A national survey of clubs medical provision and facilities in BUCS American Football 2019–2020

A range of medical personnel attended games including physiotherapists (n = 10), graduate sports therapists (n = 2), paramedics (n = 13), St Johns Ambulance First aiders (n = 1), a student in training (n = 1) and a sports rehabilitator (n = 1). No doctors were present as pitch-side first aiders.

Less than half of teams (41.9%, n = 13) reported that they had a regular team first aider who attended each week. Of all the regular team first aiders, 100% (n = 13) were reported to attend home games in the 2019/2020 season and 61.5% attended away games. However, 61.5% (n = 8) of the regular team first aiders did not attend team training. Pearson’s chi square test found no relationship between divisions and whether teams had a regular team first aider or not (p =  − 0.127). When participants were asked the highest qualification the team first aider held, in most cases, this was unknown (61.3%, n = 19), followed by postgraduates (25.8%, n = 8).

Of those teams who did not have a regular team first aider who attended training (61.5%, n = 8), medical provision was provided by a second party; a coach with first aid training (54.8%, n = 17), player with first aid training (32.3%, n = 10), reported ‘other’ (12.9%, n = 4) and an external paramedic’s company (9.7%, n = 3). Those teams, who stated ‘other’, reported relying on university facility/ground staff who were first aid trained, students studying physiotherapy and coaches who had first aid training, but the level of first aid training was not stated.

A thematic analysis highlighted prominent themes. Several barriers to medical provision were discussed, including expense of hiring medical provision, the hiring of medical personnel with a lack of reliability and/or experience of the game of American Football and lack of institutional support. However, two individual teams commented that they were successful in hiring an external party to provide medical cover.

The range of medical equipment and facilities available is summarised in Table (2).

Further findings on AED access in Table 2, the majority of teams, 74.2% (n = 23), reported their home game facility had access to an AED within 100 m of the pitch and 80.6% (n = 25) reported their training facility had access to an AED within 100 m of the pitch.

Only 83.9% (n = 26) of teams reported carrying a designated fully charged phone (with signal) which was available at each game. Of those who answered ‘yes’ to carrying this phone, 65.4% (n = 17) reported the coach as carrying this phone, followed by the medic (15.4%, n = 4), game-day staff member (15.4%, n = 4) and unknown (3.8%, n = 1).

When asked if the team had a designated medical room at their home grounds (not including a change room facility or use of a spare changing room), 61.3% reported they did not.

The majority of teams (96.8%, n = 30) reported that there was clear vehicular access for an emergency vehicle at the facility, with 76.7% (n = 23) of those respondents indicating this was with direct access to the field of play.

When asked about whether an emergency action plan (EAP), including a risk assessment, was outlined for each home game, 67.7% (n = 21) of all teams reported yes. However, fewer clubs had these documents in place for each away game, with 54.8% (n = 17) reporting they had no EAP in place for each away game.

Only 33.3% (n = 11) coaching staff reported feeling confident removing a player’s helmet and pads in an emergency, and 6% (n = 2) were not confident at all. Participants also reported on the confidence of their first aider to remove a player’s helmet and pads in an emergency. A total of 27.2% (n = 9) reported feeling very confident, and 3% (n = 1) not confident at all.

The most recurrent themes across the commentary sections for medical personnel/provision and medical facilities are outlined next and in Table 3. Medical personnel/provision included cost/funding, lack of institutional support, unreliability, lack of experience in the game and lack of knowledge of the game. With regard to facilities, teams reported institutional barriers, lack of direct access and unknown equipment carried by the first aider.

Appropriate medical provision is fundamental to the longevity of athletes’ playing careers and health when injuries occur [20, 21]. Like BAFA, other NGBs such as the Rugby Football Union (RFU) stipulate the level of medical cover required at games (including BUCS which differs across the league levels) [12, 13]. Previous research has indicated that higher leagues have access to more support staff [22]. However, this study found that there was no relationship between divisions and access to a regular team first aider suggesting that the division standing of a team has no impact on team finances or access to knowledgeable medical practitioners during games. The reason for the varied medical provision across the leagues might be explained by findings within the thematic analysis which highlighted institutional barriers as the key restriction to suitably qualified practitioners with BAF experience. One of these barriers was the cost of financing medical cover. As one participant reported, ‘the teams athletic union is responsible for paying for and arranging medical cover’, i.e. a sports therapist, paramedic, highlighting the lack of control in the selection of appropriate medical support. This statement was supported by another team who stated, ‘there’s little to support us receiving an experienced medical person to cover’. Access to medical provision for some teams is, therefore, out of the hands of the BAF BUCS team themselves who may be more aware of the intricacies of the type of medical provision that is required for BAF and so better placed to hire personnel.

