Emergency Action Plans Should be Reviewed, Rehearsed Annually

The revered basketball coach, John Wooden (UCLA, 1948- 1975), had as one of his favorite quotes: “Failing to prepare is preparing to fail.” This principle is at the heart of creating and maintaining emergency action plans (EAPs) specific for each activity venue in which our high school students participate. Over the past several years, much has been presented regarding the professional and legal responsibility incumbent upon those who oversee and safeguard the wellbeing of student-athletes.

The Scout motto “Be Prepared” is something to strive for in providing an appropriate response in emergency situations. The venue-specific EAP is a written document that outlines the appropriate procedures to be followed and individual contact information for those responsible when an emergency occurs. Components of the EAP include:

• Awareness of potential safety issues, such as sudden cardiac arrest, exertional heat stroke, head and neck injuries, exertional sickling, adverse weather conditions such as lightning, etc.

• Trained onsite personnel

• EMS contact information and access to the venue

• Timely access to emergency equipment (AED, cooling tub, etc.)

• Annually reviewed and rehearsed

The venue-specific EAP should be reviewed as part of a pre-event administrative meeting (referred to as a ‘Medical Time-Out’) by the covering medical team, which may include athletic trainer, athletic director, officials, emergency medical services personnel, attending physician, and event administrator.

This brief pre-event meeting identifies personnel, communication, equipment, transportation and environmental conditions (such as heat, lightning, etc.), and the appropriate outlined response for each member of the medical team. A simple, pre-event informational card8 distributed to officials, coaches, administrators and other emergency team members would be helpful to guide and outline the EAP for that event. Look for more information about the Medical Time-Out in next month’s HST.

Implementation of an effective emergency action plan includes three basic steps3:

1. A venue-specific EAP must be written and posted to communicate a clear response mechanism and allow for continuity among emergency team members.

2. Educate all members of the emergency team regarding the EAP and their specific roles. Training would include activation of emergency medical service (EMS); recognition of sudden cardiac arrest (SCA) with appropriate cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) practice; cooling techniques in situations involving heat stroke, management of head and neck injuries, along with basic first aid, and prevention of disease transmission.

3. The EAP is reviewed and rehearsed annually. While an annual review of the EAP is important, a live rehearsal of the EAP at an annual in-service training will be far more effective when an emergency situation occurs.

With regard to the importance of live rehearsal of EAPs as part of being prepared for an emergency, a thoughtful article by Stephanie Kuzydym provides some perspective:

“Schools drill for fires and tornadoes because one day they could happen. In the last 10 years, seven students have died from a tornado on school property in the United States. In the last 10 years, no student has died from a fire at a school. In the last 10 years, at least 200 students have died playing high school sports.”(Louisville Courier Journal, April 18, 2023, updated Nov. 1, 2023, https://www. courier-journal.com/in-depth/news/investigations/2023/04/18/safer-sidelines-the-courier-journals-methodology-and-how-wedid-it/69862146007/)

An informative article by Samuel T. Johnson, et al., compared the adoption of EAPs and associated best practices in Oregon high schools before and after a policy requiring an EAP and if they did, was the EAP venue-specific, available at the venue, distributed to personnel, and annually reviewed and rehearsed. There was a significant increase of the schools that reported having an EAP after the policy went into effect and venue-specific EAPs also significantly increased. However, no best practice recommendations related to EAP availability, distribution, review or rehearsal changed after the policy; and, while schools met the minimum requirements of the policy, other related best practices did not significantly improve.(The Effect of a Statewide Policy on High School Emergency Action Plans, Sports, Oct. 2022; https://www.mdpi.com/2075-4663/10/10/161)

This would encourage state high school associations to engage in how to assist their affiliated schools in effectively implementing best practices into their EAPs. The NFHS strives to assist state associations and their member schools to be prepared when medical emergencies occur by providing online course training through the NFHS Learning Center4-6 (https://nfhslearn.com/).

