National Athletic Trainers’ Association Position Statement: Emergency Planning in Athletics

National Athletic Trainers’ Association

Position Statement: Emergency Planning
in Athletics
J. C. Andersen*; Ronald W. Courson†; Douglas M. Kleiner‡;
Todd A. McLoda§
*Armstrong Atlantic State University, Savannah, GA; †University of Georgia, Athens, GA; ‡University of Florida,
Health Science Center/Jacksonville, Jacksonville, FL; §Illinois State University, Normal, IL
J. C. Andersen, PhD, ATC, PT, SCS, contributed to conception and design; acquisition and analysis, and interpretation of the
data; and drafting, critical revision, and final approval of the article. Ronald W. Courson, ATC, PT, NREMT-I, CSCS, Douglas
M. Kleiner, PhD, ATC, CSCS, NREMT, FACSM, and Todd A. McLoda, PhD, ATC, contributed to acquisition and analysis and
interpretation of the data and drafting, critical revision, and final approval of the article.
Address correspondence to National Athletic Trainers’ Association, Communications Department, 2952 Stemmons Freeway,
Dallas, TX 75247.
Objectives: To educate athletic trainers and others about the
need for emergency planning, to provide guidelines in the development of emergency plans, and to advocate documentation
of emergency planning.
Background: Most injuries sustained during athletics or other physical activity are relatively minor. However, potentially
limb-threatening or life-threatening emergencies in athletics and
physical activity are unpredictable and occur without warning.
Proper management of these injuries is critical and should be
carried out by trained health services personnel to minimize risk
to the injured participant. The organization or institution and its
personnel can be placed at risk by the lack of an emergency
plan, which may be the foundation of a legal claim.
Recommendations: The National Athletic Trainers’ Association recommends that each organization or institution that
sponsors athletic activities or events develop and implement a
written emergency plan. Emergency plans should be developed
by organizational or institutional personnel in consultation with
the local emergency medical services. Components of the
emergency plan include identification of the personnel involved,
specification of the equipment needed to respond to the emergency, and establishment of a communication system to summon emergency care. Additional components of the emergency
plan are identification of the mode of emergency transport,
specification of the venue or activity location, and incorporation
of emergency service personnel into the development and implementation process. Emergency plans should be reviewed
and rehearsed annually, with written documentation of any
modifications. The plan should identify responsibility for documentation of actions taken during the emergency, evaluation of
the emergency response, institutional personnel training, and
equipment maintenance. Further, training of the involved personnel should include automatic external defibrillation, cardiopulmonary resuscitation, first aid, and prevention of disease
Key Words: policies and procedures, athletics, planning, catastrophic
Although most injuries that occur in athletics are relatively minor, limb-threatening or life-threatening injuries are unpredictable and can occur without warning.1 Because of the relatively low incidence rate of catastrophic injuries, athletic program personnel may develop a
false sense of security over time in the absence of such injuries.1–4 However, these injuries can occur during any physical
activity and at any level of participation. Of additional concern
is the heightened public awareness associated with the nature
and management of such injuries. Medicolegal interests can
lead to questions about the qualifications of the personnel involved, the preparedness of the organization for handling these
situations, and the actions taken by program personnel.5
Proper emergency management of limb- or life-threatening
injuries is critical and should be handled by trained medical
and allied health personnel.1–4 Preparation for response to
emergencies includes education and training, maintenance of
emergency equipment and supplies, appropriate use of personnel, and the formation and implementation of an emergency
plan. The emergency plan should be thought of as a blueprint
for handling emergencies. A sound emergency plan is easily
understood and establishes accountability for the management
of emergencies. Furthermore, failure to have an emergency
plan can be considered negligence.5
Based on an extensive survey of the literature and expert
review, the following is the position of the National Athletic
Trainers’ Association (NATA):
1. Each institution or organization that sponsors athletic activities must have a written emergency plan. The emergency plan should be comprehensive and practical, yet
flexible enough to adapt to any emergency situation.
