A proposal for an evidenced-based emergency department discharge form for mild traumatic brain injury

Patient-centered mild traumatic brain injury interventions in the emergency department

INTRODUCTION

Traumatic brain injury (TBI) results in 2.5 million emergency department (ED) visits per year in the US, with mild traumatic brain injury (mTBI) accounting for 90% of cases. There is considerable evidence that many experience chronic symptoms months to years later. This population is rarely represented in interventional studies. Management of adult mTBI in the ED has remained unchanged, without consensus of therapeutic options. The aim of this review was to synthesize existing literature of patient-centered ED treatments for adults who sustain an mTBI, and to identify practices that may offer promise.

METHODS

A systematic review was conducted using the PubMed and Cochrane databases, while following PRISMA guidelines. Studies describing pediatric patients, moderate to severe TBI, or interventions outside the ED were excluded. Two reviewers independently performed title and abstract screening. A third blinded reviewer resolved discrepancies. The Mixed Methods Appraisal Tool (MMAT) was employed to assess the methodological quality of the studies.

RESULTS

Our search strategy generated 1002 unique titles. 95 articles were selected for full-text screening. The 26 articles chosen for full analysis were grouped into one of the following intervention categories: (1) predictive models for Post-Concussion Syndrome (PCS), (2) discharge instructions, (3) pharmaceutical treatment, (4) clinical protocols, and (5) functional assessment. Studies that implemented a predictive PCS model successfully identified patients at highest risk for PCS. Trials implementing discharge related interventions found the use of video discharge instructions, encouragement of daily light exercise or bed rest, and text messaging did not significantly reduce mTBI symptoms. The use of electronic clinical practice guidelines (eCPG) and longer leaves of absence from work following injury reduced symptoms. Ondansetron was shown to reduce nausea in mTBI patients. Studies implementing ED Observation Units found significant declines in inpatient admissions and length of hospital stay. The use of tablet-based tasks was found to be superior to many standard cognitive assessments.

CONCLUSION

Validated instruments are available to aid clinicians in identifying patients at risk for PCS or serious cognitive impairment. EDOU management and evidence-based modifications to discharge instructions may improve mTBI outcomes. Additional research is needed to establish the therapeutic value of medications and lifestyle changes for the treatment of mTBI in the ED.

Lack of association between four biomarkers and persistent post-concussion symptoms after a mild traumatic brain injury

Approximately 15 % of individuals who sustained a mild Traumatic Brain Injury (TBI) develop persistent post-concussion symptoms (PPCS). We hypothesized that blood biomarkers drawn in the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and PPCS at 90 days post mild TBI. We conducted a prospective cohort study in seven Canadian EDs. Patients aged ≥ 14 years presenting to the ED within 24 h of a mild TBI who were discharged were eligible. Clinical data and blood samples were collected in the ED, and a standardized questionnaire was administered 90 days later to assess the presence of symptoms. The following biomarkers were analyzed: S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial Fibrillary Acidic Protein (GFAP). The primary outcome measure was the presence of PPCS at 90 days after trauma. Relative risks and Areas Under the Curve (AUC) were computed. A total of 595 patients were included, and 13.8 % suffered from PPCS at 90 days. The relative risk of PPCS was 0.9 (95 % CI: 0.5-1.8) for S100B ≥ 20 pg/mL, 1.0 (95 % CI: 0.6-1.5) for NSE ≥ 200 pg/mL, 3.4 (95 % CI: 0.5-23.4) for GFAP ≥ 100 pg/mL, and 1.0 (95 % CI: 0.6-1.8) for C-Tau ≥ 1500 pg/mL. AUC were 0.50, 0.50, 0.51 and 0.54, respectively. Among mild TBI patients, S100B protein, NSE, c-Tau or GFAP do not seem to predict PPCS. Future research testing of other biomarkers is needed to determine their usefulness in predicting PPCS.

Post-Concussion Symptoms Rule: Derivation and Validation of a Clinical Decision Rule for Early Prediction of Persistent Symptoms after a Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) is a common problem. Depending on diagnostic criteria, 13 to 62% of those patients develop persistent post-concussion symptoms (PPCS). The main objective of this prospective multi-center study is to derive and validate a clinical decision rule (CDR) for the early prediction of PPCS. Patients aged ≥14 years were included if they presented to one of our seven participating emergency departments (EDs) within 24 h of an mTBI. Clinical data were collected in the ED, and symptom evolution was assessed at 7, 30 and 90 days post-injury using the Rivermead Post-Concussion Questionnaire (RPQ). The primary outcome was PPCS at 90 days after mTBI. A predictive model called the Post-Concussion Symptoms Rule (PoCS Rule) was developed using the methodological standards for CDR. Of the 1083 analyzed patients (471 and 612 for the derivation and validation cohorts, respectively), 15.6% had PPCS. The final model included the following factors assessed in the ED: age, sex, history of prior TBI or mental health disorder, headache in ED, cervical sprain and hemorrhage on computed tomography. The 7-day follow-up identified additional risk factors: headaches, sleep disturbance, fatigue, sensitivity to light, and RPQ ≥21. The PoCS Rule had a sensitivity of 91.4% and 89.6%, a specificity of 53.8% and 44.7% and a negative predictive value of 97.2% and 95.8% in the derivation and validation cohorts, respectively. The PoCS Rule will help emergency physicians quickly stratify the risk of PPCS in mTBI patients and better plan post-discharge resources.

