Article Text

Athlete health and safety at large sporting events: the development of consensus-driven guidelines
  1. Margo Mountjoy1,2,
  2. Jane Moran2,3,
  3. Hosny Ahmed4,
  4. Stephane Bermon5,
  5. Xavier Bigard6,
  6. Dominik Doerr7,
  7. Alain Lacoste8,
  8. Stuart Miller9,
  9. Alexis Weber10,
  10. Jeremy Foster11,
  11. Richard Budgett12,
  12. Lars Engebretsen12,
  13. Louise M Burke13,
  14. Vincent Gouttebarge14,
  15. Marie-Elaine Grant15,
  16. Brian McCloskey16,
  17. Paul Piccininni17,
  18. Sebastien Racinais18,
  19. Mark Stuart19,
  20. David Zideman20
  1. 1 Bureau—Sport Medicine Liaison, McMaster University Michael G DeGroote School of Medicine, Hamilton, Ontario, Canada
  2. 2 Medical and Scientific Commission—Games Group—Sport Medicine, International Olympic Committee, Lausanne, Vaud, Switzerland
  3. 3 Medical Commission, International Skating Union, Victoria, British Columbia, Canada
  4. 4 ADU, International Handball Federation, Basel, Switzerland
  5. 5 Sports Medicine, World Athletics, Monaco
  6. 6 Sport Medicine, Union Cycliste Internationale, Aigle, Vaud, Switzerland
  7. 7 International Weightlifting Federation (IWF), Budapest, Hungary
  8. 8 Sports Medicine, World Rowing, Lausanne, Vaud, Switzerland
  9. 9 Science & Technical Department, International Tennis Federation, Roehampton, UK
  10. 10 Medicine & Science, FIFA, Zürich, Switzerland
  11. 11 Association of Summer Olympic International Federations (ASOIF), Lausanne, Switzerland
  12. 12 Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
  13. 13 Nutrition Working Group, International Olympic Committee, Lausanne, Vaud, Switzerland
  14. 14 Mental Health Working Group, International Olympic Committee, Lausanne, Vaud, Switzerland
  15. 15 Medical and Scientific Commission Games Group—Physiotherapy, International Olympic Committee, Lausanne, Vaud, Switzerland
  16. 16 Medical and Scientific Commission—Games Group—Public Health, International Olympic Committee, Lausanne, Vaud, Switzerland
  17. 17 Medical and Scientific Commission—Dental, International Olympic Committee, Lausanne, Vaud, Switzerland
  18. 18 Medical and Scientific Commission—Games Group Sport Science: adverse weather impact, International Olympic Committee, Lausanne, Vaud, Switzerland
  19. 19 Medical and Scientific Commission Games Group—Pharmacy, International Olympic Committee, Lausanne, Vaud, Switzerland
  20. 20 Medical and Scientific Commission—Games Group Anaesthesiologist and Emergency Pre-Hospital Care Consultant, International Olympic Committee, Lausanne, Vaud, Switzerland
  1. Correspondence to Dr Margo Mountjoy, Bureau - Sport Medicine Liaison, McMaster University Michael G DeGroote School of Medicine, Hamilton, Canada; mountjm{at}mcmaster.ca

Abstract

All sport events have inherent injury and illness risks for participants. Healthcare services for sport events should be planned and delivered to mitigate these risks which is the ethical responsibility of all sport event organisers. The objective of this paper was to develop consensus-driven guidelines describing the basic standards of services necessary to protect athlete health and safety during large sporting events. By using the Knowledge Translation Scheme Framework, a gap in International Federation healthcare programming for sport events was identified. Event healthcare content areas were determined through a narrative review of the scientific literature. Content experts were systematically identified. Following a literature search, an iterative consensus process was undertaken. The outcome document was written by the knowledge translation expert writing group, with the assistance of a focus group consisting of a cohort of International Federation Medical Chairpersons. Athletes were recruited to review and provide comment. The Healthcare Guidelines for International Federation Events document was developed including content-related to (i) pre-event planning (eg, sport medical risk assessment, public health requirements, environmental considerations), (ii) event safety (eg, venue medical services, emergency action plan, emergency transport, safety and security) and (iii) additional considerations (eg, event health research, spectator medical services). We developed a generic standardised template guide to facilitate the planning and delivery of medical services at international sport events. The organisers of medical services should adapt, evaluate and modify this guide to meet the sport-specific local context.

