Survey of ER docs and pediatricians highlights need for training, tools to manage kids' concussions

(Press-News.org) While general pediatricians and pediatric emergency physicians value their role in concussion management, a study of their self-reported knowledge, practices and attitudes points to the need for improved concussion-specific training and infrastructure to support optimal patient care. The study, released today in the journal Pediatrics, served as a catalyst for The Children's Hospital of Philadelphia (CHOP) to create a new "medical home" model for managing pediatric and adolescent concussion.

The study surveyed 145 emergency medicine and primary care providers, among whom 91 percent had cared for at least one concussion patient and 92 percent had referred at least one patient to a concussion specialist in the prior three months. Authors noted variability in how respondents recognized signs, symptoms and physical exam findings for concussion. They recommend specialized, continuing medical education training for primary care and emergency medicine clinicians, coupled with standardized clinical decision support tools and patient education tools.

"We have seen concussion visits within our emergency department, primary care and specialty care network at CHOP quadruple since 2009 to a current total of more than 6,700 each year," says Mark Zonfrillo, M.D., M.S.C.E., the study's lead author, a researcher at CHOP's Center for Injury Research and Prevention and a pediatric emergency medicine specialist. "The emergency department and primary care settings often serve as the entry point of care for children with a suspected concussion, and we know that early diagnosis and treatment of concussion can lead to faster, more complete recovery."

"With the increased occurrence and recognition of concussions, it can be challenging to schedule a follow-up appointment with a concussion specialist immediately following injury. However, families can usually see a CHOP primary care provider within the first few days after sustaining a concussion at one of more than 30 locations, so they can promptly begin treatment and monitor recovery," notes Zonfrillo.

Zonfrillo and his colleagues believe the primary care setting is the most appropriate place for management and follow-up for most pediatric concussion cases. The best practice for managing a diagnosed concussion in the initial weeks following the injury involves two essential components: using a systematic, clinical assessment to determine if concussion symptoms are resolving, and adhering to a step-by-step program of gradual return-to-learn and return-to-play. However, the study found inconsistent clinical assessment and inconsistent prescribing of the "return" protocols in discharge instructions. Pediatric primary care and emergency medicine providers agreed that standardized evaluation and decision-making tools, and training in their use, would increase their comfort with diagnosing and managing concussions.

With this valuable input from primary care and emergency medicine providers, concussion specialists at CHOP developed an infrastructure, including necessary diagnostic and patient education support tools, that is now delivered network-wide through CHOP's electronic medical record system.

"We adapted state-of-the-science protocols used by concussion specialists into an electronic interactive form that is part of the patient's medical record," says Zonfrillo. "This form, which is specific to concussion, provides a guide for the primary care provider for the systematic evaluation of concussion patients, including potential symptoms and physical exam findings."

The provider can print out fact sheets that walk the parents through the return-to-learn and return- to-play process, as well as a letter intended for the child's school explaining the diagnosis and treatment. The interactive form indicates when a patient should be referred to a specialist if, for example, they have certain pre-existing conditions or for persistent symptoms.

Earlier this year, CHOP's concussion experts provided special training to more than 100 providers, , representing all 30 primary care locations in the CHOP Care Network. The CHOP Network is the largest pediatric health system in the country and its new Medical Home model for concussion management could eventually be applied in other health systems. Zonfrillo and his colleagues are closely monitoring and adjusting the new model in hopes that it can improve outcomes for children in the greater Philadelphia region, as well as the hundreds of thousands of children who suffer concussions each year across the U.S. Visit www.chop.edu/concussion for information about youth concussions, as well as CHOP's unique approach to managing pediatric concussion.

### Zonfrillo's co-authors are CHOP colleagues Christina Master, M.D., Matthew Grady, M.D., Flaura Winston, M.D., Ph.D., James Callahan, M.D., and Kristy Arbogast, Ph.D. The study was funded by the Chair's Initiatives at CHOP.

"General pediatric and emergency medicine providers' self-reported knowledge, practices, and attitudes about concussion," Pediatrics, published online Nov. 12, 2012. doi:10.1542/peds.2012.1431

About The Children's Hospital of Philadelphia: The Children's Hospital of Philadelphia was founded in 1855 as the nation's first pediatric hospital. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country, ranking third in National Institutes of Health funding. In addition, its unique family-centered care and public service programs have brought the 516-bed hospital recognition as a leading advocate for children and adolescents. For more information, visit http://www.chop.edu.