Collaborative Goal Setting: A Clinical Approach for Adults With Mild Traumatic Brain Injury

Purpose Speech-language pathologists (SLPs) have many available procedural options when setting treatment goals. Extant literature supports goal setting protocols that include and value the perspectives of the client; however, in practice, rehabilitation professionals may lean toward expert models of care when planning treatment. Our purpose is to describe a newly developed approach for SLPs and individuals with mild traumatic brain injury (mTBI) to work together to build meaningful, relevant goals. Method We utilized a multiple case study format to exemplify goal setting procedures. Specifically, we describe procedures and outcomes for a 29-year-old female 28 days postinjury and a 70-year-old male 9 months postinjury. Results Clients who engaged in this protocol worked collaboratively with a clinician to identify strengths and challenges postinjury, select and prioritize goal areas, and discuss and develop meaningful, personalized treatment activities. For both participants, use of the proposed protocol resulted in meaningful goals that addressed their self-reported deficits as well as their respective cognitive-linguistic deficits noted on objective, standardized measures. Conclusions Clinician and client collaboration during treatment goal development can facilitate increased client motivation and functional outcomes. The described approach is feasible from a clinical resource standpoint and promotes a systematic approach to placing the client at the forefront of clinical decision making to enhance therapeutic gains. Such client-centered approaches may be particularly valuable for individuals with mTBI who experience substantial cognitive and communicative challenges but may maintain high levels of self-awareness postinjury.

Emergency department discharge instruction for mild traumatic brain injury: Evaluation on readability, understandability, actionability and content

INTRODUCTION

Emergency departments (EDs) routinely provide discharge instructions due to a large number of patients with mild traumatic brain injury (mTBI) being discharged home directly from ED. This study aims to evaluate the quality of available mTBI discharge instructions provided by EDs of Malaysia government hospitals.

METHODS

All 132 EDs were requested for a copy of written discharge instruction given to the patients. The mTBI discharge instructions were evaluated using the Patient Education Materials Assessment-Printable Tool (PEMAT-P) for understandability and actionability. Readability was measured using an online readability tool of Malay text. The content was compared against the discharge instructions recommended by established guidelines.

RESULTS

49 articles were eligible for the study. 26 of the articles met the criteria of understandability, and 3 met the criteria for actionability. The average readability level met the ability of average adult. Most of the discharge instructions focused on emergency symptoms, and none contained post-concussion features.

CONCLUSION

Majority of the discharge instructions provided were appropriate for average people to read but difficult to understand and act upon. Important information was neglected in most discharge instructions. Thus, revision and future development of mTBI discharge instruction should consider health literacy demand and cognitive ability to process such information.

Discharge communication practices in pediatric emergency care: a systematic review and narrative synthesis

BACKGROUND

The majority of children receiving care in the emergency department (ED) are discharged home, making discharge communication a key component of quality emergency care. Parents must have the knowledge and skills to effectively manage their child's ongoing care at home. Parental fatigue and stress, health literacy, and the fragmented nature of communication in the ED setting may contribute to suboptimal parent comprehension of discharge instructions and inappropriate ED return visits. The aim of this study was to examine how and why discharge communication works in a pediatric ED context and develop recommendations for practice, policy, and research.

METHODS

We systematically reviewed the published and gray literature. We searched electronic databases CINAHL, Medline, and Embase up to July 2017. Policies guiding discharge communication were also sought from pediatric emergency networks in Canada, USA, Australia, and the UK. Eligible studies included children less than 19 years of age with a focus on discharge communication in the ED as the primary objective. Included studies were appraised using relevant Joanna Briggs Institute (JBI) checklists. Textual summaries, content analysis, and conceptual mapping assisted with exploring relationships within and between data. We implemented an integrated knowledge translation approach to strengthen the relevancy of our research questions and assist with summarizing our findings.

RESULTS

A total of 5095 studies were identified in the initial search, with 75 articles included in the final review. Included studies focused on a range of illness presentations and employed a variety of strategies to deliver discharge instructions. Education was the most common intervention and the majority of studies targeted parent knowledge or behavior. Few interventions attempted to change healthcare provider knowledge or behavior. Assessing barriers to implementation, identifying relevant ED contextual factors, and understanding provider and patient attitudes and beliefs about discharge communication were identified as important factors for improving discharge communication practice.

CONCLUSION

Existing literature examining discharge communication in pediatric emergency care varies widely. A theory-based approach to intervention design is needed to improve our understanding regarding discharge communication practice. Strengthening discharge communication in a pediatric emergency context presents a significant opportunity for improving parent comprehension and health outcomes for children.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42014007106.

Sport-Related Concussion in Children and Adolescents

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.

A Scoping Review of Emergency Department Discharge Instructions for Children and Adolescents With Mental Disorders

BACKGROUND

Although most young people under the age of 25 years with mental health presentations to the emergency department (ED) are discharged home, several studies suggest discharge instructions are inadequate. We conducted a scoping review to characterize and map the literature, identify research gaps, and prioritize targeted areas for future reviews for ED discharge instructions for young people with mental disorders.

METHODS

Our review was conducted in an iterative approach with 6 stages including identifying the research question, identifying relevant studies, study selection, data extraction, collaring and summarizing, and stakeholder engagement. We characterized the available information on discharge instruction interventions using the Behavior Change Wheel.

RESULTS

Of the 805 potential publications screened, 25 were included for extraction. Nine of the 25 articles focused on suicide or self-harm, 6 were on mental health in general or mixed groups, and 9 focused on alcohol, tobacco, or substance use in general. Five studies included younger children (ie, less than 12 years) but ages ranged significantly among studies. Education and persuasion were intervention functions most commonly reported in publications (n = 13 and n = 12, respectively). From the policy categories, recommendations regarding service provision were most frequently made from four publications. Descriptions of theory were limited in publications.

