Extracts of RFU Report – (138 Page Report) Catastrophic Injury Task Group Report to Management Board April 2007 DEFINITIONS OF CATASTROPHIC, VERY SERIOUS AND SEVERE INJURY FROM A THEORETICAL AND OPERATIONAL PERSPECTIVE 3. Definitions of injury can be broadly categorised into theoretical and operational definitions.
4. There has been a lack of consistency to date between individual researchers and national unions with regard to both the theoretical and operational definitions of injuries, including those for catastrophic injury (CI) and very serious injury (VSI). The task group has reviewed the range of existing definitions and proposes that the following definitions are the most appropriate from both the theoretical and operational perspectives and are consistent with the current global standard; the IRB injury definition consensus statement. Theoretical definitions 5. These terms are used principally within injury research and have been clearly defined in the IRB injury reporting consensus document. Using these terms in other contexts may therefore cause confusion. It is also important to recognise that they have a time component to them and thus for instance; an individual’s injury is not defined as a catastrophic injury until it is clear that their disability will be permanent i.e. greater than 12 months. It is often not possible to determine this with any certainty in the early stages of an injury. 6. Non fatal Catastrophic Injury (CI): a brain or spinal cord injury sustained as a result of playing rugby or taking part in organised rugby squad training that results in permanent (>12 months) severe functional disability. Severe functional disability is defined by the World Health Organisation as a loss of more than 50% of the capability of the structure. 7. Severe Injury: an injury, sustained as a result of playing rugby or taking part in organised rugby squad training that results in the player being unavailable for full training and match play for 28 days or more. INJURY SURVEILLANCE 12. The rarity of catastrophic injury within rugby (approx 4 episodes per year in England) and the lack of a global standard to date for catastrophic injury data collection poses particular challenges when attempting to collect and analyse the available data necessary to inform the creation of evidence based risk mitigation strategies for catastrophic injury.
13. There are known to be substantial deficiencies in the RFU systems for the reporting of catastrophic injuries from an injury surveillance perspective as the current systems have been developed predominantly from a player welfare perspective. The critical areas to improve are identified in Annex 2 and need to be systematically addressed in a fashion that will be compliant with the definitions and processes that eventually become the global standard for catastrophic injury. 14. The sub-group on Player Safety reviewed how the injury surveillance element could be improved and invited Dr Colin Fuller, the Associate Professor for Sports Medicine at the University of Nottingham, to submit proposals for a research project to achieve this. Dr Fuller’s proposals are set out at Annex 3.
15. Given the importance and urgency of the need for the research project, the Task Group has already authorised the establishment of this research project. Mike Miller (CEO iRB) has agreed that the iRB will fund half the project cost. Dr Mick Molloy (Medical Officer iRB) will be consulted on the research project. This will facilitate a global perspective and it is anticipated that the timescale of the proposed catastrophic injury risk assessment will both influence and run in parallel with any development by the iRB of the anticipated global standards in this area. 16. Once the research project has assessed the probability of a catastrophic injury in conjunction with an estimation of the likely consequences for all levels of the game, the Task Group will need to reconvene to evaluate the results and the level of risk found and to determine what level of risk it believes is acceptable and what level needs mitigation with appropriate control measures. Recommendations: 17. That the RFU catastrophic injury reporting and surveillance systems are revised to optimise both welfare reporting and catastrophic injury surveillance. The catastrophic injury surveillance function will need to be developed in conjunction with the anticipated iRB global standard. 18. That catastrophic injury reporting be embedded in a whole game injury surveillance system for all injuries as outlined at Annex 2.
19. Injury surveillance should be formally integrated into the interdisciplinary working practices of the RFU (see comments on the broad scope of a comprehensive injury surveillance project compared with an injury reporting process). 20. That the Task Group is reconvened once the catastrophic injury risk assessment has assessed the probability of a catastrophic injury in conjunction with an estimation of the likely consequences for all levels of the game. It will need to review and report on what level of risk it believes is an acceptable level and what level needs mitigation with appropriate control measures.
Global Data 27. The sub-group on player safety also reviewed the catastrophic injury statistics from other rugby playing nations to see if there were similar trends to those seen in England.
28. Dr Mick Molloy (iRB Medical Officer) summarised and reviewed the injury statistics from other rugby playing nations at all levels by medical-attention, time loss and catastrophic injury groupings.
