Abstract
Background:
Rates of emergency action plan (EAP) implementation and compliance with EAP guidelines vary in United States secondary schools. There are limited data on emergency preparedness in schools without athletic trainers (ATs).
Hypothesis:
Rural and high poverty schools have poor emergency preparedness for high school athletic events due to financial barriers and lack of ATs.
Study Design:
Cross-sectional study.
Level of Evidence:
Level 5.
Methods:
A web-based questionnaire was emailed by each State High School Athletics Association to ATs, athletic directors, and coaches of recipient schools to assess emergency preparedness.
Results:
A total of 686 responses were received (response rate ~3.5%). Schools with an AT on staff were more likely to have an EAP (P < 0.01). Schools with a higher enrollment were more likely to have an EAP (P < 0.01), an AT on staff (P < 0.01), require additional training for coaches (P < 0.01), and have an automated external defibrillator (AED) onsite for all events (P < 0.01). Urban (odds ratio [OR], 3.514; 95% CI [2.242, 5.507]; P < 0.01) and suburban (OR, 4.950; 95% CI [3.287, 7.454]; P < 0.01) districts were more likely than rural districts to have an AT on staff. High poverty districts were less likely to have an AED (OR, 0.660; 95% CI [0.452, 0.964]; P = 0.03) or EAP (OR, 0.511; 95% CI [0.306, 0.853]; P < 0.01) at athletic venues.
Conclusion:
Lower enrollment, high poverty, and rural schools are less prepared for athletic emergencies than their higher enrollment, low poverty, and suburban counterparts as these schools are generally less likely to have an AT on staff, AEDs, and EAPs and less likely to provide additional training to coaches and other staff.
Clinical Relevance:
This study assesses athletic emergency preparedness—a critical component of ensuring athlete safety and recovery after injury.
In 2022, nearly 8 million adolescents participated in school-related sporting activities according to the 2021-2022 High School Athletics Participation Survey conducted by the National Federation of State High School Associations. 14 From 2011 to 2014, the Centers for Disease Control and Prevention reported nearly 5.6 million injuries related to sport or recreation among persons aged 5 to 24 years. 21 Although the majority of injuries are not life threatening, there is still a significant number of catastrophic and fatal injuries. According to the National Center for Catastrophic Sport Injury Research at the University of North Carolina at Chapel Hill’s 38th annual report, between 1982 and 2021, there have been 2328 catastrophic injuries in high school sports, with 48 occurring in the 2020-2021 school year. 13 Catastrophic injuries were defined as fatalities, permanent disability injuries, serious injuries (fractured neck or serious head injury) (even if the athlete had a full recovery), temporary or transient paralysis, heat stroke due to exercise, or sudden cardiac arrest/sudden cardiac or severe cardiac disruption. 13
Implementing an emergency action plan (EAP) is an essential part of ensuring an efficient response to any catastrophic event in high school athletics. 4 An EAP is a written guideline of emergency planning designed to help people to respond to a catastrophic sports injury. The National Athletic Trainers’ Association (NATA) has described necessary components of the EAP, as well as published recommendations on emergency preparedness in organized athletics through their position statements.1,2,4 NATA’s recommendations identify the components of emergency response preparation, which includes formation and implementation of an EAP, proper education and training for personnel, acquisition and maintenance of emergency equipment and supplies, and appropriate use of personnel. 1 In addition, the Sideline Preparedness Collaboration (comprised of 6 major professional organizations: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine) as well as the American Academy of Pediatrics and the American Heart Association all endorse the formation and implementation of EAPs in schools.3,17,20
EAP adoption has been studied at the national level; however, all but 1 study solely surveyed school athletic trainers (ATs).15,18,22 Other research has identified that, in some states, only 50% of schools have AT access,8,10,11 suggesting that EAP adoption is not well studied in schools without ATs. Given the importance of the AT, this shows that many schools who may be at higher risk of poor emergency preparedness have not been well studied. The purpose of this study is to identify the emergency preparedness of United States high school athletics departments, analyze school characteristics leading to improved compliance, and identify barriers to implementation of national guidelines.
Methods
A web-based questionnaire was developed to perform a cross-sectional analysis of the emergency preparedness of high schools. The survey questions were developed using current literature and position statements on emergency action planning and readiness from NATA.1,2,4 The questionnaire included 24 questions focused on demographics of the study population, EAP adoption,1,2,4 compliance with national EAP guidelines, 1 access to certified medical personnel (defined in the survey as an AT, physician, or other such qualified persons designated to respond to medical needs),2,4 and training received by athletics personnel. 1 Additional questions were added based on potential barriers that schools may have to meeting guidelines.