CONCLUSIONS

The available literature regarding discharge instructions in the ED for youth with mental disorders is focused on certain content areas (eg, self injurious behaviors, substance use) with more work required in chronic mental disorders that make up a significant proportion of ED visits. Research that extends beyond education and with theoretical underpinnings to explain how and why various interventions work would be useful for clinicians, policy-makers, and other researchers.

Traumatic brain injury education for adult patients and families: a scoping review

Traumatic brain injury (TBI) is increasingly viewed as a chronic condition, bringing long-term needs for patient and caregiver knowledge pertaining to symptom and problem management over time. In light of these needs, we performed a scoping review of the literature on brain injury education provided to adult patients and/ or family members affected by TBI. Objectives were to describe the types of educational interventions that have been developed; to review the effects of these interventions; and to determine gaps that might be filled by future research efforts. Of 88 articles meeting search criteria and subjected to data extraction, 34 concerned education about mild TBI and 54, moderate to severe TBI. Most mild TBI articles focused on education in the Emergency Room, while most moderate/ severe TBI education was directed toward family members/ caregivers and was frequently combined with other treatment components, making the effects of education difficult to discern. Only 1 article incorporated elements of self-management training (SMT), a model proved effective in other chronic health conditions. We recommend further exploration of SMT principles in long-term TBI care, as well as more precise definition of treatment components in all patient and family interventions, so that the specific effects of education and other treatment elements may be more readily evaluated.

Essential Content for Discharge Instructions in Pediatric Emergency Care: A Delphi Study

OBJECTIVE

The aim of this study was to identify the 5 most essential discharge instruction content elements that should be communicated to all caregivers of children who present to the emergency department (ED) with asthma, vomiting/diarrhea, abdominal pain, fever, minor head injury, or bronchiolitis.

METHODS

A discharge information content list was developed for each illness presentation following a review of the literature. Using a modified Delphi technique, 6 lists were distributed to a panel of experts from EDs across Canada using a secure online survey tool with the goal of achieving the 5 most essential discharge instruction elements.

RESULTS

A total of 37 emergency clinicians completed all 4 rounds of the Delphi. Consensus for the final 30 content items ranged from 51.4% to 100%. Items pertaining to diarrhea/vomiting, abdominal pain, fever, and bronchiolitis obtained relatively high levels of consensus for all top 5 items. The majority of items (n = 19 [63.3%]) that reached consensus across the illness presentations were associated with instructions intended to educate caregivers on instances when they should return to the ED department.

CONCLUSIONS

Findings from this study provide a better understanding of what should be communicated to caregivers of children who present to the ED with a number of different illness presentations. Results from this study suggest that health care providers agree on the importance of providing information to caregivers regarding when to return to the ED with their child. Reaching consensus among all experts in this study provides insight into the difficulty of standardizing discharge communication in the absence of widely accepted guidelines.

Annual Trends in Follow-Up Visits for Pediatric Concussion in Emergency Departments and Physicians' Offices

OBJECTIVE

To assess whether children and youth with concussion receive follow-up visits in accordance with the recommended guidelines.

STUDY DESIGN

We conducted a retrospective, population-based study using linked health administrative data from all concussion-related visits to emergency department and physician offices by children aged 5 through 18 years (range, 5.00-18.99) in Ontario between 2003 and 2013. We analyzed the percentage of children and youth seen for follow-up. The Mann-Kendall test for trends was used to assess a monotonic increasing trend over time in concussion follow-up visits.

RESULTS

A total of 126 654 children and youth were evaluated for an index concussion visit. The number of children and youth assessed for concussion follow-up (N = 45 155) has increased significantly over time (P < .001). In 2003, 781 of 7126 patients (11.0%; 95% CI, 10.3-11.7) with an index visit for concussion had a follow-up assessment. By 2013, 6526 of 21 681 (30.1%; 95% CI, 29.5-30.7) patients received follow-up care.

CONCLUSIONS

The proportion of children and youth receiving follow-up after an acute concussion has significantly increased between 2003 and 2013. Nevertheless, more than two-thirds of all patients do not seek medical follow-up or clearance as recommended by current concussion guidelines, suggesting that ongoing efforts to improve and monitor compliance with recommended guidelines by patients and physicians are important.

Characteristics of patients included and enrolled in studies on the prognostic value of serum biomarkers for prediction of postconcussion symptoms following a mild traumatic brain injury: a systematic review

OBJECTIVE

Mild traumatic brain injury (mTBI) has been insufficiently researched, and its definition remains elusive. Investigators are confronted by heterogeneity in patients, mechanism of injury and outcomes. Findings are thus often limited in generalisability and clinical application. Serum protein biomarkers are increasingly assessed to enhance prognostication of outcomes, but their translation into clinical practice has yet to be achieved. A systematic review was performed to describe the adult populations included and enrolled in studies that evaluated the prognostic value of protein biomarkers to predict postconcussion symptoms following an mTBI.

DATA SOURCES

Searches of MEDLINE, Embase, CENTRAL, CINAHL, Web of Science, PsycBITE and PsycINFO up to October 2016.

