Emergency Action Plan Prepare for sudden cardiac arrest on campus

Emergency Action Plan Prepare for sudden cardiac arrest on campus

Ron Courson, ATC, PT, NREMT-I, is the associate athletic director for sports medicine at the University of Georgia (UGA) and a strong proponent for emergency action plans (EAPs) on college campuses that feature deployment of automated external defibrillators (AEDs). He and his colleagues developed one of the first higher-education AED programs in the U.S., a model that has become a template for the National Athletic Trainers’ Association (NATA) and has been emulated by countless colleges and universities nationwide. Following is an interview with the nationally acclaimed champion. Why did you become involved in the cause to save lives threatened by sudden cardiac arrest (SCA)? I was on an advisory board for an AED company in the early 1990s and helped develop protocols and educational materials. I had been personally involved in SCA incidents. In 1995, I was involved in a save with a Southeastern Conference (SEC) football official. In 1996, when I was serving on the medical staff with the Summer Olympic Games, I worked a cardiac arrest incident during opening ceremonies. Most recently, in 2011, Al Schmidt, a track and field coach from Mississippi State, collapsed in SCA on the first day of the SEC Outdoor Track and Field Championships. Our track and field medical staff recognized what was happening right away and started CPR. We used the AED and were able to resuscitate him.

When did you first develop the Emergency Action Plan (EAP) at UGA? In 1992, there was an incident in which a football player died from SCA. I believe that any time you have an adverse outcome, you should evaluate your program to determine if anything could have been done differently to affect the outcome. When I started working at UGA in 1995, I wanted to develop an AED program to have trained responders and equipment on site. We cover every athletic practice and competition at UGA with certified trainers. I met with Vince Dooley, our athletic director, to propose an AED program. As our local EMS average response time was 14 minutes, I felt that unless something was done, if we had another sudden cardiac arrest, we would have a death. 

By placing AEDs in the hands of our athletic training staff, we could cut our response time to two to three minutes. Our AED program was an easy sell. It just made sense. Everyone was on board. Why is an EAP important? It’s important not only to develop an EAP, but also to rehearse it regularly. The number one cause of litigation in college sports is the failure to have an EAP, or having one, but failing to implement it properly. It’s important that everyone knows where emergency equipment is located and knows how to use it. Every August, we review the EAP. If we have an actual emergency, it’s not the first time we put the plan into action. Who is trained through the UGA emergency action plan? At least once a year, all coaches and strength and conditioning staff undergo CPR and AED training. 

We try to time our training sessions so they occur immediately prior to the sport season, so the information is fresh in their minds. For example, we conduct training with our football coaching staff in late July before the start of fall practice on August 1. Our athletic trainers take ACLS [advanced cardiac life support] with physicians. We use scenario based training. We practice together; we work together as a team. All athletic training students are required to be trained as well. By doing this, the overall number of first responders has increased. We have also started to train all student athletes, and we are about halfway there. Every August, we rehearse our EAP. Since every venue—the swimming pool, track and field, basketball, volleyball, the campus rec center, etc.—is different, there are multiple EAPs. For football, there are four EAPs: one for practice, one for game day, one for scrimmage day and one for indoor drills. Does the emergency action protocol advise calling 9-1-1 or an on-site emergency number in the event of an emergency? It depends on the venue. Each setting is considered carefully.

Generally, we advise calling 9-1-1 first. Campus police get all 9-1-1 calls through their scanners and are generally the first emergency service to respond to the scene, usually within two to three minutes. Are AEDs deployed at all sporting events? Any time there is an athletic event, including practices, an athletic trainer (AT) is there with an AED. ATs also carry 12-lead EKGs. Does UGA conduct routine heart screenings for athletes? The NCAA requires colleges to conduct PPEs [pre-participation examinations] for athletes, however cardiac screening policies vary greatly. Seventeen years ago, we began to conduct 12-lead EKG exams and echoes [echocardiograms] for all athletes. We test every athlete for every sport. We made a commitment to treat all athletes the same and not just screen high-risk individuals. We focus on prevention. The more information we have about an athlete, the better equipped we are to keep him or her healthy. We believe it’s fundamental to conduct heart screening, but we know that despite our best efforts, we are not going to pick up everything. Has funding ever been an obstacle to developing the heart screening program? Screening costs about $150 per person, or a total of $15,000– 20,000 per year. Our annual athletic budget is $88 million, so that’s a drop in the bucket. We are blessed to be at a place with tremendous resources and support from our administration. When did you first start writing about the topic of SCA in athletes? In 2002, I served as a co-author of NATA’s position statement on emergency planning in athletics.1 In 2006, Jonathan Drezner, MD, team physician at the University of Washington, published a review of nine cases of sudden death in NCAA student athletes. Subsequently, we worked together with NATA to raise awareness about sudden cardiac arrest in collegiate athletics. We formed an inter-association task force with multiple organizations—NATA, and various cardiac emergency medicine and sports medicine groups, which published recommendations in four professional journals in 2007.2 We found there were delays in taking action when someone collapsed suddenly and unexpectedly, especially in cases of commotio cordis [a disruption of the heart rhythm that occurs when there

is a blow to the chest, directly over the heart]. One of the primary problems identified was a lack of recognition of sudden cardiac arrest. The most recent consensus statement was published earlier this year (see NATA consensus statement, p. 9 and www.sca-aware.org/campus.) How common is sudden cardiac arrest among college athletes? Sudden cardiac arrest is the leading medical cause of death and disability during exercise in NCAA student athletes. Current methods of data collection underestimate the risk of SCA. Accurate assessment of SCA incidence is necessary to shape appropriate health policy decisions and develop effective strategies for prevention.3,4 Mary Newman, MS, is the president and cofounder of the Sudden Cardiac Arrest Foundation.