This research proposal was reviewed by the Institutional Review Board (IRB) but was determined to be exempt from IRB approval process because the surveys do not include human subject information.
The questionnaire was delivered electronically through email by each State High School Athletics Association to ATs, athletic directors, and coaches of recipient schools. Questionnaire distribution and data organization were done using REDCap (Research Electronic Data Capture) software.5,6
For statistical analysis, responses were stratified by student enrollment, poverty status, or between rural/suburban/urban status. Poverty status was defined by the percentage of students receiving free or reduced-price lunches (FRPLs), as this is a surrogate marker of poverty used commonly by state governments in funding allocation processes. Schools in which >40% of students received FRPLs were considered impoverished. Geography definitions were established using the National Center for Education Statistics Locale Classifications and were provided in our survey as follows: urban status was defined as “Territory inside an urbanized area and inside a principal city;” suburban was defined as “Territory outside a principal city but inside an urbanized area;” rural was defined as “Territory that is more than 5 miles outside an urbanized area.” Underserved status was determined by asking schools to self-identify if they were underserved. For the analysis of responses by enrollment, Cochran-Armitage tests for trend were used to test for relationships between enrollment and survey answers. For the analysis of responses stratified between rural, urban, and suburban, a chi-square test was used to analyze dichotomous responses. One-way analysis of variance tests were used for responses that were continuous, with Tukey’s method used for post hoc comparisons. A P value < 0.05 was considered statistically significant. Statistical analysis was performed in R Version 4.0.5.
Results
There were 686 responses to the survey. Although we cannot determine the exact number of schools that received our survey, we assume that the total number was near the 19,500 schools that are served by the National Federation of State High School Associations, 14 yielding a response rate of approximately 3.5%. We received responses from 49 of 51 states (including District of Columbia) with the exceptions being Montana and Wyoming, and the approximate response rate for each state is listed in Table 1, although the number of state association member schools may be different than it was at the time of survey distribution and/or different from the number of schools who received the survey. The demographics of the study population are shown in Table 2. Overall results are summarized in Table 3. Schools with an AT on staff were more likely to have an EAP (P < 0.01); of the 484 schools with an AT on staff, the majority (451/484, 93.2%) had an EAP.
Approximate response rate by state
Total number of state association members may not be the same as when the survey was sent. In addition, some state associations provided an estimate of membership, so response rates are not exact.
Ten submissions did not select a state.
Demographics of high schools surveyed
Emergency preparedness
AED, automated external defibrillator; AT, athletic trainer; CPR, cardiopulmonary resuscitation; EAP, emergency action plan.
Results by Enrollment
A higher enrollment was significantly associated with a higher proportion of schools with an AT on staff (P < 0.01). No significant trend was found in the proportion of districts having an ambulance at football games (P = 0.46). Higher enrollment was significantly associated with greater proportions of having an EAP (P < 0.01), requiring additional training for coaches (P < 0.01), and having an automated external defibrillator (AED) on-site for all events (P < 0.01). Among schools that did have an EAP, higher enrollment was associated with a higher proportion of districts having site-specific EAPs (P < 0.01), whereas no significant trend was found in regard to reviewing the EAP with opponents before an event (P = 0.54).
Results by Poverty Status
In all, 96 of 161 (59.6%) urban schools, 69 of 263 (26.2%) suburban schools, and 157 of 262 (59.9%) rural schools reported that their district was considered impoverished (40% of students receive FRPLs). Districts that reported high poverty were less likely to have an AT on staff (odds ratio [OR], 0.471; 95% CI [0.336, 0.660]; P < 0.01). No significant difference was found in requiring additional training for coaches (OR, 0.788; 95% CI [0.582, 1.066]; P = 0.12) or having an ambulance on-site for football games (OR, 1.093; 95% CI [0.789, 1.515]; P = 0.59). Among districts with an AT on staff, districts with high poverty had ATs that worked, on average, 6 fewer hours (∆ = 6.088 hours; 95%CI [3.337, 8.840]; P < 0.01). For districts that did not have an ambulance at football games, there was no significant difference in time from the nearest ambulance (∆ = 0.024 minutes, 95% CI [-1.290, 1.338]; P = 0.97). High poverty districts were less likely to have an AED for all athletic venues (OR, 0.660; 95% CI [0.452, 0.964]; P = 0.03) and less likely to have an EAP (OR, 0.511; 95% CI [0.306, 0.853]; P < 0.01). Among districts that did have an EAP, there was no significant difference in having site-specific EAPs (OR, 1.008, 95% CI [0.620, 1.639];P = 0.97) or reviewing the EAP with opponents before an event (OR, 1.070, 95% CI [0.703, 1.628]; P = 0.75).
