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Concussion Protocol

Pembroke High School Concussion Protocol


Pembroke High School is committed to the safety of all our student athletes. The purpose of this policy is to educate our parents, student-athletes, coaches, administrators, school personnel, and volunteers on the seriousness of head injuries, and more specifically concussions. This policy provides standardized procedures for any persons involved in the training, prevention, recognition, management, and return to play decisions regarding students who sustain head injuries while involved in extracurricular athletic activities, including but not limited to interscholastic sports and intramurals, to protect their health and safety.

 A team led by Mass General Brigham has developed these policies and procedures for Pembroke High School. These policies and procedures have been developed in the best interest of our student-athletes, in compliance with the Massachusetts Department of Public Health(MDPH) regulations (105 CMR 201.00: Head Injuries and Concussions in Extracurricular Athletic Activities), to ensure and maintain a safe environment for all.

Section 1: Implementation

Pembroke High School is responsible for overseeing the development, implementation and revision of policies, procedures and protocols regarding the school systems management of head injuries and concussions in all extracurricular athletic activities in accordance with 105 CMR 201.006(A)(1). The athletic director, coaches, certified athletic trainers and school nurses, whether employed directly by the school or through contracted means shall be responsible for all duties and responsibilities outlined in this policy and appendices.

Section 2: Annual Training

A.      Annual training is required per 105 CMR 201.007 regarding the prevention and recognition of sports-related head injury, and associated health risks including second impact syndrome.  Annual training must be completed by coaches, certified athletic trainers, volunteers, athletic director, parents of students and students who participate in athletics. Annual training resources can be found in appendix A
B.      Coaches, Certified Athletic Trainers, volunteers, athletic director, parents of students and students who have not demonstrated proof of completion of training will be contacted by email and telephone by athletic department personnel and not allowed to perform their duties until the requirement is met.
C.      Students shall not be allowed to participate in extracurricular activities unless both the student AND parent/guardian have completed concussion training.
D.     The Director of Athletics will be responsible for verifying completion of all training required and maintain accurate and up to date records.

Section 3: Pre-Participation Requirements

A.     Pre-Participation Physical Exam
  1. Documentation of a physical examination prior to a student’s participation in any extracurricular athletic or marching band activity must be completed annually, consistent with 105 CMR 200.100 (B)(3), Physical Examination of School Children, and will be placed in the student’s health record file as kept by the school nurse.
  2. Every student athlete must be separately and carefully examined by a duly licensed physician, nurse practitioner or physician assistant, prior to a student’s participation in competitive athletics, on an annual basis consistent with 105 CMR 200.100(B)(3).  The completed and signed copy of the medical clearance form should be mailed, faxed or hand-delivered to either the school nurse or athletic office.
  3. In compliance with MIAA policy, Pembroke High School accepts physical examinations completed within 13 months, to the date, to allow for insurance coverage.
  4. No student athlete will be allowed to participate in athletic activities until all forms, including annual physical examinations, are signed, and submitted.
B.      Pre-Participation Head Injury/Concussion Reporting Form for Extracurricular Activities
  1. Prior to each sports season students and parents must complete the Pre-participation Head Injury/Concussion Reporting Form for Extracurricular Activities or school-based equivalent, (herein after “Pre-Participation Form”), regarding an athlete’s history of head injuries and concussions. This form must be completed and signed by both the parent/guardian and the student in accordance with 105 CMR 201.006(A)(4). The form can be found in Appendix B (Can also be done on Family ID)

Section 4: Medical Documentation Review Process

A.      Information on pre-participation forms and documentation will be maintained by the school and reviewed by the school nurse, athletic trainer, and team physician as appropriate. Pertinent information will be relayed to the athlete’s coach on a need-to-know basis. Clearance to participate in extra-curricular activities will be made by the physician who has completed the students’ pre-participation physical. Based upon this review, and after consultation with the student’s physician, appropriate school athletic staff and the parent, the school may use a student’s history of head injury or concussion as a factor to determine whether to allow the student to participate in an extracurricular athletic activity, and whether to allow such participation under specific conditions or modifications.
B.      In the event of an in-season head injury, the Nurse, Athletic Trainer, and team physician as appropriate, will review the Report of Head Injury Form. Based on the information provided, the healthcare professionals will determine the best course of action for the student-athlete.

