Context

Exertional heat stroke (EHS) deaths can be prevented by adhering to best practices.

Objective

To investigate high schools' adoption of policies and procedures for recognizing and treating patients with EHS and the factors influencing the adoption of a comprehensive policy.

Design

Cross-sectional study.

Setting

Online questionnaire.

Patients or Other Participants

Athletic trainers (ATs) practicing in the high school (HS) setting.

Main Outcome Measure(s)

Using the National Athletic Trainers' Association position statement on exertional heat illness, we developed an online questionnaire and distributed it to ATs to ascertain their schools' current written policies for using rectal temperature and cold-water immersion. The precaution adoption process model allowed for responses to be presented across the various health behavior stages (unaware if have the policy, unaware of the need for the policy, unengaged, undecided, decided not to act, decided to act, acting, and maintaining). Additional questions addressed perceptions of facilitators and barriers. Data are presented as proportions.

Results

A total of 531 ATs completed the questionnaire. Overall, 16.9% (n = 62) reported adoption of all components for the proper recognition and treatment of EHS. The component with the highest adoption level was “cool first, transport second”; 74.1% (n = 110) of ATs described acting on or maintaining the policy. The most variability in the precaution adoption process model responses was for a rectal temperature policy; 28.7% (n = 103) of ATs stated they decided not to act and 20.1% (n = 72) stated they maintained the policy. The most frequently cited facilitator of and barrier to obtaining rectal temperature were a mandate from the state HS athletics association (n = 274, 51.5%) and resistance to or apprehension of parents or legal guardians (n = 311, 58.5%), respectively.

Conclusions

Athletic trainers in the HS setting appeared to be struggling to adopt a comprehensive EHS strategy, with rectal temperature continuing as the biggest challenge. Tailored strategies based on health behavior, facilitators, and barriers may aid in changing this paradigm.

Key Points
  • Overall, 17% of athletic trainers reported adopting all 4 policy components for the diagnosis and management of patients with exertional heat stroke, whereas 48% described adopting all 3 cold-water immersion policies.

  • The most often cited facilitator of a rectal temperature policy was a mandate from the state high school athletics association, whereas the most frequently cited barrier was resistance or apprehension from parents.

  • The facilitator reported most commonly for a cold-water immersion policy was having a medical professional onsite, whereas the barrier described most often was financial limitations.

Exertional heat illness (EHI) represents a constellation of medical conditions in which heat exposure plays a key role.1  Data from the past decade have indicated that the rate of EHI in high school (HS) athletes ranges from 0.12 to 0.13/10 000 athlete-exposures.2,3  The proper management and care of patients with exertional heat stroke (EHS), the only fatal EHI, has been examined extensively in the scientific literature for decades. Synthesis of the current standards of care is provided in numerous position and consensus statements48  and other supporting literature specific to the HS setting.9  Belval et al6  introduced a paradigm on the prehospital care of EHS consisting of 4 steps: (1) rapid recognition, (2) rapid assessment, (3) rapid cooling, and (4) rapid advanced care. In short, recognition of altered mental status and confirmation of extreme hyperthermia (>40.5°C) using rectal thermometry to diagnose EHS, followed by onsite whole-body, cold-water immersion (CWI) within 30 minutes of collapse ensures survival.4,10  Evidence suggests that, when all steps of this paradigm are followed, the survival rate of EHS is 100%,10  whereas a lapse in any 1 step can prove fatal.11 

The use of evidence-based best practices in the development, implementation, and adoption of comprehensive health and safety policies for HS athletics allows for proactive planning and preparation to mitigate the EHI risk. Despite the data that suggested implementing health and safety policies at the state level reduced risk,12  examination of the compliance of local adoption of these health and safety policies at the HS level has not been comprehensive.1315  At the HS level, only 3.2% of athletic trainers (ATs) who reported treating a patient with suspected EHS took a rectal temperature,16  though it is unclear if this was the AT's written policy or if it was operational but not written. Although best practices may be operational at an HS (eg, practicing the skill or best practice) and not written (eg, not inscribed in the policies and procedures handbook), it is imperative that all best practices be both operational and written. Failure to put policies and procedures in writing implies a lack of proactive consideration for managing catastrophic events such as EHS.

Why HSs are resistant to adopting and implementing EHS best practices is unclear. For emergency action plans (EAPs), access to an AT and a requirement from the school to have a policy in place appeared to be the greatest influencing factors for EAP adoption.1719  The most commonly reported barrier to EAP adoption was financial limitations, but this is an interesting finding given the zero cost of adopting an EAP.17  Data related to facilitators and barriers may provide insight into influencing factors; however, these data fail to address decision-making processes. Health behavior models, such as the health belief model and the precaution adoption process model (PAPM), help researchers understand how individuals think through change.20  For example, the health belief model has been used to identify that ATs who perceived more barriers, fewer perceived benefits, less seriousness of EHS, and less perceived susceptibility were less likely to obtain a rectal temperature.21  However, the literature has not addressed the applicability of the PAPM to similar decision making regarding the adoption of EHS best practices.