DATA SELECTION AND EXTRACTION

Two reviewers independently screened for potentially eligible studies, extracted data and assessed the overall quality of evidence by outcome using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

A total of 23 298 citations were obtained from which 166 manuscripts were reviewed. Thirty-six cohort studies (2812 patients) having enrolled between 7 and 311 patients (median 89) fulfilled our inclusion criteria. Most studies excluded patients based on advanced age (n=10 (28%)), neurological disorders (n=20 (56%)), psychiatric disorders (n=17 (47%)), substance abuse disorders (n=13 (36%)) or previous traumatic brain injury (n=10 (28%)). Twenty-one studies (58%) used at least two of these exclusion criteria. The pooled mean age of included patients was 39.3 (SD 4.6) years old (34 studies). The criteria used to define a mTBI were inconsistent. The most frequently reported outcome was postconcussion syndrome using the Rivermead Post-Concussion Symptoms Questionnaire (n=18 (50%)) with follow-ups ranging from 7 days to 5 years after the mTBI.

CONCLUSIONS

Most studies have recruited samples that are not representative and generalisable to the mTBI population. These exclusion criteria limit the potential use and translation of promising serum protein biomarkers to predict postconcussion symptoms.

Discharge Instructions for Concussion: Are We Meeting the Patient Needs?

Education to improve symptom management is an agreed-upon strategy to reduce the impact of symptoms on the quality of life for persons with mild traumatic brain injury. The purpose of this study was to investigate whether current discharge education practices are deemed adequate by persons treated and released from the emergency department with concussion. A review of current literature identified a need for patient education improvements in emergency departments. Strategies for improving information retention in the mild traumatic brain injury patient population for effective symptom management are identified. A concussion symptom management booklet was created using current scientific information. The concussion education booklet along with standardized postconcussion education was provided to patients with mild traumatic brain injuries who were discharged from a level I trauma center emergency department. A prospective small-scale study was performed to establish the ease of use and usefulness of the newly created concussion education booklet and determine whether patients preferred the booklet of information over the standard discharge instructions.

Parental Knowledge and Recall of Concussion Discharge Instructions

INTRODUCTION

Children increasingly are being seen in the emergency department for a concussion, or mild traumatic brain injury (mTBI). A key aim of the ED visit is to provide discharge advice that can help parents to identify an evolving neurosurgical crisis, facilitate recovery, and prevent reinjury. The present study examined parents' knowledge of symptoms and recall of discharge instructions after their adolescent's mTBI and the effect of supplementing written discharge instructions with verbal instruction and reinforcement.

METHODS

We performed a nested observational study of parents/caregivers of patients who participated in a larger mTBI study. After their adolescent's mTBI, parents were given verbal and standardized written instructions. The ED discharge process was observed using a structured checklist, and parents were surveyed 3 days after discharge on knowledge and recall of discharge instructions.

RESULTS

Ninety-three parents completed the postsurvey. Nearly 1 in 5 parents were confused about when to return to the emergency department after evaluation for head injury. Up to 1 in 4 parents could not recall specific discharge advice related to concussion. Parents who received verbal reinforcement of written discharge instructions were more likely to recall them.

CONCLUSION

Emergency nurses and clinicians should strive to utilize both verbal and written discharge instructions with families to help increase understanding.

Understanding discharge communication behaviours in a pediatric emergency care context: a mixed methods observation study protocol

BACKGROUND

One of the most important transitions in the continuum of care for children is discharge to home. Optimal discharge communication between healthcare providers and caregivers (e.g., parents or other guardians) who present to the emergency department (ED) with their children is not well understood. The lack of policies and considerable variation in practice regarding discharge communication in pediatric EDs pose a quality and safety risk for children and their parents.

METHODS

The aim of this mixed methods study is to better understand the process and structure of discharge communication in a pediatric ED context to contribute to the design and development of discharge communication interventions. We will use surveys, administrative data and real-time video observation to characterize discharge communication for six common illness presentations in a pediatric ED: (1) asthma, (2) bronchiolitis, (3) abdominal pain, (4) fever, (5) diarrhea and vomiting, and (6) minor head injury. Participants will be recruited from one of two urban pediatric EDs in Canada. Video recordings will be analyzed using Observer XT. We will use logistic regression to identify potential demographic and visit characteristic cofounders and multivariate logistic regression to examine association between verbal and non-verbal behaviours and parent recall and comprehension.

DISCUSSION

Video recording of discharge communication will provide an opportunity to capture important data such as temporality, sequence and non-verbal behaviours that might influence the communication process. Given the importance of better characterizing discharge communication to identify potential barriers and enablers, we anticipate that the findings from this study will contribute to the development of more effective discharge communication policies and interventions.

Development and feasibility testing of the Pediatric Emergency Discharge Interaction Coding Scheme

Background

Discharge communication is an important aspect of high‐quality emergency care. This study addresses the gap in knowledge on how to describe discharge communication in a paediatric emergency department (ED).

Objective

The objective of this feasibility study was to develop and test a coding scheme to characterize discharge communication between health‐care providers (HCPs) and caregivers who visit the ED with their children.

Design

The Pediatric Emergency Discharge Interaction Coding Scheme (PEDICS) and coding manual were developed following a review of the literature and an iterative refinement process involving HCP observations, inter‐rater assessments and team consensus.

Setting and participants

The coding scheme was pilot‐tested through observations of HCPs across a range of shifts in one urban paediatric ED.

Main variables studied

Overall, 329 patient observations were carried out across 50 observational shifts. Inter‐rater reliability was evaluated in 16% of the observations. The final version of the PEDICS contained 41 communication elements.

Results

Kappa scores were greater than .60 for the majority of communication elements. The most frequently observed communication elements were under the Introduction node and the least frequently observed were under the Social Concerns node. HCPs initiated the majority of the communication.

Conclusion

Pediatric Emergency Discharge Interaction Coding Scheme addresses an important gap in the discharge communication literature. The tool is useful for mapping patterns of discharge communication between HCPs and caregivers. Results from our pilot test identified deficits in specific areas of discharge communication that could impact adherence to discharge instructions. The PEDICS would benefit from further testing with a different sample of HCPs.

