CHOP Study Finds Need for Concussion Management Tools

A study of physicians’ knowledge of and attitudes toward concussion management practices points to the need for improved concussion-specific training and infrastructure to support optimal patient care. The findings, recently published online in Pediatrics, led The Children’s Hospital of Philadelphia (CHOP) to create a new “medical home” model for managing adolescent and pediatric concussion.

The study, which was conducted by researchers at Children’s Hospital’s Center for Injury Research and Prevention (CIRP), surveyed 145 emergency medicine and primary care providers. Of those, 91 percent had cared for at least one concussion patient while 92 percent had referred at least one patient to a concussion specialist in the prior three months.

“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,” said lead author and CIRP researcher Mark Zonfrillo, MD, MSCE.

The best practice for managing a diagnosed concussion in the initial weeks following an 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.

The study’s authors also found some variability in how respondents recognized the signs, symptoms and physical exam findings for concussion. As a result, the study recommends specialized continuing medical education training for primary care and emergency medicine clinicians, coupled with standardized clinical decision support tools and patient education tools.

The providers who took part in the study agreed that standardized evaluation and decision-making tools, and training in their use, would increase their comfort with diagnosing and managing concussions. To that end, with the providers’ input concussion specialists at CHOP have developed a novel infrastructure, which offers diagnostic and patient education support tools, that is now delivered 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,” said Dr. 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 that explains 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.

In addition, earlier this year Children’s Hospital concussion experts provided special training to more than 100 providers across the CHOP Care Network, which comprises more than 30 primary care locations across the Philadelphia area. The hope is that Children’s Hospital’s new Medical Home model for concussion management could eventually be applied to other health systems.

Dr. 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.

To learn more about youth concussions and CHOP’s unique approach to managing pediatric concussion, visit www.chop.edu/concussion.