Original Research: Concussions at School: The Experiences and Knowledge of School Nurses.

BACKGROUND: School nurses' knowledge about and confidence in managing concussions are important to ensure continuity of care between a student's school and home environments. This mixed-methods study explored concussion-related knowledge, confidence, and management experiences among urban and rural school nurses in Washington State. METHODS: Public school nurses, identified via state educational service district websites and recruited by e-mail, completed an online survey assessing their concussion knowledge and confidence levels. Following the survey, a subset of respondents participated in semistructured interviews aimed at exploring their confidence in managing concussions. RESULTS: Of the 945 school nurses to whom the survey was sent, 315 responded (33% response rate). Most survey respondents held an RN license (89.6%) and were from urban areas (90.8%). Overall, the respondents exhibited accurate concussion knowledge; only one significant difference was noted based on rural-urban status. Correct responses were given for most questions (67.4% to 98.7% correct responses). In interviews with a subset of six school nurses, emergent themes pertained to communication, assessment, and monitoring, and the nurse's role in postconcussion management. Barriers can include a lack of relevant school policies, low concussion awareness among teachers and parents, and limited resources. CONCLUSIONS: The study findings suggest that school nurses possess high levels of concussion knowledge and confidence in managing concussions. Continuing education remains important to ensure that current research and evidence inform practice regarding ongoing concussion management among school-age children.

Mild Traumatic Brain Injury in the Emergency Department: A Clinical Practice Gap.

This article, "Concussion Care in the Emergency Department: A Prospective Observational Brief Report," by seeks to examine current clinician practice patterns related to the evaluation and management of patients identified as at risk for a sustained mild traumatic brain injury (mTBI). The findings are discussed in the context of an evaluation and management gap surrounding mTBI care among emergency department (ED) providers at a Level I trauma and emergency care center. Although variabilities exist among mTBI care in the ED, provider education, standardization of guidelines, and implementation practices are strategies for increasing the uptake of care in the ED for patients presenting with mTBI.

Application of Components of the Massachusetts' Sports Concussion Regulations to All Students With Concussion: A Survey of School Nurses.

Appropriate management by schools of all students with a concussion, regardless of the cause, has not received the same attention as sports-related concussions. Focus groups conducted with Massachusetts School Nurses in 2015 found that some had applied protocols required in the state's sports concussion regulations to all students with concussion, not just student athletes. We surveyed high school nurses in Massachusetts to examine (1) the extent of this practice and (2) the extent to which protocols for all students with concussion are included in school policies. Of 168 (74%) responding, 94% applied the return-to-learn and play, and medical clearance requirements to all students with concussion, regardless of how or where the concussion occurred and 77% reported their school's policy required these protocols for all students with concussion. A significant association (odds ratio: 13.3, 95% confidence interval [2.4, 72.8], p <.01) existed between the two measures. These findings have important clinical and academic implications.

School Nurses' Management and Collaborative Practices for Student-Athletes Following Sport-Related Concussion.

The purpose of this study was to examine school nurses' management and collaboration with health-care providers (HCPs) for student-athletes following a concussion. Secondary school nurses accessed an online survey titled the Beliefs, Attitudes, and Knowledge of Pediatric Athletes with Concussions (access rate = 15.6%; n = 1,246/8,000). Approximately 40% of schools where nurses were employed administered baseline and postinjury concussion assessments. No significant differences were found between employment model (single vs. multiple sites) in regard to conducting baseline (p = .908) administration at their site; however, those employed at a single school more frequently offered postinjury assessments at their site than those at multiple sites (p = .019). School nurses most frequently reported relationships with an athletic trainer (38.8%, n = 483/1,246) compared to other HCPs. A concussion management team, including school nurses, and other recommended members should develop comprehensive concussion management plans. Plans should comprise of multiple concussion assessments to aid in the return-to-learn/play processes.

Concussion Symptom Prevalence, Severity and Trajectory: Implications for Nursing Practice.

PURPOSE: The purpose of this study was to describe the symptom severity and trajectory in concussed children who were followed during a one year period at a concussion clinic. DESIGN AND METHODS: A retrospective chart review was completed to describe the symptom trajectory up to three months during the recovery. RESULTS: One hundred and thirty-six patients were included (74 female, 62 male) with a median age of 15.4years (range 13-17). The most common mechanisms of injury included: falls (19.9%), hockey injuries (15.4%), soccer (14.0%) and football injuries (6.6%). Most concussion symptoms decreased in severity or improved over time. Four symptoms including fatigue/low energy, drowsiness, concentration difficulties and irritability had the highest symptoms scores at both 28 and 84days post-injury in patients with persistent symptoms. Emotionality and nervousness/anxiousness and nausea/vomiting scores were seen to increase over time in patients with persistent symptoms. IMPLICATIONS: Clinical use of standardized assessment tools can help caregivers track and monitor concussion symptoms over time. Appropriate management strategies need to be devised for symptoms that are prevalent or increasing over time.