  • elite performance
  • health
  • injury prevention
  • public health
  • illness

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Introduction

The Olympic Games is the ultimate sporting event which for many athletes is the pinnacle of their sporting career. To qualify for the Olympics, athletes must compete in International Federation (IF) sporting events during the time period in-between the Games. While television and social media audiences around the globe are entertained by the athletes’ acts of physical prowess on the fields of play, behind the cameras there are large numbers of sport medicine experts working as a team to achieve the goal of protecting the health and safety of all participants. The protection of athletes’ health and well-being is the responsibility of all members of the athlete entourage1 and is mandated in a variety of normative frameworks including the Olympic Movement Medical Code,2 the Athlete’s Rights and Responsibilities Declaration3 and the Olympic Charter, which defines the mission and role of sport to include the obligation ‘to encourage and support measures relating to the medical care and health of athletes’.4

For the Olympic Games, the Medical and Scientific Department of the IOC, in collaboration with the host country medical services, are responsible for the planning and delivery of the Games-time healthcare programme. However, for IF sport events occurring between editions of the Olympic Games, the governing IFs’ medical committees take responsibility for liaising with local host city healthcare personnel and systems to meet the sport-specific health demands of their events. In the planning period prior to, and during the Olympic Games, the IOC relies on the IFs to provide sport-specific and event-specific healthcare requirements, health-related rules and regulations and the identification of high-risk events.

To accomplish the goal of delivering an optimal healthcare programme during the Olympic Games, various planning meetings occur in a 4-year time period prior to the Games to facilitate knowledge translation, foster collaboration and ensure adequate time and resources for acquiring appropriate equipment and drugs as well as recruiting and training personnel. Prior to the XXXII Olympic Games (Tokyo 2020), one such meeting of the IF Medical Chairpersons and the IOC Medical and Scientific Commission leadership was held in Lausanne, Switzerland in October 2019. On consultation with the Medical Services Department of the Tokyo 2020 Olympic Games, it became evident that the IFs were either not submitting sport-specific healthcare plans or were submitting healthcare plans that were often incomplete with inconsistent requirements. This deficit and discrepancy in the quality of IF event healthcare planning, prompted the decision to develop evidence-based guidelines to assist the IF medical committees in their planning of IF event healthcare. Therefore, to address the identified problem, the objective of this paper was to develop consensus-driven guidelines describing the basic standards of medical services necessary to protect athletes’ health and safety during large sporting events.

Although originally developed for IF sporting events, this paper is also intended to facilitate the coordinated planning and implementation of healthcare initiatives for major event organisers (eg, Commonwealth Games, Beach Games and so on), Continental Championships (eg, Asian Games, Pan American Games and so on), professional sport organisations (eg, NHL, NBA and so on) and other large sporting events (eg, mass participation marathons, Ironman races and so on).

Methods

Theoretical framework

The theoretical framework underpinning the development of the Healthcare Guidelines for IF Events was the Knowledge Transfer Scheme by Verhagen et al, which was designed to accommodate a ‘bottom up’ approach to implementing change.5 As indicated in figure 1, the impetus for developing an intervention for change can be motivated by real-life situations or ‘practice’ to identify the gap or problem, which then subsequently drives the evidence-based and experience-based approach to knowledge translation and implementation into practice. This approach is in contrast to the ‘top down’ approach, where the research or policy agenda drives knowledge translation into practice.5 For this project, the identified gap in the practice of IF medical committees stimulated the development of the ‘intervention for change’: an evidence-based and experience-based guideline document of healthcare requirements and considerations for sport organisations to facilitate the development and implementation of comprehensive healthcare programmes for large sporting events.