2. Emergency plans must be written documents and should
be distributed to certified athletic trainers, team and at-
100 Volume 37 • Number 1 • March 2002
tending physicians, athletic training students, institutional
and organizational safety personnel, institutional and organizational administrators, and coaches. The emergency
plan should be developed in consultation with local emergency medical services personnel.
3. An emergency plan for athletics identifies the personnel
involved in carrying out the emergency plan and outlines
the qualifications of those executing the plan. Sports medicine professionals, officials, and coaches should be
trained in automatic external defibrillation, cardiopulmonary resuscitation, first aid, and prevention of disease
4. The emergency plan should specify the equipment needed
to carry out the tasks required in the event of an emergency. In addition, the emergency plan should outline the
location of the emergency equipment. Further, the equipment available should be appropriate to the level of training of the personnel involved.
5. Establishment of a clear mechanism for communication to
appropriate emergency care service providers and identification of the mode of transportation for the injured participant are critical elements of an emergency plan.
6. The emergency plan should be specific to the activity venue. That is, each activity site should have a defined emergency plan that is derived from the overall institutional or
organizational policies on emergency planning.
7. Emergency plans should incorporate the emergency care
facilities to which the injured individual will be taken.
Emergency receiving facilities should be notified in advance of scheduled events and contests. Personnel from
the emergency receiving facilities should be included in
the development of the emergency plan for the institution
or organization.
8. The emergency plan specifies the necessary documentation supporting the implementation and evaluation of the
emergency plan. This documentation should identify responsibility for documenting actions taken during the
emergency, evaluation of the emergency response, and institutional personnel training.
9. The emergency plan should be reviewed and rehearsed
annually, although more frequent review and rehearsal
may be necessary. The results of these reviews and rehearsals should be documented and should indicate whether the emergency plan was modified, with further documentation reflecting how the plan was changed.
10. All personnel involved with the organization and sponsorship of athletic activities share a professional responsibility to provide for the emergency care of an injured
person, including the development and implementation of
an emergency plan.
11. All personnel involved with the organization and sponsorship of athletic activities share a legal duty to develop,
implement, and evaluate an emergency plan for all sponsored athletic activities.
12. The emergency plan should be reviewed by the administration and legal counsel of the sponsoring organization
or institution.
Need for Emergency Plans
Emergencies, accidents, and natural disasters are rarely predictable; however, when they do occur, the rapid, controlled response will likely make the difference between an effective
and ineffective emergency response. The response can be hindered by the chaotic actions and increased emotions of those
who make attempts to help persons who are injured or in danger. One method of control for these unpredictable events is
an emergency plan that if well designed and rehearsed, can
provide responders with an organized approach to their reaction. The development of the emergency plan takes care and
time to ensure that all necessary contingencies have been included. Lessons learned from major emergencies are also important to consider when developing or revising an emergency
Emergency plans are applicable to agencies of the government, such as law enforcement, fire and rescue, and federal
emergency management teams. Furthermore, the use of emergency plans is directly applicable to sport and fitness activities
due to the inherent possibility of ‘‘an untoward event’’ that
requires access to emergency medical services.6 Of course,
when developing an emergency plan for athletics, there is one
notable difference from those used by local, state, and federal
emergency management personnel. With few exceptions, typically only one athlete, fan, or sideline participant is at risk at
one time due to bleeding, internal injury, cardiac arrest, shock,
or traumatic head or spine injury. However, emergency planning in athletics should account for an untoward event involving a game official, fan, or sideline participant as well as the
participating athlete. Although triage in athletic emergency situations may be rare, this does not minimize the risks involved
and the need for carefully prepared emergency care plans. The
need for emergency plans in athletics can be divided into 2
major categories: professional and legal.
