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Exercise and the Heart |

Low Compliance With National Standards for Cardiovascular Emergency Preparedness at Health Clubs* FREE TO VIEW

Kyle McInnis, ScD; William Herbert, PhD; David Herbert, JD; Jason Herbert, BA; Paul Ribisl, PhD; Barry Franklin, PhD
Author and Funding Information

*From the University of Massachusetts (Dr. McInnis), Boston, MA; Virginia Tech (Dr. W. Herbert), Blacksburg, VA; Herbert and Benson Attorneys at Law (Mr. D. Herbert), Canton, OH; PRC Publishing (Mr. J. Herbert), Canton, OH; Wake Forest University (Dr. Ribisl), Winston-Salem, NC; and William Beaumont Hospital (Dr. Franklin), Birmingham, MI.

Correspondence to: Kyle J. McInnis, ScD, Department of Human Performance and Fitness, University of Massachusetts Boston; 100 Morrissey Blvd, Boston, MA 02125; e-mail: kmcinnis@rippelifestyle.com



Chest. 2001;120(1):283-288. doi:10.1378/chest.120.1.283
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Published online

There is heightened concern that older adults and individuals with occult or known heart disease are exercising at fitness facilities that do not provide adequate cardiovascular screening and emergency procedures, as outlined in contemporary recommendations. To evaluate adherence to these standards, we surveyed 122 randomly chosen fitness clubs in Ohio (53% response rate; n = 65) that included > 110,000 total members. Special programs for older adults, cardiac patients, or both, were offered at 52% of these clubs. More than one fourth of the clubs (28%) failed to employ pre-entry screening to identify members with signs, symptoms, or history of cardiovascular disease, even though 17% reported one or more cardiovascular emergencies (ie, acute myocardial infarction, sudden cardiac death, or both) in their facility during the past 5 years. Moreover, a majority of the clubs (53%) had no written emergency response plan and 92% failed to conduct emergency response drills as described in published national standards. Only 3% of the centers reported having automated external defibrillators. These findings indicate that staff at public fitness facilities must work to identify members with signs, symptoms, or history of cardiovascular disease and prepare for prompt and appropriate responses to cardiovascular emergencies as described in contemporary national recommendations. Such risk management procedures may reduce exercise-related cardiovascular events among the escalating number of moderate-to-high-risk adults who are being mainstreamed into health and fitness facilities.

Figures in this Article

The promotion of routine physical activity is an important focus of our national public health agenda.12 Moderate-to-vigorous levels of physical activity and exercise are achieved in a number of settings, including > 15,000 health/fitness facilities across the country. The number of health/fitness facilities and members is expected to increase significantly over the next decade, adding to the 30 million men and women who already exercise at these facilities.3In the recent past, most health club members were young, healthy individuals, but an aging population and general promotion of physical activity to the public will likely change these fitness facility demographics. Current market research indicates that 50% of health/fitness facility members are ≥ 35 years old, and the fastest-growing segments of users are those aged 35 to 54 years and those ≥ 55 years old.4 Specialty exercise programs for older persons and individuals with chronic diseases such as coronary heart disease (CHD) are becoming more popular as facilities diversify to attract more members.

An estimated 25% of adult Americans have some form of cardiovascular disease.5Although regular exercise reduces subsequent cardiovascular morbidity and mortality,6the incidence of a cardiovascular event during exercise among patients with cardiac disease is estimated to be ≥ 10 times than that among apparently healthy persons.78 Therefore, adequate screening and evaluation of individuals with underlying cardiovascular disease prior to participation in moderate-to-vigorous levels of exercise, which should occur in a health club or fitness center, is important to promote safe participation. During the last decade, several professional groups have published guidelines to address concerns regarding safety, staffing, and programs at health clubs.912 Despite these guidelines, there is heightened concern that individuals at greater cardiovascular risk, such as those with known or occult CHD, are exercising at fitness facilities that fail to provide for adequate cardiovascular screening and emergency procedures. A survey of 110 health/fitness facilities in Massachusetts indicated that efforts to screen new members at enrollment were limited and inconsistent, while more than two thirds of the facilities in that study, including the so-called “high-quality clubs,” did not routinely practice emergency drills.13

The most recent comprehensive recommendations for safety measures at health/fitness facilities were published simultaneously in two medical journals by the American Heart Association (AHA) and the American College of Sports Medicine (ACSM).14 These recommendations address preparticipation cardiovascular screening of all persons (children, adolescents, and adults), staff qualifications, and emergency policies related to cardiovascular safety. The purpose of the present study was to evaluate compliance with these recommendations. Responses to key questions on emergency risk management procedures from the current survey were compared with published results from a previous survey,13 which was conducted prior to the publication of the recent AHA/ACSM recommendations, to determine if these recommendations may have influenced these practices in a positive direction.

