Quality Improvement in Athletic Health Care

Organizational Expectations Regarding Documentation Practices in Athletic Training

CONTEXT

Although guidance is available, no nationally recognized standard exists for medical documentation in athletic training, leaving individual organizations responsible for setting expectations and enforcing policies. Previous research has examined clinician documentation behaviors; however, the supervisor's role in creating policy and procedures, communicating expectations, and ensuring accountability has not been investigated.

OBJECTIVE

To investigate supervisor practices regarding support, hindrance, and enforcement of medical documentation standards at an individual organization level.

DESIGN

Mixed-methods study.

SETTING

Online surveys and follow-up interviews.

PATIENTS OR OTHER PARTICIPANTS

We criterion sampled supervising athletic trainers (n = 1107) in National Collegiate Athletic Association member schools. The survey collected responses from 64 participants (age = 43 ± 11 years; years of experience as a supervisor = 12 ± 10; access rate = 9.6%; completion rate = 66.7%), and 12 (age = 35 ± 6 years; years of experience as a supervisor = 8 ± 5) participated in a follow-up interview.

DATA COLLECTION AND ANALYSIS

We used measures of central tendency to summarize survey data and the consensual qualitative research approach with a 3-person data analysis team and multiphase process to create a consensus codebook. We established trustworthiness using multiple-analyst triangulation, member checking, and internal and external auditing.

RESULTS

Fewer than half of supervisors reported having formal written organization-level documentation policies (n = 45/93, 48%) and procedures (n = 32/93, 34%) and an expected timeline for completing documentation (n = 24/84, 29%). Participants described a framework relative to orienting new and existing employees, communicating policies and procedures, strategies for holding employees accountable, and identifying purpose. Limitations included lack of time, prioritization of other roles and responsibilities, and assumptions of prior training and record quality.

CONCLUSION

Despite a lack of clear policies, procedures, expectations, prioritization, and accountability strategies, supervisors still felt confident in their employees' abilities to create complete and accurate records. This highlights a gap between supervisor and employee perceptions, as practicing athletic trainers have reported uncertainty regarding documentation practices in previous studies. Although supervisors perceive high confidence in their employees, clear organization standards, employer prioritization, and mechanisms for accountability surrounding documentation will result in improved patient care delivery, system outcomes, and legal compliance.

Comparing the Primary Concerns of Injured Collegiate Athletes With the Content of Patient-Reported Outcome Measures

CONTEXT

Patient-reported outcome measures (PROMs) have been endorsed for providing patient-centered care. However, PROMs must represent their target populations.

OBJECTIVE

To identify the primary concerns of collegiate athletes experiencing injury and compare those with the content of established PROMs.

DESIGN

Cross-sectional study.

SETTING

Collegiate athletic training facilities.

PATIENTS OR OTHER PARTICIPANTS

Collegiate athletes experiencing injury (N = 149).

MAIN OUTCOME MEASURE(S)

Open-ended responses to the Measure Yourself Medical Outcome Profile were used to identify primary concerns, which were linked to International Classification of Functioning, Disability and Health taxonomy codes. Items of the Patient-Reported Outcomes Measurement Information System; modified Disablement of the Physically Active Scale; Lower Extremity Functional Scale; Knee injury and Osteoarthritis Outcome Score (KOOS); International Knee Documentation Committee Subjective Knee Form (IKDC); Foot and Ankle Ability Measure; Disabilities of the Arm, Shoulder, and Hand; Functional Arm Scale for Throwers; and Kerlan-Jobe Orthopaedic Clinic questionnaire were linked to International Classification of Functioning, Disability and Health codes. We calculated χ2 single-sample goodness-of-fit tests to determine if 70% of the content was shared between PROMs and participant-generated codes.

RESULTS

Participant-generated concerns were primarily related to sport participation (16%) and pain (23%). Chi-square tests showed that the Lower Extremity Functional Scale and Foot and Ankle Ability Measure presented significant content differences, with common participant-generated lower extremity responses at all levels. The Patient-Reported Outcomes Measurement Information System; modified Disablement of the Physically Active Scale; KOOS; IKDC; Disabilities of the Arm, Shoulder and Hand; Functional Arm Scale for Throwers; and Kerlan-Jobe Orthopaedic Clinic questionnaire did not have significant content differences for level 2 codes; still, significant differences were present for level 3 analyses except for the KOOS and IKDC (P < .001). All measures except the IKDC contained significant superfluous content (P < .05).

