Cardiovascular Emergency Preparedness in Recreation Facilities at ...

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PREVENTIVE CARDIOLOGY

CLINICAL STUDY

Cardiovascular Emergency Preparedness in Recreation Facilities at Major US Universities: College Fitness Center Emergency Readiness William G. Herbert, PhD;1 David L. Herbert, JD;2,3 Kyle J. McInnis, ScD;4 Paul M. Ribisl, PhD;5 Barry A. Franklin, PhD;6 Mandy Callahan, BS;7 Aaron W. Hood, BS1

Recent American Heart Association/American College of Sports Medicine (AHA/ACSM) guidelines advocate preparticipation screening, planning, and rehearsal for emergencies and automated external defibrillators in all health/fitness facilities. The authors evaluated adherence to these recommendations at 158 recreational service departments in major US universities (51% response rate for 313 institutions queried). Many made their facilities available to unaffiliated residents, with 39% offering programs for those with special medical conditions. Only 18% performed universal preparticipation screening. Twenty-seven percent reported having 1 or more exercise-related instances of cardiac arrest or sudden cardiac death within the past 5 years. Seventy-three percent had an automated external defibrillator, but only 6% reported using it in an emergency. Almost all had written emergency plans, but only 50% posted their plans, and only 27% performed the recommended quarterly emergency drills. The authors’ findings suggest low awareness of and adherence to the AHA/ACSM recommendations for identifying individuals at risk for exercise-related cardiovascular complications and for handling such emergencies in university-based fitness facilities. (Prev Cardiol. 2007;10:128–133) ©2007 Le Jacq From Virginia Tech, Blacksburg, VA;1 Herbert and Benson Attorneys at Law, Canton, OH;2 PRC Publishing, Canton, OH;3 University of Massachusetts, Boston, MA;4 Wake Forest University, Winston-Salem, NC;5 William Beaumont Hospital, Birmingham MI;6 and Youngstown State University, Youngstown, OH7 Address for correspondence: William G. Herbert, PhD, Department of Human Nutrition, Foods & Exercise, 213 War Memorial Hall, Virginia Tech, Blacksburg, VA 24061-0351 E-mail: [email protected] Manuscript received April 13, 2006; revised July 20, 2006; accepted August 16, 2006

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hysical inactivity is a serious health problem worldwide, contributing to early development of obesity, diabetes, hypertension, and cardiovascular diseases.1 To address these concerns, public health policy strategies are being discussed and debated at all levels of society, with a goal of restoring normal activity levels in the populations of industrialized societies.2–5 The universal aim is to encourage sedentary individuals to increase habitual levels of activity safely, ultimately leading to participation in moderate physical activity most days of the week.6 With these initiatives, equal consideration must be given to improving the number, accessibility, and safety of environments where virtually all persons may participate in healthful physical activities. The capacity to respond rapidly and effectively to cardiovascular emergencies constitutes an important safety consideration in these activity environments. The American Heart Association and the American College of Sports Medicine (AHA/ACSM) have published joint recommendations that address safety concerns.7,8 Surveys of commercial health clubs in the Eastern and Midwestern United States completed within the past decade have demonstrated low compliance with the AHA/ACSM recommendations, particularly with respect to cardiovascular screening and emergency procedures.9,10 Major US universities represent another important venue where many adults engage in moderate to vigorous physical activity; however, this is a setting in which screening and emergency practices have not previously been systematically surveyed. The National Intramural Recreation and Sports Association (NIRSA) is the peer association most directly concerned with management of services at university recreation facilities throughout the United States; however, this association appears not to have published any explicit recommendations of their own on these safety-related concerns.11 One in 4 adult Americans has some form of cardiovascular disease.12 Although regular exercise

Preventive Cardiology® (ISSN 1520-037X) is published quarterly (Jan., April, July, Oct.) by Le Jacq, a Blackwell Publishing imprint, located at Three Enterprise Drive, Suite 401, Shelton, CT 06484. Copyright ©2007 by Le Jacq. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Karen Hurwitch at [email protected] or 781-388-8470.