National Athletic Trainers’ Association Consensus Statement

1. Access to early defibrillation is essential. A goal of less than three to five minutes from the time of collapse to delivery of the first shock is strongly recommended. 

2. Pre-participation physical examinations should include completion of a standardized medical history form and attention to episodes of exertional syncope or pre-syncope, chest pain, a personal or family history of sudden cardiac arrest (SCA), and exercise intolerance.

3. SCA should be suspected in any athlete who has collapsed and is unresponsive. A patient’s airway, breathing, circulation and heart rhythm (using an AED) should be assessed. An AED should be applied as soon as possible for rhythm analysis. 

4. Myoclonic jerking (brief, involuntary twitching) or seizure-like activity is often present after collapse from SCA and should not be mistaken for a seizure. Occasional or agonal gasping should not be mistaken for normal breathing. 

5. Cardiopulmonary resuscitation should be provided while the AED is being retrieved, and the AED should be applied as soon as possible. Interruptions in chest compressions should be minimized by stopping only for rhythm analysis and defibrillation. 

Treatment should proceed in accordance with American Heart Association guidelines.1 Reference 1. Casa DJ, Guskiewicz KM, Anderson SA, et al. National athletic trainers’ association position statement: Preventing sudden death in sports. J Athl Train. 2012;47(1):96–118

Emergency Action Plan Checklist 

1. Develop and post written EAP for each individual athletic venue. 

2. Integrate EAP with local EMS response. 

3. Establish efficient communication system to activate EMS and on-site responders. 

4. Designate EAP coordinator and train targeted responders in CPR and AED use.

5. Strategically place AEDs and check them regularly. 

6. Determine transportation route for ambulances to enter and exit each venue. 

7. Practice and review EAP. 

8. Establish catastrophic incident guidelines. For more information, visit www.sca-aware.org/campus.

Legal Concerns

On any given day, educational institutions house more than 20% of the U.S. population. As such, educational settings are ideal locations for AED deployment. In the past, concerns regarding legal liability and litigation have been perceived as a barrier to purchasing and deploying AEDs. However, a shifting paradigm has occurred during the past few years. Due to the increasing availability of AEDs, coupled with their proven success rate and low cost, organizations are now finding themselves having to justify the absence or non-use of an AED. This recent trend has seen lawsuits filed when AEDs haven’t been used, aren’t available or are available but their presence isn’t advertised to the general public. As such, many entities are now acquiring AEDs and developing policies and procedures related to their storage, use and maintenance. From the onset, it’s important to note that the overwhelming majority of jurisdictions afford some type of legal liability protection for AED users. Often, these protections are provided by Good Samaritan statutes. Typically, AED users are protected from liability so long as they act in a reasonable and rational manner. Liability protections generally don’t cover gross negligence or willful or wanton conduct, such as consciously seeking to injure the patient or using an AED in a non-accepted, non-standard way. In the educational setting, many different statutes can play a role in determining what liability exposure, if any, school employees and staff members would face. This is particularly true with public institutions, for which staff members are public-sector employees. Educational facilities shouldn’t allow liability concerns to dissuade them from instituting an AED program on their campus. Administrators should become familiar with the Good Samaritan and AED protections in their jurisdictions and structure AED programs to comply with statutory requirements. Given the recent trends in AED litigation, a facility without an AED may, arguably, be more at risk for a lawsuit than one with an AED. Although the likelihood of success on these types of lawsuits is slim, the institution’s public image may be damaged. —Andrew R. Roszak, JD, MPA, EMT-P.

References 

1. Anderson, JC, Courson RW, Kleiner, DM, McLoda, TA. National Athletic Trainers’ Association position statement: emergency planning in athletics. J Athl Train. 2002;37(1):99–104. 

2. Drezner JA, Courson RW, Roberts WO, et al. Inter-Association Task Force Recommendations on emergency preparedness on SCA preparedness in high school and college athletic programs: A consensus statement. J Athl Train. 2007;42(1):143–158. 

3. Harmon KG, Asif IM, Klossner D, et al. Incidence of sudden cardiac arrest in national collegiate athletic association athletes. Circulation. 2011;123(15):1594–600. 

4. Harmon KG, Drezner JA, Klossner D, et al. Sickle cell trait associated with an RR of death 37 times in NCAA football athletes: A database with 2 million athlete years as the denominator. Br J Sports Med.2012; 46(5):325–30.