Health care impact of implementing a clinical pathway for acute care of pediatric concussion: a stepped wedge, cluster randomised trial.

OBJECTIVES: To test the effects of actively implementing a clinical pathway for acute care of pediatric concussion on health care utilization and costs. METHODS: Stepped wedge, cluster randomized trial of a clinical pathway, conducted in 5 emergency departments (ED) in Alberta, Canada from February 1 to November 30, 2019. The clinical pathway emphasized standardized assessment of risk for persistent symptoms, provision of consistent information to patients and families, and referral for outpatient follow-up. De-identified administrative data measured 6 outcomes: ED return visits; outpatient follow-up visits; length of ED stay, including total time, time from triage to physician initial assessment, and time from physician initial assessment to disposition; and total physician claims in an episode of care. RESULTS: A total of 2878 unique patients (1164 female, 1713 male) aged 5-17 years (median 11.00, IQR 8, 14) met case criteria. They completed 3009 visits to the 5 sites and 781 follow-up visits to outpatient care, constituting 2910 episodes of care. Implementation did not alter the likelihood of an ED return visit (OR 0.77, 95% CI 0.39, 1.52), but increased the likelihood of outpatient follow-up visits (OR 1.84, 95% CI 1.19, 2.85). Total length of ED stay was unchanged, but time from physician initial assessment to disposition decreased significantly (mean change - 23.76 min, 95% CI - 37.99, - 9.52). Total physician claims increased significantly at only 1 of 5 sites. CONCLUSIONS: Implementation of a clinical pathway in the ED increased outpatient follow-up and reduced the time from physician initial assessment to disposition, without increasing physician costs. Implementation of a clinical pathway can align acute care of pediatric concussion more closely with existing clinical practice guidelines while making care more efficient. TRIAL REGISTRATION: ClinicalTrials.gov NCT05095012.

ABSTRAIT: OBJECTIFS: Mettre à l'essai les effets de la mise en œuvre active d'une voie clinique pour le traitement aigu des commotions cérébrales chez les enfants sur l'utilisation et les coûts des soins de santé. MéTHODES: Essai randomisé en grappes d'une voie clinique, échelonné, mené dans cinq services d'urgence en Alberta, au Canada, du 1 février au 30 novembre 2019. Le cheminement clinique mettait l'accent sur l'évaluation normalisée du risque de symptômes persistants, la fourniture de renseignements uniformes aux patients et aux familles, et l'aiguillage vers un suivi externe. Les données administratives dépersonnalisées ont permis de mesurer six résultats : visites de retour à l'urgence; visites de suivi en clinique externe; durée du séjour à l'urgence, y compris le temps total. le temps entre le triage et l'évaluation initiale du médecin, et le temps entre l'évaluation initiale du médecin et la décision; et le nombre total de demandes de remboursement du médecin dans un épisode de soins. RéSULTATS: Un total de 2878 patients uniques (1164 femmes, 1713 hommes) âgés de 5 à 17 ans (médiane 11,00, IQR 8, 14) répondaient aux critères de cas. Ils ont effectué 3009 visites aux 5 sites et 781 visites de suivi aux soins ambulatoires, ce qui représente 2910 épisodes de soins. La mise en œuvre n'a pas modifié la probabilité d'une visite de retour à l'urgence (RC 0,77, IC à 95 %, 0,39, 1,52), mais a augmenté la probabilité de visites de suivi en clinique externe (RC 1,84, IC à 95 %, 1,19, 2,85). La durée totale du séjour à l'urgence est demeurée inchangée, mais le temps écoulé entre l'évaluation initiale du médecin et la décision a diminué considérablement (changement moyen : -23,76 minutes, IC à 95 %, -37,99, -9,52). Le nombre total de demandes de règlement de médecins a augmenté de façon significative à seulement 1 site sur 5. CONCLUSIONS: La mise en œuvre d'un cheminement clinique à l'urgence a augmenté le suivi des patients externes et réduit le temps entre l'évaluation initiale du médecin et son élimination, sans augmenter les coûts des médecins. La mise en œuvre d'un cheminement clinique peut harmoniser davantage les soins de courte durée en cas de commotion cérébrale pédiatrique avec les lignes directrices de pratique clinique existantes tout en rendant les soins plus efficaces. ENREGISTREMENT D'ESSAI: ClinicalTrials.gov NCT05095012.

