Scope of Practice: Incorporating Standing

Orders to Encourage Responsible Practice

NATA Professionally Responsibility in Athletic Training (PRAT) Presents:

Kevin Stalsberg, EdS, LAT, ATCCiara Ashworth, LAT, ATC

Disclaimers and Disclosures

The presenters are both current members of the NATA PRAT Committee.

This presentation is designed for the promotion of best practices in athletic training and not to be construed as legal advice or a catch all template for everyone.

There are no financial investments in the topic of this discussion.

Mission of the Professional Responsibility in Athletic Training Committee (PRAT)

Promote Legal, Ethical, Regulatory, and Professional Standards (LERPS) awareness, analysis, action, and adherence.

Aim of this presentation is to bring awareness and analysis relative to our responsibility to engage in appropriate professional practice within regulatory parameters.

Objectives

1. Synthesize legal, ethical, regulatory, and practice standard issues that concern athletic trainers today.○ Working within your scope of practice and adhering to

professional standards.2. Define scope of practice and how it can vary from state to state.

○ Evaluation of your state’s practice act.3. Explore how implementing the use of standing orders can assist

with scope of practice in your setting and minimize the risk of liability.

4. Explore the development of standing orders.

What are the LERPS issues, as it relates to Scope of Practice?

NATA Code of Ethics◉ 2.1-”Members shall comply with applicable local, state and federal laws, and

any state athletic training practice acts.”◉ 2.2-”Members shall understand and uphold NATA standards and the Code of

Ethics.”◉ 2.4-”Members shall cooperate in ethics investigations by the NATA, state

licensing/regulatory boards, or other professional agencies governing the athletic training profession. Failure to cooperate in ethics investigations is an ethical violation”

◉ 3.2-”Members shall provide only those services for which they are qualified through education or experience and which are allowed by the applicable state athletic training practice acts and other regulations for athletic training.

What are the LERPS issues, as it relates to Scope of Practice?

BOC Standards of Professional Practice◉ 2.1-”The athletic trainer engages in lifelong, professional and continuing

educational activities to promote continued competence.”◉ 3.1-”The athletic trainer practices in accordance with the most current BOC

practice standards.”◉ 3.2-”The athletic trainer practices in accordance with applicable local, state,

and/or federal rules, requirements, regulations, and/or laws related to the practice of athletic training.”

◉ 3.5.1-”The athletic trainer provides only those services for which they are prepared and permitted to perform by applicable local, state, and/or federal rules, requirements, regulations, and/or laws related to the practice of athletic training.”

Defining Scope of Practice & Standard of Care

Scope of Practice◉ Activities a healthcare provider are allowed to

perform within a profession or professional setting. This is set by the state practice act.

Standard of Care◉ The level at which the average, prudent provider in a

given community would practice.

What is Scope of Practice?

◉ “Your scope of practice is what your practice act and the Board’s lawyers say it is” - KS BoHA Member

◉ Protects ATs and their patients by “providing boundaries for the provider’s individual practice”

◉ Nebulous term that is INDIVIDUALIZED○ Entry-Level Practice○ Continuing Education and Training○ State Regulation○ Public Protection

◉ Remember, there is a distinction between Scope of Practice and Standard of Care!

Entry-Level PracticeImportant Documents:◉ CAATE Standards

○ Designed to exceed the practice analysis○ Outlines the knowledge and skills needed as an

entry-level athletic trainer◉ BOC Practice Analysis

○ Summary of duties entry-level athletic trainers are need to be able to perform.

◉ State Practice Act○ States what the athletic trainer is allowed to do, varies

state to state.

Continuing Education and Training

BOC - Certificate Renewal◉ Designed to develop and improve an individual’s

knowledge and skills.○ Are you up to date with what is required by an

entry level athletic trainer?○ Standard 66 has requirements for physician

direction and collaboration.◉ Promote Evidence-Based Practice◉ CAATE Standards

State Regulation

◉ Individual states allow ATs to practice with certain parameters.○ What is allowed in the state in which you work?○ Do you have a practice protocol as part of your

licensure or registration application?○ Who is your supervising physician? Do you need to

submit a physician agreement with your application or as a contingency?

Public Protection

◉ Typically falls on state regulatory board (Dept. of Health), the BOC, and the NATA COPE○ ATs to Society

■ COMPETENCE■ ALTRUISM■ MORALITY & INTEGRITY

○ Society to ATs■ AUTONOMY■ MONOPOLY■ STATUS, REWARDS, & PRIVILEGE

How do I determine my Scope of Practice & Standard of Care?

◉ Entry-Level Education○ What education did you have when you finished

your degree?◉ Continuing Education and Training

○ What skills have you added to your “tool box”◉ State Regulation

○ What does your practice act say?

What are Standing Orders (or Protocols)?

◉ Written document outlining rules, policies, procedures, and specific orders for patient care or stipulated medical situations.

◉ Document is signed by supervising physician(s) and the athletic trainer.

◉ Ensures that patients or situations of a certain criteria get the same treatment.

◉ Allows for autonomy of the Athletic Trainer to provide evidence-based care for the patient.

◉ Allows the AT to practice at the top of their scope as allowed by their state practice act.

◉ Should be updated, reviewed, and realistic for your practice as an AT.

What should be included or detailed in your Standing Orders?

