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)

Introduction:

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.

Methods:

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.

Results:

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.

Conclusion:

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.