Findings indicate that there is a shortage of suitable medical practitioners with knowledge of the game to cover events. Similar situations have been noted in Australia where it was reported that there was a shortage of doctors willing to cover sporting events due to inadequate remuneration, venue facilities, training opportunities in sports medicine and fear of medicolegal consequences [23]. Moreover, research in British mixed martial arts (MMAs) has found medical provision to be sacrificed in the pursuit of profit [24]. At present, it is unclear who is responsible for funding medical provision of BAF university teams; however, provision is likely organised and funded by the Athletic Union (AU) via student membership fees. Approach to hire could differ between universities. Some of these issues were raised in the qualitative comments on this survey. For example, costs were raised as a barrier to hiring suitably qualified medics. One team noted that they found them ‘unreliable’ and ‘the people they would send would have no experience or understanding of the game’. Another team noted that the ‘cost of trained professionals is a real roadblock’. However, one team had a more positive experience in hiring through an external company, whose medics were ‘suitably covered to cover away games’. This raises the question as to whether the participants fully understand what ‘suitably covered’ means. Indeed, research has found that appointments of medical staff in the Football Association (FA) and MMA are still informal and that continuous professional development (CPD) requirements are not prioritised despite the current medical regulations [25‐27]. There is, therefore, reason to believe that across sports, there is either practice of ignorance or disregard for the regulations.

The majority of teams who did not have a regular team first aid practitioner, used a coach with first aid qualifications during training (54.8%), suggesting that many coaches are recruited with first aid qualifications or complete this training during their coaching season. However, the level of qualification they hold is unknown. The British American Football Coaches Association (BAFCA) at present does not require coaches to have first aid certification, yet coaches are key personnel to have trained in first aid because they have the most regular contact with players and have influence over practice and team culture in respect of injury [28]. However, the fact that coaches are relied upon to provide medical cover is not unique to BAF. Similar trends are seen in Irish Rugby Union and English Youth Football where the majority of first aiders are coaches or officials [29, 30], which possibly compromises the level of medical care provided due to the dual roles of these staff.

A second concern is the use of players with a first aid qualification as the primary first aider at training. Almost a third of teams reported that a player provided first aid cover at training. This is poor practice, as should that player become injured themselves, there is no-one to care for them. Worryingly, this places the ‘first aider/player’ with competing priorities, such as short-term performance gains, e.g. winning vs the athlete’s welfare [31] which could be more significant within the first aider/player role. The prior 2017 BAFA policy stated that a member of the team could not be named medical cover in a game. However, the policy did not stipulate this in a training environment, when it is likely this sub-standard practice was taking place. Positively, the updated 2022 guidance states that no player nor official can participate in training and act as medical cover [32].

Some university teams are in a unique position to draw upon the support of medical students. One team commented that they have a ‘student sports therapist who attends occasional Sundays and home games’. This is beneficial to both the student experience, the teams they are supporting and in also developing a group of practitioners with BAF game experience [33]. However, these students should work under the observation of qualified practitioners, who also hold suitable insurance to allow the student to practical under their guidance [34]. It is unclear whether this is currently occurring, or whether the students are practicing on their own; however, it is not uncommon in combat sports for unqualified practitioners to work at events [27]. Secondly, it is concerning that some teams reported utilising students in a training environment, where students currently in medical training might be expected to work outside of their current and insured scope of practice. It would be advisable for the NGB to advise against the use of a student as medical provision without the support of a suitably qualified professional.

Positively, the majority of clubs had access to an AED. The ability to resuscitate those in cardiac arrest is a key consideration as use of an AED can improve survival rates [35‐37] and so is recommended to be present in every sports facility [38]. The majority of teams (74.2%) had access to an AED within 100 m of the game facility, yet only 51.6% listed an AED as available in their pitch-side first aid equipment and only 29% of staff were trained to use them. It is concerning that so few staff have training to use this equipment and only half of teams reported AED access as part of their first aid provisions. A 2009 review highlighted three areas that are critical to improving cardiac arrest survival: the presence of a trained rescuer to initiate CPR, early defibrillation, and access to on-site AEDs to initiate early defibrillation [39]. It is recognised in the commentary themes that inadequate funding is a barrier to suitable medical provision which might explain the limited pitch-side AED access.