The PAPM aims to identify one's readiness to act in adopting a behavior. Although typically for individual health decisions, the PAPM may have applicability for a clinician's decision-making process regarding adoption of the best practices to affect the health of others.20,22,23  In the context of providing health care for those suffering from EHS, ATs directly influence the quality of care a patient will receive. Clinical decision-making tools are taught, yet the literature continues to accentuate ATs' lack of adoption of best practices in the care of patients with EHS.13,16,18,21,2426  The PAPM can provide a unique consideration for individual behavioral factors influencing ATs to make (or not make) these decisions. Specifically, the PAPM can identify if a person is unaware of the need for EHS management strategies (unaware), aware but not considering adopting EHS management strategies (unengaged), aware and considering adopting EHS management strategies (undecided), aware and decided not to adopt EHS management strategies (decided not to act), aware and decided to adopt EHS management strategies in the next 6 months (decided to act), recently adopted strategies (acting) or adopted strategies more than 6 months ago (maintaining; Table 1).20,22  Through an increased appreciation of this process, we can create tailored interventions to one's health behavior, a technique that has demonstrated success in areas such as osteoporosis and colorectal screening.27,28 

Table 1

Operational Definitions for the Precaution Adoption Process Model (PAPM)

Operational Definitions for the Precaution Adoption Process Model (PAPM)
Operational Definitions for the Precaution Adoption Process Model (PAPM)

Athletic trainers were not likely to adhere to current best practices when treating a suspected case of EHS.16,24  However, the extent to which comprehensive policies and procedures for the management of EHS are adopted by HSs is unknown. Therefore, the purpose of our study was to investigate the current adoption of policies and procedures for recognizing and treating patients with EHS. Secondarily, we aimed to assess the factors influencing the adoption of a comprehensive policy (eg, facilitators, barriers, social determinants of health).

Using a cross-sectional questionnaire design, we evaluated the current level of EHS management strategies in HSs across the United States. A national sample of ATs was contacted to participate in this investigation in the fall of 2018 and the spring of 2019. The research study was classified as exempt by the University of Connecticut Institutional Review Board.

Participants

Athletic trainers were invited to participate via 2 methods. First, ATs who had completed the Athletic Training Locations and Services (ATLAS) project29  were emailed invitations (fall = 3319; spring = 3187). Two e-mail reminders were sent to nonresponders at 2 and 4 weeks after the initial email distribution. In the fall of 2018 and the spring of 2019, a social media blast (Facebook, Twitter, Instagram) was released to invite ATs to participate. As with the emailed reminders, the primary author (S.E.S.M) reposted the social media blast at 2 weeks and 4 weeks after the initial post. However, it is impossible to know how often the social media blast was reshared by others and at what frequencies. Given the varied distribution rates and the unknown number of ATs who viewed the social media blast, a method used in questionnaire research, an overall response rate cannot be calculated. Responses from the emailed and social media distributions from ATs only were combined and reviewed for duplicate data (eg, completion of the questionnaire using the email link and a social media link). Duplicate data were identified when the response was from the same state, and zip code and listed the same sex and years in the profession among other variables. A completed questionnaire consisted of (1) the AT's consent to participate, (2) the response from an AT working in the HS setting, and (3) answering of ≥80% of the items in the questionnaire. A total of 439 ATs started the survey in the fall 2018 and 439 in spring 2019; 100 and 114 responses did not meet the inclusion criteria (fall = 20, spring = 21) or did not complete ≥80% of the questionnaire (fall = 80, spring = 94) for fall and spring, respectively. This left a total of 417 complete responses for the fall 2018 and 324 for spring 2019 (total N = 741).

This study was part of a larger study aimed at observing policy change over time (fall to spring). As such, each AT was asked to provide a unique ID to anonymously match his or her responses. All matched responses (ie, ATs who took the survey at both time points) were removed from this analysis. A total of 105 individuals completed the survey in both the fall and the spring, leaving 312 unique observations in the fall and 219 in the spring (N = 531).

Questionnaire

The items in the online questionnaire were based on the NATA position statement on exertional heat illness4  and distributed via Qualtrics (Provo, UT). Questions pertaining to demographics (age, sex, state, years in profession, years at school overall), EHS management policy, facilitators, and barriers were asked. For EHS management, ATs were asked to report their current written policies for the use of rectal temperature, having a CWI tub available within 5 minutes, the CWI setup (filled halfway with ice and water), and the use of “cool first, transport second.” The questions about these policies were developed using a health behavior model, the PAPM, which can provide formidable information about the factors influencing an AT's ability to change policy.20,23,27  The PAPM consists of 7 stages: unaware, undecided, considering, decided not to act, decided to act, acting, and maintaining.20  For the purpose of this research, we divided the unaware stage into unaware of the need for this policy and unaware if we have this policy (Table 1). Athletic trainers were asked if their school had a written policy for preventing and treating patients with EHI (9a). An AT who selected not adopting for this item was not asked additional questions about policy components (eg, 9b to 9e). Adoption was defined as ATs who reporting acting on and maintaining a policy from the PAPM.20  All other stages combined were defined as not adopting. For the facilitators and barriers questions, ATs were asked to choose all that applied regarding policies for the adoption of a rectal temperature policy and the setup and use of CWI. See the Appendix for the questionnaire.

