© Sports Medicine Concepts, Inc. All Rights Reserved.
Standing Orders and Operating Protocol
Dr. Lynette Carlson, DHS, ACT, Contributing author
Athletic trainers render professional services under the direction of, and in collaboration with, an overseeing physician. Current legal and best practice standards call for athletic trainers to have standing orders and operating protocols, or an established written set of guidelines, rules, and regulations that define an agreement between the overseeing physician and athletic trainer, and under which the athletic trainer provides services within their training, state statutes, rule, and regulations. Some states provide a definition of standing orders and provide clear examples of written protocol, but it is ultimately the responsibility of all ATs to know their state’s practice act and to abide by them.1,2,3 Although standing orders clearly define a relationship between an overseeing physician and athletic trainer, standing orders should not be an impediment in allowing AT’s to practice to the full scope of their practice act.4
Best practice standing orders include specific language pertaining to all potential scenarios ATs treat under their state’s scope of practice and legal authority. This includes, but is not limited to, acute, subacute, and chronic injury and illnesses and any potentially catastrophic injury. Standing orders do not take the place of Emergency Action Plans (EAPs) or individual management plans, but are in concert with them. As with EAPs, standing orders should be written to allow for clinical decision making, defined as a contextual, continuous and evolving process, where data are gathered, interpreted and evaluated in order to select an evidence-based choice of action.5 Language that is too precise can create a potential malpractice problem. Therefore, standing orders should be based on a minimum safe level and not the maximum level aimed at ideal care.6 Like other written medical protocols and procedures standing orders should be updated and reviewed annually to ensure they are evidence-based and represent current legal and best practice standards.
The Standing Orders Operating Protocol is available under the Compliance and Reports and Forms section of the TeamEMSoft® Hub Page7,8. Evidence Category C
HIPPA and FERPA Considerations
The “Administrative Simplification” clause found under Title II Part C of the Health Insurance Portability and Accountability Act (HIPPA) is commonly referred to as the Privacy Rule. The intent of this provision was to establish a set of national standards for the protection of personal health information. The extent to which this clause applies to sports medicine departments is an area of ongoing debate. The debate centers on HIPPAs operational definition of a “covered” entity. Under HIPPA “covered” entities must take certain steps to guard against improper disclosure of personal health information, including taking steps to ensure that “non-covered” entities that they routinely deal with will safeguard shared private health information. The operational definition of a HIPPA “covered: entity seems to center on transmission of health information in the course of securing payment for services, which would seem to exclude most sports medicine departments9,10.
Sports medicine departments that deal with high school athletes also have the Family Educational Rights and Privacy Act, or FERPA, to contend with. FERPA governs access to student records, and in many cases supersedes HIPPA. FERPA protects against the transmission or dissemination of any personally identifiable student information, including any and all medical records. It is generally agreed upon the FERPA permits sports medicine department personnel to discuss any student-athlete medical information with those who are integral in the on-going care of the student-athlete.
Although it can be argued that FERPA provisions provide for the ability of sports medicine department to discuss a student-athlete’s private medical records with appropriate personnel, and that sports medicine departments are not HIPPA “covered” entities- and are thus able to transmit personal health information accordingly- it can also be argued to the contrary. If it were determined that a sports medicine department was in violation of HIPPA or FERPA, the consequences would mostly involve the Department of Health and Human Services (HHS) seeking voluntary compliance, but there are provisions for civil and criminal penalties. If found in violation of HIPPA or FERPA regulations, a sports medicine department would most likely have to develop a consent and authorization form that specifically grants the department permission to share personal information for specific reasons.