29. Differences in catastrophic injury definitions and surveillance methodologies between investigators and countries made accurate comparisons between countries extremely difficult. Catastrophic injury surveillance systems in most other rugby playing countries are currently limited by similar problems to those identified in the RFU’s surveillance system. The best estimate of the global incidence of catastrophic injury is currently 3.2 injuries/ per year/100,000 players. New Zealand currently has the best systems to report catastrophic injury rates accurately. Their catastrophic injury rates are 1.1catastrophic injuries/per year/ 100,000 players. The catastrophic injury rate in South Africa is reported to be rising particularly within the schoolboy population, but the data to support this is of poor quality.
30. New Zealand is recognised to have has the most effective catastrophic injury surveillance system currently. Reasons for this include: a tightly defined identifiable playing population; statutory catastrophic injury reporting responsibility; a small number of dedicated spinal units; and an effective, well funded partnership between NZRFU and the New Zealand Accident Compensation Corporation (ACC). The latter delivers the majority of the injury surveillance and injury prevention work across all sports in New Zealand. New Zealand has reported a significant decrease in serious spinal cord injuries particlularly scrum injuries (with a 97% probablity that this is a real decrease in past five years) but the catastrophic injury risk associated with the tackle does not appear to have changed over the same period. The (educational) initiatives that New Zealand believe have contributed to this decrease include: (a) the introduction of the “Front row factory” in 1996 – all youth players receive a structured scrum coaching session; (b) the introduction of the RugbySmart player safety programme in 2001; and (c) the creation and dissemination of a scrum safety DVD in 2005.
RISK ASSESSMENT AND RISK MONITORING 32. The Task Group believes that it is only through a risk assessment and risk monitoring process that a proper assessment can be made as to why catastrophic injuries are occurring and whether any changes should be made to the laws of the game or the way the game is coached or refereed.
33. A generic risk management process is common in any business and is becoming more common in sport. Risk management refers to the overall process of assessing and controlling risk within an organisational setting. It includes the sub-processes of risk assessment and risk mitigation. 34. The first step of a risk assessment for catastrophic injury is the identification of risk factors (conditions, objects or situations) that may interact to create a potential source of catastrophic injury, and estimations of the levels of risk.
35. A published analysis of the RFU Injury Audit data has identified some risk factors for non-catastrophic cervical spine injuries in rugby union.2 The same sort of analysis has not yet been undertaken for catastrophic injury to date. 36. Identifying clear causal relationships between catastrophic injury risk factors and catastrophic injury is often far from straightforward and is usually complicated by the small numbers involved and the poor quality of the catastrophic injury surveillance data available. This situation is not confined to rugby. If the necessary data to determine objectively risk and risk factors is not available from epidemiological studies, then one option, while waiting for this data to be collected (which must be done but will take a number of years) is to make estimations with reference to world-wide expert opinion.
37. The next step of the risk management process involves determining the acceptability of the risk of catastrophic injury for all groups of participants in rugby union. Whilst the risks associated with many occupational activities are assessed against specified values for acceptable levels, currently there are no defined acceptable risk levels within sport. One of the major influences on the level of acceptable risk for catastrophic injury in rugby union will be the public’s perceptions about the risk of this type of injury.
38. The game’s stakeholders will need to agree what the acceptable levels of risk for catastrophic injury are, across all levels of the game. If the current levels of risk are deemed to be unacceptable then risk mitigation will need to be reviewed and/or implemented in order to reduce the levels of risk to a level that is acceptable. 39. Risk mitigation strategies typically involve the following options: Risk acceptance; Risk reduction.
(FOOTNOTE 2 Brooks JHM, Fuller CW, Kemp SPT. The incidence, severity and nature of cervical injuries in professional rugby union. British Journal of Sports Medicine 2005;39:377.) 40. The former implies that an informed decision has been made to accept the consequences and/or likelihood of injury. It may also be decided that any residual risk is mitigated through the use of insurance to cover the costs of any losses incurred either to the individual, to the organisation, or both.
41. The latter, risk reduction, involves the application of appropriate control measures to modify the risk factors such that they reduce the probability of occurrence and/or reduce the consequences of injury.
42. These again can be divided into: injury prevention (Primary Prevention – reducing the likelihood and/or consequences of catastrophic injury); and injury treatment (Secondary Prevention – reducing the severity of the injury through optimal injury treatment; andrehabilitation (Tertiary Prevention – reducing the residual disability through optimal injury rehabilitation).
