Award: AAP/SONS Award, Kenneth Shulman Award
Authors: Aaron Michael Yengo-Kahn, MD; Nishit Mummareddy, MD; Michael Bezzerides, BA; Adam Vukovic; Cody Penrod, MD; Stephen Gannon, CCRP; Christopher Bonfield, MD; E. Haley Vance (Nashville, TN)
Over 1 million annual Pediatric Emergency Department (PED) visits are related to traumatic brain injuries, the majority of which are concussions. Many patients are discharged without complete concussion-specific follow-up and/or discharge instructions, representing a major challenge. Therefore, we implemented an education intervention along with a discharge template for providers and patients, to improve rates of referral and discharge instruction disbursement.
From July 2016 to December 2018, 769 medical records of children diagnosed with concussion in the emergency department were identified using billing codes (ICD-10). Children with positive head CT scans or requiring admission were excluded. Implementation of a consensus-guideline based discharge instruction template and dedicated provider education sessions (peer to peer, PED resident/fellow education conference teaching) were completed in October 2017. The presence of discharge instructions including those for return-to-play (RTP), return-to-learn (RTL), follow-up referral to our institution, and documentation of a follow-up visit were recorded both prior to and following implementation. Chi-square tests were used to compare pre- and post-intervention discharge success.
Of the 769 (402 pre-intervention, 367 post-intervention) concussed patients in the PED, the majority (58%) were non-sport-related. Compared to before our intervention, a significantly greater proportion of patients received instructions for RTP (89.4% vs 61.8%, X2(1)=77.79,p<0.0001), RTL (54.9% vs 6.2%, X2(1)=218.37,p<0.0001) and were referred to a follow-up visit within our institution (51.7% vs 28%, X2(1)=15.94,p<0.0001) after the intervention. However, there was no change in the proportion of patients who completed the follow-up visit.
Ensuring follow-up and providing adequate discharge instructions remains a challenge even in large pediatric medical centers. However, a simple, low-cost intervention such as peer-to-peer education and consensus-guideline based discharge instruction templates can improve discharge readiness after concussion. Further work is needed to increase the proportion of patients completing follow-up visits with providers trained in concussion management.