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.
Background
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.
Methods
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.
Results
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.
Viewpoints
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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As an ATS I have not had an issue with yet with following the EHS guidelines. I understand where there is apprehension of taking a rectal temperature of a minor but if you are doing so in order to save their life I do not see an issue liability wise. I am not sure of the state practice acts for those states though or the standing physicians orders but as long as those are being met there shouldn’t be an issue following EHS best guidelines!
Hi Katherine, I agree with you that there may be apprehension, and as long as athletic trainers are following EHS there is a reasonable amount of protection but I think one result of this study that helps frame the conversation is that 1/3 (161/531) respondents stated that they did not have a written EHS plan and considered themselves “not adopting”. Which would suggest that not only do they not have a written plan, they are not in the process of creating one. I think that this is an alarming stat in that when these policies are in place they provide ample protection of liability. I would say now we need to better understand what those barriers are for creating and maintaining such a plan so we can begin to address that. What are your thoughts?
I am currently a student in a MSAT program, so I do not have a lot of clinical experience, however, I do find this article concerning that only 17% of athletic trainers reported adopting all 4 policies for treating EHS. I understand that the use of a rectal temp varies, however, as an athletic trainer it is necessary to provide the best standard of care while following local policies. If I was hired by a school that did not have a EHS policy, one of the first thing I would do is write one. There must be a policy in place in order to protect the AT and the patient in event of an EHS. The policy needs to be reviewed just like other components of an EAP and if a rectal temp cannot be taken then other measures must be taken as well as greater preventative measures.
Peyton, thank you for your comment. I agree and was in a position just as your described, at one point. I created written standard operating procedures and policies for multiple scenarios. One thing that seems to have been brought up in this study though that I would be interested to know more about, is the support for having such policies in writing. While we know the benefit of having it and rehearsing such a plan, every position on the sports medicine team plays a different role and may look at such a policy differently. This is where our advocacy for our patients and the best standard of care is critical. Now, I am fully aware that the model used by each institution varies, but if an athletic trainer was met with resistance for writing such a policy, how do you think they could advocate for it?