43. Prevention strategies in any of these areas should be evidence based. Unfortunately, there have been no published prospective studies looking at the effectiveness of prevention initiatives at reducing the risk of catastrophic injury in rugby. The nearest we have come is the apparent reduction in scrum related catastrophic injury rates after the introduction of the crouch – touchpause-engage sequence of scrum engagement in the 1980’s. This has often been quoted as evidence for the effectiveness of the law change, although no studies were conducted to substantiate this claim.
44. We therefore need to accept that although the game has implemented a number of risk management initiatives; it is still at a relatively early stage in this process. Rather than being a problem, this provides the opportunity to adopt a systematic approach to this issue; pulling together these RFU initiatives, adopting best practice were it exists and developing best practice where there are gaps. This should be led by an expert in this field with the time and resources to do so. 45. It is important to understand that there is a broad range of potential control measures that might form part of the catastrophic injury risk mitigation strategy. These include the following:
(a) physical controls – design and fabrication of sports equipment and facilities (including medical); (b) management controls – the definition and implementation of the sport’s rules; (c) personal controls - the development of the capabilities and behaviours of the participants and stakeholders.
46. Existing RFU initiatives and resources that have been implemented as control measures include the following (examples only): (a) RFU Coaching Manuals; (b) RFU Referees Courses; (c) RFU CPD Courses; - Tackle Safety
- Front Row in Union - RFU First Aid - Pitch side trauma care course
(d) RFU Player Safety Leaflets;
(e) CR Positional Skills Handbook; (f) RFU Health & Safety Toolkit.
47. Dr Fuller’s research project will address these issues in detail.
48. The Task Group believes that it is not possible to suggest any changes to the laws of the game or to the way the game is coached or refereed in England or internationally until the research project has completed its work.
MODEL OF SUPPORT Reporting 49. In addition to the reporting of injuries in order to monitor trends from a player safety perspective, there is also a need for reporting from a player welfare perspective and to ensure the club and RFU respond appropriately to the injury accident and the injured player. The key to responding effectively and providing appropriate support to players who suffer a very serious injury is to ensure that their injuries are reported in a timely manner. 50. The Task Group proposes that the definitions of Reportable Injury Events and Very Serious Injuries (“VSI”) set out in Annex 5 should apply from the point of view of reporting for welfare purposes and the appropriate response. The term VSI is used because it incorporates certain very disabling injuries that are not included under the recently internationally agreed theoretical definition of Catastrophic Injury. The Task Group has also produced a proposed reporting procedure and a reportable injury event form. These are set out at Annex 6. Recommendations: 51. That the proposed welfare reporting procedure set out at Annex 6 be implemented.
52. That the Reportable Injury Event form as set out at Annex 6 be issued toclubs and its use appropriately mandated.
Background 54. Catastrophic and Very Serious injuries are rare in rugby union. However, when they do occur, the RFU and others have a role to play in supporting those involved effectively and appropriately. Because the game is played across both the amateur and professional levels, such support needs to be delivered in a fair and equitable manner. There have unfortunately been incidents where support has perhaps not been delivered as effectively as it could have been, and incidents have occurred where a lack of clear policy in this area has created problems.
55. By establishing clear policy and levels of support the following benefits should be realised: (a) improved access and utilisation of financial support available to injured players; (b) improved distribution of RFU charitable funds;
(c) improved welfare support to the injured player and their next of kin; (d) improved welfare support to clubs and officials;
(e) improved visibility of insurance claims within the RFU; and
(f) improved protection of the assets and reputation of the RFU and the game of rugby.
RFU Welfare Support 71. For many years, the RFU has provided a level of welfare support through, what is now called the Injured Player Welfare Officer (“IPWO”) (previously the Serious Injuries Administrator). This is a part time role on a consultancy contract. Unfortunately, the role was poorly defined, with little involvement or support from CBs. In particular, and the IPWO has been left trying to support VSI players across the whole country for as long as they have needed, with limited direction from the RFU. 72. In April 2005 the IPWO joined the newly formed Community Rugby Sports Medicine Department. This led to a review of the role, with the following outcomes: (a) the need for the role was confirmed;
(b) development of a formal job description;
(c) transfer away of responsibility for injury surveillance for research purposes;
(FOOTNOTE 3 SIA offer support to individuals who become paralysed and their families, from the moment a spinal cord injury occurs, for the rest of their lives. They provide services which enable and encourage paralysed people to lead independent lives. They campaign for improved medical care and research into spinal cord injury. They work to create awareness and understanding of the causes and consequences of injury. Headway’s aim is to promote understanding of all aspects of brain injury; and to provide information, support and services to people with a brain injury, their family and carers.) (d) development of standardised information packs for player/NOK, and clubs. This includes details of the IPWO, charities, guidance on financial issues and fundraising; and
(e) establishment of a VSI player welfare database. This records all player details, injury type, club details, visits, hospital details, current status etc. It enables cases to be monitored. 73. However, the IPWO is not able to cover all VSI players across the whole country indefinitely. A number of issues therefore need to be addressed.