High poverty districts were more likely to report barriers from finances (OR, 2.362; 95% CI [1.726, 3.23]; P < 0.01) and access to certified medical personnel (OR, 1.788; 95% CI [1.182, 2.703]; P < 0.01), with no significant difference with medical/legal barriers (OR, 0.609; 95% CI [0.202, 1.839]; P = 0.38).
Results by Urban/Suburban/Rural Status
Results by urban/suburban/rural status are summarized in Table 4.
Summary of results by urban/suburban/rural
AT, athletic trainer; EAP, emergency action plan; OR, odds ratio.
Mean difference (95% CI).
Urban districts were more likely than rural districts to have an AT on staff (OR, 3.514; 95% CI [2.242, 5.507]; P < 0.01). Suburban districts were also more likely to have an AT than rural districts (OR, 4.950; 95% CI [3.287, 7.454]; P < 0.01). There was no significant difference between urban and suburban districts (OR, 0.710; 95% CI [0.430, 1.173]; P = 0.18). Urban districts were found to be less likely to have an ambulance at football games than both suburban (OR, 0.438; 95% CI [0.289, 0.665]; P < 0.01) and rural districts (OR, 0.266; 95% CI [0.172, 0.411]; P < 0.01). In addition, suburban districts were less likely to have an ambulance than rural districts (OR, 0.607; 95% CI [0.410, 0.899]; P = 0.01). With regard to requiring additional training, urban districts were not significantly different from suburban (OR, 0.830; 95% CI [0.559, 1.23]; P = 0.36) or rural (OR, 1.454; 95% CI [0.980, 2.159]; P = 0.06) districts, while suburban districts were more likely to require it than rural districts (OR, 1.751; 95% CI [1.239, 2.475]; P < 0.01). Urban districts were not significantly different from rural districts at having an AED on site for all events (OR, 1.316; 95% CI [0.824, 2.103]; P = 0.25). Suburban districts were more likely to have an AED than rural (OR, 2.444; 95% CI [1.547, 3.864]; P < 0.01) and urban (OR, 1.859; 95% CI [1.098, 3.145]; P = 0.02) districts. Neither rural (OR, 0.985; 95% CI [0.479, 2.027]; P = 0.97) nor suburban (OR, 1.809; 95% CI [0.928, 3.526]; P = 0.08) districts were significantly different from urban districts in terms of having an EAP. However, suburban districts were more likely to have an EAP than rural districts (OR, 1.836; 95% CI [1.040, 3.240]; P = 0.03). Among districts that had an EAP, urban (OR, 2.152; 95% CI [1.105, 4.190]; P = 0.02) and suburban (OR, 1.908; 95% CI [1.106, 3.290]; P = 0.02) districts were more likely than rural districts to have site-specific EAPs. There were no significant differences found for reviewing an EAP with opponents before events (urban-suburban, P = 0.63; urban-rural, P = 0.77; suburban-rural, P = 0.83). Suburban districts were less likely to report financial barriers than rural districts (OR, 0.507; 95% CI [0.355, 0.722]; P < 0.01). No significant differences were found between urban and suburban (OR, 1.443; 95% CI [0.960, 2.169]; P = 0.08) or rural districts (OR, 0.731; 95% CI [0.491, 1.087]; P = 0.12). Both urban (OR, 0.271; 95% CI [0.149, 0.492]; P < 0.01) and suburban (OR, 0.302; 95% CI [0.186, 0.489]; P < 0.01) districts were less likely to report barriers related to access to certified medical personnel than rural districts. No significant differences were found for medical/legal barriers (urban-suburban, P = 0.46; urban-rural, P = 0.54; suburban-rural, P = 0.13). Rural districts were more likely than both urban (OR, 1.901; 95% CI [1.104, 3.268]; P = 0.02) and suburban (OR, 2.825; 95% CI [1.770, 4.505]; P < 0.01) districts to report that additional funding would help meet NATA EAP best practice standards. There was no significant difference between urban and suburban districts (OR, 1.487; 95% CI [0.926, 2.388],P = 0.10).
