BOC Study Guide 2019

Roles and Responsibilities of the Athletic Trainer

Injury and Illness Prevention and Wellness Promotion Examination, Assessment and Diagnosis Immediate and Emergency Care Therapeutic Intervention Healthcare Administration and Professional Responsibility (PRACTICE ANALYSIS)

Standards for Accreditation of Professional Athletic Training Programs

Prerequisite Coursework and Foundational Knowledge Core Competencies: • Patient-Centered Care • Interprofessional Practice and Interprofessional Education • Evidence-Based Practice • Quality Improvement • Health Care Infomatics • Professionalism Patient / Client Care • Care Plan • Examination, Diagnosis, and Intervention Prevention, Health Promotion, and Wellness Health Care Administration

DESIGNING AN ATHLETIC TRAINING FACILITY: size

(#students at peak/20 per table per day) x 100ft^2=total square footage; Minimum of 300 square feet; minimum for school/collage facility should be 1000-1200 square feet • Proportion of work that will be done in each setting (type of client served will largely determine this factor) • Must factor in anticipated growth into size estimates • Number of clients • Number and qualifications of staff • Amounts and kinds of equipment needed

Common Elements of the PPE

1) Health History: past/existing medical problems; athletes should be reassured info is held in confidence 2) Physician's Examination: a. general review of systems, including examination of the head, eyes, ears, nose, throat, chest and abdomen, and genitalia b. height, weight, body composition, blood pressure, pulse, heat & lung function, urinalysis & blood work 3) Cardiovascular Screening: critical task of identifying life-threatening conditions (recognition of abnormal heart sounds and other signs of pathology) a. Possible findings: hypertrophic cardiomyopathy, aortic stenosis, Marfan's syndrome 4) Maturity Assessment: commonly used methods include the circumpubertal (sexual maturity), skeletal & dental a. Tanner staging: evaluates pubic hair/genitalia development in boys & pubic hair/breast development in girls. Other indicators include facial and axillary hair. b. Stage 1: puberty not evident; stage 5: full development i. Crucial stage=stage 3 (fastest bone growth - growth plates are 2-5x weaker than the joint capsule and tendon attachments) 5) Orthopedic Examination: ROM, joint stability, leg length, previous injury history, postural observation 6) Wellness Screening: evaluate healthy lifestyle behaviors (drug use, eating/exercise habits, stress control, safety) 7) Special Tests: common: urinalysis (detect protein or sugar), Snellen eye chart 8) Sport Disqualification: the individual athlete is the only person who can make the final decision 9) Physical Fitness Testing: establish baseline for athlete's fitness (should be last element completed)

Purchasing Process

1) Request for Quotation: document that provides vendors with the specifications for the bidding on the sale of goods and services (types of products to be purchased via bidding should be consumable supplies and some types of durable equipment - don't bid on services because quality may be reflected in lower prices) 2) Negotiations: the process of bargaining (capital equipment, medium-priced annual rebuys, lower-cost consumable supplies) a. Price: playing on vendor against another after bids have been returned is frowned upon b. Supply: many schools' fiscal years begin July 1 (order in May, take possession in June, defer billing until after July 1 - allows time to restock and prepare for fall season while not paying until next fiscal year) c. Quality: i. implied warranty (unstated understanding that a vendor will "make good" if product is faulty); ii. may negotiate for a express warranty (statement specifying the conditions, circumstances, and terms under which a vendor will replace or repair a product if found to be faulty) d. Shipping: payment of shipping costs and freight-on-board (FOB) point i. FOB point: point at which the title for shipped goods passes from vendor to purchaser 1. Clarifies cost by factoring cost of shipping into bid 2. Generally, AT should specify institution of clinic as FOB point e. Support: important for computers and isokinetic testing/rehabilitation devices; becomes an important factor in the overall cost during the life of the equipment 3) Requisition: formal or informal communication used for requesting authorization to purchase goods/services 4) Purchase Order: a document that formalizes the terms of purchase and transmits the intentions of the buyer to purchase goods or services from a vendor a. Should make the award based on the cost for each individual item (rather than on the cost of entire order) b. Only do for purchase orders over $200 (most vendors have a minimum-order policy) 5) Receiving: process of accepting delivery of goods; should be immediately checked to make sure packing slip matches contents and to determine whether all goods specified in order were received; inspect for damage 6) Accounts Payable: a. Educational, professional, or industrial settings: submit invoice to business office ASAP to take advantage of early payment discounts b. Independent clinics: evaluate terms of early payment discount • Alternative purchasing strategies: pooled buying consortia, alumni/booster groups, external funding programs o Buy or Lease Capital Equipment? Purchasing: cost, program owns equipment (may be bad if technology becomes obsolete) Leasing: possible tax advantages, lower initial cost, use capital on other things

Ethical Standards Relevant to Athletic Training

1. Members shall respect the rights, welfare, and dignity of all individuals 2. Members shall comply with laws & regulations governing athletic training 3. Maintain & promote high standards in the provision of services 4. Do not engage in any form of conduct that constitutes a conflict of interest or that adversely reflects on the profession

Risk Reduction Strategies

1. Preparation for activity a. Administer PPEs b. Monitor fitness levels c. Assess activity areas d. Monitor environmental conditions 2. Conduct of the activity a. Maintain equipment b. Use proper instructional techniques c. Provide adequate work-rest intervals 3. Injury management a. Have a physician supervise all medical aspects of program b. Evaluate and treat injuries correctly and promptly c. Supervise student athletic trainers 4. Records management a. Document physician orders b. Document the treatment plan c. Document the treatment record d. Document the patient's progress

PRINCIPLES OF CONDITIONING

1. Warm-up/cooldown 2. Motivation (vary training program, incorporate techniques of periodization) 3. Overload (stress should not be so great as to cause injury before the body has had time to adjust) a. SAID principle: (specific adaptations to imposed demands) when the body is subjected to stresses and overloads of varying intensities, it will gradually adapt over time to overcome whatever demands are placed on it 4. Consistency (exercise program must be completed on a regularly scheduled basis to be effective) 5. Progression (increase intensity of conditioning program gradually and within athlete's ability to adapt) 6. Intensity (stress the intensity of the work rather than the quantity; the tired athlete is prone to injury) 7. Specificity (identify specific goals for the training program - should be relative to sport athlete plays) 8. Individuality (needs of individual athletes vary consistently 9. Minimize stress (expect that athletes will train as close to their physiological limits as they can; don't push too hard) 10. Safety (educates athletes on proper technique and when they should push harder or back off)

American Academy of Pediatrics, Sports Committee

1979 - educate about special needs of kids in sport

AAFP

American Academy of Family Physicians; founded in 1947 to promote and maintain high quality standards for family doctors who are providing continuing comprehensive medical care to the public

ACSM

American College of Sports Medicine; 1954, membership composed of doctors, philosophers, physical educators, athletic trainers, coaches, exercise physiologists, biomechanists, etc. Medicine and Science in Sports and Exercise (published worldwide)

AOSSM

American Orthopaedic Society for Sports Medicine; created in 1972 to encourage and support scientific research in orthopedic sports medicine; members are orthopedic surgeons and allied health professionals involved in sports medicine; American Journal of Sports Medicine