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments

Evidence-based clinical practice guidelines can facilitate proper evaluation and management of concussions in the emergency department (ED), often the initial and primary point of contact for concussion care. There is no universally adopted set of guidelines for concussion management, and extant evidence suggests that there may be variability in concussion care practices and limited application of clinical practice guidelines in the ED. This study surveyed EDs throughout New England to examine current practices of concussion care and utilization of evidence-based clinical practice guidelines in the evaluation and management of concussions. In 2013, a 32-item online survey was e-mailed to 149/168 EDs throughout New England (Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine). Respondents included senior administrators asked to report on their EDs use of clinical practice guidelines, neuroimaging decision-making, and discharge instructions for concussion management. Of the 72/78 respondents included, 35% reported absence of clinical practice guidelines, and 57% reported inconsistency in the type of guidelines used. Practitioner preference guided neuroimaging decision-making for 57%. Although 94% provided written discharge instructions, there was inconsistency in the recommended time frame for follow-up care (13% provided no specific time frame), the referral specialist to be seen (25% did not recommend any specialist), and return to activity instructions were inconsistent. There is much variability in concussion care practices and application of evidence-based clinical practice guidelines in the evaluation and management of concussions in New England EDs. Knowledge translational efforts will be critical to improve concussion management in the ED setting.

Treatment of Head and Neck Injuries in the Helmeted Athlete

Sport-related concussion treatment includes three major phases: initial evaluation at the time of the injury, treatment while the patient is symptomatic, and evaluation of the readiness for a gradual return to participation. Each concussion evaluation should include similar elements: assessment of symptoms, assessment of cognitive ability, assessment of coordination (of the eyes, upper extremities, and lower extremities), and assessment for additional injuries. The spine-boarding recommendations from the American College of Emergency Physicians, National Association of EMS Physicians, and National Athletic Trainers' Association have changed. These recommendations include both decreased use of spinal immobilization and removal of the helmet and shoulder pads prior to securing the athlete to the board when sufficient numbers of trained providers are present. Preseason training and pregame meetings or "medical time outs" should become standard practice for the sidelines medical team (including the athletic trainer, team physician, emergency response personnel, and possibly others).

Implementing evidence-based recommended practices for the management of patients with mild traumatic brain injuries in Australian emergency care departments: study protocol for a cluster randomised controlled trial

Background

Mild head injuries commonly present to emergency departments. The challenges facing clinicians in emergency departments include identifying which patients have traumatic brain injury, and which patients can safely be sent home. Traumatic brain injuries may exist with subtle symptoms or signs, but can still lead to adverse outcomes. Despite the existence of several high quality clinical practice guidelines, internationally and in Australia, research shows inconsistent implementation of these recommendations. The aim of this trial is to test the effectiveness of a targeted, theory- and evidence-informed implementation intervention to increase the uptake of three key clinical recommendations regarding the emergency department management of adult patients (18 years of age or older) who present following mild head injuries (concussion), compared with passive dissemination of these recommendations. The primary objective is to establish whether the intervention is effective in increasing the percentage of patients for which appropriate post-traumatic amnesia screening is performed.

Methods/design

The design of this study is a cluster randomised trial. We aim to include 34 Australian 24-hour emergency departments, which will be randomised to an intervention or control group. Control group departments will receive a copy of the most recent Australian evidence-based clinical practice guideline on the acute management of patients with mild head injuries. The intervention group will receive an implementation intervention based on an analysis of influencing factors, which include local stakeholder meetings, identification of nursing and medical opinion leaders in each site, a train-the-trainer day and standardised education and interactive workshops delivered by the opinion leaders during a 3 month period of time. Clinical practice outcomes will be collected retrospectively from medical records by independent chart auditors over the 2 month period following intervention delivery (patient level outcomes). In consenting hospitals, eligible patients will be recruited for a follow-up telephone interview conducted by trained researchers. A cost-effectiveness analysis and process evaluation using mixed-methods will be conducted. Sample size calculations are based on including 30 patients on average per department. Outcome assessors will be blinded to group allocation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12612001286831 (date registered 12 December 2012).

Management of pediatric patients with concussion by emergency medicine physicians

OBJECTIVE

Despite an increase in concussion diagnoses among pediatric patients, little is known about the management of pediatric patients with concussion in emergency departments (EDs). The objective of this study was to assess strategies used by emergency medicine physicians when treating pediatric patients with concussions.

METHODS

A 17-item questionnaire was e-mailed to members of the American Academy of Pediatrics Section on Emergency Medicine. Two serial e-mails were distributed at 2-week intervals to nonresponders. The survey included multiple-choice and free-text questions that were created by the team of investigators on the basis of prior surveys of family practitioners and physical trainers. We collected demographic information and specific information regarding the use of medications, neuropsychological testing, neuroimaging, return-to-play decision making, and use of published guidelines. Simple descriptive statistics were used.

RESULTS

Two hundred sixty-five (29%) physicians completed the questionnaire, of which 52% had been an attending physician for more than 10 years. Ninety-nine percent of the respondents reported managing concussions, with the majority (76%) seeing more than 24 patients with concussion per year. Most clinicians (81%) reported using a published guideline in their management of concussions. The symptoms most likely to prompt head imaging in the ED included a focal neurological deficit (92%), altered mental status (82%), and intractable vomiting (80%). Most (91%) respondents reported using medications to manage the symptoms of patients with concussion, mainly acetaminophen (78%) and nonsteroidal anti-inflammatory medications (77%), whereas 54% of the respondents used ondansetron and 7% of the respondents used narcotics. More than half (56%) of the respondents referred patients with concussion for neuropsychological testing from the ED. Of those, nearly half (49%) of the respondents refer their patients to a sports concussion clinic, whereas 5% of the respondents refer their patients to a neuropsychologist. When discussing discharge instructions, 86% of the clinicians recommended follow-up with a primary care physician, 62% of the clinicians recommended follow-up with a sports concussion clinic, and 11% of the clinicians recommend follow-up with a neurologist. Most respondents (70%) have access to a designated sports concussion clinic.