In districts that had an AT on staff, both urban (∆ = 7.924 hours; 95% CI [3.390, 12.458]; P < 0.01) and suburban (∆ = 8.101 hours; 95% CI [4.088, 12.114] P < 0.01) districts had ATs that worked more hours than rural districts, with no significant difference between urban and suburban districts (∆ = 0.177 hours; 95% CI [-3.924, 4.278]; P = 0.99). In districts that did not have an ambulance on-site at football games, both urban (∆ = 2.295 minutes; 95% CI [0.314, 4.277]; P = 0.02) and suburban (∆ = 2.405 minutes; 95% CI [0.459, 4.351]; P = 0.01) districts had an ambulance closer than rural districts, with no significant difference between urban and suburban districts (∆ = -0.109 min; 95% CI [-1.889, 1.671]; P = 0.99).
Results by Poverty Status and Urban/Suburban/Rural Status
Among districts that were impoverished, rural districts were less likely than urban (OR, 0.268; 95% CI [0.153, 0.469]; P < 0.01) and suburban (OR, 0.121; 95% CI [0.056, 0.260]; P < 0.01) districts to have an AT on staff, with no difference between urban and suburban districts (OR, 2.222; 95% CI [0.960, 5.143];P = 0.06). There was no significant difference in having an EAP (rural-urban, P = 0.31; rural-suburban, P = 0.24; urban-suburban, P = 0.79) or having a site-specific EAP (rural-urban,P = 0.16; rural-suburban, P = 0.13; urban-suburban, P = 0.78). Rural districts were more likely than suburban districts to report financial barriers (OR, 1.867; 95% CI [1.051, 3.318]; P = 0.03), with no difference between rural and urban (P = 0.35) or urban and suburban (P = 0.23) districts. In addition, rural districts reported more access barriers than urban (OR, 3.403; 95% CI [1.666, 6.949]; P < 0.01) and suburban (OR, 3.900; 95% CI [1.664, 9.144]; P < 0.01) districts. For additional funding, rural districts were more likely to than suburban (OR, 3.039; 95% CI [1.286, 7.183]; P < 0.01) but not urban (P = 0.50) districts to say that additional funding would help meet NATA EAP standards.
Discussion
The results of this study suggest that lower enrollment schools, high poverty schools, and rural schools are less prepared for athletic emergencies than their higher enrollment, low poverty, and suburban counterparts. Among these classifications, rural status may be the most important indicator, given that a comparison of impoverished schools demonstrates that rural schools were less likely to have ATs on staff and more likely to report financial barriers and barriers related to access to medical providers compared with impoverished urban and suburban schools.
First, lower enrollment, high poverty, and rural schools are all less likely to have an AT on staff, and, for schools with an AT on staff, they work fewer hours in high poverty and rural schools. This is critical, given the correlation between access to an AT and compliance with best practice recommendations, 8 including having EAP implementation, AED access, and heat-illness policies. 11 Second, AEDs were less likely to be available at all athletic venues in high poverty and low enrollment schools and in urban and rural schools compared with suburban schools. The importance of AED access is obvious as it relates to preventing death in sudden cardiac arrest,2,22 but AED access has also been shown to correlate positively with the presence of an EAP and comprehensive emergency response planning.12,22 Third, having and implementing an EAP was less likely in high poverty and low enrollment schools and in urban and rural schools compared with suburban schools. In addition, low enrollment and rural schools are less likely to have site-specific EAPs. Finally, additional training for coaches was more likely in higher enrollment schools as well as suburban schools compared with urban and rural schools. Additional training is a critical recommendation of the NATA as many schools rely on athletic directors, coaches, and other staff to implement EAPs. 1
Our findings are explained and contextualized by the fact that high poverty schools and rural schools were more likely to face financial barriers and barriers related to access to medical professionals. Barriers that schools may face in achieving full implementation of necessary health and safety policies may be numerous, including cost, lack of understanding/education related to policy recommendations and guidelines, and lack of institutional willpower. 16
Comparing results of impoverished schools further revealed that rural status presents a challenge to emergency preparedness. Although there was no significant difference among impoverished schools in having an EAP, impoverished rural schools were less likely to have an AT on staff and were more likely to report financial barriers and barriers related to access to medical providers.
