shley Spires is Care Manager and Registered Nurse for the Department of Veteran’s Affairs, an Ohio University Doctor of Nursing Practice candidate and a youth and middle school wrestling coach at a central Ohio public school system.
Decreasing Skin and Soft Tissue Infections in Wrestlers: Educating Coaches, Protecting Teams
Lack of coach education, standardized disinfection protocols, and standardized return to play procedures amongst wrestling programs have led to a high incidence of Skin and Soft Tissue Infections (SSTI) in the school age and adolescent athletic community. An educational intervention was performed with coaching staff in a pre/post intervention study. SSTI rates were calculated both pre and post intervention to assess for effective intervention in reducing SSTI incidence in the youth athletes. Pre-intervention review of aggregate infection data revealed a 22.6% SSTI occurrence rate. Post-intervention the SSTI occurrence rate was reduced to 3.5%. A McNemar chi-square test was run and the results were statistically significant at X 2 (1) = 54.721, p < 0.001. The intervention had a significant impact in lowering the SSTI rate in wrestlers. Future directions include improved education of youth wrestling coaches to include recognition of SSTI as well as best practice disinfection and infection control protocols.
Key words: SSTI, skin infection, wrestling, infection prevention, coach education
SSTI affects an estimated 30-50% of all youth athletes annually (1). Athletes participating in sports with significant skin-to-skin contact such as wrestling have a higher rate of SSTIs. When comprehensive prevention strategies such as scheduled interval skin surveillance, best practice disinfection schedules, planned hand hygiene protocols, and return to play protocol for athletes’ post-infection are in place, the incidence of SSTI has decreased. Best evidence includes residual mat cleaners, wrestler hand hygiene, return to play protocols and education of coaches and team volunteers on the prevention plan (2). Adherence to a strict cleaning schedule helped to decrease the incidence of skin infections in a multi school study by thirty-three percent over programs without mandatory coach education and prevention protocols (2). Comprehensive learning programs for coaches and staff on disease recognition and athlete disqualification for the health and safety of the team are recommended to prevent SSTI are recommended for all coaching staff, but frequently absent from athletic programs (3). Evidence also suggests that a standardized set of protocols for athletes to return to play following an active skin infection can reduce reinfection as well as the spread of disease (4).
Selection of Participants
Participants for this project were recruited by offering voluntary program participation to all wrestling coaches in all levels of a local youth program that serves athletes from kindergarten to twelfth grade. The intervention group included thirty-two wrestling coaches representing all coaches from the local youth wrestling program. Attendance of 100% coaching staff participated in the program. Demographics and pre-intervention questionnaires were completed, and the results compiled for review.
Participants included twenty-nine males and three females, thirty of which were Caucasian and two African American. Eighteen participants identified as married with eleven having never been married, two divorced, and one widowed. Participants also reported their highest level of education with results as follows; one with some high school having been completed, fifteen with a high school diploma, five having some college, nine achieving an associate degree and two a bachelor’s degree. Twenty-nine coaches reported having current healthcare coverage, but 46% of coaches reported experiencing a time when healthcare was avoided due to financial concerns in the past twelve months. 53% of coaches reported that in the past twelve months, they or someone in their immediate family has experienced an SSTI, but only 6% reported having ever received formal SSTI training. Coaches were then asked how many times per day on average they wash their hands or utilize hand sanitizer with over 70% reporting between zero and four times per day, and 28% washing five or more times per day. When asked how big of a problem SSTI are currently in the wrestling community today coaches answered on a one through ten scale with one being no problem at all and ten being a very large problem. Over 68% percent of coaches reported SSTI’s at a problem rating of six or greater.
An educational intervention consisted of a single one-hour session offered at three different times to accommodate coach schedules. These sessions focused on recognition and prevention of SSTI as well as the importance of standardized disinfection, skin surveillance, and return to play procedures. Best practice protocols for each strategy were presented in the interactive teaching program with handouts of highlight information provided to all attendees. After completion of training with all coaches, a checklist of disinfection and prevention practices was provided to the coaches for use during practices and competitions. This checklist was a self-report of the coaching staff compliance of 100% see Figure 1.
A retrospective review of deidentified 2017-18 SSTI data was used as pre-intervention data. The SSTI data was collected for three months during 2018-19 wrestling season post coaches’ educational session. The three months compared reflect the same three-month span, but from different years.
A 19.1% reduction in SSTI occurrence was noted from the pre-intervention rate of 22.6% to the post-intervention rate of 3.5%. A McNemar chi-square test was run and the results were statistically significant at X 2 (1) = 54.721, p < 0.001. This means the intervention had a significant impact in lowering the SSTI rate in wrestlers. See also Figure 2.
A comprehensive prevention and education program can be effective in minimizing athlete exposure to SSTI. A significant intervention effect was demonstrated on incidence of SSTI in a midwestern youth wresting program. The supplementation of a coaching education curriculum with specific focus on best practice disinfection, SSTI identification, and return to play guidelines has the potential to decrease SSTI rates in athletes. Follow-ups of longer duration are needed to explore intervention effects on larger populations of athletes. This programming should be replicated in other youth and collegiate athletic programs to affect the STI rates affecting athletes. The education level and volunteer nature of the coaching staff may have an impact on the current health related knowledge of the coaches and should be considered when applying the intervention.
APPLICATIONS IN SPORT
While the high incidence of SSTI in youth athletics with an increase in skin-to-skin contact may be attributed to the prevalence of community-acquired infections and the ease of disease transmission amongst youth athletes, prevention is possible. High incidence of SSTI in youth wrestling leagues may also be attributed to the volunteer nature of coaching staff with little to no required formal training on public health and hygiene prior to team interaction. A relationship exists between coach education for SSTI prevention and management and lower incidence of SSTIs. Educational initiatives by trained professionals in conjunction with standardized comprehensive management policies may lead to practices that limit SSTIs in this at-risk population.
Previous studies of athletes have demonstrated a direct association between the existence of organizational policies to prevent SSTIs and a reduction in SSTIs rates (5). Research has shown that coaches and athletic directors with formal education and written guidelines were less likely to report SSTIs among their athletes than those without education or a written policy (6). In the present study, only 6% of participants reported having participated in a formal SSTI prevention education session. This finding suggests that there is a relationship between coach training and a lower incidence of SSTIs. Further studies are needed to better define this relationship. An organizational policy including mandatory coach education may be one component of a multilevel approach to reducing the prevalence of SSTI in athletes