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Abstract
The cessation of amateur and recreational sport has had significant implications globally, impacting economic, social and health facets of population well-being. As a result, there is pressure to resume sport at all levels. The ongoing prevalence of SARS-CoV-2 and subsequent ‘second waves’ require urgent best practice guidelines to be developed to return recreational (non-elite) sports as quickly as possible while prioritising the well-being of the participants and support staff.
This guidance document describes the need for such advice and the process of collating available evidence. Expert opinion is integrated into this document to provide uniform and pragmatic recommendations, thereby optimising on-field and field-side safety for all involved persons, including coaches, first responders and participants.
The nature of SARS-CoV-2 transmission means that the use of some procedures performed during emergency care and resuscitation could potentially be hazardous, necessitating the need for guidance on the use of personal protective equipment, the allocation of predetermined areas to manage potentially infective cases and the governance and audit of the process.
- sport
- protective clothing
- communicable disease
- cardiology
- paediatrics
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Background
Recent recommendations to mitigate the risk of COVID-19 (the clinical illness caused by SARS-CoV-2) in sport are personnel, resource and investigation intense.1–4 They are primarily aimed for the higher echelons of sport, in which organisations have more resources available. It is recognised that the level of medical provision/first aid below the elite level varies between different governing bodies, sporting levels, settings and countries. Standardised guidance could help to mitigate the risk of COVID-19 spread in these sporting environments.
An iterative process was performed working with high-profile sports and exercise medicine (SEM) organisations and SEM clinicians to establish best practice recommendations. This was with particular consideration for the resources likely to be available at the non-elite level of organised sport to maintain pitch-side safety for clinicians, first aiders and participants. This paper describes the process of formulating the guidance for non-elite sport made available online5 and serves as an accompaniment to recently published consensus guidelines for elite sport.2–4
Objectives
Many professional sports leagues and competitions have resumed after a COVID-19 lockdown. These elite levels of sport may operate under different circumstances from normal, the most notable of which is the absence of spectators. Acknowledging the physical, social and financial benefits of sports participation, some non-elite sport have followed suit and resumed under modified conditions, but a significantly high prevalence of the SARS-CoV-2 virus remains in many communities and countries. Even in areas where the rise in COVID-19 cases has initially been contained, subsequent waves of infection have been reported.6–8 At elite level, with greater resources and jurisdiction over professional players, the ability to mitigate the risk of infection is greater. These include the introduction of the concept of the ‘biologically safe environment’ or ‘bio bubble’, precompetition medical examinations, readily available medical care and regular diagnostic testing such as reverse transcription polymerase chain reaction (RT-PCR) tests and enzyme-linked immunosorbent assay (ELISA) antibody tests for SARS-CoV-2.9–11 Without these additional and stringent protective interventions, players and medical support teams at the non-elite level are at greater danger of contracting and transmitting SARS-CoV-2. In such environments, pitch-side preparation and precautions assume even greater importance than at the elite level. This guidance seeks to set minimum standards by which the safest possible environment can be created for the return of non-elite sport.
Stakeholder involvement
Similar to the process followed for the elite sport interassociation consensus, which used Public Health England (PHE) policy and the UK Government guidance on return to sport and recreation,2–4 12 agreement was sought from high-profile UK sports associations and SEM bodies, supported by international SEM institutes. Recommendations were devised for pitch-side emergency care based on published data specific to COVID-19. Where this was not available, expert opinion was obtained. An expert was defined as a medical specialist in SEM, cardiology, respiratory medicine, paediatrics or epidemiology, who works with elite athletes and has had at least 10 years’ experience in their field.
The process was facilitated by the medical education lead of the Football Association using an iterative process, over a period of several months during mid-2020, building off consecutive contributions by each participant, submitted in an edited document via email. The following UK sporting associations were represented: The English Football Association, The English Rugby Football League, The Scottish Football Association, The Lawn Tennis Association, The Welsh Rugby Union and Scottish Rugby, supported by these UK and international SEM bodies: The English Institute of Sport, The Scottish Institute of Sport, Federation Internationale de Football Association, the South African Rugby Union and Wits Sport and Health, University of the Witwatersrand, South Africa.