Patient triage to specialist outpatient clinics-time to standardize terminology.

Objectives: The objectives of this study were to evaluate existing nomenclature used for outpatient referrals triage and propose a system, which meets the needs of McMaster Children's Hospital and can be modified for use in other hospitals. Methods: We reviewed triage practices in the Department of Pediatrics, McMaster Children Hospital, Hamilton, Ontario and conducted a literature search to assess terminology used for outpatient referrals triage at other institutions. Results: There is lack of unified terminology for triaging outpatient referrals. Existing systems are not widely accepted, lack uniformity, and often miss recording the true acuity of the referral. We developed a system that covers most outpatient triage scenarios, allocates either flexible or precise visit timelines to referrals and plans for logistics of the patient's visit. Triage categories are iMMediate (MM), Acute (A) (1 to 14 days), Semi-Acute (S) (1 to 3 months), Timetabled (T) (next available appointment slot), Evaluated (E) (used for either forwarding to another provider or requesting additional information), and Rejected (R) categories-McMASTER triage system. Several numbered subcategories are used in each category to define precise timelines, if needed. Visit logistics categories are the following: Hub (H) (place to see the patient), How to notify patient and referring provider (HP) and (HD), need to Start with tests prior to appointment (S), and need to Complete (C) other relevant local processes-HHSC logistics system. Both these systems may be adapted for local use in other institutions. Conclusion: This is the first publication that proposes terminology standardization in triaging outpatient referrals for specialist paediatric services.

"What is the actual goal of the pathway?": examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework.

BACKGROUND: Multiple evidence-based clinical practice guidelines (CPGs) exist to guide the management of concussion in children, but few have been translated into clinical pathways (CP), which operationalize guidelines into accessible and actionable algorithms that can be more readily implemented by health care providers. This study aimed to identify the clinical behaviours, attitudinal factors, and environmental contexts that potentially influence the implementation of a clinical pathway for pediatric concussion. METHODS: Semi-structured interviews were conducted from October 2017 to January 2018 with 42 emergency department clinicians (17 physicians, 25 nurses) at five urban emergency departments in Alberta, Canada. A Theoretical Domains Framework (TDF)-informed interview guide contained open-ended questions intended to gather feedback on the proposed pathway developed for the study, as well as factors that could potentially influence its implementation. RESULTS: The original 14 domains of the TDF were collapsed into 6 clusters based on significant overlap between domains in the issues discussed by clinicians: 1) knowledge, skills, and practice; 2) professional roles and identity; 3) attitudes, beliefs, and motivations; 4) goals and priorities; 5) local context and resources; and 6) engagement and collaboration. The 6 clusters identified in the interviews each reflect 2-4 predominant topics that can be condensed into six overarching themes regarding clinicians' views on the implementation of a concussion CP: 1) standardization in the midst of evolving research; 2) clarifying and communicating goals; 3) knowledge dissemination and alignment of information; 4) a team-oriented approach; 5) site engagement; and 6) streamlining clinical processes. CONCLUSION: Application of a comprehensive, evidence-based, and theory-driven framework in conjunction with an inductive thematic analysis approach enabled six themes to emerge as to how to successfullly implement a concussion CP.

Symptom Burden, School Function, and Physical Activity One Year Following Pediatric Concussion.