CONCLUSIONS

The presence of significant content differences supports clinician-perceived barriers regarding the relevance of established PROMs. However, the IKDC was a relevant and efficient PROM for evaluating the primary concerns of collegiate athletes experiencing lower extremity injury. Clinicians should consider using patient-generated measures to support coverage of patient-specific concerns in care.

Lessons Learned and Potential Long-Term Effects on Athletic Trainers and Clinical Practice After a Global Pandemic

CONTEXT

Perceived stress and burnout are significant concerns among athletic trainers (ATs) due to growing professional demands. The global COVID-19 pandemic brought additional stressors, especially for health care providers, including the need to learn and integrate new skill sets in order to continue providing safe and effective patient care.

OBJECTIVE

To explore the influence of COVID-19 stressors on ATs engaged in patient care.

DESIGN

Cross-sectional study.

SETTING

Internet survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 429 ATs (age = 33 ± 9 years; experience = 11 ± 9 years; 74 men, 355 women) currently providing patient care.

MAIN OUTCOME MEASURE(S)

We recruited participants from social media sites to complete a questionnaire with the Coronavirus Anxiety Scale (CAS), Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS MP), and qualitative questions related to the effects of COVID-19. We calculated correlations between CAS and MBI-HSS MP composite scores (emotional exhaustion, personal accomplishment, and depersonalization) and used regression analysis to explore if CAS scores could be predicted by vaccination status (vaccinated or unvaccinated), sex, and MBI-HSS MP composite scores. We analyzed the qualitative data using a phenomenological, inductive approach with multianalyst triangulation and peer review as trustworthiness strategies.

RESULTS

Significant correlations existed between CAS and MBI-HSS MP composite scores (P < .001). Emotional exhaustion (P < .001) and depersonalization (P = .008) explained 28% of the variance in CAS scores (F2,405 = 81.29, P < .001). Three major areas of focus emerged: effects on wellness, emphasis on the value of athletic training, and the lessons learned and future innovation to inform potential long-term changes in the athletic training profession.

CONCLUSIONS

Key factors of emotional exhaustion and depersonalization during the pandemic may have exacerbated the potential for burnout among ATs. The pandemic affected ATs' wellness, changed perceptions of ATs, and altered operating procedures. Healthy coping strategies and organizational support are suggested for those who are struggling.

The critical need for advanced training of electronic records use: implications for clinical practice, education, and the advancement of athletic training

CONTEXT

The effective use of electronic records (ie, electronic health/medical records) is essential to professional initiatives and the overall advancement of the athletic training profession. However, evidence suggests comprehensive patient care documentation and wide-spread use of electronic records is still limited in athletic training. The lack of formal training and education for clinicians and students are often cited as primary barriers to electronic records use. Other healthcare disciplines have used academic electronic health records (AEHR) systems to address these barriers with promising results.

OBJECTIVES

To identify common challenges associated with the effective use of electronic records in clinical practice, discuss how an AEHR can address these challenges and encourage more effective use of electronic records, and describe strategies for deploying AEHRs within the athletic training profession.

DESCRIPTION

The AEHR is an electronic records system specifically designed for educational use to support simulation learning among all types of learners (eg, practicing clinicians, students). Mimicking the form and function of an EHR, the AEHR offers various educational tasks including patient care documentation projects, critical reviews of standardized patient cases, and assessments of patient care data for quality improvement efforts. Clinical and Research Advantages: Recent evidence suggests the use of an AEHR can improve knowledge and enhance skills. Specifically, AEHR use has been associated with enhanced attitudes toward EHR technology, enhanced informatics competencies, and improved documentation skills. Also, the use of an AEHR has been associated with improved critical thinking and decision-making skills. AEHRs appear to be valuable tools for health professions education and athletic training stands to benefit from AEHR use to better train and upskill clinicians and students alike for clinical practice. Although the implementation of an AEHR will require much time and large-scale coordinated efforts, it will be a worthy investment to address current challenges and advance the athletic training profession.