FINANCIAL SUPPORT 95. It is proposed that those individuals who fulfil the definition of VSI are entitled to the support outlined above. From historical data, there are likely to be 6 to 10 players per season entitled to such support under such a definition.
96. The RFU has made a significant contribution to the financial support for VSI players in the form of the premiums it has paid for its personal accident policies. Details of these are set out below. Personal Accident Policy 06/07 £2,500,000 05/06 £2,300,000 04/05 £1,900,000 03/04 £1,900,000 02/03 £1,900,000
97. In addition, the RFU has made a significant donation to SPIRE each year. Details of these are also set out below. Spire 05/06 £367,000 04/05 £548,000 03/04 £139,000 02/03 £278,000
98. As can be seen from the Insurance section below, the RFU provides a significantly enhanced level of personal accident insurance cover for those injured whilst on England duty. This level of cover is the same for all Guinness Premiership contracted players.
99. If a VSI player’s injuries were incurred whilst on England duty, it is likely that the RFU would take the lead or make a very great contribution to fund-raising efforts for that player as it did for Matt Hampson. However, there has been a lack of clarity in the past as to whether a VSI player injured on England duty should receive additional funding to pay for such matters as medical bills, his family’s expenses in visiting him in hospital, wheelchairs and additional food and care whilst in hospital. Such additional funding is not given to anyone injured whilst not on England duty
100. One of the biggest debates and toughest issues the Task Group faced was the issue of whether the RFU should pick up medical bills and expenses of any VSI player injured whilst they were on England duty. PRL and the PRA believe that the RFU has a “moral” duty to fund such costs and expenses in this scenario. Essentially their view is that the amount the RFU contributes relates to the situation in which the injury occurs (ie an England player injured whilst on England duty merits substantially more financial assistance than an England player injured otherwise than on England duty or indeed a community rugby player). However the other members of the Task Group found this difficult to reconcile as they believed that any help should be given on the basis of need rather than because of the situation in which the injury occurred. The other members of the Task Group also considered that an England player already received a greater insurance pay out than someone with the same injury but who was not a contracted Guinness Premiership player. They thought it was morally wrong to provide much greater financial assistance for a person just because of the situation in which the injury occurred rather than because of their actual need. INSURANCE Background 115. There are two alternative policy types. The first is an “Occupation” based policy which provides fixed benefits in the event that an individual is either unable to continue in their usual occupation, or is unable to work in any occupation. The second is what is known as a “Continental Scale” basis. This provides fixed benefits in the event that an individual has specific disabilities as a result of the injury, each having a specified benefit payable. A “sweeper” clause normally operates to pick up unspecified injuries. 116. There are advantages and disadvantages of each type of scheme. The advantages of the Occupation based scheme are (i) the basis of assessment is relatively easy; (ii) the relatively small number of claims means higher benefits for the seriously injured; and (iii) it provides a safety net for those who lose their job or are not fit to work in any capacity. The disadvantages of this type of scheme are (iv) that some seriously injured players do not receive a benefit; and (v) those in more physically demanding jobs are more likely to make a claim.
117. The advantages of the Continental Scale scheme are (i) more injured players will receive a benefit; (ii) the “sweeper” clause gives an opportunity to give benefit to an individual whose career is not affected by injury. The disadvantages are (iii) the “sweeper” clause is difficult to operate and can lead to disputed claims; (iv) usually significantly more claims arise on this basis with resultant additional costs; and (v) a pre-existing injury clause would have to be applied to protect the insurer from degenerative type injuries. The RFU’s Personal Accident Insurance 118. The RFU’s personal accident policy is an Occupation based one but with some fixed benefits as per the Continental Scale. The benefits payable are as set out below. The matrices set out in Annex 10 show the additional benefits for England, EPS and Guinness Premiership Registered Players.
119. If a person is unable to work again a fixed sum of £500,000 is paid. If they are unable to carry out their usual occupation the sum of £50,000 is paid. If a person is a professional player (ie senior registered Guinness Premiership player), now as a result of the jointly funded policy between the PRA, PRL and the RFU a professional player would receive £500,000 for a catastrophic injury. This is in addition to the £500,000 due under the RFU’s main policy.