OBJECTIVES: To characterize symptom burden, school function, and physical activity in youth 1 year following acute concussion and those with subsequent repeat concussion. STUDY DESIGN: Secondary analysis of Predicting Persistent Postconcussive Problems in Pediatrics prospective, multicenter cohort study conducted in 9 Canadian emergency departments. Participants were children between ages 5 and 18 years who presented consecutively ≤48 hours of concussion and agreed to participate in a post hoc electronic survey 1 year after injury. Outcomes were assessed using a standardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school function and physical activity outcomes were queried. The primary outcome was total symptom score 1 year following concussion, defined as the number of symptoms experienced more than before injury. RESULTS: Of 3052 youth enrolled in the Predicting Persistent Postconcussive Problems in Pediatrics study, 432 (median [IQR] age, 11.5 [9,14] years; 266 [62%] male) completed the 1-year survey; 34 respondents reported a repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (75% vs 50%; difference = 25% [95% CI 8-41]; P = .002) and to have recovered fully (90% vs 74%; difference = 17% [95% CI 5-34]; P = .002) after 1 year. Although physical symptoms were less 1 year after initial emergency department presentation for both groups (P < .001), youth with a repeat concussion reported greater headache persistence (26% vs 13%; difference = 13% [95% CI 1,31]; P = .024). Both groups returned to their normal school routine (100% vs 95%; difference = 5% [95% CI -5 to 8; P = .618). Youth without repeat concussion more frequently returned to normal physical activities (98% vs 85%; difference = 13% [95% CI 4-28]; P < .0001) and sport (95% vs 82%; difference = 13% [95% CI 3-29]; P = .009). CONCLUSIONS: Most youth are symptom-free and fully recovered 1 year following concussion. Some children with repeat concussion have worse outcomes and have delays in returning to normal school routines and sport.

Efficacy of Melatonin for Sleep Disturbance in Children with Persistent Post-Concussion Symptoms: Secondary Analysis of a Randomized Controlled Trial.

Sleep disturbances are commonly reported in children with persistent post-concussion symptoms (PPCS). Melatonin treatment is often recommended, yet supporting evidence is scarce. We aimed to evaluate the efficacy of treatment with melatonin for sleep disturbance in youth with PPCS following mild traumatic brain injury (mTBI). This article is a secondary analysis of a clinical trial of melatonin compared with placebo to treat PPCS. Youth (8-18 years of age) with PPCS and significant sleep-related problems (SRPs) at 4-6 weeks post-injury were eligible. Exclusion criteria: significant medical/psychiatric history; previous concussion/mTBI within 3 months. Treatment groups were: placebo, melatonin 3 mg, or melatonin 10 mg. Primary outcome was change in SRPs measured using the Post-Concussion Symptom Inventory (PCSI) after 2 weeks of treatment. Secondary outcomes included change in actigraphy sleep efficiency, duration, onset latency, and wake-after-sleep-onset. Behavior was measured using Behaviour Assessment for Children (2nd edition). Seventy-two participants (mean age 14.0, standard deviation [SD] = 2.6) years; 60% female) with PPCS and significant sleep disturbance were included in the secondary analysis: placebo (n = 22); melatonin 3 mg (n = 25); melatonin 10 mg (n = 25). Sixty-four participants had actigraphy data. SRPs decreased across all groups over time with a significant effect of melatonin 3 mg (3.7; 95% confidence interval [CI]: 2.1, 5.4) compared with placebo (7.4; 95% CI: 4.2, 10.6) and melatonin 10 mg (6.4; 95% CI: 3.6, 9.2). Sleep duration increased in the melatonin 3 mg (43 min; 95% CI: 6, 93) and melatonin 10 mg groups (55 min; 95% CI: 5, 104) compared with placebo. A per protocol analysis demonstrated improved sleep efficiency in the melatonin 10 mg group (p = 0.029). No serious adverse events were reported. Depressive symptoms significantly decreased with melatonin 3 mg (-4.7; 95% CI: -9.2, -.2) but not with melatonin 10 mg (-1.4, 95% CI: -5.9, 3.2) treatment compared with placebo. Changes in cognition or behavior were otherwise not significantly different between treatment groups. Short-term melatonin is a well-tolerated treatment for sleep disturbance in youth with PPCS following mTBI. In this context, it may also be associated with a reduction in depressive symptoms.

Introducing an innovative model of acute paediatric mental health and addictions care to paediatric emergency departments: a protocol for a multicentre prospective cohort study.