Exploring concussion awareness in hockey with a First Nations community in Canada.

OBJECTIVE: The purpose of this pilot study was twofold: (1) to begin to understand concussion in youth hockey in a First Nations community in Canada and (2) to determine the impact of a novel concussion education workshop. DESIGN: A one-group quasiexperimental time series study was undertaken. SAMPLE: A total of 41 participants consented, with 71% (n = 29) completing data collection at all three study time points. MEASUREMENT AND INTERVENTIONS: Two nurses one from the First Nations community and one from the tertiary care center collaborated to develop and deliver the intervention on concussion specifically general, hockey and symptom knowledge. The primary outcome was Total Knowledge Score (TKS), whereby correct responses to a self-reported questionnaire were summed and then converted to a percentage. RESULTS: The TKS were similar across study time points; preworkshop 71.7%, postworkshop 71.8%, and 6-month follow-up 72%. CONCLUSIONS: Nurses worked collaboratively with cultural experts from a First Nations community to integrate Indigenous ways of knowing into concussion awareness and safety for First Nations youth playing hockey.

Concussion in sport: the importance of accurate and reliable discharge advice.

Concussion in sport is a common presentation in urgent and emergency care settings, so it is essential that nurses have a full understanding of the condition. Most patients who attend an emergency department with concussion are discharged and discharge advice must be well-informed and evidence based. This article outlines the normal anatomy of the brain and the pathophysiology of concussion, and discusses the guidelines on returning to sport following this injury.

Psychometric Evaluation of a New Instrument to Evaluate School Nurses' Perceptions on Concussion Care Management.

The rate of concussions in adolescents has risen over the last decade, resulting in cognitive and emotional problems. Neurologists recommend cognitive and physical rest during the recovery period, followed by a transitional return-to-classroom protocol. The purpose of the study was to develop and test an instrument that explores the beliefs and roles of school nurses in concussion care management. The instrument was a cross-sectional descriptive survey based on the theory of planned behavior, using Qualtrics®. The psychometric properties of the instrument were assessed through exploratory factor analysis with orthogonal rotation. The reliability of the instrument was assessed for internal consistency reliability using Cronbach's α. Kaiser-Meyer-Olkin for sample adequacy was .8; Cronbach's α strong (.851).

School Nurses on the Front Lines of Medicine.

Head trauma is a common chief complaint encountered by school nurses. This article describes the initial assessment and management of head trauma in children and adolescents, delineates reasons that may prompt the school nurse to transfer a student to a local emergency department, and discusses the role of the school nurse when a student is diagnosed with a concussion.

A Comparison of Psychiatric and Nonpsychiatric Nurse Practitioner Knowledge and Management Recommendations Regarding Adolescent Mild Traumatic Brain Injury.

BACKGROUND: Nurse practitioners (NPs) are statutorily authorized to provide assessment and cognitive recommendations for concussion in most states. Their scope of practice includes assessment and management of concussion sequalae including anxiety, insomnia, and depression, as well as return to school and activity guidance. OBJECTIVES: Analysis of symptom-based diagnosis of mild traumatic brain injury (TBI) in adolescents, including return to school and school workload recommendations comparing psychiatric and nonpsychiatric NPs. DESIGN: Cross-sectional Web-based survey with embedded videos using standardized actors and scripts randomized for patient sex and sport. A total of 4,849 NPs licensed in Oregon or Washington were invited by e-mail to view and respond to this study, with a response rate of 23%. RESULTS: Psychiatric mental health nurse practitioners (PMHNPs) were 44% less likely than family NPs to report using standardized concussion tools. 17% had completed continuing education on mild TBI compared to 54.5% of family NPs. Seven PMHNPs provided additional feedback related to discomfort in completing the survey due to lack of comfort or experience. Return to school recommendations and reduced workload advice did not significantly differ by NP type. CONCLUSION: PMHNPs may support individualized assessment through concussion evaluation, use of standardized tools, and differential consideration of TBI for mental health symptoms. More research is required related to the role and contribution of cognitive rest to full recovery.

Head Injuries in Soccer.