However it should be noted that an inability to perform their “usual occupation” does not apply to professional rugby players under the RFU’s main policy as this is catered for under the PRA/PRL/RFU policy. 120. There is an enhanced level for EPS players in terms of a pay out for career ending injury. EPS players receive a pay out of £120,000 for a career ending injury. Non EPS players who were aged over 26 received £60,000. Those non EPS players aged below 26 have their payments scaled down.
121. The RFU have plugged the gap for those players who had not had an occupation before their injury (eg students) and now pay a fixed sum in the event of some specific injuries. 122. The cover set out for Contracted Registered Players applies on a “24/7” basis and would therefore include cover for injuries sustained outside rugby as well. The RFU “On Duty” cover applies from the time the player leaves his home to travel to be on duty until the time he returns. Anomalies 123. The matrix of insurance available to England Representative Teams in Annex 10 shows a number of anomalies. The Task Group believes that these anomalies could be corrected without too much additional cost and recommends that the Insurance Task Group looks at this as a matter of urgency.
A Different Type of Policy 124. The cost to add limited fixed benefits to the current policy with a maximum benefit of £250,000 is indicated at £650,000. The costs to transfer to a full Continental Scale basis with £500,000 maximum benefit would be significantly higher. A full insurance market review would be required.
Focus of the RFU’s Insurance 125. The focus of the RFU’s insurance had been to increase the pay outs for those injured catastrophically. However, the Task Group noted that the benefits available from the relevant local authority for those catastrophically injured have never been properly factored into the debate on what should be the correct level of insurance for these players.
The Task Group noted that a review was being undertaken of how much a player injured catastrophically actually needed depending on their injury. However, the Task Group believed that such research was of somewhat limited value as everyone was different and one person’s need was potentially very different to another’s. The Task Group believed that
in any event, insurance was something of a blunt instrument and a charity would be able to fund much more on the basis of actual need. Funding of Additional Premiums 126. The sub-group was of the view that any additional premium for a more far reaching insurance policy should be funded by those who play the game. Consultation must therefore take place within the game to see if those playing the game do want enhanced insurance cover and if they would be willing to pay for it by way of a compulsory insurance scheme. The Rugby-First database would be invaluable for this purpose. Although “top up� insurance is currently available, this is voluntary and not widely taken up. Insurance Provided by Other Unions 127. As can be seen from section on the support given by other Unions below the RFU needs to consider carefully the benefits provided under its insurance policies for those injures that are very serious but not catastrophic. The RFU provides greater cover for Permanent Total Disablement from gainful employment or quadriplegia, tetraplegia, triplegia or hemiplegic, than Scotland and Wales. However, the benefits paid for those very serious injuries below catastrophic level are significantly less than those provided by Scotland and Wales. The Task Group believes that benefits provided by France are far greater than those provided by the RFU. Details have been provided by the FFR and these are set out in Appendix 11. Recommendations: 128. An Insurance Task Group should be set up as soon as possible by the Management Board to undertake the following:
(a) Immediately review if the anomalies between different categories of players wearing the England shirt can be corrected and if so, how much this should cost;
(b) Immediately produce a clear and explicit fact sheet for players in each representative team setting out what is and is not covered when they are on England duty;
(c) Immediately perform a detailed analysis of exactly what VSI players need financially bearing in mind funding from Local Authorities, PCTs and the DSS, then analyse how much insurance they need and how much this would cost; (d) if it is determined that increased insurance is needed and therefore increased premiums payable, set out proposals to determine how these should be funded; and
(e) that once all this work has been completed, a detailed debate at Council should be held. Marsh – RFU Insurance Brokers 131. The principal focus of liaison between the RFU and Marsh is on financial matters, and thus sits within the remit of the Finance Department. However, insurance claims made by clubs/schools for injured players are of medical and welfare interest. Historically, the
passage of information between Marsh and the RFU on injury insurance claims has only been ad hoc. The Community Rugby Sports Medicine Department has now established a framework for improving information sharing and monitoring of player injury insurance claims. The first meeting took place on 16 October 2006. The following benefits are anticipated: (a) improved data collection on injuries resulting in insurance claims on the RFU Compulsory Insurance Scheme; and (b) improved monitoring of injury insurance claims.