The target users are medical support teams and first aiders operating field side in non-elite sport, across all sporting codes, as well as their educating bodies. These recommendations provide structures where healthcare professionals (HCPs) are provided (tier 1) and emergency care is provided by first aid responders (tier 2). These may include lower league professional teams, amateur leagues, universities and schools.
Development and methods
Guidance documents from PHE, The Health and Safety Executive (UK) and the UK Government were collated along with those published from other international sporting bodies and those from relevant UK Royal Colleges updated to reflect COVID-19 changes. A thorough search of peer-reviewed papers was conducted during the periods June–August 2020, using the MEDLINE database. Search terms used were ‘SARS-CoV-2’ OR ‘COVID-19’ OR ‘Coronavirus’, AND ‘emergency first-aid’, OR ‘sports first-aid OR ‘personal protective equipment’, OR ‘sport’, OR ‘athlete’, OR ’sport and recreation’, OR ‘return to training’, OR ‘exercise’, OR ‘trauma care’, OR ‘resuscitation’, OR ‘cardiovascular’, OR ‘respiratory’, OR ‘first aid’, OR ‘sanitisation’ OR ‘decontamination’. The references of each paper were examined for additional relevant articles.
Evidence was sought to provide insight into the transmission of SARS-CoV-2, the protective effects of a range of personal protective equipment (PPE) and practices, incubation periods postinfection, potential systemic effects of COVID-19 (especially respiratory and cardiac) and return-to-sport guidelines.
Current evidence was strongest for the respiratory and cardiovascular implications of COVID-19,13 14 although in non-sporting populations. The unique context of sport in the COVID-19 pandemic has meant that little published evidence exists regarding best practice so expert opinion was sought from experienced field-side clinicians against this novel epidemiological backdrop. External clinical review was provided by UK and internationally based SEM experts asked to critically evaluate the guidance, provide further recommendations and, where required, suggest additional source references. The recommendations were shared with the author group for consideration in the next revision. All co-authors agreed on the final guidance. The reliance on expert opinion is a necessary limitation of this document, and as such will necessitate regular updating as new evidence emerges. The high infectivity of SARS-CoV-2, the exponential surge in cases worldwide, the potential severity of infection and the impending resumption of all levels of sport, necessitated urgent guidance despite these limitations. Even without robust data, facilitating best practice that protects participants and avoids disease transmission outweighs the risks of medical and first aid staff acting without protection, risking their health and their ability to provide ongoing care for those in the sporting environment. Importantly, many of the recommendations may be appropriately applied in future epidemics.
Managing participants’ welfare in non-elite sport may vary considerably from elite level, where stricter guidance and more defined parameters are maintained in a controlled environment. Nevertheless, it remains the responsibility of all first aid and healthcare providers to remain up to date with PPE recommendations and return to participation, regional or devolved national, public health and government authority guidance on COVID-19 guidelines and updates.
Participant risk reduction
Advise participants to complete a self-screening questionnaire prior to attendance (table 1) as a means of minimising those with possible COVID-19 or suspected COVID-19 attending a training session or competition. This aims to minimise transmission risk through sporting activity and may be pencil and paper or electronic app based.
Example of a self-screening check list prior to each session
Governance
Appoint a COVID-19 compliance officer who must be responsible for implementing and recording all recommended protocols.
Conduct an emergency and first aid risk assessment, amending emergency action plans (EAPs) to mitigate identified risks; include modifications to the emergency/first aid kit, provision of PPE and plans should individuals present with symptoms in a session.
All HCPs and first aid responders should be aware of all EAPs before entering the environment for the first time.
Attempts should be made to identify individuals involved in the sporting environment who may be considered to be at a higher risk of severe COVID-19 infections15 and mitigation strategies applied as appropriate.
Para-sport athletes and those participants with underlying health conditions are recommended to undertake a preparticipation check with an HCP to determine their own personal risk, health and vulnerability.
Organisations should keep a clear record of who was present on site to support national track and trace systems in the event of a positive COVID-19 case.
Refer to table 2 for guiding principles on making an environment COVID-19 safe.