Figure 1

The five-step Knowledge Translation Scheme.5

Step 1: identification of the gap

The genesis of the Healthcare Guidelines for IF Events began in August 2019 when planning the agenda for the IF medical chairpersons’ workshop. A 2-day workshop on the medical planning for the 2020 Tokyo Olympic Games was held in Lausanne, Switzerland in October 2019, under the leadership of the Association for Summer Olympic International Federations’ Science and Medical Consultative Group in collaboration with the IOC Medical and Scientific Department. Medical representatives from 22 summer IFs and 2 winter IFs attended, in addition to experts from the IOC Medical Games Group, the Association of Summer Olympic International Federations, the International Testing Agency and international content-expert speakers. The objectives of the IF workshop were to:

  • define the roles and responsibilities of medical personnel at the Olympic Games;

  • examine best practices for venue medical services and field of play emergency care at Olympic and IF events;

  • collaborate with the IOC and the Tokyo 2020 Organising Committee on athlete health care-related planning and medical services provision for the 2020 Olympic Games;

  • encourage the sharing of IF best practices and collaborations.

Agenda topics included Tokyo 2020-related field of play emergency evacuation plans, medical emergency action plans, health risk assessment modelling, public health risks, prevention and management of environmental heat-related health issues and athletes’ travel health and safety. The Tokyo 2020 medical team presented a summary of the IF medical guidelines they had received. It became evident that the IFs were either not submitting sport-specific healthcare guidelines or were submitting guidelines that were lacking key content areas and with inconsistent requirements. During the workshop process, the IF medical Chairpersons were asked to evaluate their own respective guidelines for completeness, and following discussion, they identified significant gaps and inconsistencies in their medical guidelines and implementation practices for healthcare programmes at international sporting events. This gap stimulated the development of the intervention to mitigate these inconsistencies. Therefore, to address the identified gap, the objective of this paper is to describe the development of consensus-driven guidelines outlining the basic standards of medical services necessary to protect athlete health and safety during large sporting events.

Step 2: identification of the content areas for inclusion

Content areas for inclusion in the Healthcare Guide were identified following a narrative review of the scientific literature on Mass Gathering Medicine from both outside of sport,6 and from inside sport.7 Two IFs had published event medical guidelines (FINA-aquatic sports8 and IHF—handball9), which were also reviewed. The IOC circulates unpublished Games-specific health information to IFs and National Olympic Committees. The 201610 and 201811 versions of this document were included in the literature reviewed. Topic areas related to the provision of healthcare services for athlete injury and illness were determined following a review of epidemiological studies on the risk of injuries and/or illnesses during the Olympic Games,12–19 Continental Games20 and Olympic IF sport events.21–59 Based on this review, the content areas were then chosen by consensus by the sport medicine physician members of the core writing group with experience at IF events and Olympic Games (MM, JM, RB, LE).

Step 3: identification of the content expert working group

Once the content areas were finalised, criteria were identified to determine the content experts who would form the Knowledge Translation Expert Working Group. For details, please see table 1. Experts were required to have a minimum of four criteria for inclusion in this Group.

Table 1

Criteria for the identification of content experts to form the Knowledge Translation Expert Working Group

Step 4: literature review

The content experts of the Knowledge Translation Expert Working Group were tasked with conducting a narrative review of the scientific literature to identify evidence-based recommendations in their respective content areas. In addition, they were requested to also collate best practice principles from their extensive practical experience from implementing healthcare programmes at international sporting events.

Step 5: iterative development process to meet consensus

An initial draft was written by the project lead (MM) to provide a template for the structure, scope and style of the Healthcare Guidelines for IF Events publication. Through remote collaboration, the Knowledge Translation Expert Working Group drafted their contributions within their specific area of expertise. A consensus was then reached through an iterative process involving the Knowledge Translation Expert Writing Group and a Focus Group consisting of a cross-sectional cohort of the 28 Summer IF Medical Chairpersons who constituted the Association of Summer Olympic International Federations Medical and Scientific Consultative Group (Handball, Athletics, Cycling, Weightlifting, Rowing, Tennis, Football). The IF Focus Group completed the first review and provided feedback addressing content quality and comprehensiveness, as well as resonance and practical applicability from their experience. This feedback was then collated in the second draft of the document which subsequently underwent a second round of review by the IF Focus Group. Following this round of feedback, the final document was reviewed by all members of the Knowledge Translation Expert Working Group and the IF Focus Group prior to formatting and publication. To obtain the athlete’s perspective, Athlete Commissions of the (i) IOC, (ii) the Focus Group IFs and (iii) 2 Continental Federations (Asia and Americas) reviewed the final version and provided comment at this stage. For details, please see figure 2.