◉ Evaluation of Injuries and Illnesses◉ Return to Activity/Play Decision Making◉ Rehabilitative and Treatment Procedures ◉ Medical Records◉ Conditions or Circumstances that the AT will

consider/review for referral to another Licensed Healthcare Provider for additional evaluation and treatment.○ Head Injuries○ Spinal Injuries○ Extremity Injuries

What should be included or detailed in your Standing Orders?

◉ Medications◉ Use of bandaging, wrapping, taping, padding, splinting, etc. ◉ Emergency Plans for specific cases:

○ Head/Neck Injury○ Sudden Cardiac Arrest○ Heat/Environmental

◉ Standardized Management for MSK Injuries○ Rules/Standardization for referral

◉ Concussion Management ◉ Functional Testing◉ When should the standing orders be reviewed?◉ Signature of the Physician and Athletic Trainer

Development Team:◉ Athletic Trainer◉ Physician◉ Possible consultation with

a lawyer or risk manager for review.

Specialized Considerations:◉ How much the document can

change with experience.◉ What setting and where you practice

as an AT◉ What care or specialty the physician

is comfortable supervising◉ Your education/experience as an AT◉ Your scope of practice and state

practice act◉ NATA Position Statements

Considerations when developing and evaluating your Standing Orders

Kevin’s Story◉ Background◉ Why did I feel I needed it?◉ The Process

○ State Practice Act○ Position, Consensus, and

Official Statements○ Local EMS Protocols○ EAP/Scope of

Practice/Standard of Care○ Continuing Education○ Previous Experience

◉ Reviewed annually (typically over 2 days)

◉ Shared with everyone!

Ciara’s Story◉ Background

○ College Preparation○ 1st Athletic Training Job○ Finding a Physician

◉ Experience◉ Networking◉ Process

○ Similar to Kevin’s Story

Process and Development of Standing Orders

Sample Standing Orders (Protocols)

The following sides are not to be copy and pasted for use, but may be used as a starting point for ATs looking to

develop their own standing orders.

Sample Standing Orders

Standing Orders (Protocol) for Athletic Trainer at Sample High School

This serves as standing treatment orders and protocols for BLANK, athletic trainer at BLANK SCHOOL. The medical care identified herein is consistent with the Practice of Athletic Training by the BLANK/STATE Department of Health and with the education and training received as a nationally Certified Athletic Trainer through the Board of Certification.

Sample Standing Orders Continued

1. The AT may evaluate and initiate first level care for injuries and illnesses.

2. Return to Activity/Play Decision-Making:○ Follow established school and school district policies,

state athletic/activities association policies, and athletic training measures in order to return to play (RTP).

○ For an athlete under the direct care of the AT, professional discretion shall be used when making RTP decisions. The athlete should have near full strength, near full range-of-motion, minimal pain/discomfort, and demonstrate appropriate strength and sport-specific agility in order to RTP.

Sample Standing Orders Continued

2. Return to Activity/Play Decision-Making:○ Concussion management will follow established

international Zurich guidelines, comply with STATE concussion legislation, and include a graduated return to play protocol monitored by the AT.

3. The AT will utilize appropriate rehabilitative and treatment procedures as needed to increase range of motion, strength, and agility. Procedures may include but are not limited to use of the following: heat, cold, water, compression, light, sound, electricity, massage, traditional mobilization techniques, and exercise programs.

Sample Standing Orders Continued

4. Evaluation records will be maintained on athletes who have presented with injuries that result in loss of playing time and subsequent injury evaluation. Treatment and recovery/progress notes will be recorded in instances where an athlete receives assessment, physical modality, injury care, and/or corrective exercise.

Sample Standing Orders Continued

5. Conditions or circumstances that the AT will consider/review for referral to another LHP for additional evaluation and treatment.

○ Head Injuries:i. Loss of Consciousnessii. Head injuries presenting with deteriorating neurological symptomsiii. Significant facial injuriesiv. Significant dental trauma

○ Spine Injuriesi. Persistent radiculopathy or bilateral radiculopathyii. Structural injury or instabilityiii. Suspected spinal fractures or spinal cord injury

○ Extremity Injuriesi. Suspected Fracturesii. Dislocationsiii. Severe Sprains and Strains

Sample Standing Orders Continued

6. Medications:a. Prescribed medications may not be given to an athlete by

the AT.b. Over-the-counter medication may not be provided to

minors without expressed written consent of that athlete’s parent/guardian.

c. An Epi-Pen may be administered by the AT to those exhibiting anaphylaxis.

Sample Standing Orders Continued

7. Utilize appropriate bandaging, wrapping, taping, padding, bracing, and splinting procedures for the prevention and management of injuries when signs and symptoms warrant such usage.

8. This standing protocol is to be reviewed by the named Athletic Trainer and their Supervising Provider/Physician annually, prior to the start of fall sports.

9. Name, Signature, and Date of Athletic Trainer and Supervising Provider.

Example

Example

Example

Resources

◉ NATA Position Statements◉ State Practice Acts◉ Sports Medicine Legal Digest, Fall 2020, The Relationship

of State Practice Act and Scope of Practice◉ National Athletic Trainers Association Secondary School

Athletic Trainers’ Committee: Guidelines for Developing a Team Physician Services Agreement in the Secondary School. Published 2016. https://www.nata.org/sites/default/files/ss_team_physician_contract_guidelines.pdf

Thank you for your time!

If you have any questions and would like to contact the presenters, please use the email addresses below:

Kevin Stalsberg - kevinstalsberg159@smsd.org Ciara Ashworth - ciara.ashworth17@gmail.com