pdf. Accessed April 11, 2019. 10. Sickle cell solubility test, Division I NCAA Bylaw, § (2010).

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CONTENTSJuly 2019NCAA and SSI are trademarks of the National Collegiate Athletic Association. Introduction 1Background 2Recommendation 1 | Sportsmanship 5Recommendation 2 | Protective Equipment .6Recommendation 3 | Acclimatization and Conditioning 7Recommendation 4 | Emergency Action Plan .9Recommendation 5 | Responsibilities of Athletics Personnel ..10Recommendation 6 | Education and Training 11Interassociation Recommendations | Checklist 12References ..16Appendix A | 2016 Safety in College Football Summit Agenda .18Appendix B | 2016 Safety in College Football Summit Participants 19Appendix C | Endorsing Organizations ..21

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1INTRODUCTIONThe second Safety in College Football Summit resulted in interassociation consensus recommendations for three paramount safety issues in collegiate athletics: 1. Independent medical care for collegiate athletes. 2. Diagnosis and management of sport-related concussion. 3. Year-round football practice contact for collegiate athletes. This document, the fourth arising from the 2016 event, addresses the prevention of catastrophic injury, including traumatic and nontraumatic death, in collegiate athletes. The ˜nal recommendations in this document are the result of presentations and discussions on key items that occurred at the summit. After those presentations and discussions, endorsing organization representatives agreed on 18 draft foundational statements (available upon request) that became the basis for this consensus paper, which has been subsequently reviewed by relevant stakeholders and endorsing organizations. This is the ˜nal endorsed document for preventing catastrophic injury and death in collegiate athletes. This document is divided into the following components:BACKGROUNDThis section provides an overview of catastrophic injury and death in collegiate athletes. INTERASSOCIATION RECOMMENDATIONS: PREVENTING CATASTROPHIC INJURY AND DEATH IN COLLEGIATE ATHLETES This section provides the ˜nal recommendations of the medical organizations for preventing catastrophic injuries in collegiate athletes. INTERASSOCIATION RECOMMENDATIONS: CHECKLIST This section provides a checklist for each member school. The checklist will help the athletics health care administrator to ensure that policies are in place and followed, and are consistent with this document, Interas-sociation Recommendations: Preventing Catastrophic Injury and Death in Collegiate Athletes. REFERENCES This section provides the relevant references for this document. APPENDIXES This section lists the agenda, summit attendees and medical organizations that endorsed this document.

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2BACKGROUNDData about catastrophic injuries and illnesses in col -legiate athletes began with intermittent accounts from print media, and more formally in 1931, through the American Football Coaches Association™s initiation of the Annual Survey of Football Injury Research. Since 1982, the National Center for Catastrophic Sport Injury Research at the University of North Carolina, Chapel Hill,1 has been the nation™s premier source of catastrophic injury and death related to participa -tion in organized sports at all levels of competition, including college. The NCCSIR monitors, collects and analyzes data on catastrophic injuries, illnesses and death and provides publicly available reports about football and other sports.1 In order to create enhanced national surveillance abilities for catastrophic injuries, illness and death, the NCCSIR has partnered with the Consortium for Cata -strophic Injury Monitoring in Sport. The consortium in -cludes the division on traumatic injury at the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center at the University of North Carolina, Chapel Hill; the division on exertional injury at the Korey Stringer Institute at the University of Connecticut; and the division on cardiac injury in sport at the University of Washington. 1 Working through the consortium, the NCCSIR has developed new methods of data collec-tion and analysis, including the use of a public-facing online reporting system. 2Researchers who study the epidemiology of cata -strophic injury and death in sport identify two mech -anisms by which these events occur. Traumatic cata-strophic injuries, also called direct injuries, are bodily injuries caused directly by participation in a sport activity. 1 An example of a traumatic catastrophic injury is a spinal cord injury caused by tackling in the sport of football. The three leading causes of death from traumatic injury are traumatic brain injuries, spinal cord injuries and internal organ injuries. 1 Nontraumatic cat-astrophic injuries, also known as indirect or exertional injuries, are the firesult of exertion while participating in a sport activity or by a complication that was second-ary to a non-fatal injury.fl 1 An example of a nontrau-matic catastrophic injury is sudden cardiac arrest in an athlete occurring during a basketball practice. The two leading causes of death from nontraumatic injury are sudden cardiac death and exertional injuries. 1,3