Parental Perceptions of the Importance and Effectiveness of Patient-Centered Care Delivery

Integrative patient-centered care (PCC) models encompass all dimensions of the patient, including physical well-being, evidence-based shared decision making, and determinants of health as they relate to quality of life. The purpose of this study was to explore parental experiences with the principles of PCC, related to the healthcare of their dependent after interactions with a provider. Using an observational design, our results demonstrated that parents of adolescent athletes rated PCC concepts as “very important” and the care delivered in relation to PCC by providers as “very effective.” PCC is perceived as valuable to parents, and therefore, athletic trainers must continue to develop and integrate PCC in the delivery of care within their clinical practice.

Cost and Treatment Characteristics of Sport-Related Knee Injuries Managed by Athletic Trainers: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Knee injuries are common during sport participation. However, little is known about the overall management and estimated direct costs of care associated with these injuries when under the care of athletic trainers.

OBJECTIVE

To describe the treatment characteristics and direct costs of care for athletic training services provided for patients with knee injuries.

DESIGN

Descriptive study.

SETTING

Ninety-five athletic training facilities across 24 states.

PATIENTS OR OTHER PARTICIPANTS

A total of 117 athletic trainers (females = 56.4%, age = 29.4 ± 8.7 years, years certified = 4.7 ± 6.0, years employed at site = 1.6 ± 4.1).

MAIN OUTCOME MEASURE(S)

Complete patient cases were identified using International Classification of Disease-10 diagnostic codes between 2009 and 2020. Summary statistics were calculated for patient demographics, treatment characteristics, and direct costs of care. Treatment characteristics included the type of athletic training service, duration, amount (eg, number of visits), and direct costs of care.

RESULTS

A total of 441 patient cases were included. The most common injuries reported were cruciate ligament sprain (18.1%, n = 80), medial collateral ligament sprain (15.4%, n = 68), and knee pain (14.1%, n = 62). Injuries occurred most frequently during football (35.4%, n = 156), basketball (14.7%, n = 65), and soccer (12.7%, n = 56). A total of 8484 athletic training services were recorded over 4254 visits, with therapeutic exercise (29.8%, n = 2530), hot or cold pack (25.8%, n = 2189), and therapeutic activities (11.2%, n = 954) being the most frequently reported services. The median duration of care was 23 days and number of visits was 8. The median total cost of care was $564 per injury and $73 per visit.

CONCLUSIONS

Patients with knee injuries demonstrated greater time loss than those with other lower extremity injuries. Thus, it is unsurprising that knee injuries were associated with a longer duration and higher cost of care than other lower extremity injuries such as ankle sprains. Future researchers should examine the effectiveness of common treatment strategies and aim to identify treatments that can reduce costs and improve patient outcomes.

Looking to Improve Your Practice? Consider the Science of Quality Improvement to Get Started

Quality improvement in health care is the responsibility of everyone (eg, patients, families, health providers, and administrative staff) to work toward delivering high-quality patient care, advancing professional knowledge and skills, and creating effective and efficient processes of care. Those involved in athletic health care, similar to other health care professionals, should strive to create patient care experiences that are safe, timely, effective, efficient, equitable, and patient centered. Exploring the differences between quality improvement and research will help define the focus of improvement sciences on the health of systems, which is to identify quality gaps and evaluate processes of care, as opposed to filling knowledge gaps. Furthermore, considering the principles of quality improvement will set the foundation for quality initiatives in health care to focus on patients, value teams, emphasize systems and processes of care, appreciate variability, and require data. With a greater understanding of the principles of the quality improvement sciences, athletic trainers will be better positioned to create a culture of quality improvement and to take the initiative in leading improvement efforts so that local systems support the delivery of high-quality patient care.

Patient Care Documentation in the Secondary School Setting: Unique Challenges and Needs

CONTEXT

Athletic trainers (ATs) recognize patient care documentation as an important part of clinical practice. However, ATs using 1 electronic medical record (EMR) platform reported low accountability and lack of time as barriers to documentation. Whether ATs using paper, other EMRs, or a combined paper-electronic system exhibit similar behaviors or experience similar challenges is unclear.

OBJECTIVE

To explore ATs' documentation behaviors and perceived challenges while using various systems to document patient care in the secondary school setting.

DESIGN

Qualitative study.