The discrepancy with respect to urban/suburban/rural status for AT availability has been studied by the NATA’s Athletic Training and Services (ATLAS) project and was highlighted recently in their 2020 report using data from 2017 to 2019 to report “the percentage of full-time [AT] services is 42% in city secondary schools, peaks in the suburban locale with 54% of schools and then is reduced in towns (36%) and rural locales (23%).” 9
It is important to consider the fact that some of the differences and trends related to low enrollment and rural status may be intrinsic to the geography of the school and region. For example, urban schools are the least likely to have ambulances stationed at football games, while rural schools are the most likely to have ambulances at football games. However, of the schools that do not have ambulances, the distance/time to the nearest ambulance is found to be longer in rural communities compared with urban and suburban communities. Thus, while ambulances at football games are an important component of safety planning, it is more important for rural schools to have ambulances because they tend to be farther away in these communities compared with their urban and suburban counterparts. This discrepancy could also be combated by having onsite personnel that are prepared to provide care until an ambulance can arrive. Similarly, many of the trends are predictable given long-standing and well-reported realities of rural, high poverty, and low enrollment schools. For example, rural schools facing barriers due to lack of access to medical professionals are not surprising, given the well-reported shortages of rural health care providers. 7
Identifying trends related to enrollment and poverty was relatively straightforward, given the binary that we used for those demographic markers. Analysis of the effect of urban/suburban/rural status was not as straightforward given that 3 different statuses were being compared. However, we noted several instances in which suburban schools showed a significant increased likelihood of compliance with best practice indicators compared with either urban or rural schools (or both urban and rural schools). This finding was noted with regard to having/implementing EAPs, providing additional training, and having an AED onsite.
Critically, suburban schools were less likely than rural schools to report financial barriers, although there was no significant difference between urban and rural schools in this regard. This is also not a surprising finding, given that poverty rates are typically the highest among the most urban and the most rural regions, 23 and this is the case in our results as well, in which 59.9% of rural schools and 59.6% of urban schools were considered impoverished compared with only 26.2% of suburban schools. Accordingly, it is likely that financial barriers may represent a challenge that underlies many of our findings, as predicted by previous research herein. 16
Although some challenges may be difficult to overcome, it remains true that EAP creation and implementation, AED access, and additional training represent opportunities for the improvement of the safety and preparedness of schools nationwide.
Finally, though many of our findings point to the inherent difficulties that schools may have in meeting NATA guidelines, recent evidence by Scarneo-Miller et al 19 suggest that, at the state level, policies have shown great improvement toward emergency preparedness in the past 5 years. In a review of each state’s high school athletics association’s policies and guidelines, since AY16/17, 38 states were found to have made major improvements to their guidelines on emergency preparedness. 20 Although this is encouraging, the results of our study suggest that the same barriers to implementation of NATA guidelines may indicate inability to implement these state-level policies and guidelines as well. Particularly as state high school athletics associations continue to improve policies in accordance with NATA guidelines, it is important to identify and work to overcome barriers to implement at the level of the individual schools affected.
Limitations
This study is biased since only 686 surveys were received (approximately a 3.5% response rate). It is possible that schools with an AT on staff were more likely to respond to the survey, and that may explain that the rates of ATs on staff identified in this study are higher than other reported averages. In addition, as previously discussed, although we are not able to determine the exact response rate, we estimate it is around 3.5% (as is further supported by Table 1, which lists the approximate response rate by state). Accordingly, this response rate is a major limitation of this study, as we were unable to have a larger sample size. In addition, some responses may be duplicates if the same school submitted the survey more than once. Survey responses were received anonymously through REDCap; therefore, we were unable to determine whether there were any duplicate entries. Respondents were asked to classify their school as impoverished/not impoverished and rural/suburban/urban based on definitions that we provided. Further, the definition of impoverished used in this study (>40% of students receiving FRPLs) is a marginal measure of poverty, which is an additional limitation of this study. This could result in misclassification of school status if respondents failed to designate their school correctly.
Conclusion
Schools with an AT on staff were more likely to have an EAP (P < 0.01). In addition, this study suggests that lower enrollment, high poverty, and rural schools are less prepared for athletic emergencies than their higher enrollment, low poverty, and suburban counterparts, given their lower rates of compliance with best practices for emergency action planning. Among these classifications, rural status may be the most important indicator, given that a comparison of impoverished schools demonstrates that rural schools were less likely to have ATs on staff and more likely to report financial barriers and barriers related to access to medical providers compared with impoverished urban and suburban schools.
Footnotes
The following authors declared potential conflicts of interest: R.B. has received speaking fees from Gatorade. B.G.V. has received consulting fees from Artelon and DePuy, research support from Stryker, and holds stock options with Altior, Carbon 22, and Spinal Simplicity.