Professional Need. The first category for consideration in
determining the need for emergency plans in athletics is an organizational and professional responsibility. Certain governing
bodies associated with athletic competition have stated that
institutions and organizations must provide access to emergency medical services if an emergency should occur during
any aspect of athletic activity, including in-season and off-season activities.6 The National Collegiate Athletic Association (NCAA) has recommended that all member institutions
develop an emergency plan for their athletic programs.7 The
National Federation of State High School Associations has
recommended the same at the secondary school level.8 The
NCAA states, ‘‘Each scheduled practice or contest of an institution-sponsored intercollegiate athletics event, as well as
out-of-season practices and skills sessions, should include an
emergency plan.’’6 The 1999–2000 NCAA Sports Medicine
Handbook further outlines the key components of the emergency plan.6
Although the 1999–2000 NCAA Sports Medicine Handbook
is a useful guide, a recent survey of NCAA member institutions revealed that at least 10% of the institutions do not maintain any form of an emergency plan.7 In addition, more than
one-third of the institutions do not maintain emergency plans
for the off-season strength and conditioning activities of the
Personnel coverage at NCAA institutions was also found to
be an issue. Nearly all schools provided personnel qualified to
administer emergency care for high-risk contact sports, but
fewer than two-thirds of institutions provided adequate personnel to sports such as cross-country and track.9 In a memorandum dated March 25, 1999, and sent to key personnel at
Journal of Athletic Training 101
all schools, the president of the NCAA reiterated the recommendations in the 1999–2000 NCAA Sports Medicine Handbook to maintain emergency plans for all sports activities, including skill instruction, conditioning, and the nontraditional
practice seasons.8
A need for emergency preparedness is further recognized
by several national organizations concerned with the delivery
of health care services to fitness and sport participants, including the NATA Education Council,10 NATA Board of Certification, Inc,11 American College of Sports Medicine, International Health Racquet and Sports Club Association,
American College of Cardiology, and Young Men’s Christian
Association.12 The NATA-approved athletic training educational competencies for athletic trainers include several references to emergency action plans.10 The knowledge of the key
components of an emergency plan, the ability to recognize and
appraise emergency plans, and the ability to develop emergency plans are all considered required tasks of the athletic
trainer.11 These responsibilities justify the need for the athletic
trainer to be involved in the development and application of
emergency plans as a partial fulfillment of his or her professional obligations.
In addition to the equipment and personnel involved in
emergency response, the emergency plan must include consideration for the sport activity and rules of competition, the
weather conditions, and the level of competition.13 The variation in these factors makes venue-specific planning necessary
because of the numerous contingencies that may occur. For
example, many youth sport activities include both new participants of various sizes who may not know the rules of the
activity and those who have participated for years. Also, outdoor sport activities include the possibility of lightning strikes,
excessive heat and humidity, and excessive cold, among other
environmental concerns that may not be factors during indoor
activities. Organizations in areas of the country in which snow
may accumulate must consider provisions for ensuring that
accessibility by emergency vehicles is not hampered. In addition, the availability of safety equipment that is necessary
for participation may be an issue for those in underserved
areas. The burden of considering all the possible contingencies
in light of the various situations must rest on the professionals,
who are best trained to recognize the need for emergency plans
and who can develop and implement the venue-specific plans.
Legal Need. Also of significance is the legal basis for the
development and application of an emergency plan. It is well
known that organizational medical personnel, including certified athletic trainers, have a legal duty as reasonable and prudent professionals to ensure high-quality care of the participants. Of further legal precedence is the accepted standard of
care by which allied health professionals are measured.14 This
standard of care provides necessary accountability for the actions of both the practitioners and the governing body that
oversees those practitioners. The emergency plan has been categorized as a written document that defines the standard of
care required during an emergency situation.15 Herbert16 emphasized that well-formulated, adequately written, and periodically rehearsed emergency response protocols are absolutely required by sports medicine programs. Herbert16 further
stated that the absence of an emergency plan frequently is the
basis for claim and suit based on negligence.
One key indicator for the need for an emergency action plan
is the concept of foreseeability. The organization administrators and the members of the sports medicine team must question whether a particular emergency situation has a reasonable
possibility of occurring during the sport activity in question.14,15,17 For example, if it is reasonably possible that a
catastrophic event such as a head injury, spine injury, or other
severe trauma may occur during practice, conditioning, or
competition in a sport, a previously prepared emergency plan
must be in place. The medical and allied health care personnel
must constantly be on guard for potential injuries, and although the occurrence of limb-threatening or life-threatening
emergencies is not common, the potential exists. Therefore,
prepared emergency responders must have planned in advance
for the action to be taken in the event of such an emergency.