The questionnaire was developed by the 6 authors, who are experts in the field of EHI and health behavior. To ascertain the relevance, importance, and clarity of the questions, we conducted a pilot test with 7 ATs who worked in the HS setting. Revisions of the questionnaire were based on feedback from the pilot test; 4 questions were revised for clarity.

Data Analysis

Policy data (PAPM stages and overall adoption) along with facilitators and barriers were summarized and are presented as proportions with 95% CIs. As our primary purpose was to identify the current adoption of guidelines for the recognition and treatments of patients with EHS, we aimed to evaluate the adoption of all components for a heat policy. We termed this the comprehensive EHS management policy, which included adoption of all 4 components.

We sought to determine if age or the number of students enrolled at the school between those with (eg, adopting) a policy and those without (eg, not adopting) differed. For the rectal temperature policy question (9b), a Welsh t test with 95% CIs was run to determine this difference due to the assumption of homogeneity of variances being violated, as assessed by the Levene test for equality of variances (age P = .001, students P = .05). For the CWI available onsite (9c), CWI setup (9d), and cool first, transport second (9e), an independent-samples t test with 95% CI was performed, as homogeneity of variances was present as assessed by the Levene test for equality of variances (P > .05). Finally, χ2 tests of association were calculated between the years in the professional role (dichotomized as 0–10 years [56.4%] versus 11+ years [43.6%]) and years working in the current HS (dichotomized as 0–5 years [60.2%] and 6+ years [39.8%]). The dichotomization for professional role and years working in their current HS was based on a natural cut in the data. Statistical significance was determined as P < .05. All statistical analysis was carried out in SPSS (version 26; IBM Corp).

On average, respondents were aged 35 ± 9 years. Most of our respondents were from Texas (n = 59, 11.1%), Florida (n = 28, 5.3%), and North Carolina (n = 31, 5.8%). Overall, the majority of ATs in this sample had been working in the profession for 1 to 5 years (n = 169, 31.9%) and at their current HS for 1 to 5 years (n = 288, 54.2%).

Adoption of EHS Management Strategies

Nearly a third of ATs reported they did not have a written policy for EHS prevention or treatment (not adopting, n = 161, 30.32%, 95% CI = 26.44%, 34.43%). The most adopted policy component as cool first, transport second with 66.21% (n = 241, 95% CI = 61.10%, 71.06%) of ATs reporting acting or maintaining for this policy (Table 2). The most variability in the PAPM responses was in the question: “Does your school have a rectal temperature policy for the diagnosis of EHS?” (9b) with 28.69% (n = 103, 95% CI = 24.07%, 33.67%) of ATs reporting they decided not to act and 20.06% (n = 72, 95% CI = 16.04%, 24.58%) reporting maintaining (Table 3). When we evaluated the adoption of a comprehensive EHS management policy, 16.9% (n = 62, 95% CI = 13.20%, 21.13%) of ATs reported adopting all 4 components for the diagnosis and management of EHS (Figure). When assessing only the treatment of EHS, 47.1% (n = 173, 95% CI = 41.94%, 52.39%) reported adoption of all 3 CWI policies.

Table 2

Proportion of Athletic Trainers Reporting Adoption of Each of the Written Policy Components by Time Point and Aggregate of Fall and Spring, % (n) [95% Confidence Interval]

Proportion of Athletic Trainers Reporting Adoption of Each of the Written Policy Components by Time Point and Aggregate of Fall and Spring, % (n) [95% Confidence Interval]
Proportion of Athletic Trainers Reporting Adoption of Each of the Written Policy Components by Time Point and Aggregate of Fall and Spring, % (n) [95% Confidence Interval]
Table 3

Precaution Adoption Process Model Responses From Athletic Trainers Aggregated From Fall 2018 and Spring 2019 Time Points (n = 370) Within Each Policy Component, % (n) [95% CI]

Precaution Adoption Process Model Responses From Athletic Trainers Aggregated From Fall 2018 and Spring 2019 Time Points (n = 370) Within Each Policy Component, % (n) [95% CI]
Precaution Adoption Process Model Responses From Athletic Trainers Aggregated From Fall 2018 and Spring 2019 Time Points (n = 370) Within Each Policy Component, % (n) [95% CI]
Figure

Number of exertional heat-stroke management policy components adopted (rectal temperature, cold-water immersion [CWI] available onsite, CWI set up, “cool first, transport second”) as reported by athletic trainers (ATs; N = 367).

Figure

Number of exertional heat-stroke management policy components adopted (rectal temperature, cold-water immersion [CWI] available onsite, CWI set up, “cool first, transport second”) as reported by athletic trainers (ATs; N = 367).