SETTING

Individual telephone interviews.

PATIENTS OR OTHER PARTICIPANTS

Twenty ATs (12 women, 8 men; age = 38 ± 14 years; clinical experience = 15 ± 13 years; from National Athletic Trainers' Association Districts 2, 3, 6, 7, 8, 9, and 10) were recruited via purposeful and snowball-sampling techniques.

DATA COLLECTION AND ANALYSIS

Two investigators conducted semistructured interviews, which were audio recorded and transcribed verbatim. Following the consensual qualitative research tradition, 3 researchers independently coded transcripts in 4 rounds using a codebook to confirm codes, themes, and data saturation. Multiple researchers, member checking, and peer reviewing were the methods used to triangulate data and enhance trustworthiness.

RESULTS

The secondary school setting was central to 3 themes. The ATs identified challenges to documentation, including lack of time due to high patient volume and multiple providers or locations where care was provided. Oftentimes, these challenges affected their documentation behaviors, including the process of and criteria for whether to document or not, content documented, and location and timing of documentation. To enhance patient care documentation, ATs described the need for more professional development, including resources or specific guidelines and viewing how documentation has been used to improve clinical practice.

CONCLUSIONS

Challenges particular to the secondary school setting affected ATs' documentation behaviors, regardless of the system used to document care. Targeted professional development is needed to promote best practices in patient care documentation.

Aspects of Technology That Influence Athletic Trainers' Current Patient Care Documentation Strategies in the Secondary School

CONTEXT

Previous research on athletic trainers' (ATs) documentation practices in the secondary school setting has focused on users of 1 electronic medical record (EMR) platform. These studies have identified that ATs use multiple platforms for documentation, including paper, even when an EMR is available.

OBJECTIVE

To examine the documentation practices of ATs who use various forms of patient care documentation, including paper, EMRs, or both.

DESIGN

Qualitative study.

SETTING

Individual telephone interviews.

PATIENTS OR OTHER PARTICIPANTS

Twenty ATs participated in this study: 12 women and 8 men who averaged 38 ± 14 years of age, 15 ± 13 years of clinical experience, and 11 ± 11 years of employment at their current secondary school.

DATA COLLECTION AND ANALYSIS

Semistructured telephone interviews were conducted to gain insight into ATs' documentation practices. Three researchers and 2 auditors inductively coded the transcripts using a consensual qualitative research process that consisted of 4 rounds of consensus coding and determination of data saturation. Trustworthiness was addressed with member checking, multiple-analyst triangulation, and peer review.

RESULTS

The ATs' documentation practices were largely influenced by technology, organized in 3 themes. Participants' current documentation strategies included the use of both paper and EMRs, as they found different benefits to using each platform. Oftentimes documentation practices were shaped by technological challenges, including unreliable networks, software design problems, and the lack of a streamlined approach. Lastly, participants identified future strategies for improving documentation, including the need for better EMR options and streamlining their individual documentation behaviors.

CONCLUSIONS

Many ATs wanted to incorporate EMRs in their clinical practice but faced challenges when attempting to do so. In turn, clinicians often duplicated documentation or used 2 platforms. Athletic trainers should communicate with administrators to select an EMR that fits their documentation needs and seek resources, such as network access and educational opportunities, to learn how to use EMRs.

Understanding the Athletic Trainer's Role in the Return-to-Learn Process at National Collegiate Athletic Association Division II and III Institutions

CONTEXT

Postconcussion, student-athletes should return to the classroom using a gradual, stepwise process to ensure that symptoms are not exacerbated by cognitive activities. The National Collegiate Athletic Association (NCAA) has mandated that its affiliated institutions develop return-to-learn (RTL) policies to support the return to the classroom.

OBJECTIVE

To investigate athletic trainers' (ATs') perceptions of their role in the RTL policy development and implementation at NCAA Division II and III institutions.

DESIGN

Qualitative study.

SETTING

Individual phone interviews.

PATIENTS OR OTHER PARTICIPANTS

Fifteen ATs (age = 40 ± 11 years, clinical practice experience = 16 ± 9 years, employment term = 9 ± 9 years) representing NCAA Division II (n = 6) or III (n = 9) institutions.