CONCLUSIONS

Nearly all emergency medicine physicians surveyed care for pediatric patients with concussion, most by using published guidelines. Emergency medicine physicians routinely use medications to treat the symptoms of concussion and often refer patients to primary care physicians as well as designated sports concussion clinics for follow-up.

Use of modified acute concussion evaluation tools in the emergency department

OBJECTIVES

Accurate recognition of pediatric concussion in the emergency department (ED) is important to ensure appropriate management for safe recovery. The study objective was to determine whether the Centers for Disease Control and Prevention's Acute Concussion Evaluation (ACE) tools, modified for ED use, improved patient follow-up and post-injury behaviors.

METHODS

The original ACE tools (ACE, ACE Care Plan) were modified for ED use via Delphi methodology with an expert panel and implemented in 2 urban pediatric EDs for patients aged 5 to 21 years evaluated within 24 hours of a head injury. Pre- (February 2009 to July 2009) and post- (December 2009 to June 2010) implementation, patient phone surveys were conducted 1, 2, and 4 weeks after ED discharge. Reported rates of patient follow-up and recovery measures were analyzed. ED clinician adherence was assessed.

RESULTS

During the study, 164 patients were enrolled pre-implementation and 190 post-implementation. The mean patient age was 10.6 years (SD, 3.7); 65% were males, 49% were African American, and 46% were Caucasian. Post-implementation, 58% of patients received the modified ACE diagnostic tool and 84% received the modified ACE discharge instructions. Follow-up was improved at all time points (32% vs 61% at week 4; P < .001; odds ratio, 3.4; 95% confidence interval, 2.1-5.4). Post-implementation, parental recall of discharge instructions was significantly increased, patient's mean total post-concussion symptom score was significantly higher, and report of return to normal activity was significantly longer.

CONCLUSIONS

The ACE tools, modified for ED use, were successfully implemented in the pediatric ED. Post-implementation, increased patient follow-up and improved recall of and adherence to ED discharge recommendations was demonstrated.

Discharge instructions for caregivers in the context of pediatric emergency care: a narrative synthesis protocol

BACKGROUND

The period following discharge from a pediatric emergency department (ED) can be a time of significant vulnerability for caregivers who provide ongoing care to their child when they return home. Discharge communication practice varies widely at the individual practitioner and departmental level. At present, there are no nationally accepted guidelines for discharge communication for children and/or their caregivers in the ED.The primary objective of this knowledge synthesis is to understand how and why discharge instructions work and under what conditions. We will also examine the contextual factors and barriers and facilitators associated with discharge communication across varied ED settings.

METHODS/DESIGN

Using an integrated narrative approach, we will synthesize different types of evidence and explore relationships within and between included studies to develop a theory-based and knowledge user-informed discharge communication practice guideline. We will follow key principles for knowledge synthesis including: (1) involvement of a multidisciplinary team (for example, information specialists, statisticians, and content experts); (2) developing focused and answerable questions in collaboration with the knowledge users; (3) using a systematic method including specific tools and techniques appropriate for answering questions concerned with effectiveness and the implementation of interventions; and, (4) involving knowledge users throughout the process in an integrated knowledge translation approach.

DISCUSSION

This collaborative and narrative approach will be a determining factor in increasing the reliability, validity and relevance of the study findings for healthcare practice and policy decision-makers.

TRIAL REGISTRATION

PROSPERO registration number: CRD42014007106.

Variability in discharge instructions and activity restrictions for patients in a children's ED postconcussion

OBJECTIVE

The objective of this study was to describe discharge instructions given to school-aged patients evaluated in a children's emergency department (ED) following concussion.

METHODS

This was a retrospective cohort study of children 6 to 18 years evaluated in a dedicated children's ED at a level I trauma center in 2008 following acute head trauma regardless of mechanism, identified by any of 27 International Classification of Disease, Ninth Revision diagnoses for head injury, concussion, or skull fracture. Included were those presentations consistent with the Zurich definition for concussion. Excluded were hospital admission, death before admission, evidence of intoxication, or structural abnormality on imaging. Univariate and multivariate analyses determined adjusted odds ratios (ORs) for receipt of concussion-specific discharge instructions and activity restrictions.

RESULTS

Of 350 eligible patients, the 218 included patients were mostly male (68%) with mean age 12.8 (SD, 3.4) years. Injury characteristics included sports-related, 42%; fall, 23%; loss of consciousness, 33%; headache, 75%; dizziness, 29%; amnesia, 25%; and vomiting, 19%. Most patients underwent imaging (81%). Discharge characteristics included concussion stated in final diagnosis, 31%; concussion-specific instructions, 62%; and activity restrictions, 34%. Concussion-specific discharge instructions were more likely for loss of consciousness (OR, 1.7; 95% confidence interval [CI], 1.22-2.36), and activity restrictions were more likely for sport-related injury (OR, 1.31; 95% CI, 1.02-1.76) and amnesia (OR, 1.42; 95% CI, 1.01-1.98).