Differences in age between those with (32 ± 7 years) and those without (36 ± 10 years) a written rectal temperature policy existed (t178.54 = 3.15; 95% CI = 1.23%, 5.36%; P = .002). Similarly, age between those with (34 ± 9 years) and those without (37 ± 9 years) a cool first, transport second policy (t359 = 2.31; 95% CI = 0.412%, 5.044%; P = .021) varied. We observed no differences in AT age between those with and those without CWI available onsite (P = .840) or CWI setup (P = .563). Also, the number of students did not vary between those with and those without the adoption of a rectal temperature policy (P = .178), CWI available onsite (P = .489), CWI setup (P = .523), or cool first, transport second (0.710). No differences between years in the profession and years in an HS with any of the policy variables were identified (P > .05).

Facilitators

The most commonly reported facilitators for obtaining rectal temperature were a mandate from the state HS athletics association (n = 270, 50.85%, 95% CI = 47.26%, 55.93%), state legislation (n = 270, 50.85%, 95% CI = 46.51%, 55.18%), support from someone in the authoritative position (n = 243, 45.76%, 95% CI = 41.47%, 50.11%), and seeing how others facilitate implementation of a policy (n = 228, 42.94%, 95% CI = 38.68%, 47.27%; Table 4). The most frequently described facilitators for the development of a policy to include CWI included having a medical professional (n = 273, 51.41%, 95% CI = 47.07%, 55.74%), support from someone in an authoritative position (n = 191, 46.70%, 95% CI = 42.40%, 51.05%), mandate from the state HS athletics association (n = 247, 46.54%, 95% CI = 42.21%, 50.86%), and state legislative mandate for policy (n = 209, 39.36%, 95% CI = 35.18%, 43.66%).

Table 4

Facilitators to Implementation of a Rectal Temperature and Cold-Water Immersion Policy, % (n) [95% CI]

Facilitators to Implementation of a Rectal Temperature and Cold-Water Immersion Policy, % (n) [95% CI]
Facilitators to Implementation of a Rectal Temperature and Cold-Water Immersion Policy, % (n) [95% CI]

Barriers

The most often cited barriers for a rectal temperature policy were resistance or apprehension from parents or legal guardians (n = 311,58.57%, 95% CI = 54.25%, 62.79%), liability for using it (n = 282, 53.11%, 95% CI = 48.76%, 57.42%), resistance or apprehension from coaches (n = 228, 42.94%, 95% CI = 38.68%, 47.27%), and “I am not comfortable using a rectal thermometer” (n = 183, 34.46%, 95% CI = 30.42%, 38.68%; Table 5). The most commonly reported barriers for CWI were no barriers encountered (n = 266, 50.09%, 95% CI = 45.76%, 54.43%), financial limitations (n = 141, 26.55%, 95% CI = 22.84%, 30.53%), AT is not full time (n = 55, 10.36%, 95% CI = 7.90%, 13.27%), and resistance or apprehension from coaches (n =55, 10.36%, 95% CI = 7.90%, 13.27%).

Table 5

Barriers to Implementation of a Cold-Water Immersion and Rectal Temperature Policy, % (n) [95% CI]a

Barriers to Implementation of a Cold-Water Immersion and Rectal Temperature Policy, % (n) [95% CI]a
Barriers to Implementation of a Cold-Water Immersion and Rectal Temperature Policy, % (n) [95% CI]a

Exertional heat stroke remains 1 of the leading causes of sudden death in sport and physical activity, despite boasting a 100% survival rate when current evidence-based best practices are followed.10  Given the concern and potentially catastrophic outcomes from EHS if best practices are not followed, we examined the compliance associated with the adoption and influencing factors of current best practices4  in the form of written policies for the management of EHS in HS athletics. Our main findings were that 161 (44.1%) respondents did not have a written heat illness policy at the HS for which they were employed, and only 16.9% of those who did have a written policy adopted a comprehensive policy related to the diagnosis and treatment of EHS. Further, the PAPM identified the largest proportion of ATs reported deciding not to act to adopt a rectal temperature policy (28.69%), whereas a majority reported maintaining for using the cool first, transport second mantra (66.21%). Athletic trainers were most likely to endorse a mandate from either the state's HS athletics association or through state legislature as a policy facilitator. The most frequent barriers preventing the adoption of evidence-based heat policies focused on liability surrounding the management of patients with EHS, although this reasoning lacked evidence.

Despite rectal temperature being described as the current medical standard of care for the diagnosis of EHS,4,6  only 22.83% of respondents indicated that this was included in their written policies and procedures for the management of EHS. However, nearly 1 in 3 ATs reported they decided not to act to have this policy. This finding in the present study complemented recent work by Nedimyer et al,16  who observed that only 3.9% of ATs used this diagnostic technique when examining a patient suspected of EHS. The difference between our results and those of Nedimyer et al16  was that the latter asked clinicians to indicate if they had used rectal temperature for EHS diagnosis, whereas we asked if they had a written policy for the technique. Similarly, McLean et al21  noted that when ATs perceived more barriers, fewer benefits, less perceived seriousness, and less perceived susceptibility, they were less likely to obtain a rectal temperature. Without accurately assessing this vital sign, health care providers are unable to appropriately differentiate EHS from other potentially life-threatening conditions (eg, exertional sickling, hypoglycemia, hyponatremia). The lack of a definitive diagnosis then limits the ability to initiate a proper and prompt course of treatment. Although the number of ATs who stated that they decided not to act may be concerning, it is unclear if they made this decision themselves (ie, the ATs decided they would not obtain rectal temperatures) or if the ATs lacked support (from the school administrator or supervisor) to include this item in the heat policy. Recently, McLean et al21  found that 32% of ATs selected agree or strongly agree for the item indicating that the school's administration would not allow them to use rectal temperature. It is imperative for the AT, as the health care professional, to stand up for the standard of care and not allow nonmedically trained individuals to make decisions about the health care of athletes. From a legal standpoint, it is critical for the AT to make every attempt to educate others on the importance and liability regarding a clear diagnosis and treatment of a patient with EHS. Any efforts by the AT to include this policy that are met with resistance should be documented.