Several legal claims and suits have indicated or alluded to
the need for emergency plans. In Gathers v Loyola Marymount
University,18 the state court settlement included a statement
that care was delayed for the injured athlete, and the plaintiffs
further alleged that the defendants acted negligently and carelessly in not providing appropriate emergency response. These
observations strongly support the need to have clear emergency plans in place, rehearsed, and carried out. In several additional cases,19–21 the courts have stated that proper care was
delayed, and it can be reasoned that these delays could have
been avoided with the application of a well-prepared emergency plan.
Perhaps the most significant case bearing on the need for
emergency planning is Kleinknecht v Gettysburg College,
which came before the appellate court in 1993.5,17 In a portion
of the decision, the court stated that the college owed a duty
to the athletes who are recruited to be athletes at the institution.
Further, as a part of that duty, the college must provide
‘‘prompt and adequate emergency services while engaged in
the school-sponsored intercollegiate athletic activity for which
the athlete had been recruited.’’17 The same court further ruled
that reasonable measures must be ensured and in place to provide prompt treatment of emergency situations. One can conclude from these rulings that planning is critical to ensure
prompt and proper emergency medical care, further validating
the need for an emergency plan.5
Based on the review of the legal and professional literature,
there is no doubt regarding the need for organizations at all
levels that sponsor athletic activities to maintain an up-to-date,
thorough, and regularly rehearsed emergency plan. Furthermore, members of the sports medicine team have both legal
and professional obligations to perform this duty to protect the
interests of both the participating athletes and the organization
or institution. At best, failure to do so will inevitably result in
inefficient athlete care, whereas at worst, gross negligence and
potential life-threatening ramifications for the injured athlete
or organizational personnel are likely.
Components of Emergency Plans
Organizations that sponsor athletic activities have a duty
to develop an emergency plan that can be implemented immediately and to provide appropriate standards of health care
to all sports participants.5,14,15,17 Athletic injuries may occur
at any time and during any activity. The sports medicine team
must be prepared through the formulation of an emergency
plan, proper coverage of events, maintenance of appropriate
emergency equipment and supplies, use of appropriate emergency medical personnel, and continuing education in the
area of emergency medicine. Some potential emergencies
may be averted through careful preparticipation physical
102 Volume 37 • Number 1 • March 2002
Sample Venue-Specific Emergency Protocol
University Sports Medicine Football Emergency Protocol
1. Call 911 or other emergency number consistent with organizational policies
2. Instruct emergency medical services (EMS) personnel to ‘‘report to and meet at as we have an
injured student-athlete in need of emergency medical treatment.’’
University Football Practice Complex: Street entrance (gate across street from ) cross street: Street
University Stadium: Gate entrance off Road
3. Provide necessary information to EMS personnel:
● name, address, telephone number of caller
● number of victims; condition of victims
● first-aid treatment initiated
● specific directions as needed to locate scene
● other information as requested by dispatcher
4. Provide appropriate emergency care until arrival of EMS personnel: on arrival of EMS personnel, provide pertinent information (method of
injury, vital signs, treatment rendered, medical history) and assist with emergency care as needed
● sports medicine staff members should accompany student-athlete to the hospital
● notify other sports medicine staff immediately
● parents should be contacted by sports medicine staff
● inform coach(es) and administration
● obtain a medical history and insurance information
● appropriate injury reports should be completed
Emergency Telephone Numbers
Hospital –
Emergency Department –
University Health Center –
Campus Police –
Emergency Signals
Physician: arm extended overhead with clenched first
Paramedics: point to a location in the end zone by the home locker room and wave onto the field
Spine board: arms held horizontally
Stretcher: supinated hands in front of body or waist level
Splints: hand to lower leg or thigh
screenings, adequate medical coverage, safe practice and
training techniques, and other safety measures.1,22 However,
accidents and injuries are inherent with sports participation,
and proper preparation on the part of the sports medicine
the team will enable each emergency situation to be managed
The goal of the sports medicine team is the delivery of the
highest possible quality health care to the athlete. Management
of the emergency situation that occurs during athletic activities
may involve certified athletic trainers and students, emergency
medical personnel, physicians, and coaches working together.