CONCLUSIONS

Most children meeting diagnostic criteria for concussion were discharged without concussion-specific diagnoses or activity restrictions. Given the risks associated with untimely return to both physical and cognitive activity after concussion, improved awareness and standardization of disposition are imperative for the management of these young patients in the ED.

Trends in concussion return-to-play timelines among high school athletes from 2007 through 2009

CONTEXT

Whereas guidelines about return-to-play (RTP) after concussion have been published, actual prognoses remain elusive.

OBJECTIVE

To develop probability estimates for time until RTP after sport-related concussion.

DESIGN

Descriptive epidemiology study.

SETTING

High school.

PATIENTS OR OTHER PARTICIPANTS

Injured high school varsity, junior varsity, or freshman athletes who participated in 1 of 13 interscholastic sports at 7 area high schools during the 2007-2009 academic years.

INTERVENTION(S)

Athletic trainers employed at each school collected concussion data. The athletic trainer or physician on site determined the presence of a concussion. Athlete-exposures for practices and games also were captured.

MAIN OUTCOME MEASURE(S)

Documented concussions were categorized by time missed from participation using severity outcome intervals (same-day return, 1- to 2-day return, 3- to 6-day return, 7- to 9-day return, 10- to 21-day return, >21-day return, no return [censored data]). We calculated Kaplan-Meier time-to-event probabilities that included censored data to determine the probability of RTP at each of these time intervals.

RESULTS

A total of 81 new concussions were documented in 478 775 athlete-exposures during the study period. After a new concussion, the probability of RTP (95% confidence interval) was 2.5% (95% confidence interval = 0.3, 6.9) for a 1- to 2-day return, 71.3% (95% confidence interval = 59.0, 82.9) for a 7- to 9-day return, and 88.8% (95% confidence interval = 72.0, 97.2) for a 10- to 21-day return.

CONCLUSIONS

For high school athletes, RTP within the first 2 days after concussion was unlikely. After 1 week, the probability of return rose substantially (approximately 71%). Prognostic indicators are used to educate patients about the likely course of disease. Whereas individual symptoms and recovery times vary, prognostic time-to-event probabilities allow clinicians to provide coaches, parents, and athletes with a prediction of the likelihood of RTP within certain timeframes after a concussion.

Evaluation of emergency medicine discharge instructions in pediatric head injury

OBJECTIVES

Pediatric head trauma is a common occurrence. There is mounting evidence that even patients with minor head injury require limits on school activities and/or removal from sports and play to help speed recovery and limit morbidity. The objective of this study was to determine whether discharge instructions given to children who had sustained head injuries included information regarding activity restrictions, activity time constraints, and/or specifics of follow-up care.

METHODS

This was a retrospective chart review of patients aged 2 to 18 years evaluated and treated for head injury during a 4-month period at a level I trauma center (volume ∼23,000 pediatric patients per year). Included were those children seen, evaluated, and diagnosed with any of the following: mild head injury, concussion, minor head trauma, or mild traumatic brain injury (mTBI). Subjects were excluded if there was a positive acute head injury computed tomography finding (other than findings of a simple linear skull fracture) or if the subject required admission.

RESULTS

Among the 204 patients meeting eligibility, 95.1% received instruction to follow up with a physician, 82.8% received anticipatory guidance regarding expected symptoms, 15.2% received specific restriction time from sports, and 21.5% were removed from sports. Of these patients, 113 patients were determined "likely" to have sustained an mTBI. Patients with sports-related mTBI received return-to-sports restrictions (χ2 = 11.225, P < 0.008) and to remove the child from play (χ2 = 9.781, P < 0.004) as discharge instructions significantly more than did patients with motor vehicle accident or other mechanisms of injury.

CONCLUSIONS

Children sustaining head injury were inadequately instructed to restrict athletic activities upon discharge. This is particularly true for patients who sustain an mTBI from non-sports-related activity.

Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update

BACKGROUND

The management of minimal, mild and moderate head injuries is still controversial. In 2000, the Scandinavian Neurotrauma Committee (SNC) presented evidence-based guidelines for initial management of these injuries. Since then, considerable new evidence has emerged.

METHODS

General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Systematic evidence-based review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, based upon relevant clinical questions with respect to patient-important outcomes, including Quality Assessment of Diagnostic Accuracy Studies (QUADAS) and Centre of Evidence Based Medicine (CEBM) quality ratings. Based upon the results, GRADE recommendations, guidelines and discharge instructions were drafted. A modified Delphi approach was used for consensus and relevant clinical stakeholders were consulted.

CONCLUSIONS

We present the updated SNC guidelines for initial management of minimal, mild and moderate head injury in adults including criteria for computed tomography (CT) scan selection, admission and discharge with suggestions for monitoring routines and discharge advice for patients. The guidelines are designed to primarily detect neurosurgical intervention with traumatic CT findings as a secondary goal. For elements lacking good evidence, such as in-hospital monitoring, routines were largely based on consensus. We suggest external validation of the guidelines before widespread clinical use is recommended.

Parental recognition of postconcussive symptoms in children

Evaluation of current emergency department discharge instructions and parental recognition of symptomatology requiring further care for traumatic brain injury (TBI) is not well understood. A convenience sample of 105 parents of children aged 5 to 17 years who were seen and discharged from the pediatric emergency department with TBI was identified. Parents were surveyed by telephone 2 to 5 days after injury and a questionnaire was completed regarding identification of TBI symptoms. This study demonstrated that despite verbal and written discharge instructions, many parents with symptomatic children reported that their children were asymptomatic, and unable to identify postconcussive symptoms in their children.