Study Sample

All fitness centers that were listed in a national business directory database in the state of Ohio (n = 122) were mailed a written questionnaire inquiring about the cardiovascular risk management and medical emergency procedures common to their facility. Included were health clubs open to the general public, fitness centers with private membership (eg, corporate or work site fitness centers), and community exercise facilities. Programs intended to serve clinical populations exclusively, such as hospital-based cardiac rehabilitation programs, were excluded, as were other nontraditional health clubs, such as personal training or martial arts studios, spas, or other specialty exercise facilities. All surveys were mailed to the attention of the fitness center manager and included a self-addressed return envelope. Four weeks after the initial mailing, a follow-up letter and another copy of the survey were sent to each manager who did not return the survey. Nonresponders were contacted by telephone to encourage the completion of the survey at approximately 4 weeks and again at 6 weeks following the second mailing. No further attempt was made to collect surveys that were not returned.

Survey

The survey consisted of 30 multiple-choice questions asking the respondents to describe the cardiovascular risk management procedures commonly used at their facility, with specific emphasis on screening new members and preparation for emergency responses. Questions were based on the AHA/ACSM standards for cardiovascular risk preparation at health fitness facilities.14 The initial questions pertained to the type of fitness center (eg, private or public), size of the facility, number of members enrolled, number of part-time and full-time fitness staff, and certification and education of staff. Additionally, questions were included on pre-enrollment cardiovascular screening, whether the fitness center had written policy statements that address screening, and how frequently the questionnaire was used to screen new clients. Other items queried the existence of emergency procedures, whether the staff had written emergency plans, how often emergency drills were practiced per year, whether outside paramedical personnel were involved in devising the plans, and whether emergency training was part of staff orientation or training. The survey also requested information on the number of emergencies that required a call for an ambulance, the incidence of cardiovascular emergencies such as myocardial infarction or sudden cardiac arrest, whether clubs had an automated external defibrillator (AED) on site, and if they planned on purchasing an AED.

Survey Instructions

A cover letter accompanied the survey and stated the purpose of the study. The letter emphasized that it was not the intent of this study to make judgments or recommendations regarding the procedures used at any individual facility and that all responses were confidential. All questionnaires were number coded by the researchers for identification, and responders were asked not to identify themselves or their facility; however, respondents were encouraged to provide accurate responses regarding the risk management procedures commonly practiced at their facility.

Analysis of Data

Frequency distributions were calculated for responses to the questionnaire pertaining to preparticipation screening, related staff education or training activities, and emergency procedures practiced. Using χ2 analysis, comparisons were made between selected questions in this survey and similar ones published in a previous survey from a different geographic location13 that was conducted prior to the publication of the AHA/ACSM recommendations.14 Thus, any notable differences that we found in responses to similar questions in this safety/emergency preparedness area might be interpreted as potentially related to awareness and responsive of clubs to these new recommendations.14

Responses

Of the 122 facilities surveyed, 65 facilities (53%) responded. These included a cumulative membership of > 110,000 persons. Of all responders, 40 responders (64%) had > 500 members and 43 facilities (70%) exceeded 5,000 square feet in size. Most responses came from public fitness centers (n = 57; 88%), whereas only eight respondents (12%) were community exercise centers; none were work site facilities. More than half of the centers (52%) offered special exercise programs for the elderly, members with heart disease, or both.

Fitness Staff

At a majority of the facilities (53%), < 50% of fitness staff held a bachelor’s degree in exercise science or a related field, while in 12% of facilities, none held such a degree. One third of the clubs (32%) failed to certify their fitness and group exercise instructors in basic life support, as recommended by AHA/ACSM.

Preparticipation Screening

More than 25% of the clubs (n = 18; 28%) did no pre-entry screening to “identify users/members with heart-related medical conditions.” Of the 47 centers that conducted screening, either routinely or on occasion, 12 centers (25%) screened <50% of their new members (Fig 1 ).