SUPPORT GIVEN BY OTHER UNIONS 151. Insurance provision provided by the Scottish, Welsh and Australian Rugby Unions follows a very similar structure to that provided by the RFU. Payments are distributed depending on the severity of the injuries sustained by the individual player and the ability to carry on their usual occupation. Primary research has provided the payment schedules set out below: Scotland Wales South Africa Australia Severity of Injury Senior Death £50,000 £90,000 $100,000 Loss of two or more limbs or both eyes or one of each or Total loss of hearing in both ears £100,000 £70,000 Loss of one limb, or one eye or loss of hearing in one ear £100,000 £40,000 Max $150,000 Permanent Disablement from following usual occupation £100,000 £90,000 $300,000 PTD from gainful Employment £300,000 £100,000 Junior Death £10,000 £7,500 $10,000 Loss of two or more limbs or both eyes or one of each or Total loss of hearing in both ears £100,000 £100,000 Loss of one limb, or one eye or loss of hearing in one ear £100,000 £50,000 Max $150,000 Permanent Disablement from usual (any) occupation £300,000 £100,000 $300,000 Player Welfare Officer/Fund Yes No Yes Yes Do Clubs pay for their Insurance? Yes Yes Yes
152. Details relating to the insurance provided by the Irish and New Zealand Rugby Unions will be forwarded as soon as information is received, although from web based research it
is evident that the Irish Rugby Union do have a charitable trust in place to support players who sustain a very serious injury.
153. The South African Rugby Union in complete contrast to Scotland, Wales and Australia provide no insurance provision for their players at a club based level. Players who sustain severe injury or permanent disability from following their usual occupation have the right to apply to the South African Rugby Union to claim payment from their charitable fund. This fund is supported by the South African Rugby Union which makes an annual payment to the fund to cover seasonal claims. 154. A memo from the Canadian Rugby Union in September 2006 confirmed that the “Catastrophe Insurance” cover ($500,000 per person) they have had in place for the past two seasons has been cancelled. However Accident and Liability cover remains in place.
155. A translation of the information from the FFR as to the benefits they provide is set out in Appendix 11. 156. With the exception of PTD from gainful employment, the RFU’s insurance cover is generally less than that provided by other unions.
ANNEX 2 Current Rugby Football Union Injury Surveillance Projects and Reporting Procedures and Recommendations for Improvements
INTRODUCTION In the injury prevention model adopted by the Catastrophic Injury Prevention Working Group, there are four steps (1): 1. Establishing the extent of the problem,
2. Establishing the cause and mechanism of injuries, 3. Introducing preventive measures,
4. Assessing the effectiveness of these measures by repeating step 1.
Injury surveillance methods are used in undertaking Steps 1 and 4. Although it may also contribute to Step 2, other epidemiological methods are usually used in establishing the causes of injury (e.g. case-control and cohort studies), and investigating the effectiveness of preventive measures, Step 3 (e.g. intervention studies or randomised controlled trials). Injury reporting is the first step in operating a sports injury surveillance system. It involves the collection of data on injury (who, when, where, what, why, how, etc). It is important to understand, however, that an injury surveillance system is far more than the collection of
data through injury reporting. It also involves the analysis of that data and interpretation of the findings to guide policy development and implementation, including the development and evaluation of preventive measures and programmes. An injury surveillance system should enable the RFU to (2): Measure the incidence, nature and severity of injury Monitor trends in injury over time (e.g. within single seasons, over many seasons) Gain insight into the causes and mechanisms of injury (e.g. by identifying possible risk factors) Target research/investigation into causal factors Evaluate policy with regard to injury prevention Plan, implement and evaluate measures to prevent and control injury Prioritise the allocation of resources to injury prevention. Assess the effectiveness of preventive measures
INJURY SURVEILLANCE SYSTEMS A sports injury surveillance system should be designed primarily to meet the needs of the organisation. It is helpful if it also provides information for a broad range of potential users such as the players, coaches, trainers, doctors, government bodies and researchers. A surveillance system should (2-4): Be affordable Be simple and easy to operate Be acceptable to players and clubs Be sufficiently flexible to meet changing needs Provide complete, valid and reliable data Provide an accurate representation of injury in the sport over time Provide timely information Remain consistent and available over time. Currently a range of discrete injury surveillance projects and reporting processes serve the elite and community games. This reflects variations in resources (historical and current), the need for variations in surveillance /reporting methodologies needed to best study injuries across the whole game and the particular challenges of injury surveillance at different levels of the game. CURRENT ELITE RUGBY INJURY REPORTING AND SURVEILLANCE PROJECTS
The Premiership Injury and Training audit. This reports all match and training injuries sustained by 1st team registered Guinness Premiership players that cause time lost from playing and training. Injuries are included if they prevent a player from playing or training for more than 24 hours from midnight on the day of injury. The study commenced in 2002 and has collected data for the 2002-4 seasons and 2005 to the present time. It is the largest and most comprehensive study of injuries in the professional game in the world. Data collection is mandated by England
Rugby. High level analyses of the 2002 – 2004 seasons were published in the British Journal of Sports Medicine in 2005 and a number of papers looking at specific injuries have been published, presented at international conferences or accepted for publication, A non technical game-wide report is at a final draft stage.