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reduces cardiovascular mortality,13 the incidence of a cardiovascular event temporally related to vigorous exercise among those with known or occult cardiac disease may be considerably greater than for apparently healthy persons.14 Among young adults and even athletes, there is potential for sudden cardiac death associated with vigorous exercise, although in patients younger than 30, this is generally attributed to undiagnosed congenital cardiac abnormalities rather than underlying coronary artery disease.15 Consequently, adequate screening and evaluation of individuals for risks of underlying cardiovascular disease before their participation in moderate to vigorous exercise is an important safeguard. Several professional groups have published guidelines and standards to address concerns regarding safety, staffing, and programs at health clubs.16–19 Despite these recommendations, there is heightened concern that individuals at greater cardiovascular risk, such as those with known or occult coronary disease, are exercising at fitness facilities that fail to provide adequate screening and emergency procedures. Results of a survey study of 110 commercial health/fitness facilities in Massachusetts, published in 1997, indicated that efforts to screen new members were limited and inconsistent and that more than two-thirds of the respondent facilities failed to routinely practice emergency drills.10 A more recent survey of 122 clubs in Ohio similarly demonstrated low adherence to recommended practices of screening and rehearsing for cardiovascular emergencies.9 Systematic ongoing evaluation of safety practices in all major venues where large numbers of adults exercise is needed for assessing community-wide potential for untoward events and determining where to invest efforts and resources to mitigate risk. Thus, our objective was to evaluate facility adherence to the joint recommendations of AHA/ ACSM on pre-activity screening, readiness for cardiovascular emergencies, and the availability of automated external defibrillators (AEDs) in campus recreation departments at major universities.

METHODS

Sample Universities in our sample were those listed as National Collegiate Athletic Association (NCAA) member colleges and universities (n=313) in the 2002 Recreational Sports Directory20 of NIRSA. The questionnaires were numerically coded and mailed in March 2004, with self-addressed return envelopes, to the attention of campus recreation facility directors. Four weeks after the initial mailing, a follow-up letter and additional copy of the survey were sent to each director who had not responded by returning a completed survey. Four weeks thereafter, any remaining nonresponders were contacted by telephone to encourage completion of the


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survey. Nonrespondents were contacted once more at 6 weeks following the second mailing in a final attempt to encourage participation. Survey Content The survey consisted of 37 questions about cardiovascular risk management procedures commonly used at their facility, with specific emphasis on screening of new members and preparations for emergency responses. These questions were based primarily on the 1998 AHA/ACSM recommendations for cardiovascular risk preparation at health/ fitness facilities.7 One group of questions pertained to facility size, number of part- and full-time fitness staff, and certification and education of staff. Others related to preparticipation cardiovascular screening, whether the facility had written policies that addressed screening, and if and how consistently screening was performed with new clients. Other items queried the status of emergency procedures and special programs for those with increased risk for cardiovascular diseases, whether the staff had written emergency plans, how often emergency drills were practiced, whether outside paramedical personnel were involved in devising or reviewing these plans, and whether training for emergencies was part of staff orientation. One other group of questions asked about the incidence of emergencies in the facility that necessitated an ambulance call; the number of serious cardiovascular emergencies that had occurred within the past 5 years, such as myocardial infarction or sudden cardiac arrest; and finally, whether the facilities had an AED on site or planned to purchase one soon. Survey Instructions A cover letter that stated the purpose of the study accompanied the survey. The letter emphasized that it was not the intent of this study to make judgments or recommendations regarding the procedures used at any individual facility and assured that the identity and individual survey responses would not be disclosed to anyone or published. All questionnaires were number coded by the researchers for identification, but responders were cautioned not to identify themselves or their facility. Respondents were encouraged in the instructions, however, to answer every item and provide accurate responses regarding the questions of interest. The number-coded list of universities was destroyed upon receipt of the last completed survey. Analyses of Data Simple frequency distributions and percentages were calculated for responses to all questionnaire items in this survey. Responses to certain questions were compared with those collected for similar questions in 2 previous surveys of commercial health clubs in Massachusetts10 and Ohio.9 These differences were evaluated using χ2 analysis.


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Table. University Recreation Facility Adherence to AHA/ACSM Recommendations on Preparticipation Screening and

Emergency Readinessa AHA/ACSM HEALTH/FITNESS FACILITY RECOMMENDATIONS NO. (%) Facilities with all fitness and aerobics staff certified in basic life support 100 (63) 82 (54) Facilities with all fitness and aerobics staff certified in basic life support, with automated external defibrillator training Facilities that require at least 1 staff member certified in basic cardiac life support be on duty at all 130 (82) operational hours 29 (18) Facilities that use a screening questionnaire to identify users/members with heart problems or at risk for exercise-related heart problems Facilities using a screening questionnaire that require all new users to complete the questionnaire before participating 15 (10) 79 (50) Facilities that have a written emergency response plan posted at facility 119 (75) Facilities that have emergency telephone numbers posted throughout the facility 43 (27) Facilities that practice emergency response plan at least quarterly Facilities that have outside medical care personnel involved in developing or evaluating the plan 79 (50) 76 (48) Facilities that have records kept at facility that show results of emergency rehearsals Facilities that have an automated external defibrillator 115 (73) Abbreviation: AHA/ACSM, American Heart Association/American College of Sports Medicine. aData are numbers indicating adherence and percentages (%) from a total respondent sample of 158.