Cardiovascular Emergencies and Procedures

A cardiovascular medical emergency, described as “a sudden cardiac arrest or heart attack,” was reported to have occurred at 11 of the surveyed facilities (17%) in the past 5 years. An AED was reported to be on-site at only two clubs (3%), while three clubs (5%) planned on purchasing the device within 1 year. Despite experiencing an apparently high incidence of reported cardiovascular events, the recommendation from the AHA/ACSM to have a written emergency response plan was followed by < 50% of the facilities (n = 31; 48%). The AHA/ACSM recommendation to practice at least quarterly emergency drills was rarely followed, with 91% of all clubs deficient on that standard, while 72% either never practiced or had no plan (Fig 2 ). Low compliance with other aspects of the AHA/ACSM emergency procedure recommendations are shown in Table 1 (eg, posting emergency telephone numbers, utilizing outside medical and paramedical personnel to develop or evaluate the emergency plan, and record keeping of emergency drills or related medical emergency events). Paradoxically, a majority of clubs (n = 62; 95%) rated having an appropriate emergency response plan at their facility as “extremely-to-very” important.

Knowledge of AHA/ACSM Standards

The percentage of facilities that were aware of the published AHA/ACSM health/fitness facility recommendations for cardiovascular screening and emergency procedures was disappointingly low, with only 12 facilities (18%) familiar with this publication (Fig 3 ). When comparing compliance with selected questions on preparticipation screening or emergency procedures from this survey to similar questions from a previous survey in Massachusetts (Fig 4 ), both surveys revealed a disparity between recommendations and practices for risk management in heath clubs. No changes were noted from the most recent survey results that might suggest responsiveness the contemporary AHA/ACSM recommendations cited in this study.

Results from this study suggest low awareness of, and adherence to, previously published guidelines for administering preventive exercise programs as developed by the AHA/ACSM. The main findings indicate that > 25% of the health/fitness clubs failed to employ pre-entry screening (eg, the Physical Activity Readiness Questionnaire)15 to identify members with signs, symptoms, or history of cardiovascular disease; of those clubs that do screen potential participants, most do so sporadically. Additionally, emergency preparation at public fitness facilities appears to be quite low. More than 50% of the facilities surveyed did not have an emergency response plan, and more than one third of centers with plans never or rarely review their emergency procedures.

The latest and most explicit recommendations for safety measures at health/fitness facilities were developed by the AHA and the ACSM, along with representatives from the International Health, Racquet, and Sportsclub Association and the YMCAs of America.14 Although the implementation of these and other risk management guidelines are not mandatory at health clubs and may not unequivocally identify all persons at risk for cardiovascular events during exercise, these guidelines provide a framework for optimizing safety during exercise participation. Low awareness of the AHA/ACSM guidelines as demonstrated in the present study suggests that more effective strategies are needed to disseminate these important messages to club owners, managers, and others throughout the fitness industry. Accordingly, it appears that dissemination of guidelines per se has little effect on practices, unless systematically reinforced by advocacy initiatives among industry leaders and proactive programs of individualized education and training.

Our findings are especially timely, as national campaigns to promote habitual physical activity for all segments of the US population, including those with chronic lifestyle diseases such as CHD and older individuals, has prompted escalated enrollment of these individuals in nonmedically based fitness centers.12,16Importantly, several studies1718 have demonstrated that patients with known or occult CHD can safely participate in moderate levels of exercise in unsupervised settings such as health clubs, community centers, or at home. Nevertheless, the risk of adverse cardiovascular events for this population is significantly higher than in otherwise healthy individuals. Albert et al7 reported a relative risk of 17 for sudden cardiac death during and up to 30 min after vigorous exertion compared with the risk at rest. Such findings stress the importance of appropriate emergency preparedness in preventive exercise settings.

The present findings indicate that approximately 50% of fitness clubs do not even attempt to identify individuals with existing CHD through simple preparticipation screening procedures and most are not prepared in the event of a cardiovascular emergency. It is alarming that as many as one third of these facilities do not universally require their fitness staff to be certified in basic cardiac life support, while only a fraction have lifesaving devices such as AEDs. The lack of emergency preparedness by many clubs contradicts the trend in the health club industry of promoting special exercise programs for the elderly and those with documented CHD.34 While specific data on the incidence of cardiac emergencies in US fitness centers are lacking, the sobering fact is that nearly one in five facilities in this limited survey reported having had a cardiovascular emergency during the past 5 years.

Facility directors should consider that published standards by authoritative professional medical and exercise organizations such as the AHA/ACSM will have a critical bearing on what differentiates due care from negligent conduct in the operation of health-fitness facilities and programs offered by such facilities.19For example, a legal case occurred in which a 21-year-old college student with hypertrophic cardiomyopathy suffered a fatal cardiac arrest while exercising at a student recreation center. In this case, a large verdict was returned by a jury in favor of the student’s family since basic cardiac life support was allegedly not administered by the fitness staff, although “911” was called promptly during the emergency.20 This case demonstrates the importance of having not only a written emergency plan as part of a fitness center’s policies and procedures manual, but having staff that is properly prepared to carry out these procedures achieved through routine rehearsals.

