vanderbilt sports medicine discharge instructions for youth sports- related concussions in the...
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Vanderbilt Sports Medicine
Discharge Instructions for Youth Sports-Related Concussions in the Pediatric Emergency Department 2004-2012
Mark Riederer, MD, FAAP
Joseph BoyleElise MartinClint Morgan
George YangAllison UmfressCam Upchurch
Vanderbilt Sports Medicine
Background
• CDC estimates 1.4 million annual deaths, hospitalizations and emergency room visits due to suspected TBI.
• 144,000 annual ER visits for concussion in children 0-19 (Meehan & Mannix, 2010).
• ER visits for concussions sustained in organized sports in high school aged athletes increased over 200% from 1997-2007 (Bakhos et al. 2010).
Vanderbilt Sports Medicine
Background
• Up to 50% of youth sports-related concussions (SRC) are initially evaluated in the emergency room.
• We recognize the importance of discharge instructions to both the athlete and parent/caregiver in regards to physical and cognitive rest, recognition of symptoms, and provider/specialist follow up for reevaluation.
Vanderbilt Sports Medicine
• 1995 study published in Pediatrics evaluating discharge instructions to admitted children over a 5-year period at the Children’s Hospital of Alabama for SRC
• Used the old concussion grading scale (grade 1-3)• Out of 33 patients, only 10 received appropriate
recommended rest guidelines• First study looking at the appropriateness of discharge
instructions to youth athletes with concussions.
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• 2010 study of pediatric concussions in the emergency department in the US from 2002-2006
• 28% of patients were discharged without specific instructions to follow-up with an outpatient provider
Vanderbilt Sports Medicine
Objectives• There has been no study looking at the impact of the
2010 CDC recommendations on concussion management in terms of discharge recommendations from the emergency department for SRC
• VSCC began offering follow up for youth SRC in 2011• Our group was interested in investigating impact of
CDC recommendations and VSCC on discharge instructions
Vanderbilt Sports Medicine
Methods• Retrospective chart review• Population – All visits to the pediatric emergency department
from January 1, 2004 to June 30, 2012• SRC – based upon ICD 9 code (850.xx) and E codes (E886.0,
E917.0, E917.5)• Age, gender, sport, head CT, admitted, PCP follow-up, specialist
follow-up, cognitive rest, physical rest, duration of rest• Defined an “appropriate discharge” as one with some type of
rest AND healthcare provider follow-up
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Preliminary Results• 392,908 visits• 3,052 concussions• 497 sports-related concussions• 20 charts excluded due to lack of EMR documentation• 477 sports-related concussions
Vanderbilt Sports Medicine
Preliminary Results• Average age – 13.7 years old• 79% boys, 21% girls• 75% had recommended follow up with PCP• Overall, only 4% had recommended cognitive rest.
After 2010, this only increased to 9%• 34% discharges were labeled inappropriate. After
2010, this only decreased to 27%
Vanderbilt Sports MedicineNote: Chart does not include 2012 data
Vanderbilt Sports Medicine
2004 2005 2006 2007 2008 2009 2010 2011 20120.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
41.38%
60.61%63.27%
67.44%
58.14%
66.67%70.00%
72.73%77.59%
Percent Appropriate Discharge Instructions by Year
Vanderbilt Sports Medicine
2004 2005 2006 2007 2008 2009 2010 2011 20120.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
68.97%
75.76%
67.35%72.09%
65.12%
72.00% 71.43%
77.92% 77.59%
Percent Physical Rest Recommendations by Year
Year
Vanderbilt Sports Medicine
2004 2005 2006 2007 2008 2009 2010 2011 20120.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
0.00% 0.00% 0.00% 0.00%2.33% 2.67% 2.86%
11.69% 12.07%
Percent Cognitive Rest Recommendations by Year
Year
Vanderbilt Sports Medicine
2004 2005 2006 2007 2008 2009 2010 2011 20120.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
3.45%6.06%
2.04% 2.33%6.98%
16.00%11.43%
35.06%
53.45%
Percent Recommended Concussion Specialist Follow up
Year
Note: Includes follow up with VSCC , VSM, ATC, Neurology
Vanderbilt Sports Medicine
Preliminary Conclusions• No significant changes in appropriate discharges or
recommendations in physical rest over time, especially after 2010
• Cognitive rest continues to not be addressed during discharge recommendations, but slight improvement
• Increase in referrals to concussion specialist, especially after 2010, however still not 100% for youth SRC
Vanderbilt Sports Medicine
Future Direction• Data analysis is ongoing, statistical results pending
from biostatistician• We welcome collaboration with other groups • Study represents largest collection of youth SRC
evaluated in the pediatric ED at Vanderbilt from 2004-2012