Safe practices and personal protective equipment
Isolation procedures
Should a participant return a positive response to any of the criteria in table 1, they should stay home and follow the government issued self-isolation guidance as applicable.16
If a participant develops or displays COVID-19 symptoms during a session, they should be separated from the wider group for broader public safety and placed in an identified quarantine zone. If they require medical assistance, emergency services should be called. If they are well enough to travel home, they should do so in their own vehicle or with a household member. Participants should follow close contact principles and seek COVID-19 testing based on local availability and guidance. Other participants and coaches present would not need to automatically quarantine unless they developed symptoms, provided they have been compliant with physical distancing precautions.17
For children, it is recommended a member of their household remains nearby at sessions; thereby, in cases of illness or injury, the child can be taken to a place of safety at the earliest opportunity. If there is no parental/guardian support at the training venue, adequate first aid should be applied, and the child placed in the identified quarantine zone until an appointed emergency contact can collect them. For illness or injury concerning adult participants, if safe to do so, they should leave the facility without coming into contact with anyone. Where shared journeys are unavoidable, a face mask should be worn. All individuals should access relevant medical support as needed.
Participants returning to sports training who have had COVID-19 infection
Participants returning to sport after prolonged absence and those with confirmed or suspected COVID-19 infection should undergo a clinical assessment including a detailed history and examination by a medical professional. For the majority of participants who rely on their own means, we recommend a self-assessment algorithm that reflects the principles of the assessment of elite athletes, as suggested by Bhatia et al.18 This is a pragmatic approach that balances the likelihood of cardiac sequelae from the COVID-19 infection - and potential limitations of detailed cardiac testing in this population. It is necessary in order to encourage individuals back to safe exercise and avoid unnecessary anxiety and investigations in already overburdened healthcare systems (figure 1).
Cardiac investigations/referral for all regular exercisers and amateur athletes prior to returning to training. This protocol has been endorsed by Cardiac Risk in the Young.49
Following COVID-19 infection, participants should self-isolate for 10 days19 and not engage in exercise until they have been symptom free for 7 days.20 Participants experiencing cardiac symptoms including an elevated resting heart rate after the acute infection has resolved should seek specialist medical attention prior to return to exercise.18 20 On gradual return to training,21 self-monitoring for the occurrence of cardiac symptoms such as chest pain, palpitations, breathlessness disproportionate to the level of activity, exertional dizziness and syncope (figure 1) and monitoring for arrhythmias through a heart rate monitor (for those who have one available) is pragmatic. Participants with new symptoms or irregularities in their heart rhythm should cease exercise and liaise with their doctor. For those who never experienced symptoms, no cardiac evaluation is necessary prior to resumption of training, unless they develop new symptoms on a return to physical exertion.18
Guidance for non-elite clubs with designated HCPs: tier 1
Clinicians with a duty of care acting as a registered therapist or doctor should follow national public health guidance, conducting their own risk assessment and ensure they follow full PPE guidance as above.
Delivery of emergency care in the non-elite setting: tier 1
HCPs are expected to provide care equivalent to their level of training, which may include advanced first aid and thus potentially aerosol-generating ventilatory support.
Aerosol-generating procedures (AGPs) are recognised to be a high source of virus transmission requiring level 3 PPE. Sports-related medical care includes many scenarios that are or have the potential to become AGPs (table 3). Once an AGP is commenced, all involved that are not in level 3 PPE must step back 2 m when outdoors and vacate the room when indoors.22
Classification of aerosol-generating procedures (AGPs)
The response time for a medical emergency needs to be appropriately risk assessed with the addition of time taken to don appropriate PPE; this is imperative when considering airway interventions, chest compressions and all clinically relevant scenarios (table 4). As time is critical in determining successful outcomes, it is recommended that staff should either be wearing or have access to appropriate levels of PPE in a time frame that will not detrimentally affect the outcome of the clinical situation. Individual donning times will vary according to experience and the availability of ‘donning buddies’.
Potential situations and injuries that can occur during sport with associated PPE guidance
Medical treatment rooms in the non-elite setting: tier 1
If treatment rooms are used, physical distancing must be followed (table 5). The environment must be maintained to public health standards after each participant.23 Non-essential manual therapy is not recommended. When performing essential physiotherapy or soft tissue treatment appropriate PPE must be worn throughout. Should a participant require an assessment of their head, inclusive of face, mouth or nose, HCPs must wear, in addition to the PPE above, a fluid resistant visor or goggles23 (level 2, table 6). Personal spectacles are not considered equivalent. This needs to be a part of the club EAP.