FIMS

International Federation of Sports Medicine; created in 1928 at the Winter Olympics by doctors

American Physical Therapy Association, Sports PT Section

Journal of Orthopaedic and Sports PT

DESIGNING AN ATHLETIC TRAINING FACILITY

Location • Depends on type of facility (different for general populations than for athletics) • Close as possible to men's and women's locker rooms • Close to outside doors (permits access when rest of building is not in use; better for transport of injured athletes) • Ground floor (most accessible for clients who ambulate with difficulty) - at least close to elevator • Proximity to other health care services o enhanced cooperation between facilities o ability to share certain operations (save $$!!!!) i.e. medical records can be stored in one location no duplication of private exam rooms, medicine dispensing areas o difficult on a school campus (athletic facilities typically located on periphery of campus) Ergonomics • Ergonomics: scientific study of human work • Athletic trainers perform a variety of tasks, come in all shapes and sizes • Tables: taping tables of several different heights (32-40 inches); ideally adjustable tables • Shelves & cupboards: easy to reach (not on floor); step stools available; should hang things on wall pegs • Stools: adjustable-height stools available at every tx station (especially when tx tables are not adjustable) • Carts & dollies: rolling carts, dollies, & laundry bins so equipment & supplies can be moved easily • Flooring: the harder the surface, the more difficult it will be to stand for long periods of time; floors with an excessively high or low coefficient of fiction will present slipping or tripping hazards Electrical Systems • Ground fault interrupters (especially in areas of water) - interrupts electricity if a surge of ≥5 milliamps o Can be installed as part of a circuit breaker or as part of the electrical outlet • Three-pronged hospital-grade plugs and electrical outlets (green dot) - check for GFI • Electrical outlets should be spaced every 4 feet throughout and at least 3 feet from the floor • Pull cords for patients to stop treatment if it becomes painful (also a master switch in office for every outlet) • A single circuit should service a limited number of modality outlets (to prevent overload) Plumbing Systems • Should be designed to be easily expandable • Floor drains should be placed at strategic points (floor should be sloped at least 1° towards these drains • Wet wall: hot and cold supply • Hydrotherapy room o Built-in drain of each hydrotherapy tank should connect directly to a dedicated floor drain o Standpipe drain: drain raised above floor level; to prevent splashing o Mixing valve: fixture designed to blend hot and cold water, eliminating need for separate controls o Foot-pedal activator: for hand-washing stations • Ice machine should have a separate cold water line and floor drain • Accessories: built-in liquid soap dispensers; paper towel dispensers; water fountain; paper cup dispensers Ventilation Systems • Temperature and humidity control: max of 0.75ft/sec draft factor, 8-10 changes of air/hour, 40-50% humidity • Should have its own thermostat (ATRs get warmer due to proximity to showers and locker rooms) • Humidity: comfort and hygiene problem (viruses, fungi, bacteria) o Hydrotherapy areas should have exhaust fans to keep humidity at reasonable levels Lighting • Illuminated at 30-50 foot-candles at 4 feet above floor • Different areas have different lighting requirements o Most: physician examination and treatment of injured athletes and other physically active patients (provide floor lamps for procedures such as wound debridement and suturing) o More: taping, bandaging, wound care areas; less: storage, hydrotherapy areas • Combination of natural and artificial lighting Special Service Areas Office • Several purposes: program records, patient medical files, budget information, correspondence, insurance information, product information, and educational materials • AT should have a clear view of entire facility from office (windows) • Should contain a desk, filing cabinets, bookshelves, and a telephone • Extra telephone line for data transfers from a computer • Able to accommodate several people at one time (meetings, etc.) - at least 10x12 feet Taping & Bandaging Area • Often most busy, especially pre-practice (in school-based athletic training facilities) • Adequate number of taping stations; individual tables or large platforms; minimum height of 36 inches o Against a wall or more centrally located (tape from both sides) • Adequate counter space; easily cleanable counters (i.e. Formica) • Cupboards and drawers for short-term storage of supplies • Floor covering: difficult (both adhesive sprays and petroleum-based ointments can permanently stain carpet & vinyl tile - contract a company that provides carpet runners for doorways and entrances and periodically replace) Hydrotherapy Area • Should be physically separated (water spills, noisy turbines) & glass enclosure (AT able to monitor) • Adequate space for cooler and ice chest storage • Ceramic tile floors and cinder block walls painted with a high-gloss epoxy paint (easily cleaned) General Treatment Area • Largest space commitment - treatment tables and any electrotherapeutic equipment • Allow 30 inches between tables (space for carts with modalities) • Electrical outlet, fluorescent light, and sliding drapes for each table • Materials for floors/walls should be light colored and easy to clean (vinyl tile, carpet) Rehabilitation Area • Requires a great deal of space (isokinetic equipment, treatment tables, treadmills, UE/LE ergometers, stair climbers, isotonic weight machines, floor space for function & CKC rehabilitation, patient safety) • Best arrangement: rehab area has its own room within ATR (esp. if gym located nearby) • Best flooring is carpet (absorb shock and noise of dropped equipment) • Walls should allow insertion of hooks and screws (storage of rehab tools); also full-length mirrors (feedback) Storage • Commonly overlooked; should be 80-100 square feet • Should be located within sports medicine center itself (as close as possible to taping/bandaging area) • Must be cool and dry at all times (many expendable items deteriorate in warm, humid environments) • Plenty of shelves and cupboards; access should be strictly controlled (prevent unauthorized supplies removal) Lavatory & Changing Area • Commonly included in newer facilities; can be designed to service both clients and staff • Should include handicapped-accessible toilet and sink, shower & lockers • Shelf for storing towels, bin for disposal of soiled laundry Private Examination Room • Does not need to be large, should be comfortable • Examination table, mobile lamp, sink for washing hands, and a counter and cupboards to hold supplies • Gowns and drapes for clients; examination room can be combined with office if necessary Additional Areas Pharmacy Area • Room for storing and administering medications • All medications (including OTC) should be kept under lock and key • Only team physician or pharmacist should have access to the storage cabinet containing prescription meds • Records for administering medications to athletes should be kept here

NASM

National Academy of Sports Medicine; offers Certified Personal Trainer and Performance Enhancement Specialist

NATA

National Athletic Trainers' Association; 1950, publishes The Journal of Athletic Training

NSCA

National Strength and Conditioning Association; 1978; offers the Certified Strength and Conditioning Specialist (CSCS) and the NSCA Certified Personal Trainer (NSCA-CPT)

Developing a Policies and Procedures Manual: operation planning

Operational planning: defines organization activities in the short term, usually no longer than 2 years

Developing a Policies and Procedures Manual: PERT

Program Evaluation and Review Technique: a method of graphically depicting the time line for and interrelationships of different stages of a program

Reporting Information

Reporting Information • Documentation of patient caseloads and summaries of any specific program accomplishments are often compiled in an annual report o Hospital accreditation: request summary statistics on patient outcomes & compliance to professional standards of practice o Education accreditation: require data related to student outcomes (graduation, certification, employment rates) • Compliance with OSHA Bloodborne Pathogen Standard (employers must develop programs that protect employees from occupational exposure to bloodborne pathogens, especially HIV & hepatitis B) o Significant record-keeping requirements that must be retained for 3 years o Documents that must be entered into the employee's medical record must be maintained for the duration of employment, plus 30 years