Section 5: Procedure for Identifying an Injury

A.      Any student who, in the judgment of the coach, athletic trainer or other appropriately trained individual, during a practice or competition, sustains a head injury or suspected concussion, or exhibits signs and symptoms of a concussion (Appendix C), or loses consciousness, even briefly, shall be removed from the practice or competition immediately and may not return to the practice or competition that day.  The student-athlete must be evaluated by an athletic trainer, a physician providing sideline coverage in support of an athletic trainer, or by a coach when an athletic trainer is not available. The evaluator shall use an assessment tool that is based on the most up-to-date medical information and recommendations and appropriate for their position. See Appendix D for appropriate evaluation material.
B.      In the event a student-athlete loses consciousness for any reason during competition or practice, the athletic trainer will start the Emergency Action Plan (EAP) by activating Emergency Medical Services (EMS); check circulation, airway and breathing (CAB’s); stabilize the cervical spine if indicated; and ensure proper transport of the injured student-athlete to the appropriate hospital via ambulance.
C.      If the athletic trainer is not available, the coach should immediately call EMS, check CABs, and not move the athlete until help arrives unless CPR is required.
D.     Any student who is removed from the competition or event and begins to develop signs and symptoms indicating a worsening brain injury will be transported to the hospital immediately in accordance with the EAP. Refer to Appendix C for Critical symptoms.
E.      Any student who is symptomatic but does not show signs or report symptoms indicating a worsening head injury is allowed to go home with his/her parent(s)/guardian(s) and is to follow up with the student’s Primary Care Physician for further evaluation, diagnosis, and a plan of care.
F.       Any student-athlete that sustains a head injury immediately suspected of being a concussion in competition or during practice may return to participation if it is determined by a licensed medical professional through their evaluation that the injury to the head does not involve a concussion.

Section 6: Procedure for Reporting a Head Injury

A.      In the event of a head injury and suspected concussion, the person who witnesses the injury and/or performs the evaluation will need to report the necessary information to appropriate personnel per 105 CMR 201.006(A)(7).  A Report of Head Injury Form (Appendix B) shall be completed by the athletic trainer if present during the practice or competition.  If an athletic trainer is not present the Report of Head Injury Form shall be completed by the coach. The coach shall notify the athletic trainer, athletic director, school nurse and parent as specified in 105 CMR 201.010(c) and 105 CMR 201.010(d).  This form shall be reviewed and placed in the students’ health record as per 105 CMR 201.015.
  1. If the head injury occurs at a game, event, or practice, with the athletic trainer present, they will complete the Report of Head Injury Form (Appendix B) and notify the student’s parent(s)/guardian(s) after the evaluation. The athletic trainer will release the student into the care of their parent(s)/guardian(s) after explaining the findings of the evaluation and recommend follow-up care with a physician as appropriate. The athletic trainer will provide the parent(s)/guardian(s) with the Concussion Information Packet (Appendix B) and notify the coach, athletic director, and school nurse of the injury.
  2. If the head injury occurs at a game, event, or practice and the athletic trainer is unavailable, the coach will notify the student’s parent(s)/guardian(s) after removing the student from participation. The coach will release the student into the care of their parent(s)/guardian(s), provide them with the Concussion Information Packet, and recommend that they seek medical attention. The coach will notify the athletic director, and athletic trainer of the incident and fill out the Report of Head Injury Form and file it with the athletic office.
  3. If the head injury occurs during the school day, the school nurse will notify the student’s parent(s)/guardian(s). The school nurse will give the Concussion Information Packet to the student’s parent(s)/guardian(s) and recommend that they seek medical attention. The Nurse will also fill out the Report of Head Injury Form, file it with the athletic office, and notify the athletic trainer, and coach of the incident.
  4. If the individual completing the Report of Head Injury Form is unable to communicate directly with the student’s parent(s)/guardian(s) they will document the time and date of the call and message left in the report.  
  5. If the head injury occurs outside of school, either at home or participating in nonaffiliated athletics, the parent(s)/guardian(s) must notify the school athletic office, athletic trainer, and school Nurse of this injury and fill out the Report of Head Injury Form, and provide all medical documentation related to the injury to the athletic trainer or school nurse.