It should be noted that innovative practice was observed within the commentary section of the survey. One team reported ‘all coaches also use the “what three words app”’, a tool designed to specify a very specific location, to support navigation in emergencies. This is a unique approach to game day practice, which is previously unknown to the researchers, yet recommendable to others to follow alongside current policy.

The level of compliance by BUCS teams is somewhat difficult to evaluate due to the role of the university AU in game day facilitation. Just over half of teams (67.7%, n = 21) had outlined an EAP for each home game, despite BAFA medical policy. However, the majority of teams (83.9%, n = 26) reported access to a designated fully charged mobile phone for game days, showing the majority of teams were compliant to only one element of BAFA medical policy in 2019/2020.

Nonetheless, it should also be noted that each individual BUCS team will be required to follow their institutions AU guidelines with respect to game-days, which further adds to the complexity of compliance. BAFA states that if their medical regulations are not met (as deemed by the game day referees), the game should be suspended or cancelled. This raises the question as to whether referees are sufficiently checking the medical provision prior to each game. League officials should look to drive best practice for player welfare as on occasions, officials may not ensure teams are meeting the minimum standards of compliance.

This survey found that 61.3% (n = 19) of the teams were unsure if the medical personnel had the required qualifications to meet the game-day minimum requirements. However, some teams may have been unaware of the first aiders qualifications despite the first aider being well qualified, particularly if medical cover is arranged through the AU. It appears that this is not unique: Coughlan et al. [30] found that many rugby union clubs were without acceptable provision for the level of competition. It could, thus, be argued that increasing the number of medical practitioners at BAF games is wise. Indeed, it has been questioned whether meeting the minimum medical standards is enough [38, 40]. Hence, revising the current medical guidelines for game day and training is advisable.

Emergency action plans (EAPs) provide guidelines to support the management of emergencies including acute injuries [39], define the procedures to be used in the acute management of injury and provide a plan for mild through to life-threatening injuries of all involved in the game [41, 42]. EAPs should be specific to the facility, population, medical personnel and documentation [43]. A lack of defined emergency procedures can increase the time delay in emergency situations, providing a poorer chance of outcome for those injured [41]. The prior 2017 BAFA medical policy stated within the minimum requirements for games that the game day medic ‘must have carried out a risk assessment’ and ‘a telephone capable to use to summon the emergency services must be available’. Yet our data has highlighted inconsistent medical care; thus, it is not clear if each new medical practitioner is conducting a risk assessment prior to a game or if the club has written their own risk assessment and that the game day medical practitioners are aware of its details. Binder [41] highlighted that identification of medical personnel is critical to success of an EAP further highlighting the need for consistent practitioners to be present. Secondly, a risk assessment differs from an EAP. The risk assessment often briefly outlines injury risk but not the procedures to follow if an incident occurs.² With 58.1% of teams reporting a lack of consistent medical cover, it could be presumed that teams lack EAPs and the practice simulation of emergency scenarios should an incident occur. This puts athletes at risk of further harm and the team staff at risk of negligence accusation due to a lack of their duty of care [41]. Simple steps can be taken through the development of emergency plans to both support and protect players and staff [41]. For example, the NGB could support the education of teams on EAP development, providing an example EAP for each team to revise for their own needs which could include step-by step plans for responding to minor and major emergencies [41].

Confidence, cohesion and trust in medical staff are important for both athletes and coaches [44‐46]. In this survey, there was a common theme of lack of game knowledge by first aiders. Whilst confidence was not directly measured, it indicates that some teams may not have been wholly satisfied that the first aider knew about the game and common injuries in BAF. Research suggests that effective teams work in a multidisciplinary manner, using open communication and having clearly defined roles [47]. Teams without a clear and consistent medical provision plan cannot hope to manage player welfare and are unlikely able to build an effective performance environment [39, 48, 49]. In order to develop the sport in this country and increase participation, strong and stable club organisation is key to development [50].

Only 38% of BUCS teams participated in this survey. Therefore, these data might not be representative of all BUCS club medical provision. However, whilst the response rate was small, they were comparable to similar audits in rugby union [22, 30], and the results and opinions should not be discredited.

Medical polices and associated practices could be supported through educational workshops and training provided by the NGB. With recognised training and qualifications in place, the NGB could stipulate in policy guidelines that only accredited qualified medical practitioners can cover BAF games. However, the practicalities of this implementation should be evaluated and discussed with all stakeholders. Implementation of appropriate medical cover would ensure that teams are adequately supported, with the correct training to deal with medical emergencies relating to the sport of American Football. Any new programmes or guidance should be reviewed on the success and uptake to support continued delivery and improvement. Further suggested policy is stated in Table 4.