly 80% of the sampled athletic administrators reported adopting a written exertional heat illness policy. However, very few incorporated or were aware of all the necessary components to adhere to best clinical practices. The authors found that access to athletic training services was associated with better adoption of exertional health policies. This finding aligns with the fact that it would be an athletic trainer carrying out such policies. It’s worth recognizing that only 7% of contacted administrators completed the survey. Hence, these results may not accurately reflect what is going on in high schools around the country. One possibility is that people more interested in policies or exertional heat illness completed the survey. Hence, these results may show us the best-case scenario for having written policies (78%) that include all the components (6%) – which is a worrying sign.

Clinical Implications

Encouraging state mandates and schools to hire athletic trainers can help ensure written policies are in place to address exertional heat illness. Clinicians may also want to consider strategies to educate coaches and parents/guardians about the rationale for these policies, like rectal thermometers and cold water immersion tubs.

Questions for Discussion

Do you have difficulty adding rectal temperature into your exertional heat illness protocol? Do you communicate with your athletic administrator regarding the adoption, implementation, and annual review/practice of your emergency policies?

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Written by Jane McDevitt
Reviewed by Jeffrey Driban

9 EBP CEU Courses