Understanding the Standard of Care for Managing Sport-Related Concussions

1
Understanding 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

2
Concussion

• 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!
3
Anquan Bolden Concussion Fall 2008
4
Stewart Bradley Concussion Fall 2010
5
Sports-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.
6
DE News Journal Media Coverage
7
Federal Regulations on the Horizon?
8
So Whats The Big Deal for ME?
9
Part 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.
10
Part 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

11
Strategies 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

12
Strategies 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

13
No 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.

14
Legal 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

15
Part II - What Exactly is the Standard of Care?
16
NATA Position Statement
17
NCAA Sports Medicine Handbook
18
DIAA 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.
19
DIAA 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.
20
DIAA 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
21
What Should the ATC be Doing with Regard to SRC
Assessment and Evaluation?
22
Zurich 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)
24
SCAT2
25
(No Transcript)
26
Concussion Symptom Checklist
27
Glasgow Coma Scale
28
Maddocks 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
29
Standardized Assessment of Concussion
30
Balance 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
32
Coordination Examination
Athletic Training Research Laboratory
33
Rationale for Neurocognitive Testing

• Cognitive abilities
• Memory
• Attention
• Language
• Visuospatial skills
• Psychological function
• Personality
• Psychiatric symptoms

Athletic Training Research Laboratory
34
Zurich Group (2008) Graduated RTP Protocol
Athletic Training Research Laboratory
35
Zurich Group (2008) Concussion Modifiers
Athletic Training Research Laboratory
36
UD Concussion Guidelines
Athletic Training Research Laboratory
37
What About Educational Programming
CONCUSSION A fact sheet for student-athletes
Athletic Training Research Laboratory
38
What About Educational Programming
Concussion in Sports - What You Need To Know
http//www.nfhslearn.com/electiveDetail.aspx?cours
eID15000
Athletic Training Research Laboratory
39
CDC 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
41
DE CARES(Concussion Assessment Registry and
Educational System) A Proposal to Examine
Sport-Related Concussions in DE Youth
42
Why 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
43
Study 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.

44
Study 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.

45
INTER-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

46
You Must Have Some Questions????
47
Thank You