RESULTS

Respondent Profile Of the 313 universities surveyed, 158 (51%) responded. Student enrollment of respondent universities averaged 23,600 in addition to having an average of 1400 faculty/staff and significant but unknown numbers of classified staff and local residents who utilized their recreational fitness facilities. Of all responders, 96% made their facilities and services available to faculty and staff. At 98% of these facilities, recreational activity space exceeded 5000 square feet, with 53% having more than 100,000 square feet. Seventy-two percent of respondents offered special exercise programs for nonstudents, including elderly clients and those with coronary heart disease. In 39% of responding universities, facilities and programs were also available to other citizens in nearby communities. Fitness Staff At a majority (82%) of the facilities, over half (57%) of the fitness staff held a bachelor’s degree in exercise science or a related field, while only 8.5% held no such degrees. The average number of physical activity staff certified in basic life support (BLS) was 82%, while the average number reporting that their staffs were certified in BLS plus AED training was 64%; however, only 63% and 54%, respectively, indicated that 100% of their physical activity staff were trained and certified at these 2 levels (Table), as is the recommendation of AHA/ ASCM.7 Eighty-two percent of the respondents indicated that they required at least 1 BLS-certified physical activity staff member to be on duty during all facility operation hours. Preparticipation Screening As shown in the Table, only 18% (n=29) of respondent facilities performed preparticipation screening

to “identify users/members with heart problems or at-risk for exercise-related heart problems,” as is recommended by AHA/ACSM.7 Furthermore, only 10% reported that they were consistently adhering to this practice. In the subset of respondent facilities offering programs for persons needing medical clearance (34%), however, 85% reported that they consistently performed screening with these users/members. Cardiovascular Emergencies and Procedures At least 1 cardiovascular medical emergency within the past 5 years, defined as “a sudden cardiac arrest or heart attack,” reportedly occurred at 27% (43) of the respondent facilities. All but 3 facilities reported having an emergency response plan, 75% indicated that they posted an emergency telephone number, and half indicated that their emergency plans were posted in the facility (Table). Figure 1 shows the distribution of respondents with respect to emergency rehearsals. Twentynine percent of facilities never rehearsed their emergency protocol, while another 27% held at least quarterly emergency drills, as recommended by the AHA/ACSM.7 With regard to adherence to other aspects of the AHA/ACSM emergency procedure recommendations, 50% of the facilities utilized outside medical and paramedical personnel to develop or evaluate their emergency plans, and nearly half kept records of emergency drills (Table). Yet, nearly all facilities (98%) rated having an appropriate emergency response plan as “very” or “extremely” important. Knowledge of AHA/ACSM Recommendations The percentage of facilities that were aware of the published AHA/ACSM health/fitness facility recommendations for cardiovascular screening and emergency procedures7,8 was disappointingly low (30%). Just half of that small subset indicated that


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27% n=43 23% n=36

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DISCUSSION

Not practiced 16% n=26

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Results from this study indicate a low level of awareness, understanding, and utilization of the most current published recommendations for identifying adults at increased risk for cardiovascular complications associated with moderate-to-vigorous exercise and for preparing to handle such emergencies. Eighty percent of respondent facilities reported either being inconsistent about conducting screenings or failing to conduct pre-entry screenings at all. This step can be achieved with simple self-administered questionnaires (eg, the Physical Activity Readiness Questionnaire)21 to identify individuals with signs, symptoms, or history of cardiovascular disease. While almost all respondents indicated having a written emergency plan, only half posted their plan and practiced emergency drills more than once a year. Nearly 75% indicated having an AED and over half reported that their physical activity staff was certified in BLS with AED training. Paradoxically, however, 93% reported that their facility had at least 1 medical emergency within the past 3 years that was serious enough to warrant calling an ambulance. In addition, more than 1 in 4 indicated having had a serious cardiovascular emergency “such as sudden cardiac arrest or heart attack” in the preceding 5 years. Only 6% reported that their AEDs were used in an emergency. Industry leadership began expressing support for AED deployment as early as 2001,22 and the AHA/ACSM recommendation8 on this matter was published 1 year later. Thus, our findings suggest that many recreation facilities at major universities were not prepared in 2004 to respond to cardiovascular emergencies or to use AEDs within the first few minutes after a victim’s collapse, when survival rates may be improved the most.23 An additional caveat regarding interpreting these survey results is that our respondents may represent a better informed and more diligent segment (51%) of the overall population of 313 NIRSA member institutions. If true, then adherence to these emergency preparedness recommendations7,8 and the potential for successful management of cardiovascular emergencies in the overall population of university-based facilities may be substantially lower than suggested here. Figure 2 presents comparative data on responses related to cardiovascular emergencies and risk

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2x/y