INTRODUCTION: Children and youth with mental health and addiction crises are a vulnerable patient group that often are brought to the hospital for emergency department care. We propose to evaluate the effect of a novel, acute care bundle that standardises a patient-centred approach to care. METHODS AND ANALYSIS: Two paediatric emergency departments in Alberta, Canada are involved in this prospective, pragmatic, 29-month interventional quasi-experimental study. The acute care bundle comprises three components, applied when appropriate: (1) assessing self-harm risk at triage using the Ask Suicide-Screening Questionnaire (ASQ) to standardise the questions administered, enabling risk stratification; (2) use of the HEADS-ED (Home, Education, Activities/peers, Drug/alcohol, Suicidality, Emotions and behaviour, Discharge Resources) to focus mental health evaluations for those who screen high risk on the ASQ; and (3) implementation of a Choice And Partnership Approach to enable shared decision making in care following the emergency department visit. The overarching goal is to deliver the right care at the right place and time for the patients. The study design involves a longitudinal collection of data 12 months before and after the introduction of the bundle and the use of quality improvement strategies such as Plan-Do-Study-Act cycles during a 5-month run-in period to test and implement changes. The primary study end-point is child/youth well-being 1 month after the emergency department visit. Secondary outcomes include family functioning, child/youth well-being at 3 and 6 months, satisfaction with emergency department care, and health system outcomes (hospital admissions, length of emergency department stays, emergency department revisits). ETHICS AND DISSEMINATION: The study is registered at www.ClinicalTrials.gov and has received ethics and operational approvals from study sites. The results of the study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement. Results will be shared broadly with key policy and decision makers and disseminated in peer-reviewed academic journals and presentations at conferences. TRIAL REGISTRATION NUMBER: NCT04292379.

Efficacy of Melatonin in Children With Postconcussive Symptoms: A Randomized Clinical Trial.

BACKGROUND: Approximately 25% of children with concussion have persistent postconcussive symptoms (PPCS) with resultant significant impacts on quality of life. Melatonin has significant neuroprotective properties, and promising preclinical data suggest its potential to improve outcomes after traumatic brain injury. We hypothesized that treatment with melatonin would result in a greater decrease in PPCS symptoms when compared with a placebo. METHODS: We conducted a randomized, double-blind trial of 3 or 10 mg of melatonin compared with a placebo (NCT01874847). We included youth (ages 8-18 years) with PPCS at 4 to 6 weeks after mild traumatic brain injury. Those with significant medical or psychiatric histories or a previous concussion within the last 3 months were excluded. The primary outcome was change in the total youth self-reported Post-Concussion Symptom Inventory score measured after 28 days of treatment. Secondary outcomes included change in health-related quality of life, cognition, and sleep. RESULTS: Ninety-nine children (mean age: 13.8 years; SD = 2.6 years; 58% girls) were randomly assigned. Symptoms improved over time with a median Post-Concussion Symptom Inventory change score of -21 (95% confidence interval [CI]: -16 to -27). There was no significant effect of melatonin when compared with a placebo in the intention-to-treat analysis (3 mg melatonin, -2 [95% CI: -13 to 6]; 10 mg melatonin, 4 [95% CI: -7 to 14]). No significant group differences in secondary outcomes were observed. Side effects were mild and similar to the placebo. CONCLUSIONS: Children with PPCS had significant impairment in their quality of life. Seventy-eight percent demonstrated significant recovery between 1 and 3 months postinjury. This clinical trial does not support the use of melatonin for the treatment of pediatric PPCS.

Derivation and Initial Validation of Clinical Phenotypes of Children Presenting with Concussion Acutely in the Emergency Department: Latent Class Analysis of a Multi-Center, Prospective Cohort, Observational Study.