UNLABELLED: Soccer is currently the most popular and fastest growing sport worldwide, with approximately 265 million registered soccer players existing around the world. The popularity of the sport, coupled with the high incidence of 18.8-21.5 head injuries per 1,000 player hours reported, make it essential that clinicians, coaches, and the athletes, have a solid understanding of head injuries. The successful rehabilitation of athletes with head injuries relies upon early and accurate identification strategies and implementation of appropriate return to play measures across all areas in the continuum of care. CLINICAL RELEVANCE: Soccer is a frequently played sport, and head injuries are common. Therefore, it is imperative that clinicians, coaches, and the athletes themselves have a solid understanding of head injury prevention, diagnosis, and treatment options. The purpose of this article was to provide rehabilitation nurses with current information regarding frequently occurring head injuries in the widespread sport of soccer.

Heads Up: Communication Is Key in School Nurses' Preparedness for Facilitating "Return to Learn" Following Concussion.

BACKGROUND: Recent literature advocates for a school academic team, including school nurses, to support concussed students' return to the classroom. This study aimed to assess the current understanding and practices of a sample of school nurses regarding the concept of "return to learn" in concussed students. METHODS: Cross-sectional survey of New England school nurses. RESULTS: The greatest barrier to the school nurses' functioning within the academic rehabilitation team for students with concussion was "inadequate communication with the provider that diagnosed the concussion" (73%). Of the 151 school nurses surveyed, 19% felt that they did not have the training necessary for this role. Other barriers included "inadequate concussion training" (38%) and "inadequate time necessary to care for a student with concussion" (30%). CONCLUSIONS: By identifying specific gaps in knowledge and challenges at the school level, these results inform interdisciplinary medical teams about the importance of educating and facilitating effective "return to learn" academic plans.

Current Recommendations on Management of Pediatric Concussions.

Concussions are a form of traumatic brain injury (TBI). Concussion is defined by the American Academy of Neurology as a "trauma-induced alteration in mental status that may or may not involve loss of consciousness" (Kirkwood, Yeates, & Wilson, 2012, p. 1360). At least 1.7 million TBIs occur annually, with 75% being in the form of concussion. Almost half a million patients ages 14 years and younger visit emergency rooms annually for TBI (Centers for Disease Control and Prevention [CDC], 2011). Diagnosing a concussion can be difficult because symptoms vary among individuals and may be subtle and vague, and neuro-radiologic imaging studies typically reveal no abnormalities. Due to the varying degree of symptomatology and recovery, there are no specific recommendations on when it is safe for patients to resume normal activity. Complications can arise if a second injury occurs prior to complete healing from the initial concussion. This literature review identifies current recommendations on the screening and management of concussion in the pediatric population. A clear, concise definition of concussion is presented, as well as recommendations for concussion management. Return to play and return to learn guidelines are explored. The nursing role in concussion management is discussed, and future implications are explored.

Arrhythmias in the epilepsy monitoring unit: watching for sudden unexpected death in epilepsy.

Nurses who work with patients at risk for seizures should be informed that both adult and pediatric patients are at risk for sudden unexpected death in epilepsy (SUDEP). Although the exact pathophysiology of SUDEP is not determined, patients with mesial temporal lobe epilepsy represent an at-risk population because of autonomic dysregulation. With prompt treatment, patients with near-SUDEP can continue to lead normal productive lives. This case series presents three patients with near-SUDEP diagnosed with temporal lobe epilepsy.

Caring for patients with closed traumatic brain injury in rural settings.

The Centers for Disease Control and Prevention (CDC) has acknowledged closed traumatic brain injuries (cTBIs), a form of traumatic brain injury (TBI), as being a major public health matter in the United States. Statistical analysis, as well as public health data, has suggested that there are approximately 1,300 cases of cTBI per year in the United States alone. The standard of care for patients with a cTBI is to undergo diagnostic imaging, most commonly computerized tomography, which is considered to be a luxury and seldom exists in rural clinics. Despite increasing TBI awareness and publicity, healthcare providers, including advanced practice registered nurses, have yet to have a full understanding of the severity of damages that can result from a cTBI. The purpose of this article is to provide an understanding of cTBI and concise clinical best practice guidelines that will aid healthcare providers in rural settings to properly diagnose, treat, and provide education for patients with cTBIs.

Concussion evaluation and management in pediatrics.

Concussions are among the most complex injuries to assess and manage in sports medicine and primary care. Sports concussion in youth has received much attention in recent years because research shows that improperly managed concussion can lead to long-term cognitive deficits and mental health problems. There are several notable risk factors affecting the incidence and severity of concussion in school-age children and adolescents, including a history of a previous concussion. A more conservative approach for return to activities following concussion has been proposed for children and adolescents. Programs of individualized, stepwise increases in physical activity have largely replaced use of algorithms for assigning a grade and activity expectations to concussions. Although validity and reliability testing is ongoing to support use of concussion assessment instruments in pediatric patients, it is practical and appropriate that clinicians incorporate symptom checklists, sideline and balance assessment tools, and neurocognitive assessment instruments into their practice in accordance with evidence-based guidelines.