Recommendations on Emergency Preparedness and Management of SCA in High School and College Athletic Programs: Interview with Jon

Describe who participated in the Inter-Association Task Force. The Inter-Association Task Force was made up of representatives from 15 different national medical societies. Also participating in the task force were some invited participants, such as athletic trainers and physicians with specific expertise in sudden cardiac arrest in athletes. What are the four links in the American Heart Association's (AHA) chain of survival? The four links encouraged in the chain of survival are early activation of the emergency medical system, early CPR, early defibrillation, and rapid transition to advanced cardiac life support. Please also describe the essential elements of an emergency action plan. How often should the EAP be reviewed and practiced? An EAP should be developed in advance of a potential emergency; it is meant to prepare a school or institution in case of a cardiac emergency. The elements of the EAP include establishing a communication system, identifying who the response team will be, acquiring the necessary equipment to handle a cardiac emergency (this includes access to early defibrillation or implementation of an on-site AED program), and choosing the emergency transportation route both for incoming and outgoing emergency response vehicles. It is very important to practice and review an emergency response plan with all the potential first responders at a minimum on a yearly basis. Can you give us an example of what the recommended step-by-step protocol should be for when there is a witnessed collapse of an athlete? The first step would be to recognize that the athlete may be in cardiac arrest I believe this has been one of the main obstacles in properly managing athletes who collapse on the athletic field. The next steps would be activating your emergency response system, calling for someone to retrieve the school's AED (if one is available), followed by assessing for respiration and starting CPR. Most importantly, apply and turn on the AED as soon as it is available for any collapsed and unresponsive athlete to avoid delays in defibrillation and treatment of cardiac arrest. SCA in athletes can be mistaken for many other causes of collapse. What are some special circumstances in which the collapsed athlete may not be in SCA? Up to 30 percent of individuals with a cardiac arrest may have some seizure-like activity in which their extremities are moving back and forth for at least a brief moment after the attack. Therefore, I think cardiac arrest could very easily be mistaken for a seizure disorder. Other causes of collapse in an athlete could be simply fatigue, exhaustion, heat exhaustion or heat stroke, an arrhythmia that has caused syncope or collapse but not necessarily cardiac arrest, or head/neck trauma. There is definitely a variety of causes that could be to blame. However, I believe that sudden cardiac arrest occurs infrequently enough that when a responder or rescuer assesses a collapsed and non-responsive athlete, SCA might not be the first thing they think of, but it should be. How soon should the first responder arrive from the time of collapse to the first shock? As early as possible! In our consensus statement, the recommendation is to reach the athlete between collapse and first shock within less than 3 - 5 minutes. If you look at the standards used in other public access defibrillation programs, specifically in airports and casinos, survival rates have dramatically improved by equipping responders on-site with defibrillators they use a standard response time that is less than three minutes. Other studies have recommended less than five minutes, although the general consensus is that if your emergency medical system cannot be there within five minutes, you should have an on-site AED. However, once you have an on-site AED program, your target response time should be less than three minutes. What are the chances that these young athletes will experience SCA on the playing field? Traditional estimates of cardiac arrest in college or high school age athletes have been approximately 1 in 100,000 to 1 in 200,000 athletes per year, but these estimates really underrepresent the magnitude of the problem. More recent research suggests that there is probably a sudden cardiac arrest episode in organized athletics every 3 - 4 days in the United States. In fact, the calculations that I've done project SCA incidences to more like 1 in 50,000 young athletes per year. Describe what roadblocks one might experience when implementing an EAP plan. The biggest obstacle by far is cost. In the collegiate setting, the resources are much greater, so colleges tend to be better prepared than high schools at this point. Most colleges already have AEDs in place and are refining their existing emergency action plans. However, high schools have more limited resources that are already spread thinly between student education and safety measures on school campuses. Thus, the main obstacle right now is getting funding for schools not only to purchase the AED but to have some funding available to devote to an emergency plan, train their responders, and have some amount of maintenance upkeep of their plan and their AED. There are some other obstacles such as legal or liability concerns, as well as the fear of not knowing how to use the AED, and uncertainty about whether or not it is cost effective. However, the biggest roadblock for high schools is cost. Where should AEDs be placed? Also, how can we more effectively train bystanders and first responders? In terms of placement, each school needs to do their own site assessment about where the AED can be centrally located in order to reach as many places within the target goal of 3 - 5 minutes. If an athlete did collapse, schools need to make sure they also have a communication system in place so if there is