Adoption of evidence-based policies surrounding CWI for the treatment of EHS was greater than that for rectal temperature. Most respondents said they had a CWI tub onsite (63%), had the CWI tub setup (53%), and followed the cool first, transport second EHS treatment mantra (75%). Our results are consistent with those of Kerr et al,14  who determined that 57.1% of ATs had an immersion tub prepared to treat patients with EHS onsite before the start of practice. Among our sample, 37% commented that they did not have a written policy for a CWI tub onsite for EHS treatment; we are unaware if they had a policy for an effective alternative body cooling method. Tarp-assisted cooling, an alternative body cooling modality that uses an impermeable tarp instead of a tub, is an effective means of rapidly cooling the body and may be a suitable option for settings where access to a tub is not feasible.30,31 

Though small, the proportion of ATs who reported being unaware for the need for a policy (1.37% to 5.85%) or unaware if they had a policy (4.40% to 5.85%) was an interesting result. The need to obtain a rectal temperature and use CWI have been discussed in the literature and in athletic training educational programs for decades.8,32  We found that younger ATs were more likely to have written policies in place for rectal temperature assessment and cool first, transport second than were older ATs. In 2011, the fifth edition of the Education Competencies was released,33  which included updates requiring accredited athletic training programs to provide both didactic and hands-on education and training specific to the assessment of internal body temperature using rectal thermometry and treatment of EHS using CWI. These updates may have been a catalyst for the differences observed between younger and older ATs, as the younger respondents in our study may have been educated under the fifth edition of the competencies. However, we also identified no differences in the adoption of these policies based on the number of years in the profession. This information may offer a better indication of the possible influence of the AT's educational background on whether policies were adopted, mainly to evaluate the effectiveness of the change in competencies.2426,34  We are unable to speculate further on this, as we did not assess the extent to which these concepts were covered in each AT's educational program.

When designing interventions, it is imperative to identify what strategies or facilitators will help improve adoption. In this study, ATs cited state-level mandates, legislation, or both as positive facilitators in the adoption of EHS management policies. As state requirements have been shown to improve patient outcomes12  and overall adoption,14,35  this finding was not surprising. Furthermore, having the support of a person in an authoritative position (eg, athletics director, principal) assisted in ensuring that these policies were adopted locally. This result aligns with prior literature,17  as ATs have described support from administration as a common facilitator for the adoption of EAPs. Given that athletics directors are often in charge of the logistics and operations of athletics, their support allows for comprehensive “buy in” from the other individuals involved with athletics. Although exceedingly uncommon in HSs, it may be worthwhile to evaluate the feasibility of a medical model in the HS setting to facilitate administrator support from an individual (eg, district medical director) with a health care background rather than one with no medical expertise.

With our findings showing that only 16.9% of ATs adopted all 4 policies for the assessment and treatment of EHS, a concerted effort must be undertaken to address this in HS athletics. The failure of ATs to adopt evidence-based policies for the assessment and treatment of patients with EHS may be related to the barriers revealed in our dataset. Potential strategies to overcome the common barriers we reported can be found in Table 6. Regarding obtaining rectal temperature, ATs primarily described resistance from parents or legal guardians (58.57%) and coaches (42.94%), potential legal liabilities for performing this diagnostic measure on minors (53.11), as well as their personal comfort level in performing this psychomotor skill (34.46%). However, to our knowledge, these are perceived barriers, and no literature indicates that coaches and parents would not support evidence-based policies that lead to survival from EHS. Although not as prevalent, barriers to the use of CWI centered on financial implications and apprehension from the coaching staff. It is important to emphasize that, as mentioned earlier with respect to coaches and parents, barriers related to financial limitations and coaches' apprehension are also not evidence based; we are aware of no published literature that supports these barriers as influencing the ability to adopt comprehensive EHS policies. The most concerning barrier was the perception of the potential legal liabilities, as these evidence-based recommendations have been in the literature for nearly 20 years and were included in athletic training education programs for more than 8 years. Given the efforts in the athletic training profession to practice evidence-based medicine, it is concerning that more ATs have not adopted best-practice recommendations. We are unaware of any instance in which an AT acting within the scope of practice and providing medical care consistent with current medical evidence was the subject of litigation.