DATA COLLECTION AND ANALYSIS

Interviews were transcribed verbatim and checked for accuracy by the principal investigator. A 2-member data-analysis team independently coded a portion of the transcripts and then met to discuss the codebook. The codebook was applied to the remaining transcripts, confirmed, and externally reviewed.

RESULTS

Five themes emerged: (1) approach, (2) collaborative practice, (3) patient advocacy, (4) institutional autonomy, and (5) barriers. Policies must allow for an individualized, evidence-based approach through facilitated, active communication among members of the RTL team and the student-athlete. Collaborative practice was described as key to successful policy implementation and should include interprofessional collaboration beyond health care providers (eg, educating academicians about the purpose of RTL). The RTL process was triggered by a specific member of the RTL team, usually a medical doctor or the head AT. Participants noted that the purpose of the RTL policy was to advocate for the student-athlete's successful postconcussion outcomes.

CONCLUSIONS

For the development and implementation of a successful RTL policy, strong communication and interprofessional practice must extend beyond health care professionals. Members of the health care team must establish a network with academic partners to develop a policy that is appropriate for the institution's available resources and the needs of its student-athletes.

Research at the Point of Care: Using Electronic Medical Record Systems to Generate Clinically Meaningful Evidence

CONTEXT

Health care leaders have recommended the use of health information technology to improve the quality of patient care. In athletic training, using informatics, such as electronic medical records (EMRs), would support practice-based decisions about patient care. However, athletic trainers (ATs) may lack the knowledge to effectively participate in point-of-care clinical research using EMRs.

OBJECTIVES

To discuss the role of EMRs in athletic training and identify methodologic approaches to conducting clinical research at the point of care.

DESCRIPTION

The 2020 Commission on Accreditation of Athletic Training Education curricular content standards included the use of an electronic patient record to document care, mitigate error, and support decision making through the collection and use of patient data (Standard 64). Patient data are collected by ATs at the point of care via routine documentation, and these data can be used to answer clinical questions about their practice. Observational or descriptive study designs are ideal for this type of data. Observational research (ie, case-control, cross-sectional, cohort studies) evaluates factors that influence patients' lives in the "real world," whereas descriptive research (ie, case study or series, descriptive epidemiology studies) identifies characteristics of individuals and groups. If ATs are comprehensively documenting patient care using an EMR, they have the means to participate in observational and descriptive research.

CLINICAL AND RESEARCH ADVANTAGES

Using an EMR to its full capacity allows ATs to collect meaningful data at the point of care, conduct practice-based research, and improve health care for the patient and clinician. However, to ensure data quality, these approaches must include routine and comprehensive documentation habits.

Roller Massage: A Descriptive Survey of Allied Health Professionals

BACKGROUND

In sports medicine, the interprofessional care of athletes has become a frequent practice. This type of care often involves different interventions used among professionals. One common intervention prescribed is roller massage (RM) or self-myofascial release. The trends in the use of RM among allied health professionals are nonexistent. The surveillance of such responses has not been documented.

PURPOSE

To survey and document responses in the knowledge, clinical application, and use of RM devices among allied health professionals in the United States.

DESIGN

Cross-sectional descriptive survey study.

METHODS

A 20-question survey was sent to allied health professionals including physical therapists, athletic trainers, and fitness professionals. The survey covered topics such as demographics, beliefs about RM, preferred devices, exercise prescription, and client education.

RESULTS

One thousand and forty-two professionals (N = 1042) completed the survey. Most respondents believed that RM decreases pain (82%) and increases mobility (76%). A high percentage use a foam roller in their practice (81%), recommend a full-size foam roller (49%), and believe the medium density (48%) is the most effective. A high proportion of respondents prescribe RM for injury treatment (69%) and for preexercise and postexercise (61%). They also recommend rolling daily for 30 seconds to 2 minutes per muscle group (33%) at a self-paced cadence (46%). A high percentage of respondents use patient-reported outcomes (74%), joint range of motion (49%), and movement-based testing (48%) to measure effects of RM. Eighty-seven percent use live instruction to educate clients, and 88% believe there is a gap in the research.

CONCLUSION

The results of this survey document responses in the use of RM among allied health professionals. The reported responses provide insight into how professionals are using RM as an intervention and the potential gaps between the research and professional practice. Future studies are needed to further validate these findings.