In conclusion, the present findings suggest that a significant gap exists between national recommendations and practices related to cardiovascular risk management procedures in public health clubs. Limitations of this study include a relatively small sampling of public fitness centers from one state, specifically Ohio. Whether these findings are generalizable to other states is not known. However, comparison data from a similar survey in Massachusetts13 showed equally poor adherence to nationally recommended safety practices. Collectively, these results suggest that fitness club practices in preliminary screening and emergency preparedness are probably similar in most regions of the United States.

Finally, it can be argued that the results of this study represent a“ best case scenario” regarding compliance with standards and application of risk management principles at health clubs. One might speculate that nonresponders to this survey were likely to be less compliant, further widening the gap between recommendations and practices. Therefore, current efforts to promote increased physical activity among the general public must coincide with adequate and careful evaluation of all individuals who join fitness centers, especially the elderly, and those with multiple risk factors and/or major signs or symptoms suggestive of cardiovascular, pulmonary, or metabolic disease. Staff at public fitness facilities must also work to prepare for prompt and appropriate responses to acute medical emergencies that occur. In this way, the potential to provide safe exercise participation at fitness centers can be maximized for all individuals, including those who are at increased risk of exercise-related complications.

Abbreviations: ACSM = American College of Sports Medicine; AED = automated external defibrillator; AHA = American Heart Association; CHD = coronary heart disease

Figure Jump LinkFigure 1. Frequency of using a preparticipation health history questionnaire to identify clients/members with heart disease (n = 65).Grahic Jump Location
Figure Jump LinkFigure 2. Frequency per year of emergency response procedures reviewed or practiced at fitness centers (n = 65).Grahic Jump Location
Table Graphic Jump Location
Table 1. Compliance With Specific AHA/ACSM Emergency Standards *
* 

Data are presented as No. (%).

Figure Jump LinkFigure 3. Percentage of facilities aware of AHA/ACSM health/fitness facility standards or recommendations.Grahic Jump Location
Figure Jump LinkFigure 4. Cardiovascular screening and emergency procedures at health/fitness facilities from a survey of 122 clubs in Massachusetts in 199613 vs 65 clubs in Ohio in 2000.Grahic Jump Location
Physical activity and health: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.
 
Healthy People 2010 (conference edition, in two volumes). Washington, DC: US Department of Health and Human Services, 2000.
 
1999 IHRSA: the state of the health club industry. Boston, MA: International Health, Racquet, and Sportsclub Association, 1999.
 
Formichelli, L Boom market: club industry.1999,28 Intertec Publishing. Pittsfield, MA:
 
American Heart Association heart and stroke facts: 2000 statistical supplement. Dallas, TX: American Heart Association, 2000.
 
American Heart Association statement on exercise: benefits and recommendations for physical activity programs for all Americans. Circulation 1996; 94:857–862.
 
Albert, CM, Mittleman, MA, Chae, CU, et al Triggering of sudden death from cardiac causes by vigorous exertion.N Engl J Med1999;343,1355-1361
 
Van Camp, SP, Peterson, RA Cardiovascular complications of outpatient cardiac rehabilitation programs.JAMA1986;256,1160-1163. [PubMed] [CrossRef]
 
Franklin, B Whaley, MH Howley, ET eds.Guidelines for exercise testing and prescription 6th ed.2000 Williams & Wilkins. Baltimore, MD:
 
Peterson, JA Tharrett, SJ eds.American College of Sports Medicine health/fitness facility standards and guidelines 2nd ed.1997 Human Kinetics Publishers. Champaign, IL:
 
Fletcher, GF, Balady, G, Froelicher, VF, et al Exercise standards: a statement from the American Heart Association.Circulation1995;91,580-615. [PubMed]
 
The Association of Quality Clubs standard facilitation guide. Boston, MA: International Health, Racquet, and Sportsclub Association, 1993.
 
McInnis, KJ, Hayakawa, S, Balady, GJ Cardiovascular screening and emergency procedures at health clubs and fitness centers.Am J Cardiol1997;80,380-383. [PubMed]
 
Balady, GJ, Chaitman, B, Driscoll, D, et al Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities.Circulation1998;97,2283-2293. [PubMed]
 
PAR-Q and you. Gloucester, Ontario: Canadian Society for Exercise Physiology, 1994; 1–2.
 
Physical activity and cardiovascular health: NIH Consensus Development Panel on Physical Activity and Cardiovascular Health. JAMA 1996; 276:241–246.
 