The project has now largely fulfilled steps 1 & 2 of the injury prevention model and whilst it will continue to record baseline injury data it will need to move into the introduction and quantification of specific injury prevention measures in forthcoming seasons. The small size of the elite playing population makes it unlikely that a significant number of catastrophic injuries will be reported in this system. CURRENT DISCRETE COMMUNITY RUGBY INJURY REPORTING AND SURVEILLANCE PROJECTS
Division 1 This Division 1 Injury audit that commenced at the start of the 2005-6 season uses very similar definitions and methodology to the Premiership audit and will enable similar and comparative analysis to be performed on Div 1 players. The study is currently planned to complete at the end of the 2006-7 season. The Age Group game An innovative 3 year PhD study, commissioned by the Community Rugby Department, in conjunction with the University of Bath, using a methodology compatible with the two previous studies commenced at the start of the 2006-7 season and will study @700 16 – 18 year olds at schools, clubs and regional academies during the 2006-7 and 2007-8 seasons. These three high quality discrete projects are compliant with the new iRB reporting standards, and report injuries coded by medical practitioners. They give the RFU very detailed information on a relatively small number of elite, semi-elite players and age-group players (and because of the numbers studied do not (thankfully) / are unlikely to include a significant number of catastrophic injuries. CURRENT COMMUNITY RUGBY INJURY REPORTING AND SURVEILLANCE PROCESSES
This ongoing reporting system for all of the community game is the system that is most likely to record catastrophic injuries. It falls short on most of the injury surveillance requirements apart from the first. The Community Rugby Dept inherited an injury reporting system which also doubled up as the injured player welfare reporting process in May 05. The system has been running for many years but was reviewed and improved prior to the 04/05 season. It aimed to collect injury data from all levels of the game; from every game played by every club, school and university in England throughout the season. The injuries that were supposed to be reported were as follows: Any head or neck injury that requires a player to be transported directly from the ground to an Accident & Emergency Dept.
Any injury that results in admission to a hospital as an inpatient after the game/training has finished and is game/training related.
Any injury that prevents a player from playing or training for a period of 8 weeks or longer. Deaths which occur during a game or within 6 hours of the game finishing where the post mortem shows the cause of death was linked to some aspect of the game. For many reasons, the system did not function as intended. Amongst the problems were: -
It was attempting to collect data from the whole game, every club, school etc. It attempted to fulfil two functions at the same time, injury surveillance and welfare reporting (These functions were separated in June 05). There is a very significant but unquantifiable level of under-reporting. The initial report forms were overlong and complicated. None of the reports submitted in 04/05 or 05/06 have all the relevant data fields completed. No training injuries were reported in 04/05 nor 05/06. There is no measure of exposure (playing/training time). The accuracy of the injury description is unknown as it is usually completed by lay people. The level of IT training in the individuals responsible for running the system prior to May 05 was inadequate.
The system inherited was not fit for task and in many respects, was a wasted effort for the clubs and the RFU. The faults with the old system were identified and a review was instigated. This process has subsequently been overtaken by the formation of the current Catastrophic Injury Working Groups. Further progress on this review was therefore put on hold until the Working Groups concluded their higher level review. For the 06/07 season the old process had already been separated into: Injury Reporting. Managed by the Community Rugby Medical Executive. The Serious Injuries Administrator (SIA) title and email address have been retained in order to avoid confusion at club level. Welfare Support. Provided by the Injured Player Welfare Officer (IPWO). Currently the categories of injuries that need to be reported are as follows: An injury which results in admission to a hospital intensive care unit, high unit, specialist spinal, or head injury unit.
dependency
Deaths which occur during or within 6 hours of a game finishing.
Any injury that is likely to result in an insurance claim to the RFU insurers.