Designated medical areas for tier 1
Definition of situational personal protective equipment level requirements (also refer to figure 2)
Illustration of personal protective equipment (permission to use from the Lawn Tennis Association (LTA)).
Optimised pitch side emergency first aid cover should consist of:
One appropriately trained responder (appropriately trained responders are those HCPs with any relevant and valid additional qualification in sports emergency or first aid training provision) in level 2 PPE with the ability to don level 3 with minimal delay, if required. For example, having additional available PPE on person or in the emergency pitch side bag.
One appropriately trained responder (appropriately trained responders are those HCPs with any relevant and valid additional qualification in sports emergency or first aid training provision) who is either already wearing or has immediate access to level 3 PPE and can respond immediately.
Additional support personnel that can don the appropriate level of PPE to assist in a medical emergency with minimal delay, when required.
Additional (support) personnel that can don the appropriate level of PPE to assist with extrication.
Please note: where a risk assessment of club facilities, emergency equipment and staffing levels concludes that level 3 PPE is beyond their clinical scope of care this should be clearly reflected in the club medical EAP. A detailed course of action that should include calling for an ambulance and providing the care that can be provided until the ambulance arrives.
Guidance for non-elite clubs with designated first aid responders: tier 2
First aid falls into two parts:
Those who respond because of an emergency arising in front of them (lay-responder) including sports coaches.
Allied HCPs contracted solely as first aiders or designated first aid responders with a duty of care (workplace first aiders).
The first duty of care as first aider or coach is to themselves, and it is imperative that all advised precautions are taken.24–27 The vast majority of incidents encountered in training may be managed with sensible planning allowing treatment to occur effectively without breaching physical distances. However, delivery of emergency first aid may necessitate the responder to breach advised social distancing guidance with a potentially injured participant, and this may include cardiopulmonary resuscitation (CPR). In the first instance, when a participant requires assistance, ideally a member of their household can aid them. All others should physically distance unless a life or limb-threatening injury necessitates emergency care.
If a first aider is present, they should be equipped with the appropriate PPE in the event that they need to compromise physical distancing to provide assistance. First aiders need to remain up to date on first aid procedure during the pandemic (table 7).28
COVID-19 update on first aid requirements
The advice for lay people and coaches with no formal duty of care or role in first aid delivery deviates slightly from those with a clearly defined pre-arranged role.27 Please refer to your club health and safety officer and your club’s EAP for COVID-19 changes, as well as this guidance to inform your planning and sessions.
Additional information for designated first aid responders in the non-elite sports setting: tier 2
Participant contact occurring while delivering emergency first aid care will need to follow PPE guidance,29–32 in line with public health recommendations:
The use of PPE is both to protect the responder from the participant and to protect the participant from the responder.
Where it is not possible to always maintain the government advised physical distance from a participant, the responder should wear PPE as advised under as per table 6.
Guidance for non-elite sport medical and first aid responders in on-field emergency situations
It must be remembered one can never be certain that a participant does not have COVID-19, even in absence of symptoms. The following guidance is based on risk mitigation and the assumption that someone could be infected during all medical and first aid provision.
Cardiopulmonary resuscitation
Cardiac function may be compromised by COVID-19, and sudden cardiac arrest is a medical emergency that can occur during sports participation.33 Therefore, each club must amend their EAP, carefully considering updated precautions for this period.
Some resuscitation advisory groups differ regarding chest compressions as AGPs due to limited data and uncertainty regarding risk.2 3 34–38 The group felt it prudent to follow the most protective advice in these unprecedented times. Automated external defibrillators (AEDs) are not considered as AGPs and considering most sports environments use AEDs, the sport guidance has been adapted to suit the needs.
Special considerations for all non-elite youth (under 18 years) sport
It is very likely in the sports setting that the child participant is well known to the responder and to avoid performing ventilatory support might not be an option they wish to make, despite the increased risk. As most common causes of cardiac arrest in children differ from those in adults, ventilation can be imperative to the chance of survival.39 For those not trained in paediatric resuscitation, the adult process can be followed. Ensuring treatment is provided quickly is most important.