Franklin, BA, Bonzheim, K, Gordon, S, et al Safety of medically supervised outpatient cardiac rehabilitation exercise therapy.Chest1998;114,902-906. [PubMed]
 
King, PA, Savage, P, Ades, PA Home resistance training in an elderly woman with coronary heart disease.J Cardiopulm Rehabil2000;20,126-129. [PubMed]
 
Herbert, DL, Herbert, WG Legal considerations.American College of Sports Medicine’s resource manual for guidelines for graded exercise testing and prescription 3rd ed.1998,610-615 Williams & Wilkins. Baltimore, MD:
 
Spiegler v State of Arizona, CV 92–13608 (Arizona Maricopa County Supreme Court). Reported in: Herbert DL, Fitness Management, May 1996; 24.
 

Figures

Figure Jump LinkFigure 1. Frequency of using a preparticipation health history questionnaire to identify clients/members with heart disease (n = 65).Grahic Jump Location
Figure Jump LinkFigure 2. Frequency per year of emergency response procedures reviewed or practiced at fitness centers (n = 65).Grahic Jump Location
Figure Jump LinkFigure 3. Percentage of facilities aware of AHA/ACSM health/fitness facility standards or recommendations.Grahic Jump Location
Figure Jump LinkFigure 4. Cardiovascular screening and emergency procedures at health/fitness facilities from a survey of 122 clubs in Massachusetts in 199613 vs 65 clubs in Ohio in 2000.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Compliance With Specific AHA/ACSM Emergency Standards *
* 

Data are presented as No. (%).

References

Physical activity and health: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.
 
Healthy People 2010 (conference edition, in two volumes). Washington, DC: US Department of Health and Human Services, 2000.
 
1999 IHRSA: the state of the health club industry. Boston, MA: International Health, Racquet, and Sportsclub Association, 1999.
 
Formichelli, L Boom market: club industry.1999,28 Intertec Publishing. Pittsfield, MA:
 
American Heart Association heart and stroke facts: 2000 statistical supplement. Dallas, TX: American Heart Association, 2000.
 
American Heart Association statement on exercise: benefits and recommendations for physical activity programs for all Americans. Circulation 1996; 94:857–862.
 
Albert, CM, Mittleman, MA, Chae, CU, et al Triggering of sudden death from cardiac causes by vigorous exertion.N Engl J Med1999;343,1355-1361
 
Van Camp, SP, Peterson, RA Cardiovascular complications of outpatient cardiac rehabilitation programs.JAMA1986;256,1160-1163. [PubMed] [CrossRef]
 
Franklin, B Whaley, MH Howley, ET eds.Guidelines for exercise testing and prescription 6th ed.2000 Williams & Wilkins. Baltimore, MD:
 
Peterson, JA Tharrett, SJ eds.American College of Sports Medicine health/fitness facility standards and guidelines 2nd ed.1997 Human Kinetics Publishers. Champaign, IL:
 
Fletcher, GF, Balady, G, Froelicher, VF, et al Exercise standards: a statement from the American Heart Association.Circulation1995;91,580-615. [PubMed]
 
The Association of Quality Clubs standard facilitation guide. Boston, MA: International Health, Racquet, and Sportsclub Association, 1993.
 
McInnis, KJ, Hayakawa, S, Balady, GJ Cardiovascular screening and emergency procedures at health clubs and fitness centers.Am J Cardiol1997;80,380-383. [PubMed]
 
Balady, GJ, Chaitman, B, Driscoll, D, et al Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities.Circulation1998;97,2283-2293. [PubMed]
 
PAR-Q and you. Gloucester, Ontario: Canadian Society for Exercise Physiology, 1994; 1–2.
 
Physical activity and cardiovascular health: NIH Consensus Development Panel on Physical Activity and Cardiovascular Health. JAMA 1996; 276:241–246.
 
Franklin, BA, Bonzheim, K, Gordon, S, et al Safety of medically supervised outpatient cardiac rehabilitation exercise therapy.Chest1998;114,902-906. [PubMed]
 
King, PA, Savage, P, Ades, PA Home resistance training in an elderly woman with coronary heart disease.J Cardiopulm Rehabil2000;20,126-129. [PubMed]
 
Herbert, DL, Herbert, WG Legal considerations.American College of Sports Medicine’s resource manual for guidelines for graded exercise testing and prescription 3rd ed.1998,610-615 Williams & Wilkins. Baltimore, MD:
 
Spiegler v State of Arizona, CV 92–13608 (Arizona Maricopa County Supreme Court). Reported in: Herbert DL, Fitness Management, May 1996; 24.
 
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