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3Enhancing a culture of safety in college sports in gen -eral, and college football in particular, is foundational to reducing the occurrence of catastrophic injury and death and the basis for bringing college athletics stakeholders to the ˜rst Safety in College Football Summit in 2014, and then reconvening in 2016. The goal of this and any sport safety initiative is protecting the life and the long-term well-being of all athletes. Catastrophic Injury Patterns Since 1982, the ˜rst year for which catastrophic injury/illness data were available across all collegiate sports (i.e., NCAA; National Association of Intercol -legiate Athletics; National Junior College Athletic Association), there have been 487 catastrophic inju -ries or illnesses. Of these, 297 (61%) were traumatic events and 190 (39%) were nontraumatic events. 1 In 2016-17, the last year for which data across all col -legiate sports are available, 19 catastrophic events occurred, ˜ve of which were fatal. 1Overall, football has the highest number of both traumatic and nontraumatic catastrophic injuries of any collegiate sport. Since 1931, the ˜rst year in which football-speci˜c fatality data were collected, there have been 94 traumatic fatalities in college football and 127 nontraumatic fatalities.4 More recently, since 1960 there have been 51 traumatic fatalities and 99 nontrau -matic in football.4 After adjusting for the total number of participating athletes, football is joined by male gymnastics, female skiing, male ice hockey and female gymnastics for the highest rates of traumatic cata-strophic injury. 1 Traumatic events in football had fallen every decade from 1960 until 1994. That decline is as -sociated with rule modi˜cations based on research, 5,6 enhanced medical care and education. Since 1994, the number of traumatic injuries has varied, but at a level generally lower than those of the 1970s and 1980s.1 Since 1970, in both high school and college football, nontraumatic fatalities have outnumbered traumatic fatalities. Nontraumatic deaths in American football have remained relatively steady for more than ˜ve decades. Data from 2017 4 reveal the current decade will continue this unfortunate and often preventable trend of nontraumatic death that occurs largely in out-of-season or preseason workouts. From 2001 to 2017, the ratio of nontraumatic to traumatic death in collegiate football was 5:1 Š 35 nontraumatic deaths compared with seven traumatic fatalities. 4While rule modi˜cation has the potential to decrease nontraumatic deaths in certain situations (e.g., veri˜-cation of sickle cell trait decreasing exertional collapse associated with sickle cell trait in Division I football), the policy and procedures to prevent nontraumatic catastrophic death have not kept pace with strength and conditioning sessions and practice sessions that continue to be the setting for record rates of high school and college athlete deaths. For example, of the nine nontraumatic deaths of football players at all lev-els of the sport in 2017, six occurred during condition -ing sessions and one occurred during a strengthening session.1 For the 2015-16 academic year, six (15%) of the 40 nontraumatic catastrophic injuries and illnesses that occurred across all sports and all levels of com -petition took place during strength and conditioning sessions.1 This means that across all sports beside football, nontraumatic injuries are occurring in practice sessions overseen by sport coaches and not during strength and conditioning sessions. Policy DevelopmentsAvailable research provides insight into risk factors for catastrophic injury and has led to policy deci -sions meant to mitigate those risks. Established research demonstrates that NCAA Division I foot -ball athletes with sickle cell trait are at a higher risk of nontraumatic catastrophic events, including death.5,7,8 In response, the last decade has seen an increase in policy recommendations for the preven -tion of exertional collapse associated with sickle cell trait (ECAST) in collegiate sport. In 2007, the National Athletic Trainers™ Association released a consensus statement on sickle cell trait in the ath-lete.9 By 2013, all three NCAA divisions had adopted legislation requiring con˜rmation of student-athlete sickle cell trait status before participation. 10-12 This policy, in tandem with targeted on-site precautions, has resulted in a statistically signi˜cant decrease in the number of ECAST deaths in college athletes.13,14 Transition periods, de˜ned below, are often asso -ciated with poor acclimatization and ˜tness levels in athletes returning to activity. 15,16 These concerns have prompted several policy developments. In 2003, the NCAA implemented preseason acclimatization legislation for football.17,18 In the same year, NCAA Division I passed a bylaw19 speci˜c to Football Bowl Subdivision and Football Championship Subdivision football that requires any strength and conditioning

