Emergency Room Practices Part 3. Evaluation and treatment of patients with concussion

Head injury is a leading cause of emergency department (ED) visits in the United States. Though the majority of head injuries are classified as mild and do not require long-term hospitalization or continued intervention, patients with mild traumatic brain injury (mTBI or concussion) are at risk for ongoing symptoms such as irritability, memory loss, and cognitive dysfunction. Studies have shown that educating patients about their injury by informing them of potential concussion symptoms can improve their long-term outcomes. For instance, one study that tested the effect of supplying educational materials to patients with TBI and providing suggestions for coping with common symptoms found that patients who received counseling reported fewer post-concussive symptoms three months following injury.1

The benefit of patient education is supported by national health organizations. In 2002, the American College of Emergency Physicians (ACEP) established standardized metrics to be used in the ED for evaluating and treating patients with mTBI. Part of their guidelines include patient education information to be disseminated upon discharge. In 2003, the Centers for Disease Control and Prevention (CDC) launched the Heads Up initiative, which consists of a series of educational materials for clinicians, patients, and families. The program aims to raise awareness of the symptoms and risks of concussion and post-concussive syndrome, and the ACEP promotes the use of Heads Up materials as part of their standard of care.

To determine the time-course for evaluation and treatment of head injury, a recent study measured the length of stay for patients who presented to the ED with head injury.2 However, the authors did not address whether or not increased length of stay was correlated with improved patient outcomes. They concluded that ED physicians should limit the use of CT scans to improve ED throughput. Both the premise and conclusions of this study speak to what many patients already know: the ED is a revolving door, and admitted patients are triaged as quickly as possible, hopefully while still receiving the best care. Often, the success of an ED is assessed using efficiency as a primary outcome.

To improve ED efficiency, emergency physicians are trained to rapidly differentiate high-risk patients from those that can be sent home. The ACEP guidelines for evaluating head injury exist for this reason—their purpose is to provide a checklist for ED doctors to quickly decide whether a patient with a head injury can be discharged, and efficiency is a key component to the equation of a successful ED. The problem with this model is that it does not account for the fact that the majority of concussion symptoms are subtle, and many of them don’t show up on radiological scans such as a CT or MRI; in fact, they may not manifest for a few days or weeks after the initial injury. As a result, patient educational materials developed by the CDC and ACEP are critical.

With evidence of the success of early intervention and patient education on improving outcomes, and knowing that patient education is supported by national health organizations like the CDC and ACEP, the hope is that such practices are actually implemented in EDs. To assess implementation, researchers have developed the TRACK-TBI study (Transforming Research and Clinical Knowledge in TBI, a TBI-centered research initiative based out of the University of California, San Francisco). A recent publication from this study surveyed patients that presented to 11 different participating EDs following head injuries.3 They found that, on average, only 42% of patients reported receiving educational materials upon discharge; the range across sites varied widely from 19-72%. Further, only 44% of patients reported following up with their primary care doctor within three months of injury, including those patients who reported experiencing common post-concussive symptoms. This result is concerning for two reasons. First, it suggests the possibility that patients are not properly counseled on follow-up care upon discharge. Second, it reduces the opportunity for continued patient education at follow-up appointments. Patients were more likely to receive education materials and to schedule follow-up appointments when they were initially treated at EDs specializing in TBI. Additionally, these patients reported that educational materials and follow-up were helpful to their recovery.

The efficiency of an ED is critical to the physicians’ ability to treat as many patients as possible. However, aiming to treat a high volume of patients should never take priority over quality of care. While some studies have shown that radiological scans are not necessary for all head injury patients and do necessarily improve outcomes,4 our understanding of the effects of patient education must drive the initiative to enact the recommendations of the CDC and the ACEP to supply head injury patients with the materials and guidance they need to take control of their own recovery.

References:

  1. Ponsford, J., et al. "Impact of early intervention on outcome following mild head injury in adults." Journal of Neurology, Neurosurgery & Psychiatry 73.3 (2002): 330-332.
  2. Michelson, Edward A., et al. "Emergency Department Time Course for Mild Traumatic Brain Injury Workup." Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health (2018).
  3. Seabury, Seth A., et al. "Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK-TBI Study." JAMA Network Open 1.1 (2018): e180210-e180210.
  4. Lavelle, Jane M., and Kathy N. Shaw. "Evaluation of head injury in a pediatric emergency department: pretrauma and posttrauma system." Archives of pediatrics & adolescent medicine 152.12 (1998): 1220-1224.
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