Section 7: Return to Play Protocol and Medical Clearance

A.      Each student who is removed from practice or competition and subsequently diagnosed with a concussion shall have a written graduated reentry plan for return to full academic and extracurricular athletic activities.  The plan will be developed by the student’s teachers, the student’s guidance counselor, school nurse, licensed athletic trainer, neuropsychologist if available, involved parent(s)/guardian(s), members of the building based support and assistance team or individualized education program team as appropriate and in consultation with the physician who is managing the student’s recovery and will be responsible for clearing the student to return to academic and extracurricular athletic activities.
  1. The licensed athletic trainer in cooperation with the school nurse and all other designated individuals will oversee the return to play protocol and medical clearance of all student athletes.  
B.      The written plan will include instructions for the student, parent(s)/guardian(s) and school personnel, addressing but not be limited to:  physical and cognitive rest as appropriate; graduated return to extracurricular athletic activities and classroom studies as appropriate, including accommodations or modifications as needed; estimated time intervals for resumption of activities; frequency of assessments, as appropriate, by the school nurse, primary care physician, school/team physician, licensed athletic trainer, or neuropsychologist if available until full return to classroom and extracurricular athletic activities are authorized. 
C.      The student must be completely symptom free at rest to begin graduated return to extracurricular athletic activities per 105 CMR 201.010(E)(3).
D.     The Return to Play Protocol (RTP) is a graduated progression back to activity with each step occurring on its own day. To progress to the next step, the student must remain symptom free during and after the activity. The protocol is detailed in Appendix E.
E.      Once a student completes the Return to Play Protocol and has returned to baseline of neurocognitive function, they must provide written medical clearance from a licensed medical professional listed in 105 CMR 201.011(A) prior to completing the final steps of the protocol which include Full Contact and Final Clearance. 
  1. The student must provide a completed Post Sports-Related Head Injury Medical Clearance and Authorization Form (per 105 CMR 201.011) or school based equivalent. The form must be completed by a licensed medical professional authorized by the DPH (per 105 CMR 201.011(A)).

Section 8: Roles and Responsibilities of Personnel

All persons (administration, athletic director, school nurse, athletic trainer, coaches, volunteers, parent(s)/guardian(s) and students) involved in extracurricular athletic activity or the management of head injuries and concussions will adhere to the roles and responsibilities as per their assigned role. The roles and responsibilities for each position are detailed in Appendix G.

Section 9: Parent(s)/Guardian(s) Information

Parent(s)/Guardian(s) of students participating in extracurricular athletic activity can obtain all necessary and required paperwork and documentation from Appendix H. Parent(s)/Guardian(s) will be notified by a member of the school athletic department or health care team in the event their child sustains a head injury or concussion. Communication will be done in person or by phone following the removal from activity. Parent(s)/Guardian(s) roles and responsibilities are detailed in Appendix G.  In the event there is a language barrier all efforts will be made to communicate necessary information to the parent(s)/guardian(s) using either an interpreter or translation software/application.

Section 10: Penalties

A.      Failure to provide an approved Pre-Participation Physical Examination clearing a student to participate in extracurricular athletic activity will result in the student being ineligible to participate.
B.      Failure to complete or provide proof of completion of annual concussion training will result in the individual being prohibited from participating or performing their assigned duties. The individual could be subject to additional consequences at the discretion of the athletic director.
C.      Failure to complete baseline neurocognitive testing by the student will make them ineligible to participate in extracurricular athletic activity if required by the school for their sport. Students will not be allowed to participate until they have a valid test per the licensed athletic trainer.
D.     Failure to report a suspected head injury or concussion in a timely manner will be subject to consequences from the athletic department appropriate for the responsible individual.
  1. A student or parent(s)/guardian(s) that fail to report a head injury that occurs away from school will not be allowed to participate until medically cleared by the treating medical professional.
  2. A coach or volunteer who fails to report a head injury in a timely manner to the licensed athletic trainer, school nurse or athletic director will be subject to discipline at the discretion of the athletic director and school administrators.