Table 6

Suggested Strategies for Overcoming the Most Common Barriers to Implementing a Rectal Temperature and Cold-Water Immersion Policy Continued on Next Page

Suggested Strategies for Overcoming the Most Common Barriers to Implementing a Rectal Temperature and Cold-Water Immersion Policy Continued on Next Page
Suggested Strategies for Overcoming the Most Common Barriers to Implementing a Rectal Temperature and Cold-Water Immersion Policy Continued on Next Page

A notable strength of this study was that it allows us to begin to better understand the current adoption of EHS management strategies in a nationally representative sample using a health behavior model. However, our investigation was not without limitations. We decided to evaluate adoption rather than implementation; therefore, we cannot infer the implementation or operation of these polices. Dunbar-Gaynor et al36  identified differences between written and operational policies. As such, ATs in this sample may have reported their school did not have a written policy, but they may have been performing that technique. Conversely, the AT may have indicated the presence of a written policy, but the policy may not have been in operation. Future researchers should further evaluate a school's written and operational policies and procedures via an onsite visit. Also, the ATs in this sample were asked to describe their school's written policies rather than provide their own perceptions of the written policies. As such, rather than ascertaining interpersonal health behavior, our data may have reflected the intrapersonal or organizational level of health behavior. Future authors should explore the differences in health behavior and readiness to act across the socioecological framework. With the development of tailored community-based interventions directed at one's readiness to act, we can better address individual concerns and motivations, thereby enhancing best-practices adoption.

In conclusion, many ATs were not likely to adopt all the evidence-based policies and procedures for the proper management and care of patients with EHS in the HS setting. Without having current evidence-based standards of care for EHS in place, participating student-athletes remain at risk. Further exploration of the actual implementation of EHS management strategies and facilitators and barriers is warranted to develop adaptive intervention strategies for improving patient care.