The identification of clinical phenotypes may help parse the substantial heterogeneity that characterizes children with concussion. This study used latent class analysis (LCA) to identify discernible phenotypes among children with acute concussion and examine the association between phenotypes and persistent post-concussive symptoms (PPCS) at 4 and 12 weeks post-injury. We conducted LCA of variables representing pre-injury history, clinical presentation, and parent symptom ratings, derived from a prospective cohort, observational study that recruited participants from August 2013 until June 2015 at nine pediatric emergency departments within the Pediatric Emergency Research Canada network. This substudy included 2323 children from the original cohort ages 8.00-17.99 years who had data for at least 80% of all variables included in each LCA. Concussion was defined according to Zurich consensus statement diagnostic criteria. The primary outcome was PPCS at 4 and 12 weeks after enrollment. Participants were 39.5% female and had a mean age of 12.8 years (standard deviation = 2.6). Follow-up was completed by 1980 (85%) at 4 weeks and 1744 (75%) at 12 weeks. LCA identified four groups with discrete pre-injury histories, four groups with discrete clinical presentations, and seven groups with discrete profiles of acute symptoms. Clinical phenotypes based on the profile of group membership across the three LCAs varied significantly in their predicted probability of PPCS at 4 and 12 weeks. The results indicate that children with concussion can be grouped into distinct clinical phenotypes, based on pre-injury history, clinical presentation, and acute symptoms, with markedly different risks of PPCS. With further validation, clinical phenotypes may provide a useful heuristic for clinical assessment and management.

Rapid response systems for paediatrics: Suggestions for optimal organization and training.

Resuscitation and cardiac arrest events in the paediatric population are rare occurrences. Improving outcomes from such events continues to be a difficult challenge. Rapid response systems and teams have been integrated into many hospitals in an effort to facilitate early identification and management of patients at risk for clinical deterioration. Optimizing education in the form of team training is a major component of successful team performance. Simulation-based team training, is a key educational supplement for existing standardized resuscitation courses. This position statement describes the evidence supporting rapid response systems and teams as well as simulation-based team training and provides recommendations for implementation in hospital care for paediatric patients.

Incorporating a Computerized Cognitive Battery Into the Emergency Department Care of Pediatric Mild Traumatic Brain Injuries-Is It Feasible?

OBJECTIVES: The use of computers to test cognitive function acutely after a concussion is becoming increasingly popular, especially after sport-related concussion. Although commonly performed in the community, it is not yet performed routinely in the emergency department (ED), where most injured children present. The challenges of performing computerized cognitive testing (CCT) in a busy ED are considerable. The aim of this study was to evaluate the feasibility of CCT in the pediatric ED after concussion. METHODS: Children, aged 8 to 18 years with mild traumatic brain injury, presenting to the ED were eligible for this prospective study. Exclusion criteria included the use of drugs, alcohol, and/or physical injury, which could affect CCT performance. A 30- or 15-minute CCT battery was performed. Feasibility measures included environmental factors (space, noise, waiting time), testing factors (time, equipment reliability, personnel), and patient factors (age, injury characteristics). RESULTS: Forty-nine children (28 boys; mean age, 12.6; SD, ± 2.5) participated in the study. All children completed CCT. Mean testing times for the 30- and 15-minute battery were 29.7 and 15.2 minutes, respectively. Noise-cancelling headphones were well tolerated. A shorter CCT was more acceptable to families and was associated with fewer noise disturbances. There was sufficient time to perform testing after triage and before physician assessment in over 90% of children. CONCLUSIONS: Computerized cognitive testing is feasible in the ED. We highlight the unique challenges that should be considered before its implementation, including environmental and testing considerations, as well as personnel training.

The Kids Are Alright: Pediatric Trauma Pearls.

Pediatric patients with trauma pose unique challenges, both practical and cognitive, to front-line care providers. The combination of anatomic, physiologic, and metabolic factors leads to unique injury patterns with different approaches and responses to treatment compared with adults. A similar traumatic mechanism can lead to slightly different internal injuries with unique management and treatment strategies between the two groups. This article is intended for community, nonpediatric trauma centers, and emergency physicians who are frequently required to assess, resuscitate, and stabilize injured children before they can be safely transferred to a pediatric trauma center for ongoing definitive care and rehabilitation.

Assessing Dehydration Employing End-Tidal Carbon Dioxide in Children With Vomiting and Diarrhea.

