High schools continue to struggle to adopt evidence based practices for the management of exertional heat stroke.

Scarneo-Miller SE, Lopez RM, Miller KC, Adams WM, Kerr ZY, Casa DJ. J Athl Train. 2021 Feb 24. doi: 10.4085/361-20. [Epub ahead of print]
Full Text Freely Available

Take-Home Message

Even though exertional heat stroke is extremely treatable, almost 1 in 3 clinicians report they decided against a written heat illness policy, and most clinicians have not adopted all available best practices.


Exertional heat stroke (EHS) is the most fatal exertional heat illness. If best practices are followed, EHS is 100% survivable. Despite this, adherence to best practices is lacking. Unfortunately, we know little about how many high schools have policies and procedures for EHS and why high schools resist using the best practices.

Study Goal

Scarneo-Miller and colleagues completed a cross-sectional questionnaire study to investigate the current adoption of policies and procedures to recognize and manage EHS. The authors also sought to understand what factors influence the adoption of these policies and procedures.


The researchers recruited 531 certified athletic trainers via social media and emails to athletic trainers who completed the ATLAS project. The questionnaire was based on the recommendations of the NATA position statement on exertional heat illness. Respondents answered questions about 1) demographic information, 2) EHS policy, and 3) barriers to adopting an EHS policy. The researchers used the Precaution Adoption Process Model to categorize responses regarding their school’s current written policies to use rectal temperature and cold-water immersion. Specifically, respondents indicated one of six possible responses: 1) “unaware” of best practices, 2) “undecided” on adopting best practices, 3) “considering” adopting best practices, 4) “decided to act” and adopt best practices, 5) “decided to not act” and not adopt best practices, or 6) “acting and maintaining” best practices.


On average, respondents were 35 years of age. The plurality of respondents had 1-5 years of professional experience (32%) and from Texas, Florida, or North Carolina (22%). Overall, only 17% of respondents reported adopting all 4 best practices for recognizing and treating EHS. Meanwhile, 30% of respondents decided not to adopt a written EHS policy. Three out of 4 respondents reported that they adhered to a policy of “cool first, transport second.” The most variable response was to the prompt about having a rectal temperature policy for the diagnosis of EHS (29% deciding not to act and 20% maintaining a policy). The most common facilitators for developing and maintaining a rectal temperature policy were 1) a state mandate from a state athletic association or state legislature and 2) support from someone in an authoritative position. The most common barriers for a rectal temperature policy were apprehension from guardians and concerns regarding liability.


The data from the current study is both interesting and concerning. Despite many best practices regarding recognizing and treating EHS, only 17% of surveyed athletic trainers reported adopting all 4 recommended practices. The low adoption of best practices is concerning because EHS is 100% survivable with proper recognition and treatment. While almost 1 in 3 respondents reported not adopting a written policy, it was reassuring that many used best practices despite the lack of written policies. Still, though, the clinician may be open to some liability concerns if the steps to identify and treat EHS are not properly documented, as suggested in the best available literature. The study also helped identify the importance of support from others in authority to facilitate the planning, documentation, and implementation of best practices for recognizing and treating EHS. The study also demonstrated that state mandates might be a key driver to improve the adoption of these best practices and overcoming critical barriers.

Clinical Implications

This study is a reminder that all clinicians should advocate for written policies based on best practice. This documentation ensures all members of the sports medicine team are prepared to treat potentially life-threatening conditions.

Questions for Discussion

Do you have an exertional heat illness policy in place? Do the facilitators and barriers reported in this study align with your experiences?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

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