Title: Understanding the Standard of Care for Managing Sport-Related Concussions
1Understanding the Standard of Care for Managing
Sport-Related Concussions
- Thomas W. Kaminski, PhD, ATC, FNATA, FACSM
- Professor
- Director of Athletic Training Education
- University of Delaware
2Concussion
- Definition - a clinical syndrome characterized by
immediate and transient post-traumatic impairment
of neural functions, such as alteration of
consciousness, disturbance of vision,
equilibrium, etc... due to brain stem(connects
cerebral hemispheres with the spinal cord)
involvement
Analogous to ice cubes in a glass of water!
3Anquan Bolden Concussion Fall 2008
4Stewart Bradley Concussion Fall 2010
5Sports-Related Concussion in the United States
- CDC now estimates that 1.6 to 3.8 million
sports-related mTBIs occur each year - (Langlois, et al., J Head Trauma Rehab.
2006, (5)375-378) - In Delaware, teens and young adults (ages 15-24)
accounted for 17 of all hospitalizations as a
result of traumatic brain injuries (including
SRC) during the reporting period of 2003-2007. - Only 8 to 19 of sports-related injuries result
in LOC.
Guskiewicz KM, et al. Am J Sports Med. 2000
28(5)643-650 Schultz MR, et al. Am J
Epidemiol. 2004160937-944. Collins MW, et al.
Clin J Sport Med. 200313222-229.
6DE News Journal Media Coverage
7Federal Regulations on the Horizon?
8So Whats The Big Deal for ME?
9Part I The Legal Stuff
- Terminology
- Liability legal responsibility!
- Clearly defined in the DE State Practice Act
4.0 Athletic Trainers (24 Del.C. 2602) 4.1
Athletic injuries 4.1.1 Athletic trainers may
treat athletic injuries. Athletic injuries shall
be considered musculoskeletal injuries to
athletes that occur while currently participating
in, or currently training for, scholastic,
professional, or sanctioned amateur athletics,
where such injury limits the athletes ability to
participate or train for their sport. Athletic
Trainers may also treat musculoskeletal injuries
received by athletes that occur while currently
participating in recreational activities, where
such recreational activities are recognized by
the Amateur Athletic Union (see website for list
of activities within the AAU). All Athletic
injuries must be documented by the Athletic
Trainer as interfering with participation in or
training for such athletic activities. Nothing
prohibits the Athletic Trainer from treating
minor sprains, strains, and contusions to
athletes currently participating in professional,
scholastic, recreational, or sanctioned amateur
athletic activities.
10Part I The Legal Stuff
- Terminology
- Standard of Care - the legal duty to provide
health care services consistent with what other
health care practitioners of the same training,
education, and credentialing would provide under
the circumstances
11Strategies for Avoiding Legal Liability
- Build relationships
- Insist on a written contract
- Obtain informed consent
- Provide physical exams
- Know the profession and its standards
- Document hazards
12Strategies for Avoiding Legal Liability
- Establish policies
- Document activities
- Maintain confidentiality
- Provide proper instruction
- Supervise your staff
- Participate in CE
- Recognize your qualifications
- Maintain insurance coverage
13No Need to Worry Im Well-Versed in Treating
Sport-Related Concussion!
- With more attention in the media on SRCs the
public has become more educated about the problem
(some high-profile athletes involved) - ATCs have become a popular target of lawsuits
alleging failures to meet the standard of care.
- In cases of unfortunate events the actions (or
inactions) of the ATC are likely to be second
guessed or blamed.
14Legal Attacks Typically Involve
- The evaluation or testing of an athlete (or lack
thereof) - Documentation of the injury
- Communication with the athlete or with a
physician about an athlete - Education of the athlete
15Part II - What Exactly is the Standard of Care?
16NATA Position Statement
17NCAA Sports Medicine Handbook
18DIAA Concussion Protocol
DIAA Concussion Regulations DIAA Regulation
1008/1009 3.1.5 Prior to resuming
participation, a player who is otherwise properly
certified to participate in interscholastic
athletics must present to the administrative head
of school or designee, a statement from a
qualified physician that the player is physically
able to participate if one of the following
conditions has occurred 3.1.5.1 The player is
physically unable to compete due to illness or
injury for five(5) consecutive days on which a
practice scrimmage or contest is held 3.1.5.2
The player was apparently unconscious 3.1.5.3
The player suffered a concussion.
19DIAA Concussion Protocol
1. If an athlete exhibits signs and symptoms
consistent with a concussion, they shall be
removed from play immediately. Be aware of the
sport specific rule covering possible
concussions A qualified health care
professional must then determine whether or not
an apparent concussion has occurred. If one of
the aforementioned qualified healthcare
professionals is not present, the injury must be
treated as a concussion and the student not be
allowed to return to practice/game until
determined otherwise from a qualified healthcare
professional. If a potential concussion, loss of
consciousness or apparent loss of consciousness
has occurred, according to DIAA regulation 3.1.5,
the athlete may only return to practice/game
after the administrative head of school or
designee receives "written clearance" from a
qualified physician. No athlete shall return to
practice or play (RTP) on the same day of a
concussion. Any athlete with a concussion should
be evaluated by their primary care provider or
qualified healthcare professional that day. 2.