Personal Qualities of the Athletic Trainer

Stamina and ability to adapt, empathy, sense of humor, communication, intellectual curiosity, ethical practice, professional memberships

Developing a Strategic Plan: WOTS UP analysis

a data collection and appraisal technique designed to determine an organization's "weaknesses, opportunities, threats, and strengths underlying planning"

Developing a Strategic Plan: accreditation

formal recognition indicating that a program meets certain prescribed quality standards o JCAHO: Joint Commission on Accreditation of Healthcare Organizations o CARF: Commission on Accreditation of Rehabilitation Facilities

RECOGNITION AND ACCREDITATION OF THE ATHLETIC TRAINER AS A ALLIED HEALTH PROFESSIONAL

o 2006 - JRC-AT (Joint Review Committee on Athletic Training) changed its name to Committee for Accreditation of Athletic Training Education (CAATE)

Immediate Care of Injury and Illness

o Certified in CPR/First Aid, knowledgeable in emergency care procedures

Clinical Evaluation and Diagnosis

o Conducting physical examinations (PPEs, injury evaluation (on-field & off-field) o Understanding the pathology of injury and illness o Referring to medical care o Referring to support services

Treatment, Rehabilitation, and Reconditioning

o Designing a rehabilitation program o Supervising rehabilitation programs o Incorporating therapeutic modalities o Offering psychosocial intervention

Risk Management

o Developing training and conditioning programs (or make recommendations to strength coach) o Ensuring a safe playing environment (hazardous objects, weather conditions) o Selecting, fitting, and maintaining protective equipment o Explaining the importance of nutrition o Using medications appropriately (proper administration, drug testing)

Professional Responsibilities

o Educator, promoting the profession, counselor, researcher

Organization and Administration

o Record keeping o Ordering equipment and supplies o Supervising personnel o Establishing policies for the operation of an athletic training program

Educational Competencies

o Risk management o Pathology of injuries and illnesses o Orthopedic assessment and evaluation o Acute care of injury and illness o Pharmacology o Therapeutic modalities o Therapeutic exercise o Medical conditions and disabilities o Nutritional aspects of injuries and illnesses o Psychosocial intervention and referral o Health care administration o Professional development and responsibilities

Professional organization goals

o To upgrade the field by devising and maintaining a set of professional standards (code of ethics) o To bring together professionally competent individuals to exchange ideas, stimulate research, and promote critical thinking o To give individuals an opportunity to work as a group with singleness of purpose, thereby making it possible for them to achieve objective that, separately, they could not accomplish

Developing a Policies and Procedures Manual: processes

~a collection of steps designed to direct the most important tasks of an organization o i.e. injury prevention, injury rehabilitation, injury recognition, organization & administration, etc.

Developing a Strategic Plan: vision statement

~a concise statement that describes the ideal state to which an organization aspires o The provider of the service o The actual services to be provided o Target clients o Quality declaration that identifies aspirations for how audiences will receive the program

Developing a Strategic Plan: mission statement

~a written expression of an organization's philosophy, purposes & characteristics o Functions: 1) help the AT direct resources toward accomplishing specific tasks; 2) should inspire ATs to do a good job; 3) should be action oriented and should stimulate a change in behavior o The particular services to be offered, the primary market for those services, and the technology to be used in delivery of those services o The goals of the program o The philosophy of the program & the code of behavior that applies to its organization o The "self-concept" of the program based on evaluation of strengths & weaknesses o The desired program image based on feedback from internal and external stakeholders

Developing a Policies and Procedures Manual: policies

~expresses an organization's intended behavior relative to a specific program subfunction o Not intended to answer detailed questions; intended as road maps (basic rules and principles)

Developing a Strategic Plan: Strategic Planning

~involves critical self-examination to bring about organization improvement o Why is there a need for such a program and what should the function of the program be within the total scope of the athletics program? (answer by administrators, athletic directors, or school boards) o To determine whether the program is consistent with the overall mission of the institution/organization o Helps build support for the program (include many people in the planning process) o Should be a tool for improvement, helping to determine the strengths and weaknesses of the program and transforming it positively

Developing a Policies and Procedures Manual: procedures

~provides specific directions for members of an organization to follow o i.e. procedure for discharge from rehabilitation

Developing a Policies and Procedures Manual: practices

~the action that takes place in response to administrative problems o i.e. procedure written that states all machines should be calibrated once a year o practices= which vendor? What time of year? Scheduling?

Catastrophic Injuries

• 98% of individuals with injuries requiring hospital ER medical attentions are treated and released • Deaths: o Chest/trunk impact with thrown objects, other players, or nonyielding objects (goalposts) o Struck in head by sports tools or objects o Direct blow to head from another player or the ground o Playing structure falling on participant • Highest incidence of indirect sports death stems from heatstroke o Also cardiovascular and respiratory problems or congenital conditions o Cervical injury/quadriplegia is most often seen in American football

Hygiene and Sanitation

• AT must be aware of OSHA guidelines (Occupational Safety and Health Administration)

The Incidence of Injuries

• Accident: an unplanned event capable of resulting in loss of time, property damage, injury, disablement, or death • Injury: damage to the body that restricts activity or causes disability to such an extent that the athlete is not able to practice or compete the next day • Incidence of injury can be studied epidemiologically from many points of view: o In terms of age at occurrence, gender, body regions, or occurrence in different sports o Sports usually classified as contact/collision, limited contact, or noncontact • Athletes in all sports participating in the span of 1 year face a 50% chance of sustaining some injury o 50% of the 50 million estimated sports injuries per year require only minor care & no activity restriction 90%: muscle contusions, ligament sprains, and muscle strains 10%: lead to microtrauma complications and lead to a severe, chronic condition later in life • Sprains/strains, fractures, dislocations and contusions are the most common o Knee has highest incidence of injury, ankle second, upper limb third o Males have a higher incidence of shoulder/upper-arm injuries than females

Assumption of Risk

• Assumption of risk: injured plaintiff understood the risk of an activity and freely chose to undertake the activity regardless of the hazards associated with it o Two conditions must be met: 1. Athlete must "fully appreciate" the type and magnitude of risk involved in participating in activity 2. Athlete must "knowingly, voluntarily, and unequivocally" choose to participate in the face of risk o May be accomplished through: Waiver signed by athlete or his/her parents • Athlete/parents have been warned of the dangers associated with sport • Athlete/parents understand risks • Athlete/parents have been offered the opportunity to ask questions regarding risks • Athlete/parents voluntarily choose to participate regardless of risks o Difficult when dealing with minors Usually courts uphold waivers and releases of liability for adults unless there is evidence of fraud, misrepresentation, or duress • Comparative negligence: the degree to which a plaintiff contributed to the harm caused by a defendant o Examples: failing to follow instructions, failing to perform rehabilitation o Court determines the degree (%) to which the AT and plaintiff contributed to the harm Plaintiff recovers the percentage of how much the defendant was to blame for negligence In most states, patient can collect damages only if comparative negligence is <50% of total

Factors to Consider in Designing the PPE

• Athlete age and level of competition: different element emphasis o Younger: more emphasis on developmental problems common to their age group o Older (i.e. NFL): more extensive orthopaedic examination, maybe imaging studies • Sport: isokinetic testing for soccer player vs. golfer; test of anaerobic power for hockey player vs distance runner • Follow-up: information collected is only valuable if problems discovered are acted upon (if institutional or community resources are too limited to allow action, a review of that PPE portion may need to occur) • Predictability of tests: athletic trainer ought to ask, "how likely is this test to uncover a problem?"

