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Sports Medicine Team Should Call ‘Time-out’ Before Start of Events

By Lawrence Lemak, M.D., and Ron Courson, ATC, PT NREMT-I, CSCS on July 28, 2014 hst Print

“Time-out”
is a common term used in athletics as well as the field of medicine. In athletics, coaches and athletes call time-out to stop play in their sport as a strategy to gather the team together and discuss game strategies or call a play. In the field of medicine, time-out is utilized prior to every surgical procedure. Instituted as a regulation by the Joint Commission (formerly JCAHO) in 2003, “time-out” mandates that immediately prior to initiating a surgical procedure, everyone in the operating room must stop to conduct a final assessment that the correct patient, site and procedure are identified.

Described in the JCAHO Hospital 2012 National Patient Safety Goals, a time-out should be conducted in the operating room/procedure room before the procedure/incision. The time-out, composed of the entire operative team, involves active communication and should be briefly documented, such as in a checklist (organization should determine the type and amount of documentation), and should include correct patient identity, correct side and site, and agreement on the procedure to be done.

The hospital/organization, in conjunction with the hospital staff, may create processes that are not specifically addressed in the “time-out” to establish a standardized protocol for patient safety. There should be processes and systems in place for reconciling differences in staff responses during the “time-out.”

We propose that athletic health-care providers adopt a similar system, calling a time-out before the start of each athletic event, whether a practice or a competition, in order to review a pre-athletic event checklist regarding emergency preparation and the emergency action plan.

Emergency situations may arise at anytime during athletic events. Expedient action must be taken in order to provide the best possible care to athletes in cases of emergency and/or life-threatening conditions.

Development and implementation of an emergency action plan (EAP) helps ensure the best care will be provided. Although most injuries in athletics are relatively minor, life- or limb-threatening injuries are unpredictable and can occur without warning. Due to the relatively low incidence rate of catastrophic injuries, sports medicine professionals may develop a false sense of security.

Sports medicine coverage for an athletic event may vary widely, based on such factors as the sport or activity, the setting and the type of training or competition. The first responder to an athletic emergency situation is typically a member of the sports medicine staff, usually a certified athletic trainer. Other athletic health-care providers responding may include emergency medical technicians and physicians. With multiple health-care providers on the scene, proper communication is critical in order to have an appropriate, coordinated emergency response and outcome.

Emphasis should be placed on having an ambulance on-site at high-risk sporting events. Ambulances may additionally be coordinated on-site for other special events/sports, such as tournaments or championships. In the event an ambulance is on-site, it should have a designated location with rapid access to the site and a cleared route for entering/exiting venue.

Dr. Atul Gawande is a general surgeon at the Brigham and Women’s Hospital in Boston, Massachusetts, and an associate professor at Harvard Medical School and the Harvard School of Public Health. In his New York Times Bestseller book, “The Checklist Manifesto,” he describes how the simple idea of the checklist can bring about striking improvements in a variety of professions – from airline pilots to surgeons. A simple surgical checklist from the World Health Organization has been adopted in more than 20 countries as a standard of care and has saved countless lives.

In an effort to create the safest playing environment, Bert Mandelbaum, M.D., has implemented the “time-out” program in Major League Soccer. MLS teams will utilize the “time-out” program as a league-wide protocol to beta test the effectiveness and acceptance of this unique new concept.

By developing and implementing an emergency plan and incorporating the “time-out” principle and use of a simple EAP checklist, athletic health-care providers can help ensure that the athlete will have the best care provided when an emergency situation does arise.

“EAP Time-Out” Pre-Athletic Event Checklist

• Physically assemble athletic health-care providers before start of each practice or competition to review EAP.
• Who is present (i.e., ATC, EMT, M.D.)? What are their roles and location?
• How will communication occur (i.e., voice commands, radio, hand signals)? What is the primary type of communication? What is the secondary or back-up plan for communication?
• Is ambulance present? If yes, where is it physically located? Does it have a clear route for entrance/exit? Is it a dedicated ambulance unit or on stand-by? If no, what is the mechanism for calling an ambulance? What is the planned route for entrance/exit?
• What emergency equipment is present? Where is it located? Has it been checked to ensure it is in proper working order and fully ready for use?
• In the event of emergency transport, what is the designated hospital? Is the hospital selection based upon most appropriate facility for the injury/illness?
• Are there any issues that could potentially impact the emergency action plan (i.e., construction, weather, crowd flow)? 

References
1. Andersen J, Courson RW, Kleiner DM, McLoda TA. National Athletic Trainers’ Association position statement: emergency planning in athletics. J Athl Train. 2002;37(1):99–104.
2. Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation. 2009;120(6):518–525.
3. Drezner JA, Courson RW, Roberts WO, Mosesso VN Jr, Link MS, Maron BJ. Inter-association Task Force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. J Athl Train. 2007; 42(1):143–158.
4. Gowanda A. The Checklist Manifesto. Metropolitan Books. New York, NY. 2009.
5. http://www.jointcommission.org/standards_information/up.aspx
6. Swartz EE, Boden BP, Courson RW, et al. National Athletic Trainers’ Association position statement: acute management of the cervical spine-injured athlete. J Athl Train. 2009;44(3):306–331.