NAPLES, FLA. – Compliance with discharge instructions is mixed among children diagnosed with a concussion in the emergency department, a study showed.
In the prospective cohort study, 87% of patients, aged 8-17 years, followed the recommended stepwise return to play (RTP) protocol for concussion management.
More than one-third (39%), however, reported returning to play on the day of their injury, Dr. Vivian Hwang said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).
Dr. Vivian Hwang
"Concussion education remains essential to improve early recognition of concussion symptoms and to discourage premature return to play before symptoms resolve," said Dr. Hwang, an emergency physician at the Inova Fairfax Hospital for Children, Falls Church, Va.
Invited discussant and EAST past president Dr. Michael Pasquale described the data as "troubling," observing that nearly all the states and the District of Columbia have enacted concussion laws, some featuring the RTP protocol.
He questioned whether the 39% of children returning to play on the day of their injury did so before the concussion was identified, as this would suggest a lack of awareness rather than noncompliance.
Dr. Hwang said these children were asked about return to play at their initial ED visit, so this likely does represent lack of awareness, although the high number still speaks to the need for improvement.
Student athletes in Virginia are required to have and sign off on concussion education each year, but she said she was unaware of any penalties for athletes or parents who fail to comply.
Dr. Hwang and her colleagues prospectively followed 150 patients with a diagnosis of concussion from November 2011 to November 2012 who received standardized discharge instructions stating there should be no return to play or normal activities with symptoms or without medical clearance.
The instructions also recommended the stepwise RTP protocol as described in 2009 by the international Concussion in Sport Group (J. Clin. Neurosci. 2009;16:755-63) and again in its most recent consensus statement (J. Am. Coll. Surg. 2013;216:e55-71).
The RTP protocol has six stages: no activity (complete physical and cognitive rest), light aerobic exercise, sport-specific exercise, noncontact training drills, full-contact practice following medical clearance, and return to normal play. Each step generally takes 24 hours, or about 1 week for the full protocol, with patients continuing to the next level only if they’re asymptomatic at the current level, Dr. Hwang explained.
Telephone follow-up of 125 evaluable patients at 2 weeks post ED visit found that 55 (44%) children had returned to play or normal activities. Of these, 19 (35%) returned to play with symptoms, and 32 (58%) did so without receiving medical clearance, Dr. Hwang said.
Among 116 children surveyed at week 4, 74 (64%) had returned to play, 17 (23%) with symptoms and 34 (46%) without medical clearance.
"Proper medical monitoring is necessary to guide care for pediatric patients," Dr. Hwang said.
Patients in the cohort were mostly male (63%), had private insurance (85%), and were an average age of 13 years. Most concussions were sports related (67%), with soccer the most common culprit (30%) followed by football (11%), lacrosse (8%), and basketball (8%).
The study was limited by the inability to enroll 200 additional concussion patients seen during the study period, follow-up was 83% at 2 weeks and 77% at 4 weeks, the potential for nonresponse bias, and self- and parent reporting of symptoms may have been inaccurate, she said. Standardized neurocognitive tests also were not done.
Dr. Pasquale, chair of surgery at Lehigh Valley Hospital, Allentown, Pa., suggested that the hospital’s discharge instructions are "a little soft.
"You really don’t mandate clearance by a medical professional, and I think it’s an opportunity in your community to improve upon that and drive home to parents the importance of clearing the athlete or nonathlete prior to resumption of activities," he said.
Dr. Hwang replied that the hospital recently expanded its concussion services including a multidisciplinary team to help with concussion screening, postinjury evaluation, and treatment. The hospital also has a concussion committee.
Dr. Hwang and Dr. Pasquale reported having no financial disclosures.