The Scope of the Athletic Training Program

• Athlete: prevention and care for entire year, or just competitive season? All illnesses, or only musculoskeletal? • Institution: are other persons to receive care? How should they be referred? Clinical setting for students? • Community: will any outside groups be served by AT staff? (Take legality and insurance into consideration) • Clinical and Corporate/Industrial Setting Considerations: should only be assigned to work with those physically active; often expected to oversee preventative and rehabilitation programs (additional education)

Evolution of the Contemporary Athletic Trainer

• Began to play a larger role in healthcare following WWI with the appearance of the AT in collegiate athletics o Dr. S.E. Bilik - physician who wrote The Trainer's Bible in 1917 • 1920s - Cramer family started a chemical company; began publication of First Aider in 1932 • 1930s - first attempt of National Athletic Trainers' Association (1938-1944, dissolved during WWII) • 1950: Kansas City, Missouri - National Athletic Trainers' Association was formed o Primary purpose: establish professional standards for the athletic trainer • Work settings: schools, professional sports, hospitals/clinics, industrial settings, military, physician extenders, medical equipment sales and support, and NASA and NASCAR

Catastrophic Insurance

• Catastrophic insurance: insurance designed to provide lifelong medical, rehabilitation, and disability benefits for the victims of a devastating injury o Usually takes effect after the first $25,000 in medical bills has been reached Member institutions of the NCAA have received catastrophic insurance at no cost since 1991 o National Federation of State High School Associations (NFSHSA) provides medical, rehabilitation, and transportation costs in excess of $10,000 not covered by other insurance benefits o Costs for catastrophic insurance is based on: Number of sports offered by institution Number of hazardous sports offered by institution • Errors and omissions liability insurance: designed to cover school employees, officers, and the district against suits claiming malpractice, wrongful actions, errors and omissions, and acts of negligence

REQUIREMENTS FOR CERTIFICATION AS AN ATHLETIC TRAINER

• Certification exam by the BOC (2006 - changed to computer-based) o BOC created in 1989 - administers exam and establishes continuing education requirements Minimum of 80 CEUs every 3-year recertification term (also CPR recertification) o Pass = credential of ATC o Candidacy for exam: 1) complete accredited athletic training education program; 2) proof of graduation; 3)endorsement by CAATE Accredited Program Director; 4) proof of certification in CPR

Reducing the Risk of Litigation

• Coach: warn athletes of potential dangers in sport, supervise regularly and attentively, properly prepare and condition athletes, properly instruct athletes in the skills of their sports, ensure proper & safe equipment & facilities are used by athletes at all times • Athletic Trainer: o Build relationships o Insist on a written contract for work o Obtain informed consent Warn athletes of dangers o Provide physical examinations Make sure content and frequency meet standards o Know the profession and its standards o Participate in continuing education o Make a documented attempt to avoid injury by removing or modifying potential hazards o Establish policies o Document activities o Maintain confidentiality o Provide proper instruction o Supervise your staff o Recognize your qualifications / limitations

The Physician and the Athletic Trainer

• Compiling medical histories, diagnosing injury, deciding on disqualification and return to play, attending practices and games, commitment to sports and the athlete, academic program medical director

Personal Information Card

• Completed by athlete at the time of health examination • Means of contacting family, personal physician, and insurance company in case of an emergency

Cooldown

• Cooldown period enables the body to cool and return to a resting state (should last 5-10 minutes) o Persons who stretch during cooldown tend to have fewer problems with muscle soreness after strenuous activity; proper cooldown decreases blood and muscle lactic acid levels more rapidly

Reports to Coaches

• Daily reports can help improve communication between athletic trainer and coach o Coaches are able to plan more effectively o Athletic trainers can easily document recommendations for participation status (legal protection) • Violation of legal and ethical duty? o Legal responsibilities of confidentiality vary depending on if AT is a covered entity under HIPAA o It is common practice to report on athletes' health status to coaches in the absence of authorization Coach may have seen injury occur or is agent of referral (already an informed party)

Purchasing Services

• Different from purchasing supplies/equipment because quality is more difficult to assess • Try to get service free of charge: volunteer physicians; donate time in exchange for an advertisement • OR: try to employ cost sharing whenever possible: physician may accept only what insurance will pay • Evaluate what each provider is willing to provide and at what price: ex) response time of ambulances • Investigate provider's reputation with other ATs: ask whom they use and why • Develop a contract of understanding, specifying expectations: helps improve communication & prevent problems; should specify a period for which contract will be in effect • Develop a database for each service provider: how many athletes seen; time of wait; rate of false-positives

CLAIMS PROCESSING

• Educational settings: ATs file all (or nearly all) claims with a single insurance company to pay other medical vendors for services rendered to the institution's student athletes • Sports medicine clinics: ATs file claims with a wide range of insurance companies for reimbursement for services they provide

DEFINING ETHICS

• Ethics: the rules, standards, and principles that dictate right conduct among members of a society or profession; based on moral values (represent norms of social interaction and have been influenced by religion)

Supplies/Equipment

• Expendable: cannot be reused (tape, bandages, hydrogen peroxide) • Nonexpendable: can be reused (compression wraps, scissors, neoprene sleeves) • Nonconsumable capital: usually not removed from athletic training facility (ice machine, tx table, modality unit) • Consumable capital: crutches, coolers, and kits

Providing Coverage

• Facility Personnel Coverage: time of coverage depends on number of staff • Sports Coverage: may be forced to decide where greatest need of coverage is (i.e. high school)

Types of Third Party Players

• Fee-for-service/indemnity plan: type of traditional medical insurance whereby patients are free to seek medical services from any provider; plan covers a portion of cost of covered procedures & patient is responsible for the balance • Health maintenance organizations (HMOs): type of insurance plan that requires policyholders to use only those medical vendors approved by the company. All medical services are coordinated by a primary care physician, who acts as a gatekeeper to specialty services o Determination of fees is usually accomplished by a capitation system (vendors received a fixed amount per patient) o Some HMOs provide services at medical facilities, whereas others provide care through a network of individual medical practitioners: Individual practice association (IPA): managed-care model whereby an HMO provides health care services through a network of individual medical practitioners. Care is provided in a physician's office as opposed to a large, multifunctional medical center • Preferred provider organizations (PPOs): type of insurance plan that provides financial incentives to encourage policyholders to use medical vendors approved by the company o Compared to HMOs: allow a greater choice of medical vendor, pay vendors on a fee-for-service basis o Patients who see vendors outside the preferred network will pay a higher percentage of costs o Variant of PPO - exclusive provider organization (EPO): medical services are reimbursed only if patient uses contracted providers • Point-of-service plan (POS): similar to PPOs, except that primary care physicians are assigned to patients to coordinate their care • Medicare: government-sponsored program for elderly • Medicaid: government-sponsored program for needy • CHAMPUS: government-sponsored program for members of armed forces & their dependents