For other injuries that occur in non-elite sport settings, appropriate management and advised PPE during the COVID-19 pandemic, refer to box 1.
Cardiac arrest changes for adults and youth (also refer to figures 3 and 4 for algorithms)
Summary of changes for adults
In the absence of level 3 PPE commence compressions with a cover over the participant’s face so as to minimise delay. Examples: a non-rebreather mask with oxygen attached (for HCPs) or a towel (for first aid responders.) The towel should provide sufficient cover to cover the patient’s mouth and nose while still permitting breathing to restart following successful resuscitation.32
HCPs should consider the use of bag mask ventilation with a viral filter34 where rescue breathing is required.
If rescue breathing is considered outside the scope of first aid practice during the pandemic due to the high risk of viral transmission, perform chest compressions only.34–36 Compression-only CPR may be as effective as combined ventilation and compression in the first few minutes after cardiac arrest.34
All other participants and individuals involved in the training session should be asked to vacate the vicinity if they are not involved in the resuscitation.
Responders are ideally already in level 2 PPE if available, and all other helpers are advised the same (or should apply quickly to not delay treatment) while awaiting support responders who are in level 3 PPE (this may require awaiting an ambulance) to provide rescue breathing.
After performing compression-only CPR, all rescuers should wash their hands (and face if no mask or eye protection worn) and should also seek advice from the local healthcare advice service or club medical adviser if later concerned about COVID-19 symptoms.
Summary of changes for those under 18 years of age
If the decision is made to perform rescue breathing, the responder should use a face shield or pocket mask with a one-way filter valve.41-43
For HCPs, a bag valve mask with viral filter is preferable.41
Providing rescue breaths will increase the risk of transmitting the COVID-19 virus, either to the rescuer or the participant. However, this risk is small compared with the risk of taking no action as this will result in certain cardiac arrest and the death of the child.43,54
Early chest compressions (with face coverings as above), AED application and ensuring medical help/emergency services are alerted.
Regarding transmission, if rescue breathing has been used during a resuscitation, there are no additional actions to be taken other than to monitor for symptoms of possible COVID-19 over the following 14 days, assuming the individual did not subsequently test positive.48
Adult emergency and first aid care algorithm for non-elite sport during COVID-19 in absence of level 3 PPE. PPE, personal protective equipment.
Paediatric emergency and first aid care algorithm for non-elite sport during COVID-19 in absence of level 3 PPE. AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; PPE, personal protective equipment.
Conclusions
Any sporting event involving individuals in close proximity taking place during the COVID-19 pandemic significantly increases the risk of viral transmission. This non-elite guidance format is deliberately aimed at scenarios where there may be less regulation, support and medical expertise making implementing risk reduction more challenging (see table 8 for summary of key points). In addition, emphasis is placed on management protocols where only first aid responder rather than HCP expertise is accessible. Modifications to recommendations may be required depending on the specific sport, setting and resources, while acknowledging the need to accede to regional and national authority regulations.
Summary of the key recommendations for non-elite sport first aid and medical care in a COVID-19 environment
Ethics statements
Patient consent for publication
Footnotes
Twitter @drccowie, @andy_massey, @dundeesportsmed, @jonpatricios
Contributors LH and GP conceived the theme; JP served as senior author and designed the article framework; LH and GP drafted the initial manuscript; RS, SaS, MP and MR contributed to the design and content in there specific areas of expertise and practice. CR, CMC, AM, RW, PM, JG, JM, NE, JH, SiS and RJ gave sport-specific insights. All authors analysed the document through four rounds of redrafting and gave final approval before final submission.
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.
Provenance and peer review Not commissioned; externally peer reviewed.
Author note This position statement is endorsed by: The English Football Association, The English Rugby Football League, The Scottish Football Association, The Lawn Tennis Association, The Welsh Rugby Union and Scottish Rugby, supported by these UK and international sports and exercise medicine bodies: The English Institute of Sport, The Scottish Institute of Sport, FIFA, The South African Rugby Union and Wits Sport and Health, South Africa.