OBJECTIVE: Serum bicarbonate reflects dehydration severity in children with gastroenteritis. Previous work in children receiving intravenous rehydration has correlated end-tidal carbon dioxide (EtCO2) with serum bicarbonate. We evaluated whether EtCO2 predicts weight change in children with vomiting and/or diarrhea. METHODS: A prospective cohort study was conducted. Eligible children were 3 months to 10 years old and presented for emergency department (ED) care because of vomiting and/or diarrhea. End-tidal carbon dioxide measurements were performed after triage. The diagnostic standard was weight change determined from serial measurements after symptom resolution. A receiver operating characteristic curve was constructed to identify a cut-point to predict 5% or more dehydration. RESULTS: In total, 195 children were enrolled. Among the 169 (87%) with EtCO2 measurements, the median (interquartile range [IQR]) was 30.4 (27.8 to 33.1). One hundred fifty-eight had repeat weights performed at home; the median (IQR) weight change from ED presentation to well weight was +0.06 (-0.14 to +0.30) or +0.72% (-1.2% to +2.1%). Sixteen percent (25/158) had 3% or more and 4% (6/158) had 5% or more weight gain (ie, percent dehydration). One hundred sixteen (60%) completed home follow-up and had acceptable EtCO2 recordings. Receiver operating curve analysis revealed an area under the curve of 0.34 (95% confidence interval, 0.06 to 0.62) for EtCO2 as a predictor of 5% or more dehydration. CONCLUSIONS: The limited accuracy of EtCO2 measurement to predict 5% or more dehydration precludes its use as a tool to assess dehydration severity in children. End-tidal carbon dioxide monitoring does not have the ability to identify those children with 5% or more dehydration in a cohort of children with vomiting and/or diarrhea presenting for ED care.

Parental experiences and preferences as participants in pediatric research conducted in the emergency department.

OBJECTIVE: To determine parental experiences and preferences regarding the conduct of pediatric research in an emergency department (ED) setting. METHODS: We conducted a cross-sectional study of parents of children ages 0 - 14 years who visited the ED of a tertiary care children's hospital. Parents completed a Web-based survey designed to assess perceptions regarding: 1) background/training of research personnel, 2) location and timing of research discussions, and 3) factors influencing their consent/refusal decision. RESULTS: Parents totalling 339 were approached, and 227 (67%) surveys were completed. Overall, 87% (197/227; 95% confidence interval [CI] 83, 92) reported they would be comfortable being approached by a university student to discuss research. This proportion did not change when stratified by the child's gender, illness severity, or season of visit. Whereas only 37% (84/227; 95% CI 31, 43) of respondents would be comfortable being approached in the waiting room, 68% (154/227; 95% CI 62, 75) would be comfortable if approached in a separate area of the main waiting room. The majority reported comfort with follow-up via email (83%; 188/227; 95% CI 78, 88) or telephone (80%; 182/227; 95% CI 75, 85); only 51% (116/227; 95% CI 44, 57) would be comfortable with a scheduled follow-up visit in the hospital. Participants identified potential complications or side effects as the most common reason for declining consent (69%; 157/227; 95% CI 63, 75). CONCLUSIONS: The majority of parents are comfortable being approached by trained university students, preferably in a separate area of an ED waiting room, and email and telephone follow-ups are preferred over a scheduled re-visit.

Advancing Concussion Assessment in Pediatrics (A-CAP): a prospective, concurrent cohort, longitudinal study of mild traumatic brain injury in children: protocol study.

INTRODUCTION: Paediatric mild traumatic brain injury (mTBI) is a public health burden. Clinicians urgently need evidence-based guidance to manage mTBI, but gold standards for diagnosing and predicting the outcomes of mTBI are lacking. The objective of the Advancing Concussion Assessment in Pediatrics (A-CAP) study is to assess a broad pool of neurobiological and psychosocial markers to examine associations with postinjury outcomes in a large sample of children with either mTBI or orthopaedic injury (OI), with the goal of improving the diagnosis and prognostication of outcomes of paediatric mTBI. METHODS AND ANALYSIS: A-CAP is a prospective, longitudinal cohort study of children aged 8.00-16.99 years with either mTBI or OI, recruited during acute emergency department (ED) visits at five sites from the Pediatric Emergency Research Canada network. Injury information is collected in the ED; follow-up assessments at 10 days and 3 and 6 months postinjury measure a variety of neurobiological and psychosocial markers, covariates/confounders and outcomes. Weekly postconcussive symptom ratings are obtained electronically. Recruitment began in September 2016 and will occur for approximately 24 months. Analyses will test the major hypotheses that neurobiological and psychosocial markers can: (1) differentiate mTBI from OI and (2) predict outcomes of mTBI. Models initially will focus within domains (eg, genes, imaging biomarkers, psychosocial markers), followed by multivariable modelling across domains. The planned sample size (700 mTBI, 300 OI) provides adequate statistical power and allows for internal cross-validation of some analyses. ETHICS AND DISSEMINATION: The ethics boards at all participating institutions have approved the study and all participants and their parents will provide informed consent or assent. Dissemination will follow an integrated knowledge translation plan, with study findings presented at scientific conferences and in multiple manuscripts in peer-reviewed journals.

Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.

IMPORTANCE: Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist. OBJECTIVE: To derive and validate a clinical risk score for PPCS among children presenting to the emergency department. DESIGN, SETTING, AND PARTICIPANTS: Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury. EXPOSURES: All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria. MAIN OUTCOMES AND MEASURES: The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury. RESULTS: In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort. CONCLUSIONS AND RELEVANCE: A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.

Test or Rest? Computerized Cognitive Testing in the Emergency Department after Pediatric Mild Traumatic Brain Injury Does Not Delay Symptom Recovery.

Rest is commonly prescribed following a mild traumatic brain injury (mTBI). There is concern that cognitive exertion by an acutely or sub-acutely injured brain may negatively alter outcome. The objective of this study was to determine if computerized cognitive testing in the emergency department alters symptom outcome from mTBI. Participants included 77 youth with mTBI who underwent computerized cognitive testing (mean age, 13.6; 95% confidence interval [CI] = 13.0-14.2) and were matched to 77 youth with mTBI who did not participate in cognitive testing (mean age, 13.5; 95% CI = 12.9-14.0). Participants who underwent cognitive testing did not differ from those who did not undergo acute cognitive testing on mean symptom ratings or the proportion who were not recovered at 7-10 days, 1 month, 2 months, or 3 months. There also was no difference in symptom outcome for those who underwent a shortened (four subtests, mean time = 16 min) or full-length (seven subtests, mean time = 28 min) version of the computerized test. Brief cognitive exertion using a computerized cognitive assessment after mTBI in youth does not result in worse symptoms at these follow-up periods, does not prolong symptom recovery, should not be considered contraindicated to recovery, and could be considered as another tool to aid in the management of these injuries. Further research with different samples is warranted.

Cognition in the Emergency Department as a Predictor of Recovery after Pediatric Mild Traumatic Brain Injury.

Cognitive abilities can be acutely disrupted in children and adolescents who sustain a mild traumatic brain injury (mTBI), with the potential that these disruptions may be predictive of recovery. The objective of this study was to determine if cognitive abilities in the emergency department (ED) can differentiate and predict poor symptom recovery following a pediatric mTBI. Participants included 77 male and female youth with a mTBI (mean age=13.6; SD=2.6). All participants completed computerized cognitive testing (four subtests from the CNS Vital Signs) when they presented to the ED. Symptom measurement occurred in the ED (for pre-injury), at 7-10 days, 1 month, 2 months, and 3 months post-mTBI using the post-concussion symptom inventory (PCSI). Recovery was determined using reliable change scores for symptom ratings from 28 orthopedic injury controls (mean age=13.9 years; SD=2.1). Significantly worse Reaction Time scores (i.e., rapid information processing) in the ED were found in those who remained symptomatic at 1 month. Performances on the Reaction Time and Cognitive Flexibility domain scores were predictive of symptom outcome at 1 month for youth (above and beyond sex and baseline symptom burden). Youth with low scores on Reaction Time and/or Cognitive Flexibility were nearly 15 times (95% CI=1.8-323.5) more likely to remain symptomatic at 1 month post-mTBI. No significant group differences were found at 7-10 days, 2 months, or 3 months post-injury. Rapid computerized cognitive testing in the ED following a mTBI may help clinicians predict which youth may or may not remain symptomatic at follow-up.

The Incidence of Postconcussion Syndrome Remains Stable Following Mild Traumatic Brain Injury in Children.