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4professional who conducts voluntary offseason weight training or conditioning activities to be certi˜ed in ˜rst aid and cardiopulmonary resuscitation and to be ac -companied by a member of the sports medicine staff who has unchallengeable authority to cancel or modify the workout for health and safety reasons. NCAA Division˚II passed similar legislation one year later. 20 In Division˚I, the unchallengeable authority component of this legislation was extended to all sports other than football in situations when a member of the sports medicine staff is present at a workout. In 2012, NATA released interassociation best practices on the pre -vention of sudden death in collegiate athletes during strength and conditioning drills. 15 As of 2016, all three NCAA divisions have legislation that requires strength and conditioning professionals to have a certi˜cation from either a nationally recognized strength and condi -tioning certi˜cation program 21,22 or from an accredited strength and conditioning certi˜cation program. 23However, despite these policy developments, cata -strophic injuries and fatalities continue to occur. In recent years, most of the fatalities are from nontrau -matic causes. These can be mitigated at the member school with appropriate strategies. Prevention Strategies Nontraumatic deaths can be mitigated locally through implementation of consensus- and science-based recommendations. Yet, the number of nontraumatic fatalities are twice those of traumatic fatalities. There have been 99 nontraumatic deaths in collegiate football compared to 51 traumatic deaths since 1960. Just as most of the fatal head injuries and catastroph -ic cervical spine injuries occurring from 1960 to 1975 can be directly related to the style of play in the sport of football during that time,24-26 nontraumatic, exer-tion-related death is directly related to the conduct and construct of workouts intended to prepare ath -letes to play sport.5,16,27,28 Whereas spearing is often the mechanism for traumatic catastrophic injury and death in football,25,26 intense, sustained exertion that is not sport-speci˜c and does not include appropriate work-to-rest ratios, coupled with modi˜cations for in -dividual risk and precautions, is too often the mecha -nism for exertion-related nontraumatic fatality. 5,9,16,27-29 Since 1970, traumatic deaths have undergone a steep and steady decline; nontraumatic deaths, however, have remained steady since 1960. The current era, from 2000 to present, is notable for the following: year-round training for football coupled with the highest incidence of nontraumatic sport-re -lated training deaths in football in recorded history. A proper combination of strategies to prevent the condition from arising in the ˜rst place; ensurance of optimal medical care delivery by key stakeholders on- site; and transparency and accountability in workouts should help to eliminate such nontraumatic deaths Š a major goal of this document.

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6RECOMMENDATION 2 | PROTECTIVE EQUIPMENT Protective equipment that is used in sport typically must be manufactured and maintained according to performance and safety standards promulgated by standards organizations such as the National Operating Committee on Standards for Athletic Equipment34,35 and ASTM International. 36 When sport playing rules require equipment to comply with existing standards, the legality of the equipment is dependent on compliance, certi˜cation or both with existing standards. For example, current playing rules in the sport of football require that helmets be manufactured and maintained according to stan -dards established by NOCSAE. These standards have been demonstrated to reduce the occurrence of catastrophic brain injury. 37 In some cases, as with the helmet in the sport of football, equipment must be maintained through a reconditioning process. Where this responsibility exists, member institutions must remain vigilant about ensuring necessary mainte -nance to ensure the continued safety and legality of protective equipment. The following should be implemented across all sports: Every member school should establish policy to ensure annual certi˜cation, recerti˜cation and compliance, as appropriate, with all protective equipment standards.