These categories will capture all catastrophic injuries, injuries resulting in a significant disability, and all deaths. The existing, very basic database that was partially developed in
2004 is still being used to record these injuries although this will need to be replaced in the future. The improvements made to the Welfare process and the introduction of a regular monitoring process provide the IPWO and the Community Medical Officer with greater visibility of the status and progress of players within the welfare system, which include the catastrophic head and neck injured players. Further improvements to the welfare and injury reporting systems have been on hold pending the outcomes of the Working Groups. An outline of the planned and thus recommended improvements is shown at Annex A.
SUMMARY 1. Three discrete but compatible Injury surveillance projects currently serve the elite, semielite and age group games. These projects are well designed and appropriately funded at the present time. How they continue to interface and the details of how they develop over time needs ongoing review. 2. The community rugby injury reporting process used by the RFU for many years is not fit for purpose. The welfare process and the injury surveillance process have been separated and have been simplified to facilitate easier reporting at club/school level. 3. It is essential that the RFU continues to resource the expansion of the existing injury surveillance projects but specifically resources the new development of an effective injury surveillance process for all injuries including catastrophic injuries within the community game. ANNEX A Outline of Recommended RFU Community Rugby Injury Reporting and Surveillance System
General If the following recommendations are accepted, and depending on how the systems are eventually run i.e. in-house or outsourced, an increase in workload will be produced, which may be considerable. Future increases in human resources should therefore be anticipated i.e. establishment of a new post responsible for all community injury surveillance (part time or full time), increase in Community Rugby Medical Officer hours. In the interim, it is recommended that the title Serious Injuries Administrator is dropped at the end of the 06/07 season and the title Injury Surveillance Administrator (ISA) is adopted. Routine Injury Surveillance The RFU requires an effective injury surveillance system; Catastrophic Injury reporting in isolation will not provide the full picture and may actually produce misleading conclusions. The Community Rugby Sport Med Dept, having identified the problems with their current system is in the process of defining the requirement and exploring options for developing a new system. These might include one or more of the following options:
Development of a new paper based system. Development of bespoke software for a web based or other ICT based system. Utilising existing web based surveillance software, with or without customisation. Outsourcing the whole process to an academic institution.
Although at an early stage, preliminary ‘market research’ has been conducted with a number of individuals, academic institutions and software companies. It is likely that the review will suggest that :
1. A project team, based on the Community Rugby Sports Med Dept should be established. This should include appropriate epidemiologist and IT expertise. For the former, it is hoped that we can attract Prof W Meeuwisse, University of Calgary, who is internationally recognised as a leader in this field, and has been involved in some related work for the IRB. 2. The system is likely to adopt a model which utilises an appropriate representative sample population which is equipped and resourced to provide high quality data from all levels of the game, rather than universal reporting which has never worked.
3. Appropriate resources and time need to be allocated to each phase of this project to ensure that the project is viable and the system developed is effective and meets the needs the RFU.
Catastrophic Injury Reporting + Surveillance The Reportable Injury Event process being proposed by the Response Working Group will capture the Catastrophic Injuries that occur in the game. If for some reason, it misses an injury there are safety nets in place; the new Welfare Reporting process and the new quarterly review meeting with Marsh, the RFU injury insurers. The small numbers involved, make meaningful analysis very difficult. This has been recognised before and it has previously been recommended at the IRB MAC that in order to obtain the necessary numbers to enable analysis, an international database of these injuries is required. It is therefore recommended that: The RFU encourages the IRB to set up an international collaborative project to develop and run a catastrophic injury database. In the interim, the following outline system is proposed. This can be integrated into the international project if it is developed, and if not, form the basis of an RFU system: Injuries are reported to the ISA under the RIE process on Form 1. The ISA confirms the nature and extent of the injury, and arranges for initial data collection to be completed: - Data continues to be collected on existing forms and entered onto existing database for seasons 06/07 and 07/08. - ISA establishes contacts with Regional Spinal Injuries Units to facilitate cooperation on data collection. - CRMO to commence development of revised data collection methodology in consultation with appropriate experts for implementation in 08/09 season.
Additional data collection is conducted at appropriate intervals in order to record appropriate clinical outcome measures and/or objective level of disability: - CRMO to commence development of revised data collection methodology in consultation with appropriate experts for implementation in 08/09 season. • Data is analysed by experts, at appropriate intervals (likely to be in 5 – 10 yearly cycles). - CRMO to identify appropriate expert(s) to conduct data analysis Note: Costs for catastrophic injury reporting development and analysis would be significantly reduced if the IRB resource the development of an international collaborative project.