​California Education Code Section 49475 (and California Laws AB-2007 and AB-2127) requires all schools that offer athletic programs to:

• Recognize signs of concussion, immediately remove the athlete from the activity for the remainder of the day, and not permit the athlete to return to play until he or she receives written clearance to return by a licensed healthcare provider

• Each athlete shall complete a graduated return-to-play protocol of no less than seven days in duration, under the supervision of a licensed healthcare provider.

• Application of California Education Code 49475

• The graduated return-to-play protocol applies to all concussions that occur at school (athletics, physical education, other activity) and concussions that occur outside of school.

• Incident documented. All forms filled out, delivered to and signed by respective parties.

• Parent/guardian collects student. (Student should not drive.) Forms provided to parent/guardian.

• Student examined and diagnosed by licensed healthcare provider.

 

Return to Learn Protocol
Step 1: School nurse or designee established as liaison between student’s licensed healthcare provider(s) and school staff

• If injury occurred outside of school, parents and student’s licensed healthcare provider are responsible for notifying school.

• If injury occurred in school, school staff are responsible for notifying school

• nurse or designee (coach, athletic trainer, PE and other teachers, administrators, etc.)

• School nurse or designee initiates Return to Learn and Return to Play for student (and parent release to exchange information).

Step 2: School nurse or designee obtains an incident report; oversees exchange of information

• For any out-of-school injury, the nurse or designee obtains a history from the parent and medical providers.

• School nurse or designee identifies licensed healthcare provider managing student’s post-concussion care (e.g., primary care doctor, rehabilitation physician, neurologist.)

School responsibility when no licensed healthcare provider is managing student’s care:

• If student does not see a licensed healthcare provider, the school will abide by the California State Law Return to Learn and Return to Play protocols.

School responsibility when student’s licensed healthcare provider refutes a concussion, despite symptoms witnessed by school staff:

• If school staff witness symptoms of concussion at school, but these observations are not validated by the child’s licensed healthcare provider, schools will abide by the minimum standard management for suspected concussion.

• Designated school staff will provide written follow up with parents/guardian.

Step 3: School nurse or designee as liaison to school personnel

• School nurse or designee notifies staff (teaching, PE, athletic, others) about concussion and to observe/report potential symptoms; school nurse distributes information received from managing licensed healthcare representative.

• If student experiences persistent symptoms in class or between classes, consider convening a meeting of a “Student Study Team” to include the following people: school nurse or designee, administrator, student’s teachers, counselor psychologist; invite parent and athletics staff; consider (based on symptoms): speech therapist, site special education representative.

• Establish point communication persons for: Student at school, school-to-parent, school-to-healthcare representative.

• School nurse or designee should provide regular reminders to teachers to modify workload as per Return to Learn plan, using information from: teacher’s own observations, student self-report, physician and parent guidance.

• Extracurricular activities (drama, clubs, etc.) to be treated same as curricular activities.

• If symptoms anticipated to be less than four weeks: use ISHP (Individualized Student Health Plan) format; Consider “contract” homework with modified expectations.

• If symptoms anticipated to be more than four weeks, consider convening a 504 Team.

• If student cannot attend school at all, consider homebound education.

Step 4: School communication with managing physician/clinician and parent

• Staff to document the following, to be communicated by school liaison:

1. Symptoms noted in school and what exacerbates these symptoms (may use Return to Learn: Daily School Checklist.

2. Difficulty noted in any select subjects.

3. Student adherence to school and physician recommendations.

4. Attendance record, time arriving in school, time leaving school.

5. Number of breaks student requires and their nature and duration.

• School staff may review the Symptom Wheel, to help note elements of a student’s behavior that may be relevant to document.

Step 5: Revisit and revise Return to Learn plan, as necessary

• Reconvene Student Study Team meeting, as necessary.

• Change individualized health plan or 504, as necessary to reflect improving or worsening condition.

• If symptoms persist for months, consider a special education referral (based on traumatic brain injury.)

 

Return to Play Protocol
1. Send Return to Play Progress form to student’s licensed healthcare provider and begin gradual return to activity based on licensed healthcare provider’s instructions.

• Schools may accept the Return to Play Prescription or other form signed by student’s licensed healthcare provider, as clearance as long as they do not permit return to play earlier than the district’s own Return to Play Clearance form.

2. “Return to Play” Protocol

• Progression is adapted from the International Concussion Consensus Guidelines and CIF Concussion Return to Play Protocol. Summary is described in Stages 1-4, below.

• A student’s medical provider may recommend more restrictions, but not fewer restrictions.

• If student’s medical provider recommends fewer restrictions than Stages 1-4 below, refer this to the school nurse or designee who can communicate with the medical provider.

• Each student must be kept from any exertive activity beyond 15 minutes of walking (Step 1) for the first and second day after the concussion.

• Student may not resume any physical activity beyond 15 minutes of walking until the student tolerates normal academics. Exception: If back-to-normal academics have not been achieved by two weeks post-concussion, a physical activity program can be prescribed by the student’s managing physician in conjunction with school health, physical education and athletic staff.

 

Progression for Physical Activity Cannot Exceed Following Steps:
Stage 1. Limited activity for 5-10 minutes that is designed to increase the student’s heart rate (e.g., exercise bike, walking, light jogging); No weight lifting, jumping or hard running. As student will be resting at home at least 24 hours after experiencing symptoms of concussion, do not start Stage 1 until at least 48 hours after head injury with symptoms of concussion.
Stage 2A. Light aerobic activity. Student can attempt 10-15 minutes of brisk walking or stationary biking under direct supervision by designated school representative.
Stage 2B. Moderate activity, with limited body and head movement. May go 20-30 minutes, but be reduced from typical routine for age. (e.g., moderate jogging, brief running, moderate intensity stationary biking, and moderate intensity weightlifting)
Stage 2C. Strenuous aerobic activity including running or stationary biking for 30-45 minutes or weight lifting up to 50% of max weight.
Stage 2D Heavy, non-contact activity (closer to what would be in student’s typical routine), but non-contact. (e.g., running, high-intensity stationary biking, regular weightlifting routine, non-contact sport-specific drills). At this stage, may add some cognitive component to practice.
Stage 3. Begin with limited contact practice. Controlled contact drills are allowed, but no scrimmaging. Then progress to full contact practice but no competition. Prior to beginning this stage, make sure that student receives written licensed healthcare provider approval.
Stage 4. Full contact and full activity can be resumed. Then, after written clearance from student’s licensed healthcare provider, student may return to competition.

 

No student is permitted to move from one stage to the next, unless there has been an absence of symptoms or signs. Refer to CIF Return to Play Protocol for details.
a) School staff will document performance in each stage and report this to school nurse (and athletic trainer, if athlete). Nurse may communicate with student’s licensed healthcare provider, as necessary; The District’s Return to Play form may be used by any school staff member when a school nurse or athletic trainer is unavailable.
b) If symptoms or signs are experienced, then withhold activity until there are no symptoms for 24 hours, and then return to the previous step.
c) On weekends and days where there is no trained school staff member or physician to document successful progression from one step to the next, school may take parent and student history.
d) If a student fails to achieve any step on three occasions, refer the student to the managing physician with this information

 
                                                                                                                                                                       ConcussionSmartMarin.org   December 2017​