someone who is near the AED, they can bring it to the site, rather than someone on-site running to get the AED and then having to run back, doubling the distance that needs to be traveled. Some schools may require more than one AED to be able to reach that target goal for all of their athletic venues. In particular, if a school's athletic venues are far away from their central campus, they may need more than one AED. Therefore, when performing their own site assessment, each school should collaborate with their local emergency medical service to determine what location(s) would be ideal to place their AED(s). In terms of getting more people trained in CPR and AED use, there are several models you can look at. The simplest model is to identify who your likely responders are, in relation to athletics in high schools and colleges those likely responders are the coaches, officials, certified athletic trainers, and other public safety personnel on school grounds such as the school nurse, team physician or administrators. This would be the minimum. However, we especially need to educate coaches on how to recognize sudden cardiac arrest, give them the training to feel comfortable in CPR and AED use, and involve them in the practice and rehearsal of the EAP so they understand where the AED is and what steps should be taken if an athlete does collapse. The teammates are also individuals who will very likely be exercising with someone else and witness a collapse. In the best scenario, you would train the specific individuals who are part of the response team to also take part in health education for students at the school. Therefore, every student who completes a health education class at some point before they graduate will be trained in CPR and AED use. Hopefully, we will produce a population of people in the United States who have CPR and AED training because they learned it in school. It isn't a difficult system to implement it has already been done in some places and has been very successful you just have to train teachers to be CPR instructors. Once they are, they can train their students. This will empower them to understand the importance of the AED device on their campus. Are AEDs currently required in schools in any of the 50 states? That is really a moving target. I believe there is between 3 - 5 states right now that have legislative mandates to have an AED in schools. However, it varies I believe one state requires the AED to be on school campus, another state requires an AED within the school district to be defined later, and yet another state requires them only at sporting events. Therefore, it does vary from state to state. Many states, including the state of Washington where I am located, have pending legislation that would require every public school to have an AED on school grounds. I think what is also important to comment on is that it is not just about obtaining an AED a lot of schools are already getting an AED through use of donations, but they are putting the AED on campus without a comprehensive emergency action plan to go with it. By doing this, you're only tackling half the battle. Too often there is an instance where a sudden cardiac arrest occurs on campus, yet no one knows where the AED is located, or the AED is locked up somewhere and is unaccessible at the time when they really need it. For example, it may be located inside a school building in a locked cabinet when a cardiac arrest is happening out on a football field. Thus, the EAP really needs to be well-planned out. Legislation that requires an AED in schools is terrific, but I believe legislation needs to also require an emergency action plan to go with it in order to make it a comprehensive system. How can a school begin implementing this EAP program? In the consensus statement we've included an emergency action plan checklist, which would be a simple place to start in terms of identifying the things you need to create an EAP on campus. Speaking with the medical advisory board in your school district or your state's interscholastic association is another resource. You may also want to do some research with local companies or discuss this with your local emergency medical service. However, the first step is realizing that you need to have this action plan in place, and going through the checklist to identify what your needs are. Again, I think funding is the biggest obstacle. Sometimes the money will come from public mandates where there is legislation, sometimes it will come from the school district, and sometimes it will come from donations. There are models of public/private partnerships where local businesses will advertise on campus in exchange for paying for the AED program. So although cost can be an obstacle, it is certainly surmountable. Has anything like this EAP plan been done before? Will you be doing any more work with this task force? I believe our consensus statement was the first to tie in both the emergency planning and management of SCA, oriented towards young athletes who might have a cardiac arrest. Our statement is also in agreement with previous guidelines; for example, the National Athletic Trainers' Association put out an excellent position statement on emergency planning that our statement is very much in agreement with. In addition, the AHA had previously released recommendations for emergency response planning in schools as well as guidelines on CPR and emergency cardiovascular care, and our task force looked closely at these recommendations and guidelines to make sure we were in agreement. It was our goal to put all this information in one document to help an athletic program prepare for and properly respond to a cardiac emergency in a young athlete. In terms of further work, now that this consensus statement has been published, our task force will work to get the recommendations more widely known so we can move forward in improving emergency planning in high schools.