Just as with an athletic team, the sports medicine team must
work together as an efficient unit to accomplish its goals.22 In
an emergency situation, the team concept becomes even more
critical, because time is crucial and seconds may mean the
difference between life, death, and permanent disability. The
sharing of information, training, and skills among the various
emergency medical care providers helps reach the goal.22,23
Implementation. Once the importance of the emergency
plan is realized and the plan has been developed, the plan must
be implemented. Implementation of the emergency plan requires 3 basic steps.23
First, the plan must be committed to writing (Table) to provide a clear response mechanism and to allow for continuity
among emergency team members.14,16 This can be accomplished by using a flow sheet or an organizational chart. It is
also important to have a separate plan or to modify the plan
for different athletic venues and for practices and games.
Emergency team members, such as the team physician, who
are present at games may not necessarily be present at practices. Moreover, the location and type of equipment and communication devices may differ among sports, venues, and activity levels.
The second step is education.23 It is important to educate
all the members of the emergency team regarding the emergency plan. All personnel should be familiar with the emergency medical services system that will provide coverage to
their venues and include their input in the emergency plan.
Each team member, as well as institution or organization administrators, should have a written copy of the emergency plan
that provides documentation of his or her roles and responsibilities in emergency situations. A copy of the emergency plan
specific to each venue should be posted prominently by the
available telephone.
Third, the emergency plan and procedures have to be rehearsed.16 This provides team members a chance to maintain
their emergency skills at a high level of competency. It also
provides an opportunity for athletic trainers and emergency
medical personnel to communicate regarding specific policies
and procedures in their particular region of practice.22 This
rehearsal can be accomplished through an annual in-service
the meeting, preferably before the highest-risk sports season (eg,
football, ice hockey, lacrosse). Reviews should be undertaken
as needed throughout the sports season, because emergency
medical procedures and personnel may change.
Journal of Athletic Training 103
Personnel. In an athletic environment, the first person who
responds to an emergency situation may vary widely22,24; it
maybe a coach or a game official, a certified athletic trainer,
an emergency medical technician, or a physician. This variation in the first responder makes it imperative that an emergency plan be in place and rehearsed. With a plan in place
and rehearsed, these differently trained individuals will be able
to work together as an effective team when responding to
emergency situations.
The plan should also outline who is responsible for summoning help and clearing the uninjured from the area.
In addition, all personnel associated with practices, competitions, skills instruction, and strength and conditioning activities should have training in automatic external defibrillation
and current certification in cardiopulmonary resuscitation, first
aid, and the prevention of disease transmission.5,7
Equipment. All necessary supplemental equipment should
be at the site and quickly accessible.13,25 Equipment should be
in good operating condition, and personnel must be trained in
advance to use it properly. Improvements in technology and
emergency training require personnel to become familiar with
the use of automatic external defibrillators, oxygen, and advanced airways.
It is imperative that health professionals and organizational
administrators recognize that recent guidelines published by
the American Heart Association call for the availability and
use of automatic external defibrillators and that defibrillation
is considered a component of basic life support.26 In addition,
these guidelines emphasize the use of the bag-valve-mask in emergency resuscitation and the use of emergency oxygen and advanced airways in emergency care. Personnel should consider
receiving appropriate training for these devices and should
limit use to devices for which they have been trained.
To ensure that emergency equipment is in working order,
all equipment should be checked on a regular basis. Also, the
use of equipment should be regularly rehearsed by emergency
personnel, and the emergency equipment that is available
should be appropriate for the level of training of the emergency medical providers and the venue.