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7RECOMMENDATION 3 | ACCLIMATIZATION AND CONDITIONINGMany nontraumatic deaths take place during the ˜rst week of activity of a transition period in training.15 Giv-en this fact, it is imperative to recognize the vulnerabil -ity during these periods and to ensure that both proper exercise and heat acclimatization are implemented. Transition periods hold particular risk, but absent ad -herence to established standards, best practices and precautions, collegiate athletes are at risk at all points in the offseason regimen. For example, February and July typically are not transition times, yet from 2000 to 2017, they are the deadliest months of winter and summer training in collegiate football.28 Acclimatization and physiologic progression with a basis of exercise science and sport speci˜city are the cornerstones of safe conditioning and physical activity. It takes approxi -mately seven to 10 days for the body to acclimatize to the physiologic and environmental stresses placed upon it at the start of a conditioning or practice period, especially during periods of warm or hot weather. 15,38,39 Acclimatization, especially heat acclimatization, can occur only through repeated exposure to a hot envi -ronment 40 while progressively increasing the volume and intensity of physical activity. 41 Unfortunately, perceived time pressures by coaches coupled with the culture of certain sports that excesses in training make athletes tough, disciplined and accountable contribute to a tendency to overload athletes during transition periods.15,42A minimum expectation is that all strength and conditioning sessions, regardless of when in the year they occur, should be evidence- or consensus-based; sport-speci˜c; intentionally administered; appropriate -ly monitored, regardless of the phase of training; and not punitive in nature. For acclimatization and conditioning, the following direction should be considered for all sports and by any individual responsible for the planning and/or implementation of training and conditioning sessions, whether that be a strength and conditioning profes -sional or a sport coach:1. Training and conditioning sessions should be introduced intentionally, gradually and progressively to encourage proper exercise acclimatization and to minimize the risk of adverse effects on health. This is especially important during the ˜rst seven days of any new conditioning cycle, which should be considered a transition period. A lack of progression and sport-speci˜city in the volume, intensity, mode and duration of conditioning programs in transition periods has been noted as a primary factor in nontraumatic fatalities.16 Importantly, in this period of year-round sport, new conditioning cycles can occur several times throughout the year and are not limited to the beginning of a competitive season. During transition periods, athletes should be instructed to avoid additional volunteer sessions of physical activity (e.g., 7-on-7 drills, pickup games, drill work). Physical activity schedules during transition periods should be well prescribed, accounting for all sources of physical activity in which an athlete engages. Examples of transition periods for athletes include, but are not limited to: a. Individual transitions.(1) Athletes new to the program. (2) Returning after an injury or illness. (3) Any delayed participation relative to the team schedule.b. Team transitions. Ł Resumption of training after an academic break (e.g., winter, spring, summer breaks). 2. Training and conditioning sessions should be exercise-science based and physiologically representative of the sport and its performance components. Conditioning programs should begin with work-to-rest ratio intervals appropriate for the goals of the training session and that allow for proper recovery. 3. Collegiate athletes are especially vulnerable to exertional injuries during the ˜rst four days of transition periods, and the data support that modi˜cations in these periods can greatly decrease the risk of catastrophic events. 14 During this time, training and conditioning sessions should be appropriately calibrated and include

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8limitations on total volume and intensity of activity. This may be accomplished in several ways. For example, holding only one training and conditioning session per day during the transition period may be effective for limiting the volume of physical activity. a. Properly training during transition periods also should greatly reduce or eliminate rhabdo -myolysis, which is largely preventable. Since 2007, 57 NCAA collegiate athletes have been reported as suffering from exertional rhabdo -myolysis in nine team outbreaks represent -ing eight different institutions, with 51 of the af˛icted athletes requiring hospitalization. 43 Novel overexertion, or exertion caused by new activities or at unaccustomed volume or intensity, is the most common cause of exer -tional rhabdomyolysis and is characterized as too much, too soon and too fast in a workout regimen. 14 Team outbreaks of exertional rhab -domyolysis in NCAA athletes have similarities of irrationally intense workouts designed and conducted by coaches and/or strength and conditioning professionals. 43b. When phasing in activity during transition pe-riods, athletics staff members should consider the following:(1) Days/week.(2) Body part.(3) Activity/exercise. (4) Sets/repetitions/distance. (5) Load (percent of one-repetition maximum, i.e., 1RM).(6) Work-rest ratio. (7) Modi˜cations: position; individual; return from injury; environment. 4. All training and conditioning sessions should be documented. In addition, all training and conditioning sessions should: a. Be approved by a credentialed strength and conditioning professional, or by the head sport coach at institutions that do not employ strength and conditioning professionals. b. Address exercise volume, intensity, mode and duration.c. Ensure the location of the training and con -ditioning session is identi˜ed in the plan to accommodate venue-speci˜c emergency action planning.d. Be reproducible upon request and be shared with the primary athletics health care providers (team physician and athletic trainer) before the session in which they are to be used. e. Be modi˜ed in response to hazardous environ -mental conditions, scheduling considerations, etc. The amended workout plan should main-tain the above principles.5. A disciplinary system should be developed and applied to strength and conditioning professionals and sport coaches who fail to follow these recommendations. Such penalties could include suspension and/or termination by the member school. Additionally, failure to follow the recommendations could be a reportable offense by member schools to the NCAA.