Figure 2

The process for the identification of the gap, determination of areas of content and development of the Knowledge Translation Expert Working Group, literature review and development of the athlete healthcare guidelines for international sport events. ASOIF, Association of Summer Olympic International Federations; IF, International Federation.

Step 6: implementation

The Healthcare Guidelines for IF Events was launched in both hard cover and on-line versions at the IOC-IF Medical Chairperson meeting held in Monaco in March 2020. The IF Medical Chairpersons were advised to adapt the document with their own sport-specific rules, regulations, examples and branding for implementation in the upcoming sport season. Implementation of such guidelines is a complex and contextual process which should be objectively evaluated for efficacy. A follow-up study is planned to evaluate the IF uptake and implementation of the Healthcare Guidelines for IF Events.

Athlete and entourage involvement

Athlete collaborators included representatives of the Athletes Commissions of the (i) IOC, (ii) the Focus Group IFs, as well as (iii) two Continental Federations (Asia and Americas). They reviewed the Healthcare Guidelines for IF Events for relevance and provided comment. Retired elite athletes and members of the athlete entourage (eg, sport medicine physicians, representatives from international sport governing bodies, sport dentistry, sport physiology, sport physiotherapy) participated in the concept development, preliminary exploration phase, literature review, drafting and review and launch phases.

Results

Step 1: identification of the gap

Throughout the course of discussions during the Olympic Games IF workshop in Lausanne in October 2019, it became evident that (i) many IFs had not provided the Medical Services Department of the Organising Committee of the Olympic Games with sport-specific medical and safety guidelines for their respective sports, and (ii) many IFs had incomplete medical and safety guidelines for their respective sport events. For example, only 32% of attending IFs had emergency action plans for their sport disciplines, and just over half (53%) had defined sport-specific field-of-play evacuation procedures. Only two-thirds of IFs (65%) held scenario-based simulations of emergency procedures and 53% had standardised guidelines for the mitigation of environmental risks such as heat exposure. When the IF Medical Chairpersons were asked to identify essential components of their healthcare guidelines, many reported deficiencies in defining required medical equipment (62%) and sport-specific recommended pharmaceuticals (87%).

Steps 2 and 3: content areas and Knowledge Translation Working Group

Table 2 summarises the results of the process undertaken to identify (i) content areas for inclusion in the Healthcare Guidelines for IF Events document and (ii) expert members of the Knowledge Translation Working Group.

Table 2

Content areas for inclusion in the Healthcare Guidelines for International Federation Events, as well as content experts constituted to participate in the Knowledge Translation Expert Working Group

Steps 4 and 5: development of the healthcare guidelines document

Each of the content experts conducted their own narrative literature review to develop a draft of evidence-based and experience-based recommendations for their respective sections. The iterative process for obtaining consensus, as well as the IF Focus Group and the athletes’ review is described in the ‘Methods’ section. The outcome of the processes of steps 4 and 5 is the Healthcare Guidelines for IF Events (see figure 3).

This publication consists of comprehensive guidelines to assist the medical committees of sport organisations and sport event organising committees with the planning of healthcare services for international sport events. The document is designed to provide flexibility for users to adapt and customise the guidelines according to the sport-specific health risks, the age of the athlete participants, the size of the event and the geographical location. Table 3 outlines the contents of the Healthcare Guidelines for IF Events document. The complete document can be accessed in the online supplemental file 1 and at: http://www.asoif.com/sites/default/files/download/health_care_guidelines_for_international_federation_events.pdf

Supplemental material

Table 3

Contents of the Healthcare Guidelines for International Federation Events

Discussion

The Healthcare Guidelines for IF Events intervention was stimulated from the ‘bottom up’ finding of significant gaps and inconsistencies in IF medical guidelines and implementation practices for healthcare programmes at international sporting events. This finding was surprising, considering the results of a 2018 survey of the same cohort of IF Medical Chairpersons which found that ‘First aid minimum standards at events’ was ranked by all IFs as being either ‘very important’ or ‘important’. When asked to self-rate the sufficiency of their activities, all IFs reported that ‘First aid minimum standards at events’ were sufficient.60 The authors of this survey, however, did not corroborate the self-analysis of the IFs. In the ‘real life’ example identified in this paper, at the practical level, the IF guidelines for healthcare at sport events were found to be incomplete, underpinning the importance of understanding the barriers to knowledge translation and evaluating the implementation component of knowledge translation.61 62 The reasons for this discrepancy may be due to a knowledge gap for what constitutes a robust healthcare plan for sporting events, or a lack of resources, such as expertise or finances, to develop sport-specific healthcare guidelines for events.