Since there is such controversy and variation in interpretation of HIPPA and FERPA, it is suggested that sports medicine departments opt to develop a signed consent and authorization form to ensure they are in compliance rather than risk the potential administrative, civil, and criminal penalties incurred for violating FERPA and HIPPA. Evidence Category: C
Sports medicine departments opting for a policy including a signed consent and authorization should ensure their forms are in compliance with all HIPPA and FERPA requirements. Authorization forms should contain a statement that clearly identifies whom the information will be shared with and for how long the information will be shared. The authorization form should also:
- have an expiration date;
- specify who may disclose information;
- specify what information may be disclosed;
- specify who may receive information;
- explain that the athlete cannot be denied care for not signing the form;
- explain that if information is disclosed to a non-covered entity, the information may no longer be protected;
- explain that an athlete has the right to revoke authorization at any time.11,12
Click here to view the TeamEMSoft® sample HIPPA/FERPA Authorization form. This document is also available under the Compliance and Reports and Forms section of your TeamEMSoft® Hub Page7,8. Evidence Category C
Execution of the emergency action plan is an on-going endeavor. The process of executing the EAP begins with development of venue specific EAP summaries that provide essential information required to respond to a potential emergency. Venue specific EAP summary posting placards are permanently placed conspicuously throughout all venues. Preparation and readiness for specific contests and events begins in the days leading up to the event. In the days prior to an event the medical team will share the venue specific EAP summary with all appropriate visiting team medical personnel. The venue specific EAP summary is shared to provide visiting team medical personnel with essential information regarding assets and procedures to aid in caring for a critically injured or ill athlete during their visit. Sharing the venue specific EAP summary also allows medical personnel to identify any athletes, coaches, or officials with medical conditions that may predispose them to onset of specific conditions or illnesses. Identifying potential predisposing medical conditions provides medical teams opportunity to review conditional protocols. Conditional protocols are procedures develop for specific medical conditions to prevent the onset of conditions or illnesses and to ensure that medical teams are properly prepared to manage at risk individuals.
The days leading up to a specific event will be used to ensure that all medical personnel are prepared by:
- Identifying at risk individuals;
- Checking emergency kits contents to ensure all necessary equipment is present, is operational, is not expired, and is deployment ready;
- Seal emergency kits with Ready Tags™;
- Developing the venue/event surveillance plan;
- Ensuring that posted placards and venue specific EAP summaries are up to date, accurate, and properly placed;
- Ensure that the venue specific EAP summary has been shared with all appropriate medical personnel.
A pre-event medical meeting will be conducted prior to the start of any event. Should the EAP be activated during a contest a medical team or other representative will communicate all necessary information to the injured/ill individual’s family and provide them with information about the receiving facility to which their family member was transported as soon as it is possible to do so. Following conclusion of an event the medical team will conduct a complete sentinel event review.
Venue Specific EAP Summaries
Venue specific EAP summaries include only the vital information required for medical personnel to conduct a medical time out and to communicate during management of a critically injured/ill individual. The EAP summary does not list all the medical personnel or assets that may be available to a team as this would result in a lengthy document that is too difficult to efficient navigate in an emergency. Rather, the EAP summary is a simple document that provides for quick access to information that facilitates communication and emergency response. The EAP summary includes the following:
- A map to highlight EMS access routes, rendezvous locations, nearest intersections, and access points;
- Surveillance plan;
- Communication signals and instructions for activating the EAP;
- Emergency response equipment and field locations;
- Receiving facilities, including directions and phone numbers;
- Emergency contacts, their field location and hotline phone numbers;
- Overview of procedural and protocol tendencies
Surveillance Planning and Proper Medical Coverage
The EAP Summary will provide details of the venue specific zone-based surveillance plan.
A venue-specific Emergency Action Plan Summary Placard shall be posted conspicuously throughout each venue. A copy of the venue-specific Emergency Action Plan Summary Placard shall also be posted in all visiting team locker rooms. Evidence Category: C
After proper care and management of a critically injured/ill individual is underway and it is appropriate to do so a medical team representative or other designated team official will contact the individual’s representative and family members to communicate important information regarding the individual’s condition, the receiving facility to which they were transported, and any other critical information.
Review of Sentinel Events
Within the days following an event requiring activation of the EAP the medical team will conduct a sentinel event review. This review will include documented discussion regarding the reasons for activating the EAP, the outcome of the event, and any recommended EAP changes. More about the sentinel event review process is covered in the Documentation section.
Annual rehearsal and Training
To ensure cognitive retention and effective choreography of multi-disciplined psychomotor skills this EAP will be reviewed and practiced a total of 15 hours annually. This will be accomplished via formal preseason EAP training session that emphasize cognitive review, live simulated testing, and performance bench-marking.14-26. This EAP session will be overseen by an appropriate independent expert who is qualified to certify that the EAP meets best practice standards and that all personnel demonstrate necessary critical care skills. A follow-up EAP review will be conducted by the medical staff to ensure an appropriate level of preparedness is maintained at all venues.
Aquatic facilities used during competition, rehabilitation, and athlete conditioning will account for a minimum of 4 hours of in-service training per month for all members of the lifeguard corps and appropriate medical team personnel. This training will address issues such as surveillance and recognition, water and land rescue skills, specific water rescue and emergency response drills, decision-making protocols, facility rules, regulations, emergency action planning, records and reports, and appropriate physical conditioning.29 .
Training will be conducted at all venues and include venue specific training for all appropriate members of the medical team, emergency medical services responding to the venue, and receiving facilities. Evidence Category: A