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9RECOMMENDATION 4 | EMERGENCY ACTION PLAN There is broad agreement that the most effective way to prevent catastrophic fatalities and manage nonfatal catastrophic events is through a sound and well-rehearsed emergency action plan. 13,15,29,44,45 Venue-speci˜c emergency action plans are a cor -nerstone of emergency readiness for campus and athletics health care providers. 38,46 Emergency action plans should be readily available to all members of the athletics community, located both centrally and at each venue at which athletics activities will occur and should be rehearsed with all relevant sports medicine and coaching staff at least once a year. The equipment necessary to execute the emergency action plan should be available to each venue at which athletics activities will occur. Emer -gency action plan rehearsal also should be incorpo -rated into new employee orientation. At a minimum, well-rehearsed and venue-speci˜c emergency action plans should be developed for the following nontraumatic catastrophic events: 1. Head and neck injury. 2. Cardiac arrest. 3. Heat illness and heat stroke. 4. Exertional rhabdomyolysis.5. Exertional collapse associated with sickle cell trait.6. Any exertional or nonexertional collapse.7. Asthma.8. Diabetic emergency. 9. Mental health emergency. In addition, well-rehearsed and venue-speci˜c emer -gency action plans should be consistent with the NCAA Concussion Safety Protocol Checklist. 47 This checklist was created in response to NCAA legisla -tion passed by the Division I conferences with auton -omy in January 2015,47 and subsequently by all three divisions. The checklist facilitates the development of a comprehensive and coordinated set of policies to guide institutions in the diagnosis and management of collegiate athlete concussions and in the eventual return to play and return to the classroom by those athletes. Concussion emergency action plans should be created for the following suspected conditions: 1. Concussion.2. Moderate or severe traumatic brain injury. 3. Cervical spine injuries.Special considerations:1. Cardiac emergencies Š Research has shown that in sudden cardiac arrest, the probability of survival drops by 7-10% for every minute of active arrest, whereas the probability of survival is 89% in prop -erly administered CPR and automated external de˜brillators.48,49 The location of AEDs should be documented and should re˛ect a strategy that ensures their arrival at the scene of a collapse with the target goal of collapse-to-shock in less than three minutes. 49 All AEDs should be checked at least monthly to assure they are fully charged. 49 2. Exertional heat illness emergencies Š Exertion -al heatstroke is a medical emergency that is characterized by extreme hyperthermia (>40.0 degrees C/>104 degrees F) and central nervous system dysfunction such as altered behavior or decreased consciousness. 41 To differentiate heatstroke from other acute medical events, primary athletics health care providers should be prepared to measure core body temperature using rectal thermometry. Rectal temperature has been demonstrated as the most accurate method for measuring body temperature, whereas other methods such as axillary, tympanic (aural), temporal, oral and skin measurements are not valid or reliable predictors of core temperature. 50 During warm weather events, but especially pre -season practices of fall season sports, resourc -es (e.g., equipment and personnel) should be readily available to ensure that full-body ice water immersion can be conducted in a timely manner. Full-body immersion in cold water (1.7 degrees C to 15.0 degrees C/35 degrees F to 59 degrees F) is the most effective immediate treatment of exertional heatstroke, with fatality rates close to zero if the body temperature is brought to less than 40.0 degrees C within 30 minutes after col -lapse.41 Full-body cold water immersion should be conducted before patient transport, and should be continued until the body has cooled to a temperature below 38.9 degrees C/102 degrees F. During cold water immersion, body temperature should be continuously monitored with rectal thermometry.

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