Warm-Up

• Function: prepare the body physiologically for upcoming physical work by gradually stimulating the cardiorespiratory system to a moderate degree to increase blood flow to muscles and increase muscle temperature o ↑ muscle temperature = ↑ elasticity (degree muscle can be stretched), ↓ viscosity (rate at which muscle can change shape) • Should begin with 2-3 minutes of whole body activities that engage large muscle groups (jog, exercise bike) in order to elevate the metabolic rate and raise core temperature • Period of stretching exercises should follow (sport-specific, related to activity to be performed) • Intensity should then be increased gradually by performing sport-specific skills (i.e. shooting layups, dribbling) • Total warm-up time should be about 10-15 minutes; activity should be started within the next 15 minutes after o Non-starters should be encouraged to stay warmed up and ready to play throughout the course of game o Continued sweating: good indication that the body has been sufficiently warmed up & ready for activity

Maintaining Confidentiality in Record Keeping

• HIPAA (Health Insurance Portability and Accountability Act): (1996) helps employees transfer their health insurance when they switch employers, ensures that their health information will remain private ,and gives people more access to their own healthcare administration (created due to increased electronic transmission of records) o 1) Obtain consent for treatment: provide with "Notice of Privacy Practices" & get patient to agree o 2) Obtain authorization to release health information: written permission to provide information to coaches, athletic administrators, scouts, and the media o 3)Release only the minimum necessary information: applies especially to nonmedical entities (coaches, administrators, insurance companies) o 4) Safeguard patient information: reasonable efforts should be made (discuss in a secure manner) o 5) Observe state laws governing the treatment of a minor's health information: specific to state o 6) Do not combine authorizations, except for research purposes: patient is required to sign a separate authorization for each purpose for which patient information will be used or released (not in research) o 7) Business associates must safeguard patient information: ATs must ensure that entities to which athletes are referred has policies to safeguard medical information; each time AT releases medical information, the release form must show the content, purpose, and receiver of the information • FERPA (Family Educational Rights & Privacy Act): 1974 federal law requiring student authorization to release educational records to a third party and ensuring access for students to their records (also called the Buckley Amendment) o Exceptions: employees may disclose to safeguard the student's health in an emergency Health records created/maintained by a physician, psychiatrist, psychologist, or other recognized professional are not considered educational records under FERPA Student athletes don't have legal right under FERPA to access the content of their health records

Legal Requirements

• Health care practitioners must obtain signed authorization from a patient for release of medical records • Be careful when answering insurance company's questions on the telephone (verify identity of caller, make sure patient has signed release authorization before answering questions, requests for detailed explanations should be submitted by the insurance company in writing on the company letterhead) • Fraud: criminal misrepresentation for the purpose of financial gain o AT should never change the date of an injury, treatment, or assessment, or fail to record payments form an insurance company on a patient's bill o Other types of fraud: claiming reimbursement for treatments that were never performed, increasing charges for treatments for patients with insurance

Diagnostic and Procedural Coding

• ICD-(?)-CM (International Classification of Diseases): coding system applied to illnesses, injuries, and other medical conditions to standardize the language associated with third-party reimbursement • CPT (Current Procedural Terminology): coding system applied to specific medical procedures to standardize the language associated with third-party reimbursement • Using improper codes will significantly increase time required by insurance company to process claim and might result in denial of claim

Injury Reports and Injury Disposition

• Injury report serves as a record for future reference • In a litigation situation, an athletic trainer may be asked questions about an injury that occurred 3 years in the past • Should make 3 copies of records (one to school health office, one to physician, one to retain)

Equipment & Supply Information

• Inventory of nonexpendable capital equipment on file (type of equipment, amount/# of units, serial #s) • Warranties, equipment maintenance records, and appropriate catalogs should be filed

Supply & Equipment Inventory

• Inventory regularly - at least once a month (expendable supplies) • Centralize storage - makes supply management easier; stockpile in other locations only enough for 1 week (requires athletic trainer to be attentive to inventory levels and helps prevent sudden or unexpected shortages) • Automate the inventory process - develop a continuous monitoring system o Computerized inventory record based on standard spreadsheet software (fill out sheet every time supplies are removed, information entered into computer record at the end of each day) • Restrict access - policies & procedures specifying who has access, responsibilities of those with keys • Keep a reminder system - "reorder when X amount remains" to remind ATs to order more supplies

Early History

• Late 19th century - establishment of intercollegiate and interscholastic athletes in the United States • No technical training, gave "rub downs"

Nonmedical Correspondance

• Letters and memoranda not associated with a specific patient's health status • Can be discarded after action is taken; that which is retained should be sorted under subject heading and not in a separate folder labeled "correspondence."

LEGAL CONCERNS OF THE COACH AND ATHLETIC TRAINER

• Liability: the state of being legally responsible for the harm one causes another person • Malpractice: liability-generating conduct associated with the adverse outcome of patient treatment o Liability may be based on: Negligent patient care Failure to obtain informed consent Intentional conduct Breach of a contract Use/transfer of a defective product Abnormally dangerous treatment

STATE REGULATION OF THE ATHLETIC TRAINER

• Licensure - limits athletic training to those who have met minimal requirements established by state board • State certification • Registration - paid a fee for being placed on an existing list of practitioners • Exemption - state realizes that athletic trainers perform functions similar to those of other licensed professions

General Health Insurance

• Medical insurance: contract between policyholder and insurance company to reimburse a percentage of the cost of the policyholder's bills (usually after policyholder has paid a deductible • Health insurance: more comprehensive; reimburses cost of preventative as well as corrective medical care • Policy: contract between an insurance company and an individual or organization • Exclusions: situations or circumstances specifically not covered by an insurance policy • Riders: additions to standard insurance policy that provide coverage for conditions that are not normally covered • Premium: invoiced cost of an insurance policy • Deductible: portion of any claim that is not covered by the insurance provider; the amount of expenses that must be paid out of pocket before an insurer will cover any expenses • Copayment: capped contribution defined in the policy and paid by an insured person each time a medical service is accessed. It must be paid before any policy benefit is payable by an insurance company.