Communication. Access to a working telephone or other
telecommunications device, whether fixed or mobile, should
be ensured.5,17,21 The communications system should be
checked before each practice or competition to ensure proper
working order. A backup communication plan should be in
effect in case the primary communication system fails. A listing of appropriate emergency numbers should be either posted
by the communication system or readily available, as well as
the street address of the venue and specific directions (cross
streets, landmarks, and so on) (Table).
Transportation. The emergency plan should encompass
the transportation of the sick and injured. Emphasis should be
placed on having an ambulance on-site at high-risk events.15
Emergency medical services response time should also be factored in when determining on-site ambulance coverage. Consideration should be given to the level of transportation service
that is available (eg, basic life support, advanced life support)
and the equipment and training level of the personnel who
staff the ambulance.23
In the event that an ambulance is on-site, a location should
be designated with rapid access to the site and a cleared route
for entering and exiting the venue.19 In the emergency evaluation, the primary survey assists the emergency care provider
in identifying emergencies that require critical intervention
and in determining transport decisions. In an emergency situation, the athlete should be transported by ambulance to the
most appropriate receiving facility, where the necessary staff
and equipment can deliver appropriate care.23
In addition, a plan must be available to ensure that the activity areas are supervised if the emergency care provider
leaves the site to transport the athlete.
Venue Location. The emergency plan should be venue specific, based on the site of the practice or competition and the
activity involved (Table). The plan for each venue should encompass accessibility to emergency personnel, communication
system, equipment, and transportation.
At home sites, the host medical providers should orient the
visiting medical personnel regarding the site, emergency personnel, equipment available, and procedures associated with
the emergency plan.
At away or neutral sites, the coach or athletic trainer should
identify, before the event, the availability of communication
with emergency medical services and should verify service
and reception, particularly in rural areas. In addition, the name
and location of the nearest emergency care facility and the
availability of an ambulance at the event site should be ascertained.
Emergency Care Facilities. The emergency plan should
incorporate access to an emergency medical facility. In the selection of the appropriate facility, consideration should be given
to the location with respect to the athletic venue. Consideration
should also include the level of service available at the emergency facility.
The designated emergency facility and emergency medical
services should be notified in advance of athletic events. Furthermore, it is recommended that the emergency plan be reviewed with both medical facility administrators and in-service medical staff regarding pertinent issues involved in athlete
care, such as proper removal of athletic equipment in the facility when appropriate.22,23,27
Documentation. A written emergency plan should be reviewed and approved by sports medicine team members and
institutions involved. If multiple facilities or sites are to be
used, each will require a separate plan. Additional documentation should encompass the following15,16:
1. Delineation of the person and/or group responsible for
documenting the events of the emergency situation
2. Follow-up documentation on evaluation of response to
an emergency situation
3. Documentation of regular rehearsal of the emergency plan
4. Documentation of personnel training
5. Documentation of emergency equipment maintenance
It is prudent to invest organizational and institutional ownership in the emergency plan by involving administrators and
sports coaches as well as sports medicine personnel in the planning and documentation process. The emergency plan should
be reviewed at least annually with all involved personnel. Any
revisions or modifications should be reviewed and approved
by the personnel involved at all levels of the sponsoring organization or institution and of the responding emergency
medical services.
The purpose of this statement is to present the position of
the NATA on emergency planning in athletics. Specifically,
104 Volume 37 • Number 1 • March 2002
professional and legal requirements mandate that organizations
or institutions sponsoring athletic activities have a written
emergency plan. A well-thought-out emergency plan consists
of a number of factors, including, but not necessarily limited
to, personnel, equipment, communication, transportation, and
documentation. Finally, all sports medicine professionals,
coaches, and organizational administrators share professional
and legal duties to develop, implement, and evaluate emergency plans for sponsored athletic activities.
This position statement was reviewed for the National Athletic
Trainers’ Association by the Pronouncements Committee and by John
Cottone, EdD, ATC; Francis X. Feld, MEd, MS, CRNA, ATC,
NREMT-P; and Richard Ray, EdD, ATC.
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