August 30, 2018

Emergency Medicine Wants You!...To Optimize ED Concussion Management

I write to inform you all of breaking news

Traumatic brain injury (TBI) is a relatively common reason for individuals to present to the Emergency Department (ED).  Alright, you were already well aware of that fact.  But to put a number on this obvious assertion, the Centers for Disease Control and Prevention reports that there were 2.5 million such visits to EDs in 2013 (the most recent data that I could verify).[1]  For those mathematical savants in the readership, that amounts to 4.75 traumatic brain injury patients every minute over the course of a year.[2]  Frequently associated with such injuries, concussions have continued to receive ample attention both in the medical literature as well as the popular press.  Concussion evaluation and management remains a multidisciplinary field, but as Emergency Medicine (EM) and Sports Medicine providers we are ideally positioned on the front lines of providing care for these ED patients.  However, the manner by which this is accomplished and our success in doing so remains fodder for discussion.

Along these lines, perhaps you perused a May 2018 article published by the modest outfit JAMA via their open network platform.   The offering is entitled “Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK-TBI Study”, and it can be found here.

While I encourage you to review that interesting piece, the current diatribe is not intended to serve as a journal club discussion.  But with that said, some of its findings were quite noteworthy.  Particularly, the authors reported that only 42% of patients received pertinent discharge material germane to their condition.  Meanwhile, a relatively paltry 44% of individuals followed-up with medical practitioner within three months of their initial presentation.  Now, there are some issues with this study, not the least of which is the inclusion criteria that required a head CT.  One would also be shrewd to cite that a fairly striking 39% of the patients with a positive head CT did not follow-up within three months of their injury either.  Regardless, the take home points seem apparent: we can do better in educating our ED patients on TBIs/concussions, and there is clearly room to improve with regard to the rate of follow-up.  As Sports Medicine-trained specialists, we are uniquely positioned to aid our EM colleagues in achieving these noble, attainable aims.

To some extent, we attempted to address these issues at Northwestern Memorial Hospital in Chicago, Illinois.  Stemming from a resident-driven quality improvement project, we implemented a multidisciplinary, collaborative effort that leveraged our institutional resources in EM, Sports Medicine, and Neurology to optimize the care of TBI/concussion patients.  After several brainstorming sessions, a few specific areas for improvement were identified and targeted.  It was determined that we might significantly enhance the care of this patient demographic if we could successfully improve the concussion knowledgebase of the EM providers (i.e. nursing staff, residents, advanced practice providers, and attending physicians), standardize the evaluation of these patients, and create a mechanism to facilitate follow-up.  Additionally, we hypothesized that such alterations would result in a substantial decrease in ED bouncebacks, generally a desirable metric in and of itself.

I will spare you the potentially REM sleep-inducing details pertaining to the process that was implemented.  However, here are the highlights of the key features:

  • Educational sessions were conducted for the ED’s health care providers reviewing the signs and symptoms of a concussion, the Canadian Head CT rules, and the proper use of the SCAT5 form to assess/quantify concussion symptoms.
  • Standardized concussion discharge instructions were created, highlighting the common symptoms associated with the condition, explaining the management of these symptoms, and detailing the developments that should prompt further evaluation and treatment
  • A mechanism was generated to schedule immediate follow-up appointments in Sports Medicine, Neurology, or with the patient’s primary care provider prior to discharge or within twenty-four to forty-eight hours of departing the ED.

At this point the results of the aforementioned changes have been encouraging.  Following six months of assessment, the use of concussion-specific discharge instructions increased from 17.8% to 67.0%.  Meanwhile, the rate of ED bouncebacks for these injuries decreased from 7.5% to 2.0% over this interval.  Finally, we were able to improve our rate of follow-up, from a fairly dismal 8.6% to 22.2% at its peak.  While maintenance to the system has been required, including continued process reminders and educational updates, the aforementioned quality improvement steps appear to represent progress in caring for these concussed patients.

Concussions may not be the life threat that intracranial hemorrhages and skull fractures can represent.  However, we are well aware of the significant impact they can have on the lives of our patients.  Possessing expertise in the evaluation and management of these injuries, we as Sports Medicine-Emergency Medicine providers are well-equipped to initiate the treatment of these maladies in the ED.  We also have the ability to help our EM colleagues provide the same superb care acutely that we learned about in fellowship.  Data from the TRACK-TBI study suggests that such efforts may be worthwhile, and on some level the preliminary work from the Northwestern Memorial Hospital ED may offer some guidance on achieving goals.  It would seem that Emergency Medicine wants you to help improve the treatment of concussion patients in the ED.  And in the immortal words of Rob Schneider in The Waterboy, “You can do it!”.

Christopher Hogrefe, MD, FACEP
Assistant Professor

[1] Data from here.

[2] That would only be 4.74 TBI patients per minute in a leap year.