1. 
International statistical classification of diseases and related health problems
.
World Health Organization
.
2021
.
2. 
Kerr
ZY,
Casa
DJ,
Marshall
SW,
Comstock
RD.
Epidemiology of exertional heat illness among U.S. high school athletes
.
Am J Prev Med
.
2013
;
44
(1)
:
8
14
.
3. 
Kerr
ZY,
Yeargin
SW,
Hosokawa
Y,
Hirschhorn
RM,
Pierpoint
LA,
Casa
DJ.
The epidemiology and management of exertional heat illnesses in high school sports during the 2012/2013–2016/2017 academic years
.
J Sport Rehabil
.
2020
;
29
(3)
:
332
338
.
4. 
Casa
DJ,
DeMartini
JK,
Bergeron
MF,
et al
National Athletic Trainers' Association position statement: exertional heat illnesses
.
J Athl Train
.
2015
;
50
(9)
:
986
1000
.
5. 
Casa
DJ,
Almquist
J,
Anderson
SA,
et al
The inter-association task force for preventing sudden death in secondary school athletics programs: best-practices recommendations
.
J Athl Train
.
2013
;
48
(4)
:
546
553
.
6. 
Belval
LN,
Casa
DJ,
Adams
WM,
et al
Consensus statement- prehospital care of exertional heat stroke
.
Prehosp Emerg Care
.
2018
;
22
(3)
:
392
397
.
7. 
American College of Sports Medicine
;
LE
Armstrong,
Casa
DJ,
et al
American College of Sports Medicine position stand: exertional heat illness during training and competition
.
Med Sci Sports Exerc
.
2007
;
39
(3)
:
556
572
.
8. 
Binkley
HM,
Beckett
J,
Casa
DJ,
Kleiner
DM,
Plummer
PE.
National Athletic Trainers' Association position statement: exertional heat illnesses
.
J Athl Train
.
2002
;
37
(3)
:
329
343
.
9. 
Adams
WM,
Hosokawa
Y,
Belval
LN.
Factors involved in the onsite management and care of exertional heat stroke in secondary school athletics
.
Athl Train Sports Health Care
.
2019
;
11
(5)
:
206
209
.
10. 
Demartini
JK,
Casa
DJ,
Stearns
R,
et al
Effectiveness of cold water immersion in the treatment of exertional heat stroke at the Falmouth Road Race
.
Med Sci Sports Exerc
.
2015
;
47
(2)
:
240
245
.
11. 
Adams
WM,
Belval
LN,
Berg
AP,
Hosokawa
Y,
Stearns
RL,
Casa
DJ.
Exertional heat stroke of Max Gilpin; a preventable death
.
Quest
.
2020
;
72
(1)
:
102
115
.
12. 
Kerr
ZY,
Register-Mihalik
JK,
Pryor
RR,
et al
The association between mandated preseason heat acclimatization guidelines and exertional heat illness during preseason high school American football practices
.
Environ Health Perspect
.
2019
;
127
(4)
:
047003
.
13. 
Kerr
ZY,
Register-Mihalik
JK,
Pryor
RR,
Hosokawa
Y,
Scarneo-Miller
SE,
Casa
DJ.
Compliance with the National Athletic Trainers' Association Inter-Association Task Force preseason heat-acclimatization guidelines in high school football
.
J Athl Train
.
2019
;
54
(7)
:
749
757
.
14. 
Kerr
ZY,
Scarneo-Miller
SE,
Yeargin
SW,
et al
Exertional heat-stroke preparedness in high school football by region and state mandate presence
.
J Athl Train
.
2019
;
54
(9)
:
921
928
.
15. 
Scarneo
SE,
DiStefano
LJ,
Stearns
RL,
Register-Mihalik
JK,
Denegar
CR,
Casa
DJ.
Emergency action planning in secondary school athletics: a comprehensive evaluation of current adoption of best practice standards
.
J Athl Train
.
2019
;
54
(1)
:
99
105
.
16. 
Nedimyer
AK,
Chandran
A,
Hirschorn
RM,
et al
Exertional heat-stroke management practices and intentions among secondary school football athletic trainers
.
J Athl Train
.
2020
;
55
(10)
:
1081
1088
.
17. 
Scarneo-Miller
SE,
DiStefano
LJ,
Singe
SM,
Register-Mihalik
JK,
Stearns
RL,
Casa
DJ.
Emergency action plans in secondary schools: barriers, facilitators, and social determinants affecting implementation
.
J Athl Train
.
2020
;
55
(1)
:
80
87
.
18. 
McLeod
TCV,
Cardenas
JF.
Emergency preparedness of secondary school athletic programs in Arizona
.
J Athl Train
.
2019
;
54
(2)
:
133
141
.
19. 
Johnson
ST,
Norcross
MF,
Bovbjerg
VE,
Hoffman
MA,
Chang
E,
Koester
MC.
Sports-related emergency preparedness in Oregon high schools
.
Sports Health
.
2017
;
9
(2)
:
181
184
.
20. 
Weinstein
ND,
Sandman
PM,
Blalock
SJ.
The precaution adoption process model
.
In:
Glanz
K,
Rimer
BK,
Viswanath
K,
eds.
Health Behavior and Health Education: Theory, Research, and Practice. 4th ed
.
Jossey-Bass
;
2008
:
123
147
.
21. 
McLean
DR,
Scarneo-Miller
SE,
Lopez
RM.
Perceptions of secondary school athletic trainers in the diagnosis of exertional heat stroke
.
J Athl Train
.
2020
;
55
(10)
:
1070
1080
.
22. 
Elliott
JO,
Seals
BF,
Jacobson
MP.
Use of the precaution adoption process model to examine predictors of osteoprotective behavior in epilepsy
.
Seizure
.
2007
;
16
(5)
:
424
437
.
23. 
Collins
CL,
McKenzie
LB,
Roberts
KJ,
Fields
SK,
Comstock
RD.
Mouthguard BITES (behavior, impulsivity, theory evaluation study): what drives mouthguard use among high school basketball and baseball/softball athletes
.
J Prim Prev
.
2015
;
36
(5)
:
323
334
.
24. 
Mazerolle
SM,
Scruggs
IC,
Casa
DJ,
et al
Current knowledge, attitudes, and practices of certified athletic trainers regarding recognition and treatment of exertional heat stroke
.
J Athl Train
.
2010
;
45
(2)
:
170
180
.
25. 
Mazerolle
SM,
Pinkus
DE,
Casa
DJ,
et al
Evidence-based medicine and the recognition and treatment of exertional heat stroke, part II: a perspective from the clinical athletic trainer
.
J Athl Train
.
2011
;
46
(5)
:
533
542
.
26. 
Schellhase
KC,
Plant
J,
Mazerolle
SM.
Athletic trainers' attitudes and perceptions regarding exertional heat stroke before and after an educational intervention
.
Athl Train Educ J
.
2017
;
12
(3)
:
179
187
.
27. 
Blalock
SJ,
DeVellis
RF,
Giorgino
KB.,
et al
Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior
.
Health Psychol
.
1996
;
15
(2)
:
84
93
.
28. 
Hester
CM,
Born
WK,
Yeh
HW,
et al
Decisional stage distribution for colorectal cancer screening among diverse, low-income study participants
.
Health Educ Res
.
2015
;
30
(3)
:
400
411
.
29. 
Athletic Training Locations and Services (ATLAS) Project.
Korey Stringer Institute, University of Connecticut.
https://ksi.uconn.edu/nata-atlas/. Accessed February 15,
2018
.
30. 
Hosokawa
Y,
Adams
WM,
Belval
LN,
Vandermark
LW,
Casa
DJ.
Tarp-assisted cooling as a method of whole-body cooling in hyperthermic individuals
.
Ann Emerg Med
.
2017
;
69
(3)
:
347
352
.
31. 
Luhring
KE,
Butts
CL,
Smith
CR,
et al
Cooling effectiveness of a modified cold-water immersion method after exercise-induced hyperthermia
.
J Athl Train
.
2016
;
51
(11)
:
946
951
.
32. 
Rav-Acha
M,
Hadad
E,
Epstein
Y,
Heled
Y,
Moran
DS.
Fatal exertional heat stroke: a case series
.
Am J Med Sci
.
2004
;
328
(2)
:
84
87
.
33. 
Athletic training education competencies, 5th ed
.
National Athletic Trainers' Association
.
2020
.
34. 
Mazerolle
SM,
Ruiz
RC,
Casa
DJ,
et al
Evidence-based practice and the recognition and treatment of exertional heat stroke, part I: a perspective from the athletic training educator
.
J Athl Train
.
2011
;
46
(5)
:
523
532
.
35. 
Scarneo-Miller
SE,
Kerr
ZY,
Adams
WM,
Belval
LN,
Casa
DJ.
Influence of state-level emergency action plan policy requirements on secondary school adoption
.
J Athl Train
.
2020
;
55
(10)
:
1062
1069
.
36. 
Dunbar-Gaynor
M,
Zimmerman
EP,
Liberi
V.
An examination of policy and procedure practices of secondary school athletic trainers
.
Int J Allied Health Sci Pract
.
2020
;
18
(2)
:
1
7
.

