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

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

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

Related Posts:

De Maio VJ, Joseph DO, Tibbo-Valeriote H, Cabanas JG, Lanier B, Mann CH, & Register-Mihalik J (2014). Variability in Discharge Instructions and Activity Restrictions for Patients in a Children’s ED Postconcussion. Pediatric Emergency Care, 30 (1), 20-5 PMID: 24365726