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Doctors Need More Resources to Manage Pediatric Concussion

Major Finding: Although 91% of pediatric and emergency providers reported caring for at least one concussed patient in the past 3 months, pediatric providers reported referring patients to specialists because they did not feel comfortable with management (49%) or lacked adequate resources for management (47%).

Data Source: Results are from a survey of 145 providers that included physicians, nurse practitioners, and physician assistants in the emergency department and primary care network of the Children’s Hospital of Philadelphia Care Network and Emergency Department.

Disclosures: The research was funded by the Children’s Hospital of Philadelphia Department of Pediatrics Chair’s Initiative. The authors said they had no relevant financial disclosures.

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More Concussions Mean More Training

Concussion is an injury doctors will see in their practice regularly because it is happening more frequently. There is increased awareness about concussion, doctors are picking up previously unreported concussions, and more state laws require medical clearance after a concussion before a return to play. There also are more children participating in contact sports year-round and at younger ages, so there is more exposure for injury. Pediatricians need to feel confident that they can provide adequate frontline care, according to Dr. Kevin Walter.

Dr. Zonfrillo’s findings indicate there is still a lot of confusion about what a concussion is, most likely because medical education about concussion is lacking. Also, kids often lie to get back to playing. As with everything in medicine, providers are being asked to do more with less time. Although there are resources like the Centers for Disease Control and Prevention’s Heads-Up tool kit and the American Academy of Pediatrics 2010 clinical report (Pediatrics 2010;126:597-615), what would be most helpful is for health systems to have a protocol or best practice guideline for providers in that system.

With concussions, everyone is different, and the cookie cutter approach used for other conditions doesn’t work with concussion. Concussion is broader and more general, so providers have to individualize care management to each patient according to the patient’s injury and situation.

Dr. Walter is with the department of orthopedic surgery and the department of pediatrics at the Medical College of Wisconsin, Milwaukee, and was lead author of the AAP’s clinical report "Sport-Related Concussion in Children and Adolescents." He made these comments during an interview.


 

FROM PEDIATRICS

Pediatric primary care and emergency providers often feel ill prepared or lacking in resources, time, or training to effectively manage concussion in children and educate families about the condition and recovery, according to a survey published in the November 2012 issue of Pediatrics.

The findings come from a survey assessing what practicing physicians, nurse practitioners, and physician assistants know about concussion as well as their treatment practices and any perceived obstacles to managing the condition, reported by Dr. Mark R. Zonfrillo of the center for injury research and prevention at Children’s Hospital of Philadelphia and the University of Pennsylvania and his associates (Pediatrics 2012;130:1-6).

An online survey using multiple-choice, Likert scale, and open-ended questions was sent to 276 providers in the Children’s Hospital of Philadelphia Care Network and Emergency Department e-mail lists. The 53% response rate included 145 responding providers with a diverse range of experience. Sixty-one percent were pediatric primary care providers, and 39% were pediatric emergency care providers.

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A recent survey showed that a number of pediatric primary care and emergency care providers don’t feel prepared or often lack resources to effectively manage concussion in children.

A total of 91% of respondents reported having cared for at least one patient with concussion in the past 3 months. Most of these providers (134, or 92%) referred at least one patient to a concussion specialist after the first exam, usually either because they were uncomfortable with managing the concussion (49%) or because they did not have the necessary resources to manage it (47%). In addition, 30% of primary care providers and 68% of emergency providers said their "setting is not always appropriate for management," the investigators said.

Both primary care providers and emergency providers were highly likely to refer concussion patients to sports medicine doctors or clinics (67% vs. 75%, respectively); primary care respondents were twice as likely as emergency providers to refer patients to neurologists (46% vs. 22%). Emergency providers also were likely to refer to a trauma surgeon or clinic (83%), while primary care providers rarely did (13%).

Past studies have found that approximately 100,000-140,000 U.S. children go to the emergency department each year for concussion, but parents and children may underreport concussion symptoms, and many youth sports coaches have misconceptions about them.

In the two scenarios presented in the survey – one of a patient with a subtle concussion and the other of a patient with more obvious symptoms – almost all respondents determined that both hypothetical patients had a concussion. However, some respondents did not recognize some of the symptoms of concussion, including abnormal eye tracking (17%), difficulty concentrating (11%), vestibular disturbance (9%), worsening school performance (6%), and sensitivity to light or noise (6%). "These more subtle signs of concussion may present in isolation and thus may be the only indication that a child has sustained the injury," the authors wrote.

A total of 104 providers reported they did not have access to a provider decision support tool relating to concussion, and 96% of these believed one would be helpful. All 57 respondents who said they didn’t have discharge instructions related to concussion said support tools would be helpful.

Doctors cited a lack of training most often when it came to obstacles to educating families about the diagnosis and recommending time off before returning to school or sports. Further, 69% of primary care providers and 77% of emergency providers said they don’t have enough time to complete formal neurocognitive testing for concussed patients.

The study was funded by the Children’s Hospital of Philadelphia Department of Pediatrics Chair’s Initiative. The authors said they had no relevant financial disclosures.

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