Exertional Heat-Stroke Preparedness in High School Football by Region and State Mandate Presence

Kerr ZY, Scarneo-Miller SE, Yeargin SW, Grundstein AJ, Casa DJ, Pryor RR, & Register-Mihalik JK. Exertional Heat-Stroke Preparedness in High School Football by Region and State Mandate Presence. J Athl Train. 2019 54(9) Online ahead of print September 2019. doi:10.4085/1062-6050-581-18.

Full Text Freely Available

Take-Home Message

Overall, 7 out of 10 football programs are not implementing six key heat-stroke preparedness strategies. Football programs within warmer regions of the United States and/or with state-level mandates had better compliance with these strategies than those without mandates or within other areas of the country.  


Exertional heat stroke is a leading cause of death among athletes. Many guidelines and recommendations promote preparedness strategies for exertional heat stroke to reduce the risk of sudden death.  Unfortunately, compliance with these guidelines varies.  These authors examined if compliance with exertional heat stroke preparedness strategies among high school football programs was related to heat safety regions or state preseason heat-acclimation mandates.  A total of 910 high school football athletic trainers (ATs) responded to a survey (13% completion rate). Responding ATs reported their high school’s exertional heat stroke preparedness strategies for the 2017 preseason. The authors inquired about 6 strategies: 1) education for recognition and treatment of exertional heatstroke, 2) policy for initiating medical services, 3) emergency response plan for school athletics, 4) immersion tub filled with ice before the start of practice, 5) monitoring wet-bulb globe temperature (WBGT), and 6) hydration access. The authors considered 3 heat safety regions based on WBGTs during warm seasons. For example, the mild region included New England and the hot region included the southeastern region of the United States.

A total of 28% of the ATs responded that their high school used all 6 preparedness strategies. Almost all ATs reported ensuring hydration access (99%). The least common strategy was monitoring WBGT (53%). The hottest region reported the highest use of all 6 strategies (34%), followed by the moderate region (25%), and mild region (19%). About 35% of ATs within states that had heat mandates reported using all 6 strategies compared to 26% of ATs in states without mandates.


This study is interesting because the authors found that 7 out of 10 ATs are not implementing all six preparedness strategies recommended by the National Athletic Training Association Inter-Association Task Force. The actual number may be higher since over 85% of contacted ATs failed to complete the survey.  It’s particularly concerning that so few football programs in the moderate and mild regions adhere to the recommendations because 25% of the fatalities happen in these cooler regions. It would be interesting to see if these fatalities were from football or from other sports. Regardless, we need to do a better job implementing exertional heat stroke preparedness strategies. Unfortunately, state mandates may not be enough since only 35% of programs used all 6 strategies in the 8 states that mandated the preparedness strategies.  The question remains what the mandate is and whether people are not complying or implementing alternative strategies that they believe meet the mandate. Ultimately, these findings provide evidence that exertional heat stroke preparedness strategies and compliance is improving, but we need to continue to make improvements across all regions, and possibly start to look at all sports (not just football).

Questions for Discussion

What is your current practice regarding cold water immersion preparedness at your site?  What do you think some barriers are for these guidelines being implemented in all high schools?

Written by: Daniel Webb & Nicole M. Cattano

Reviewed by: Jeffrey Driban

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