In addition, the NFHS Foundation distributed 1,147 AED units in 2018-19, with the goal of ensuring that every member school of a state association had at least one AED on campus. In 2022, the NFHS Foundation distributed 5,400 wet bulb globe temperature (WBGT) monitors to high schools across the country as a tool for minimizing heat-related illness. Also, the NFHS has promoted the “Anyone Can Save a Life”7 program for the past 11 years. This program is essentially a toolkit for schools to use in establishing emergency action plans in response to a collapsed individual. It has been well-received around the country and has helped save lives.

The majority of causes for catastrophic injuries in high school athletes involves Heart, Heat, Head and Hemoglobin (exertional sickling) related injuries, with more than 60 percent caused by SCA (National Center for Catastrophic Sport Injury Research data). It has been well-documented that as part of CPR training, the access to and use of an AED is essential when responding to a cardiac event, with an 85 percent survival rate when an AED is applied within three minutes of a collapse.

In an impactful and instructional two-minute video9, Dr. Jonathan Drezner discusses the recognition of sudden cardiac arrest and the importance of engaging EMS, beginning CPR and applying an AED as part of a well-rehearsed EAP. It is strongly recommended that all individuals involved in the emergency response are trained in CPR and AED application.

While it is important to be prepared to appropriately respond in an emergency, it would be instructive to keep in perspective the wisdom of the saying: “An ounce of prevention is worth a pound of cure” as it is applied to EAPs. For example, while it is appropriate to have an onsite cooling tub and rectal thermometer available to treat and monitor exertional heat stroke (EHS), adherence to well-established heat acclimatization guidelines and the use of WBGT in making modifications to team practice or events, should reduce the incidence of EHS. Likewise, knowing which athletes are susceptible to exertional sickling and making appropriate modifications in their conditioning and training, should reduce the incidence of athletes that experience exertional sickling collapse.

When evaluating what will move the needle in a positive direction with regard to accomplishing what is understood to be best practices of an effective EAP, significant effort ought to be in how to best implement and ensure that the EAPs are in place, reviewed and rehearsed annually. The NFHS strives to assist state high school associations in this effort through various online training, articles, position statements and support from the NFHS Foundation, all in an effort to “be prepared.”

Resource material:

1. Emergency Planning, AED, Saving Lives in Nations High Schools, Dr. Karissa Niehoff, HST, March 2023 https://www.nfhs.org/articles/emergency-planning-aeds-saving-lives-in-nation-s-high-schools/

2. Emergency Action Plans: Practice Makes Perfect, Lynne Young, Mark D’Anza, HST, January 2022 https://www.nfhs.org/articles/emergency-action-plans-practice-makes-perfect/

3. National Athletic Trainer’s Association Position Statement: Emergency Planning in Athletics, J.C. Andersen, et al., Journal of Athletic Training, 2002;37(1):99-104 https://www.nata.org/sites/default/files/emergencyplanninginathletics.pdf

4. NFHS “The Collapsed Athlete” Online course from NFHSLearn https://nfhslearn.com/courses/the-collapsed-athlete

5. NFHS “CPR and AED Training” Online course from NFHSLearn https://nfhslearn.com/courses/cpr-aed

6. NFHS “Sudden Cardiac Arrest” Online course from NFHSLearn.com https://nfhslearn.com/courses/sudden-cardiac-arrest

7. Anyone Can Save a Life http://www.anyonecansavealife.org/

8. Medical Time Out – Korey Stringer Institute, University of Connecticut, update July, 2023 https://ksi.uconn.edu/wp-content/uploads/sites/1222/2019/07/ksi_mto_checklist_2019.pdf

9. How to Save a Life - Recognize Sudden Cardiac Arrest in Athletes, UW Medicine Center for Sports Cardiology, Jonathan Drezner, M.D. https://www.youtube.com/watch?v=i-iN9o-cKu0

10. Preventing Sudden Death in Sport and Physical Activity, 2nd ed.; Douglas J. Casa, et al., 2017.