The Knowledge Translation Scheme provided a useful framework to guide the development of Healthcare Guidelines for IF Events—particularly as the gap was identified from the ‘bottom up’ perspective. A strength of this theoretical framework is the organisational structure provided by the five-step process; however, modifications were required to operationalise the process to best reflect the identified gap and desired outcome.

The consensus method chosen to develop the Healthcare Guidelines for IF Events was a modified NIH Consensus Development Conference.63 This methodology proved feasible and successful for the inaugural edition. As the Healthcare Guidelines are adopted, implemented and evaluated, future editions may be developed using a more formal method such as a Delphi exercise.64

A limitation of this paper is that only published guidelines for the healthcare delivery at sport events were reviewed. While it is possible that unpublished guidelines exist, these were not analysed; however, the IF Medical Chairpersons provided a self-report analysis of their guidelines during the workshop. In addition, while active athletes reviewed the draft guidelines for comment and resonance, in future editions of the Healthcare Guidelines for IF Events, the authors might explore the engagement of athletes and coaches earlier in the development process. Another limitation is that the content experts did not conduct a systematic review of the literature in their respective areas, as this was beyond the scope of this project.

Implementation evaluation

While the Knowledge Translation Scheme was found to be an effective framework to support the implementation of this project, a limitation of this paper is the lack of evaluation of the uptake and feasibility of the intervention that was developed to stimulate change in the activities of IF medical committees. Evaluation is the final step of the Knowledge Translation Scheme.5 The effectiveness of the Healthcare Guidelines for IF Events document should be objectively analysed using a systematic theoretical evaluation model such as the RE-AIM framework by Glasgow et al,65 66 which assesses five parameters: Reach, Effectiveness, Adoption, Implementation and Maintenance. Through this evaluation process, strengths can be identified, as well as areas requiring modification, which will inform the development of future editions of the Guidelines, and ultimately improve uptake, implementation and effectiveness.

Conclusions

The Healthcare Guidelines for planning, delivering and evaluating healthcare services at IF sport events was designed to bridge the gap that exists between best practice evidence and the current state. We employed a ‘bottom up’ theoretical framework of Knowledge Translation Scheme5 to develop a practical guideline document for international sport event organisers. As sport organisations have the duty of care to safeguard the health and safety of participating athletes, these Guidelines should be adapted to fit the sport-specific injury risks and healthcare demands, event size and geographical location. It is our objective that the Guidelines be implemented in the ‘real world’ of large and/or multidisciplinary international sporting events.

According to the IOC Athletes’ Rights and Responsibilities Declaration, all athletes have the right to ‘The protection of mental and physical health, including a safe competition and training environment…’3 It is the goal of the Knowledge Translation Expert Working Group and the IF Focus Group to help sport organisations achieve this right through the effective implementation of the Healthcare Guidelines for IF Events document. Athletes and all accredited participants at international sport events will potentially benefit from the application and implementation of this guideline document.

Acknowledgments

The authors would like to thank the International Federation Medical Chairpersons who attended the planning and launch meetings for their valuable feedback, encouragement and ultimately for their future implementation of these health guidelines at their respective International Federation sporting events. The authors would also like to thank the ASOIF President, Executive Director and Council for approving the project and supporting the graphic design of the final version.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Twitter @margo.mountjoy, @profhosny71, @larsengebretsen, @ephysiol

  • Contributors MM: first author, substantial contributions to conception and design, drafting and revising the manuscript and approval of the final version to be published. RB, LE, JM, LMB, VG, M-EG, BMcC, PP, SR, MS and DZ: members of the expert working group who provided expert-related content, revised the manuscript and approved the final version. HA, SB, ZB, DD, AL, SM and AW: members of the focus group who reviewed and revised the manuscript, and approved the final version. JF: substantial contribution to design and proofing of the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Research ethics approval was not required as this project is a knowledge translation initiative.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.