Accident Insurance

• Most educational institutions buy athletic accident insurance (insurance policy intended to reimburse medical vendors for the expenses associated with acute athletic accidents) • Disability insurance: insurance designed to protect an athlete against future loss of earnings because of a disabling injury or sickness

Planning the Budget

• Needs assessment: procedure to set organization or programmatic priorities based on identified needs o Phase 1: exploration (identify needs, decide on info to collect for each need, where/how to collect info) o Phase 2: information gathering (collect info, prioritize needs, determine causes for needs) o Phase 3: decision making (develop alternative solutions for needs, determine budgetary implications, prioritize solutions, integrate solutions into the program budget) • Capital Improvements o Consider pooled buying for a quantity discount o Tap into booster clubs, alumni, and fundraising groups o Sponsorships and endorsements

The Standard of Reasonable Care

• Negligence: failure to act as a reasonably prudent athletic trainer would act under the circumstances • Standard of reasonable care: assumes that an individual is neither exceptionally skillful nor extraordinarily cautious, but is a person of reasonable and ordinary prudence o Adhere to standard of care by adhering to certain standards in the performance of their duties Individual and societal standards Standards derived from institutional and professional values (i.e. position statements)

Administering Preparticipation Examinations: types of PPE

• Office-based: privacy of physician's office is ideal; wider range of specialized equipment available o Team physician or athlete's family physician? (legally responsible person vs. familiar person) o Nature of patient will determine who is best to perform As children grow older, it may become more appropriate for team physician to take over PPE • Group/station method: less private but still effective o Many nonmedical volunteers can play an important role o Role of AT: identify # of stations, recruit volunteers & provide necessary training for volunteers Parents, students, coaches: checking height/weight, controlling flow, taking $$, making sure all required forms have been completed (fitness testing - *coaches)

Professional Liability Insurance

• Only covers athletic trainer in civil cases (not criminal) o Claims made (cheapest): only covers claims made during the calendar year o Tail coverage: covers things outside of the policy year o Occurrence policy: covers any incident during the policy year Not just limited to work related situations • Recommended liability limits o $1,000,000 per occurrence o $3,000,000 annual aggregate

Personnel Information

• Personnel records are confidential and only those with a documented need should be allowed to access them • Ex: performance evaluation records, salary and promotion records, employment application information (application forms, resumes, letters of recommendation), employee contracts

CREDENTIALING

• Practice acts define different roles and responsibilities for athletic trainers and students o Different scopes of practice, allowability to charge fees, limitations on use of therapeutic modalities, specific educational requirements; most require physician supervision • States without credentialing for athletic training - follow the state's medical practice act (state law regulating the practice of medicine, usually by specifying who many practice and under what circumstances) Licensure • Licensure: form of state credentialing, established by statute and intended to protect the public, that regulates the practice of at rade or profession by specifying who may practice and what duties they may perform • Most restrictive form of governmental credentialing • Intent: protect the public by limiting the practice of AT to those who have met requirements of a licensing board established under the law • Name protection: unlicensed individuals are not allowed to call themselves athletic trainers • Service protection: unlicensed individuals are not allowed to perform tasks reserved for ATs under law • Licensure usually requires a specific educational background and passing a licensing examination ( • Boards decide who may practice; set fees required for license applications and renewals Certification • Certification: a form of title protection, established by state law or sponsored by professional associations, designed to ensure that practitioners have essential knowledge and skills sufficient to protect the public • BOC is the recognized certification agency for ensuring that ATs have basic knowledge and skills to carry out their duties as defined by the Role Delineation Study / Practice Analysis (2017) • State certification usually only protects an athletic trainer's title, not the specific tasks and he/she performs o Noncertified persons could not call themselves athletic trainers, but they could perform the duties of a AT o Kentucky, Louisiana, New York, Pennsylvania, South Carolina, Virginia Registration • Registration: type of state credentialing that requires qualified members of a profession to register with the state in order to practice (some allow a grace period during which AT may practice without being registered) o Prohibits unregistered persons from practicing, it becomes a form of title protection for the athletic trainer o States that require registration may or may not require screening devices (i.e. examinations) o Kansas, Minnesota, Missouri, Oregon Exemption • Exemption: a legislative mechanism used to release members of one profession from the liability of violating another profession's practice act (typical- physical therapy, physician assistant, medical & masseuse practice acts) o Least restrictive form of professional regulation; ATs may still be required to meet certain standards o Colorado, Hawaii, Utah, Wyoming

Injury Evaluation and Progress Notes

• Problem-oriented medical record (POMR): organizes information around a patient's specific complaint o Cover sheet: patient's past history, any personal habits, and a list of patient problems with a brief description of the plans implemented to ameliorate those problems o SOAP note: organized by subjective and objective evaluation, assessment of the patient's problem, and development of a plan for treatment • Focus charting: medical record that registers a patient's complaint date, the health care practitioner's actions, and the patient's response • Charting by exception: type of medical record that notes only those patient responses that vary from predefined norms (makes record keeping more efficient and less time consuming, inappropriate for recording initial injury evaluation, has many potential uses for recording treatments and rehab; requires strict treatment protocols) • Computerized documentation: difficult to maintain confidentiality (harder to safeguard digitally stored data) • Narrative charting: method of recording the details of a patient's assessments and treatments using a detailed, prose-based format o Dictation: act of orally recording (cassette tape or directly onto computer) the details of a healthcare assessment or treatment for later transcription and filing

Product Liability

• Product liability: liability of any or all parties along the chain of manufacture of any product for damage caused by that product (manufacturer of component parts, assembling manufacturer, wholesaler & retail store owner) o Faulty design o Faulty construction o Failure to provide adequate warning o Failure to conform to an express warranty • Product liability claims can be based on: o Negligence: risk of injury from use of product was foreseeable & company did not exercise due care in reducing or eliminating risk o Strict liability: patient using its product is injured, regardless of the foreseeability of risk or the care the manufacturer took to prevent an injury o Breach of warranty of fitness: product is found to be unfit for the purpose for which it was intended • Manufacturers of athletic equipment are strictly liable for defects in the design and production of equipment that produces injury o AT must not alter equipment in any way (invalidates manufacturer's warranty) o Express warranty: manufacturer's written statement that a product is safe (i.e. label on football helmets)

Growth of Professional Sports Medicine Organizations

• Professional organization goals: o To upgrade the field by devising and maintaining a set of professional standards (code of ethics) o To bring together professionally competent individuals to exchange ideas, stimulate research, and promote critical thinking o To give individuals an opportunity to work as a group with singleness of purpose, thereby making it possible for them to achieve objective that, separately, they could not accomplish

Budget Information

• School, college & professional settings: financial reports include budget statements, purchase orders, and invoices • Also documents that support budgetary decisions and requests for proposals (RFPs - notices from internal and external funding sources announcing the details of grant programs)