Appendix. Questionnaire

  • 1.

    Do you currently work in a secondary school?

    • Yes

    • No

  • 2.

    What is your current role or position at your high school?

    • Principal/Headmaster

    • Athletic Director

    • Head Coach

    • Assistant Coach

    • Nurse

    • Athletic Trainer

    • Parent of a Student- Athlete

    • Student-Athlete

General Information

  • 3.

    What is your school's five digit zip code?

  • 4.

    Age: _________

  • 5.

    What type of school do you work at?

    • Public

    • Private

    • Charter

    • Magnet

  • 6.

    How many students are enrolled at your high school? ________

  • 7.

    How many years have you served in your role at your school?

    • Less than 1 year

    • 1-5 years

    • 6-10 years

    • 11-15 years

    • 15 or more years

  • 8.

    How many years have you worked in your profession?

    • Less than 1 year

    • 1-5 years

    • 6-10 years

    • 11-15 years

    • 15 or more years

  • 9.

    For each component, please select the category that best describes your high school's current written policies and procedures. My school has policies and procedures on…

  • 10.

    Which, if any, of the following do you foresee OR which, if any, of the following did you encounter as barriers to your school's ability to implement the requirement of a cold water immersion tub on-site, set up for the treatment of exertional heat stroke? Check all that apply.

    • Resistance or apprehension from head coaches to modify practices

    • Resistance or apprehension from parents or legal guardians to modify practices

    • Financial limitations

    • My school does not have the time to train the coaches and school personnel on how to implement this policy

    • My school does not have the time to educate the parents or legal guardians on the importance of this policy

    • My school would need more information, assistance, etc. in order to implement all of the heat modification guidelines

    • My school does not have an AT

    • My school's AT is not full-time

    • It's not hot enough where I live, we have difficulty seeing the need for this

    • We are located in a location that makes it difficult for EMS to get to us

    • Liability

    • We don't think this policy is as important as other topics

    • No barriers encountered

    • Other: ____________________________________

  • 11.

    Which, if any, of the following do you foresee OR which, if any of the following did you encounter as barriers to your school's ability to implement utilization of rectal temperature for diagnosis and treatment of exertional heat stroke? Check all that apply.

    • Resistance or apprehension from coaches

    • Resistance or apprehension from parents or legal guardians

    • Financial limitations

    • My school does not have the time to educate the coaches and school personnel on the reason for using this

    • My school does not have the time to educate the parents or legal guardians on the reason for using this

    • My school would need more information, assistance, etc. in order to implement this

    • My school does not have an AT

    • My school's AT is not full-time

    • It's not hot enough where I live, we have difficulty seeing the need for this

    • We live in a location that makes it difficult for EMS to get to us

    • Liability for using it

    • I am not comfortable with using a rectal thermometer

    • I am not sure how to use a rectal thermometer

    • I am not sure when I would use a rectal thermometer

    • We don't think this policy is as important as others

    • No barriers encountered

    • Other: ____________________________________

  • 12.

    Select all of the following that you feel would make it easier OR did make it easier to adopt a policy to use cold water immersion to treat exertional heat stroke.

    • Having medical professional(s) (i.e. athletic trainer) at the school

    • Support from someone in an authoritative position (coach, nurse, school leader, etc.)

    • Seeing how other schools/programs facilitate implementing this policy

    • Nothing would make it easier

    • State mandate from the high school athletics association

    • State legislation for mandate for policy

    • School stakeholders believing sport safety is important and buying into these policies

    • Education on how to perform the technique

    • Training

    • Model policy that can be adopted

    • Other: ____________________________________

  • 13.

    Select all of the following that you feel would make it easier OR did make it easier to adopt a policy to use rectal temperature to diagnose exertional heat stroke.

    • Having medical professional(s) (i.e. athletic trainer) at the school

    • Support from someone in an authoritative position (coach, nurse, school leader, etc.)

    • Seeing how other schools/programs facilitate implementing this policy

    • Nothing would make it easier

    • State mandate from the high school athletics association

    • State legislation for mandate for policy

    • School stakeholders believing sport safety is important and buying into these policies

    • Education on how to perform the technique

    • Training

    • Model policy that can be adopted

    • Nothing would make it easier, I will not take a rectal temperature

    • Other: ____________________________________