Mild traumatic brain injury: key decisions in acute management

The definition of a mild traumatic brain injury (TBI) has come under close scrutiny and is changing as a result of refined diagnostic testing. Although up to 15% of patients with a mild TBI will have an acute intracranial lesion identified on head computed tomography (CT), less than 1% of these patients will have a lesion requiring a neurosurgical intervention. Evidence-based guideline methodology has assisted in generating recommendations to facilitate clinical decision making; however, no set of guidelines is 100% sensitive and specific. Evidence supports the safety of discharging patients with mild TBI who have a negative CT. However, though patients with a negative CT are at almost no risk of deteriorating from a neurosurgical lesion, a key intervention is to provide these patients at discharge from the emergency department with counseling regarding postconcussive symptoms, when to return to work, school, or sports, and when to seek additional medical care.

Health literacy and emergency department outcomes: a systematic review

STUDY OBJECTIVE

We assess emergency department (ED) patients' health literacy, the readability of ED patient materials, and the relationship between health literacy and ED outcomes through a systematic literature review.

METHODS

PubMed, PsychInfo, CINAHL, Web of Knowledge, and ERIC were searched for studies published January 1, 1980, to July 15, 2010, conducted in the United States, reporting original data, and measuring ED patients' health literacy, the readability of ED materials, or the association between health literacy and ED-related outcomes. Two reviewers evaluated each study and abstracted information from included studies into evidence tables.

RESULTS

We identified 413 articles, and 31 met inclusion criteria. Collectively, health literacy skills were assessed at or below the eighth-grade level for approximately 40% of ED patients. In contrast, ED patient materials were typically assessed at or above the ninth-grade level. Studies of adults aged 65 years and older found that those with lower health literacy were more likely to use the ED and incur higher ED costs. Studies of pediatric ED patients did not find direct effects of caregiver literacy on ED outcomes.

CONCLUSION

A substantial proportion of ED patients have limited health literacy, and ED materials are typically too complex for these patients. It is important for EDs to evaluate the accessibility and patient understanding of information presented. The evidence linking health literacy to ED outcomes is limited. Additional research is needed to better understand the relationship between health literacy and ED outcomes.

American Academy of Pediatrics. Clinical report--sport-related concussion in children and adolescents

Sport-related concussion is a "hot topic" in the media and in medicine. It is a common injury that is likely underreported by pediatric and adolescent athletes. Football has the highest incidence of concussion, but girls have higher concussion rates than boys do in similar sports. A clear understanding of the definition, signs, and symptoms of concussion is necessary to recognize it and rule out more severe intracranial injury. Concussion can cause symptoms that interfere with school, social and family relationships, and participation in sports. Recognition and education are paramount, because although proper equipment, sport technique, and adherence to rules of the sport may decrease the incidence or severity of concussions, nothing has been shown to prevent them. Appropriate management is essential for reducing the risk of long-term symptoms and complications. Cognitive and physical rest is the mainstay of management after diagnosis, and neuropsychological testing is a helpful tool in the management of concussion. Return to sport should be accomplished by using a progressive exercise program while evaluating for any return of signs or symptoms. This report serves as a basis for understanding the diagnosis and management of concussion in children and adolescent athletes.

Head injury attenders in the emergency department: the impact of advice and factors associated with early symptom outcome

PRIMARY OBJECTIVE

Many who attend hospital after head injury are not admitted to a hospital bed. This study explores the views of hospital attenders about advice received, predictors of memory for and compliance with advice and factors associated with early symptom persistence and outcome that might identify those requiring follow-up.

DESIGN

A single group prospective follow-up design.

METHODS AND PROCEDURE

Relationships between information obtained by emergency department (ED) staff during admission and about satisfaction with and memory for advice and about symptom persistence was compared in 200 attenders with head injury who were not admitted to hospital. The telephone interview comprised a structured interview and the Post-Concussional Symptoms Checklist.

RESULTS

Satisfaction with advice was high. Despite this, a minority remembered advice (alcohol/drugs 44%; medication 38%; rest/sleep 56%; work 36%; sport 36%). At follow-up, symptom complaints were not predicted by information obtained in the ED. Attenders with retrospectively assessed post-traumatic amnesia (PTA) for more than 5 minutes reported more symptoms and poorer memory for advice at follow-up.

CONCLUSIONS

Although satisfaction with advice was high, memory for advice was relatively poor and was associated with longer durations of PTA. Attenders with PTA > 5 minutes should be targeted for follow-up or inpatient admission.

Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting

This clinical policy provides evidence-based recommendations on select issues in the management of adult patients with mild traumatic brain injury (TBI) in the acute setting. It is the result of joint efforts between the American College of Emergency Physicians and the Centers for Disease Control and Prevention and was developed by a multidisciplinary panel. The critical questions addressed in this clinical policy are: (1) Which patients with mild TBI should have a noncontrast head computed tomography (CT) scan in the emergency department (ED)? (2) Is there a role for head magnetic resonance imaging over noncontrast CT in the ED evaluation of a patient with acute mild TBI? (3) In patients with mild TBI, are brain specific serum biomarkers predictive of an acute traumatic intracranial injury? (4) Can a patient with an isolated mild TBI and a normal neurologic evaluation result be safely discharged from the ED if a noncontrast head CT scan shows no evidence of intracranial injury? Inclusion criteria for application of this clinical policy's recommendations are nonpenetrating trauma to the head, presentation to the ED within 24 hours of injury, a Glasgow Coma Scale score of 14 or 15 on initial evaluation in the ED, and aged 16 years or greater. The primary outcome measure for questions 1, 2, and 3 is the presence of an acute intracranial injury on noncontrast head CT scan; the primary outcome measure for question 4 is the occurrence of neurologic deterioration.