A qualified healthcare professional shall be
defined as a MD or DO, or school nurse, nurse
practitioner, physician assistant, or athletic
trainer, with collaboration and/or supervision
by a MD or DO as required by their professional
state laws and regulations. The qualified
healthcare professional must be licensed and in
good standing with the State of Delaware and must
be approved or appointed by the administrative
head of school or designee, or the DIAA executive
director/assistant executive director.
20DIAA Concussion Protocol
3. "Written Clearance from a qualified physician
for return to play after a potential concussion
shall be a MD/DO only. The preferred method
would be to use the form that is attached. ACE
Care Plan. After medical clearance, return to
play should follow a step-wise protocol with
provisions for delayed return to play based upon
the return of any signs or symptoms. 4. Failure
to comply with medical requirements found in DIAA
regulation section 3.0 shall result in that
individual or school being considered
"ineligible" and shall be penalized according to
DIAA regulation 2.9- The school has used an
ineligible player and thus must forfeit the
contest
21What Should the ATC be Doing with Regard to SRC
Assessment and Evaluation?
22Zurich Group (2008) Abandons the Classification
of Concussion!
- Majority of concussions 80-90 resolves in a
short 7-10 day period, although recovery time may
be longer in children adolescents!
http//bjsm.bmj.com/cgi/content/full/43/Suppl_1/i7
6
23(No Transcript)
24SCAT2
25(No Transcript)
26Concussion Symptom Checklist
27Glasgow Coma Scale
28Maddocks Questions
Maddocks D, Dicker G. An objective measure of
recovery from concussion in Australian rules
footballers. Sports Health 1989 7 6-7.
Athletic Training Research Laboratory
29Standardized Assessment of Concussion
30Balance Error Scoring System (BESS)
Foot Placement Surface
1 Side by side Stable
2 Single, non-dominant foot Stable
3 Tandem, dominant in front Stable
4 Side by side Foam/Unstable
5 Single, non-dominant foot Foam/Unstable
6 Tandem, dominant in front Foam/Unstable
31 BESS
32Coordination Examination
Athletic Training Research Laboratory
33Rationale for Neurocognitive Testing
- Cognitive abilities
- Memory
- Attention
- Language
- Visuospatial skills
- Psychological function
- Personality
- Psychiatric symptoms
Athletic Training Research Laboratory
34Zurich Group (2008) Graduated RTP Protocol
Athletic Training Research Laboratory
35Zurich Group (2008) Concussion Modifiers
Athletic Training Research Laboratory
36UD Concussion Guidelines
Athletic Training Research Laboratory
37What About Educational Programming
CONCUSSION A fact sheet for student-athletes
Athletic Training Research Laboratory
38What About Educational Programming
Concussion in Sports - What You Need To Know
http//www.nfhslearn.com/electiveDetail.aspx?cours
eID15000
Athletic Training Research Laboratory
39CDC Heads Up Concussion in High School Sports
http//www.cdc.gov/concussion/headsup/high_school.
html
Athletic Training Research Laboratory
40 ThinkFirst-SportSmart Concussion Education and
Awareness Program
http//www.thinkfirst.ca/index.aspx
Athletic Training Research Laboratory
41DE CARES(Concussion Assessment Registry and
Educational System) A Proposal to Examine
Sport-Related Concussions in DE Youth
42Why is this of Interest to US?
- The State of Delaware is a microcosm of the
country and lends itself to the study of the SRC
dilemma - Models developed as a result of this proof of
concept research will be useful for both the
State of Delaware and other states as they
develop strategies to treat injured athletes and
educate the public about SRC - Pilot data will be used to apply for federal
program funding - Changes in policy governing when student-athletes
can return to competition following SRC can be
implemented as a result of such research
Athletic Training Research Laboratory
43Study Aim
- To establish Delaware CARES (Concussion
Assessment Registry and Educational System) as
the entity to perpetuate research regarding the
prevalence and assessment techniques of SRC in
youth athletes from the State of Delaware.
44Study Aim
- To survey student-athletes, coaches, parents,
administrators, and health care professionals at
the selected high schools as to their knowledge,
awareness of, and perceptions about SRC,
including knowledge about the CDCs Heads Up
Concussion in Youth Sports initiative, and the
ThinkFirst Canadian charitable organizations
ThinkFirst-SportSmart Concussion Education and
Awareness Program.
45INTER-INSTITUTIONAL RESEARCH TEAM
- Thomas W. Kaminski, PhD, ATC, FNATA, FACSM
(Chair) - University of Delaware
- Tony S. Reed, MD, MBA, CAQSM, FAAFP
- Christiana Care Health System
- Kenneth Rogers, PhD, ATC
- Nemours/AI duPont Hospital for Children
- Joseph Tracy, PhD
- Thomas Jefferson University
46You Must Have Some Questions????
47Thank You