Developing a Risk Management Plan

• Security Issues: who has access/keys to ATR (college: staff, students; HS: staff, coaches) • Fire Safety: evacuation plan; smoke detectors and fire alarm systems should be periodically tested • Electrical and Equipment Safety: o Ground fault interrupters (especially in areas of water) - interrupts electricity if a surge of ≥5 milliamps o Three-pronged hospital-grade plugs and electrical outlets (green dot) o Electrical outlets should be spaced every 4 feet throughout and at least 3 feet from the floor o A single circuit should service a limited number of modality outlets (to prevent overload) • Strategies for Managing Risk: o Avoidance: avoid a risky activity (especially when negative consequences of activity have high costs) o Transference: activities associated with high financial risk but low frequency (catastrophic sports injury) or lower financial risk but high frequency (fractures, joint injuries requiring surgery) Purchase insurance designed to cover financial loss associated with certain risks Exculpatory waivers signed by athletes and parents (this method has many flaws) o Retention: activities with an acceptable level of risk that are viewed as part of the cost of doing business Program must account for risks in the program budget and ideally establish a reserve fund to cover costs that rise above predicted levels o Reduction: careful development, implementation, monitoring & evaluation of policies & procedures can reduce rsisks • Risk Identification o Real-world observation: making inferences regarding the risk of certain activities based on clinical practice and experience (can often lead to spurious conclusions) o Inference from controlled experiments: method is difficult to implement (time intensive, costly, and frequently impractical) practical method is using an epidemiological approach- track incidence of injuries & all their associated factors (athlete characteristics, playing surface, weather, type of activity) NCAA Injury Surveillance Study • Emergency Action Plain (EAP) o Failure to have an EAP could constitute a breach of the institution's legal responsibility to conduct safe programs; plan should cover practices, games, and conditioning sessions; should be reviewed annually o List of personnel involved (roles, responsibilities, chain of command for decision making) o Procedures to be followed in event of an emergency (communication and transportation procedures) o Phone numbers (911, athletic trainers, physician) o Emergency call info: 1) Type of emergency situation; 2) Type of suspected injury; 3) Present condition of athlete; 4) Current assistance being given [i.e. CPR]; 5) Location of telephone being used; 6) Exact location of emergency o Make sure keys to gates are accessible, inform members of sports medicine team of EAP, assign roles, carry contact information for athletes, EAP should include procedures for spectator injury/illness o Form a good relationship with local EMTs and also establish guidelines and procedures o Try to obtain consent from parents if athlete is a minor (should have a signed consent form anyway)

Types of Athletic Insurance

• Self-Insurance: institutions with this type are speculating that the amount they pay out for medical expenses will be less than the amount they would pay for insurance premiums o Only purchase catastrophic coverage and pays medical bills incurred by student-athletes o NCAA have rules that prevent institutions from paying for medical expenses not directly related to sport • Primary Coverage: a type of health/medical/accident insurance that beings to pay for covered expenses immediately after a deductible has been paid o Athlete's personal insurance is not a source for payment of medical bills from athletic participation o Institutions adopt such plans because: Feel a moral obligation to pay for medical expenses without involving families & their insurance May have a student population that is substantially uninsured anyway (logical) Primary coverage simplifies and accelerates claims processing (family isn't involved) o Expensive!! (institution pays a much higher premium because insurance company takes on ALL risk) o Very few educational institutions use this policy • Secondary Coverage: insurance that begins to pay for covered expenses only after all other sources of insurance coverage have been exhausted; also known as excess insurance o Most common choice for educational institutions o Institution lowers cost by sharing risk of injuries to other potential payers (60% lower than primary) o Develops a sense of shared responsibility for safety in an athletic program Parents are even more interested in safety of children when they have a financial interest o Encourages athletic administrators to find ways to reduce and control medical costs o Claims processing takes more time & effort (communication with parents and their insurance carriers) o Requires more communication and understanding about shared responsibility of paying medical costs

Annual Reports

• Serves as a means for making program changes and improvements • Commonly includes: # of athletes served, survey of the number & types of injuries, analysis of program, and recommendations for future improvements

The Treatment Log

• Sign-in log for any athlete who receives any service • Emphasis placed on recording the treatments for the athlete who is receiving daily therapy for an injury • These records often have the status of legal documents and are used to establish certain facts in a civil litigation, an insurance action, or a criminal action after injury

Human Resources and Personnel Issues

• Specific policies dealing with recruitment, hiring and firing, performance evaluations, and promotions are mandated by federal law (equal consideration regardless of race, gender, religion, or nationality) o Recruitment: the process of planning for human resource needs and identifying potential candidates to meet those needs o Validity (in staff selection): criteria that predict how well a candidate will perform in a role o Reliability (in staff selection): consistency of staff selection procedures • Newly hired employees should clearly understand the roles and responsibilities within the sports medicine team o Position description: a formal document that describes the qualifications, work content, accountability, and scope of a job Job description: a written description of the specific responsibilities a position holder will be accountable for in an organization Job specification: a written description of the requirements or qualifications a person should have to fill a particular role in an organization • The head athletic trainer must serve as a supervisor and strive to improve job performance and enhance professional development of those being supervised o Clinical supervision: the process of direct observation of an employee's work, with emphasis on measurement of specific behaviors, and the subsequent development of plans to remediate deficiencies in performance Supervisor observes work, evaluates strengths and weaknesses, & develops a structure for improvement - Very appropriate for student interns Work sampling: identifies the type of work that ATs do & the amount of time they spend doing it • Logging activities of ATs at randomly selected times and analyzing the nature & quality of work they are doing Advantages: emphasis on collegial working relationships and cooperative planning Disadvantage: supervising AT must devote large blocks of time to supervising individual employees (most supervising ATs have significant responsibilities in treatment of clients) o Developmental supervision: emphasizes collaboration between supervisors and supervisees to help them solve problems and develop professionally Theme of participative management - employees discuss problems suggest creative solutions Advantage: emphasis on personal growth & integration of ATs & sports medicine program goals Disadvantage: heavy emphasis on collaboration can delay problem solving because of the need to preserve the collegial organizational climate o Inspection production supervision: emphasizes the use of formal authority and managerial prerogatives to improve employee efficiency and efficacy (focus on achieving goals & attainment of program mission) Every employee required to make a list of goals Usually used in formalistic bureaucratic organizations/industrial settings Advantages: sets well-defined limits on job-related behavior and clearly defines employee roles Disadvantages: measures of inputs and outputs in AT settings is difficult; not all jobs that ATs perform are easily observed or quantified; can cause ATs to feel unappreciated & unfulfilled • Performance evaluations should be routinely done at regularly scheduled interval

Budgetary Concerns

• Spending-ceiling model: requires justification only for those expenses that exceed those of the previous budget cycle (also known as incremental model) - often results in falling behind due to prices of supplies rising faster than inflation • Spending-reduction model: financial crisis model; requires reallocation of institutional funds, resulting in reduced spending levels for some programs (should identify areas that could be cut w/o serious impact) • Zero-based budgeting: requires justification for every budget line item without reference to previous spending patterns; requires documentation of actual program needs and development of priorities (rank each item) • Fixed budgeting: expenditures and revenues are projected on a monthly basis, thereby providing an estimate of cash flow; most appropriate for large, well-established sports medicine clinics during economic certainty • Variable budgeting: requires adjustment of monthly expenditures so that they do not exceed revenues; rarely used by school-based programs (very difficult to estimate costs in advance) • Lump sum budgeting: allocates a fixed amount of money for an entire program without specifying how the money will be spent; gives freedom to spend where it is needed most • Line item budgeting: allocates a fixed amount of money for each subfunction of a program o Expendable supplies, equipment repair, team physician services, and insurance o Easy to understand and prepare; the AT has limited flexibility in responding to midyear financial crises • Performance budgeting: allocates funds for discrete activities; not commonly used due to expense and difficulty of analyzing specific activity costs o Prepractice and pregame team preparation, rehabilitation, injury treatment, administration, patient education, emergency first aid.

