Variability in discharge instructions and activity restrictions for patients evaluated in a children's emergency department following concussion.
De Maio VJ, Joseph DO, Tibbo-Valeriote H, Lanier B, & Register-Mihalik J. (2013). Pediatric Emergency Care, 30(1):20-25.
Take Home Message: A lack of consistency was found in pediatric concussion diagnosis and management in one emergency department over a year. Most patients did not receive restriction upon their physical activity or instructions as to when to return to play.
Of recent, management care for concussion has advanced to encompass the importance of both cognitive and physical rest following this injury. Clear return-to-play guidelines have been established to progress athletes back to their sport in a safe manner once they have proved to be asymptomatic. These guidelines are especially important for a younger athlete, of the pediatric age, whose brain is still developing and is more susceptible to suffering a more severe concussion and possibly from a repeat concussion. Even with advances in education and management of concussion, there still may be a lack of awareness of these standards in emergency rooms. This article investigated if pediatric patients with concussion (6 to 18 years of age) were given instructions as to management care and if any activity restrictions were placed on these patients as part of their discharge instructions. Research staff examined medical records of children admitted to an emergency department for a head injury during a year. The emergency department was at a level I trauma center in an urban/suburban community. If the patient’s record indicated he/she had a concussion, as defined by the 2008 Zurich consensus statement on concussion, they were included in this study. Overall, 218 patients fit this criteria and the investigators further examined the records for demographics, injury characteristics, management plan, and discharge instructions. Of this group, 42% of these head injuries were sports related while others were caused by a fall (23%), car accident, assault, or other mechanism. Even with an appropriate injury mechanism and presence of concussion symptoms, only 31% of this entire cohort was diagnosed with a concussion. Contrarily, 62% of the group was given discharge notes that indicated the patient suffered a concussion with instructions on how to manage their injury. Most patients were instructed to follow up with their primary care physician and 66% of patients with a concussion were given no activity restrictions. Of those who did receive activity restrictions, there was a wide range of variability concerning when the child should return to physical activity and sport.
This study presents a clear inconsistency in concussion management care by healthcare professionals in an emergency department. Not only were patients given a wide range care instructions, but physicians did not accurately diagnose over two thirds of their patients with a concussion. These particular physicians assess and treat a high volume of patients with a wide range of alignments on a daily basis, perhaps because of this, their education on this particular injury is lacking. However, with our growing knowledge of the negative repercussions of this injury and the possible consequences of returning athletes to play too soon, their needs to be an improvement in care for this injury, especially in the emergency setting where many of these cases are initially seen. Physicians need to be brought up to speed on current management practices, or at least instructed to error on the conservative side of management so as to protect these children. Beyond these criticisms, it is important to keep in mind the limitations of this study. Firstly, although this study was recently published, it examined medical records from the year 2008. Over the past five years, our knowledge, education, and awareness of this injury have vastly improved. These findings may no longer be consistent with the current state of emergency management of concussion. Furthermore, the authors only examined records from one hospital, and generalizing these findings to other facilities may not be a fair representation. Overall, this study points out a lapse in concussion management and an area where education may need to be improved.
Questions for Discussion: If this study were to be conducted again today, do you believe it would yield the same results? After a patient is seen for a concussion at an emergency department, what do you believe should be included in an athlete’s discharge instructions?
Written By: Jacqueline Phillips
Reviewed By: Jeffrey Driban