Context: State laws provide general guidelines for sport-related concussion (SRC) management, but do not comprehensively address the multiple layers of management for this complex injury. While high schools are encouraged to develop a SRC protocol that includes both state law tenets and additional management practices, the execution of this warrants examination.

Objective: To investigate state law compliance and practice components included in high school SRC protocols, and determine whether the degree of sports medicine coverage influenced protocol quality.

Design: Qualitative document analysis.

Setting: High school athletics.

Participants: In total, 184 Pennsylvania high schools [24.3% of schools statewide; full-time athletic trainer=149, part-time athletic trainer=13, missing=21] voluntarily provided copies of their protocol from the 2018–2019 academic year.

Main Outcome Measures: Four athletic trainers conducted document analyses using a 67-item component analysis guide. Frequencies were computed for included protocol components related to the state law, preparticipation and prevention, recognition and assessment, and management. The difference in the total number of included components (max 60) by sports medicine coverage was assessed using a Mann-Whitney U test.

Results: There was heterogeneity in components included in the submitted protocols. Only 23.4% included all mandatory state law tenets. Immediate removal from play was noted in 67.4% of protocols, while only 1.6% contained prevention strategies. Return-to-play was addressed more frequently than return-to-learn (74.5% versus 32.6%). The sample had a mean of 15.5±9.7 total components per protocol. Schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers (15 [8.5–22.5] versus 6 [3–10.5] median components; U = 377.5, p < .001)

Conclusions: School-level written SRC protocols were often missing components of the state law and additional best practice recommendations. Full-time sports medicine coverage in high schools is recommended to increase SRC protocol and healthcare quality.

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