Current National Injury Data-Gathering Systems

• Sports injury surveillance at this time is unsatisfactory (usually systems are only concerned with accident/injury after it has happened, and focus on only injuries requiring medical assistance rather than those restricting activity) • Ideal system: epidemiological approach that studies the relationships of various factors that influence frequency & distribution of sports injury o Extrinsic factor: type of activity, amount of exposure to injury, environmental & equipment factors o Intrinsic factor: refers directly to athlete; age, gender, neuromuscular aspects, structural aspects, performance aspects, and mental & psychological aspects • National Safety Council: nongovernmental, nonprofit public service organization that draws sports injury data from a variety of sources, including educational institutions • Annual Survey of Football Injury Research: conducted at UNC-CH since 1965; data collected about public school, college, professional, and sandlot football through personal contact interviews and questionnaires o Sponsorships: AFCA, NCAA, National Federation of State High School Athletic Associations o Classifies football fatalities as: Direct: resulting directly from participation in football Indirect: produced by systematic failure by the exertion of playing football or by a complication that arose from a nonfatal football injury • National Center for Catastrophic Sports Injury Research: because of the success of the football project, the research was expanded to all sports for both men & women, and the center was established at UNC under direction of Dr. Fred Mueller; center compiles research on catastrophic injuries at all levels of sport • NCAA Injury Surveillance System: established in 1982 for the purpose of studying incidence of football injuries so that rule change recommendations could be made. o System has been greatly expanded - athletic trainers are primarily involved in the collection & transmission of injury data o Fall 2004: ISS fully converted to Web-based data-collection system (lower cost) • National Electronic Injury Surveillance System (NEISS): established as a part of the Consumer Product Safety Act of 1972; data on injuries related to consumer projects are monitored from a selection of hospital ERs o Sport injury represent 25% of all injuries reported o If a product is considered hazardous, the commission can seize the product or create standards to decrease risk

The Field of Sports Medicine

• Sports medicine: 1) performance enhancement [ex. phys, biomechanics, sport psych, nutrition, S&C] 2) injury care & management [athletic training, sport PT, sport massage therapy, dentistry, orthotists, chiro.]

Experimental Therapy

• Terms of most insurance policies exclude experimental treatments (therapies not yet proved effective) • Insurance industry often determines that a therapeutic method has made the transition from experimental to conventional several years after the medical industry does • Companies define experimental in various ways: o List in the policy what they consider experimental procedures o List the criteria by which they will determine if a procedure is experimental (less exact, poor defense) o *Decide on a case-by-case basis (can be frustrating for patients and health care providers)

THIRD-PARTY REIMBURSEMENT

• Third-party reimbursement: the process by which medical vendors receive reimbursement from insurance companies for services provided to policyholders • Insurance companies have been slow to cover athletic trainer's services o Becoming more available as more states credential athletic trainers • Seeking of third-party reimbursement from college student-athlete's personal insurance companies is frowned upon (creates the feeling that ATs might prioritize treatment based on insurance coverage)

RESPONSIBLITIES OF THE COACH

• To understand the limits of their ability to function as a health care provider • Be certified in CPR/first aid • Have understanding of the skill techniques and environmental factors that may affect the athlete (i.e. throwing biomechanics)

Torts

• Tort: a legal wrong, other than breach of contract, for which a remedy will be provided, usually in the form of monetary damages o Actions will be pressed by plaintiffs in civil legal proceedings (criminal cases initiated by government) o 3 types: intentional tort, negligent tort, and strict liability tort

Negligence

• Types of negligence: o Nonfeasance/act of omission: when an individual fails to perform a legal duty o Malfeasance/act of commission: when an individual commits an act that is not legally his to perform o Misfeasance: when an individual improperly does something they have the legal right to do • Sovereign immunity: states that neither the government nor any individual who is employed by the government can be held liable for negligence • Good Samaritan law: provides limited protection against legal liability to any person who voluntarily chooses to provide first aid o Not able to be used by AT in work setting (a higher trained person held to higher standards) o May be possible to use in volunteer setting No duty to person in volunteer setting • To prove negligence, plaintiff must prove that the defendant is guilty of 5 components: 1. Conduct a. Must prove that AT did something that links him to case (either by omission or commission) b. Nonactions (thoughts, attitudes, or intentions) cannot render AT negligent 2. Existence of Duty a. At educational institutions: duty to provide services to athletes actively engaged in the institution's athletic programs i. Duty to intramural sports participants depends on contract b. Provide or obtain reasonable medical assistance i. ASAP under circumstances in order to avoid aggravation of injury 1. Effective emergency action plan a. Necessary first-aid supplies b. Communications with ambulance services c. Maintain confidentiality of medical records d. Provide adequate and proper supervision and instruction (use established protocols) e. Provide safe facilities and equipment f. Fully disclose information about the individual's medical condition to the individual i. Long term consequences g. Abandonment: desertion of a patient-practitioner relationship by the health care provider without the consent of the patient i. Only okay to discontinue services when: 1. Practitioner provides adequate time to find alternative services 2. Jointly terminate relationship (full recovery) 3. Patient voluntarily terminates treatment (documentation, AT tells consequences) ii. If AT leaves patient in the care of another practitioner for vacation, for example, can be charged for negligence (get patient agreement to see another practitioner) 3. Breach of Duty a. Must show the athletic trainer breached a duty owed to patient b. Whether or not athletic trainer exercised the standard of care that other reasonably prudent ATs would have exercised under circumstances i. Compare actions to those of other athletic trainers in: 1. The same locality 2. Similar communities 3. The same or similar circumstances ii. The standard of care the AT is held to depends on whether the state has credentialed the profession (otherwise may be held to standard of care of other regulated professionals) 4. Causation a. Plaintiff must prove that the breach was the legal cause of the injury (or made injury worse) b. Two types of cause i. Actual cause: the degree to which a health care practitioner's actions are associated with the adverse outcomes of a patient's care 1. Coaches, physicians, or institutions may be named as codefendants 2. Severable liability: several people contributed to harm and percentage of harm is distributed among people involved 3. Joint liability: several people contributed to different levels, all pay the same ii. Proximate (legal) cause: the degree to which the harm caused by a health care practitioner was foreseeable (projectability of the likely outcome of an act) 1. ATs are not penalized for results that were improbable or unlikely 5. Damage a. An actual adverse outcome exists i. Physical, mental, lost wages or tangible benefits, pain and suffering, many others... ii. Emotional distress, loss of consortium (injury to the marital relationship)

Patient & Student Education Information

• Up-to-date database of article reprints, handouts, and other education materials that they can provide • Maintenance of database is important (body of knowledge is changing rapidly

Usual, Customary, and Reasonable Fees

• Usual, customary, & reasonable (UCR): the charge consistent with what other medical vendors would assess o Factors that determine the amount of money companies will pay: usual fee for service charged by each health care provider customary fee for geographic area (the lowest of either average fee or 90th percentile fee, the fee below which 90% of all other medical vendors charge for a service) reasonable fee (lower of either usual or customary fee) • Reduce likelihood of having claim denied by making sure referred provider will perform only nonexperimental procedures and that they will accept the UCR fee as payment in full for services rendered. • Ways to resolve claims denied due to experimental treatment or UCR causes: o Find out exact reason for which the claim was denied o Obtain a statement from provider explaining why treatment was implemented & justifying the fee o Correspond with the employer who provides the self-insurance fund (has authority to reverse denial) o Provide evidence from clinical studies to support your claim that tx should not be viewed as experimental o Try to convince provider to waive portion of fee above the UCR amount o Contact state insurance commissioner and request assistance in challenging denial