BACKGROUND: Improving our knowledge about the natural history and persistence of symptoms following mild traumatic brain injury is a vital step in improving the provision of health care to children with postconcussion syndrome. The purposes of this study were to (1) determine the incidence and persistence of symptoms after mild traumatic brain injury and (2) ascertain whether Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), symptom criteria for postconcussion syndrome in adults are appropriate for use in children. METHODS: A tertiary care pediatric emergency department was the setting for this study. This was a prospective observational follow-up cohort study of children (ages 2 to 18 years) with mild traumatic brain injury. Data were collected in person during the acute presentation, and subsequent follow-up was performed by telephone at 7-10 days and 1, 2, and 3 months postinjury. Postconcussion Symptom Inventory for parents and children was used. The DSM-IV diagnostic criteria for postconcussion syndrome were explored using receiver operating characteristic curve analysis. RESULTS: A total of 467 children (62.5% boys, median age 12.04, range 2.34-18.0) with mild traumatic brain injury participated. The median time until symptom resolution was 29.0 days (95% confidence intervals: 26.09-31.91). Three months after injury, 11.8% of children with mild traumatic brain injury remained symptomatic. Receiver operating curve characteristic analysis of the postconcussion syndrome criteria successfully classified symptomatic participants at three months postinjury; the adolescent receiver operating characteristic curve was excellent with the area under the curve being 0.928 (P < 0.001, standard error 0.019). CONCLUSIONS: Consistent with our previous study, 11.8% of children presenting to the emergency room with a mild traumatic brain injury remain symptomatic at 3 months postinjury. This is the first study to demonstrate stable incidence rates of postconcussion syndrome in children and that modified DSM-IV criteria can be used to successfully classify postconcussion syndrome in children. Although most children report a decay in symptoms over time, 10% of children develop symptoms even though they initially had a good outcome. Caution should be used when using only parent report as a surrogate for childhood outcomes following a concussion.

Postresuscitation debriefing in the pediatric emergency department: a national needs assessment.

OBJECTIVES: The objectives of this study were to assess current postresuscitation debriefing (PRD) practices in Canadian pediatric emergency departments (EDs) and identify areas for improvement. METHODS: A national needs assessment survey was conducted to collect information on current PRD practices and perspectives on debriefing practice in pediatric EDs. A questionnaire was distributed to ED nurses, fellows, and attending physicians at 10 pediatric tertiary care hospitals across Canada. Summary statistics are reported. RESULTS: Data were analyzed from 183 participants (48.7% response rate). Although 88.8% of the participants believed that debriefing is an important process, 52.5% indicated that debriefing after real resuscitations occurs less than 25% of the time and 68.3% indicated that no expectation exists for PRD at their institution. Although 83.7% of participants believed that facilitators should have a specific skill set developed through formal training sessions, 63.4% had no previous training in debriefing. Seventy-two percent felt that medical and crisis resource management issues are dealt with adequately when PRD occurs, and 90.4% indicated that ED workload and time shortages are major barriers to effective debriefing. Most responded that a debriefing tool to guide facilitators might aid in multiple skills, such as creating realistic debriefing objectives and providing feedback with good judgment. CONCLUSION: PRD in Canadian pediatric EDs occurs infrequently, although most health care providers agreed on its importance and the need for skilled facilitators.

Neurocognition in the emergency department after a mild traumatic brain injury in youth.

Abstract The early cognitive effects from a mild traumatic brain injury (mTBI) are poorly understood in youth. The aim of this study was to examine acute neurocognitive functioning in children and adolescents who presented to the emergency department (ED) after an mTBI. Youth 8-17 years of age with an mTBI (n=77; mean age, 13.6 years; 95% confidence interval [CI], 13.0-14.2) and an orthopedic injury control (OIC) group (n=28; mean age, 13.9 years; 95% CI, 13.1-14.7) underwent a very brief computerized neurocognitive assessment (four subtests from CNS Vital Signs) in a pediatric trauma hospital ED. The mTBI and OIC groups were not significantly different on age, gender, handedness, computer familiarity, race, median family income, pain rating scales, or time from injury to assessment. There were no significant differences between the mTBI and OIC groups for accuracy on immediate memory, delayed memory, and measures of attention and executive functioning. However, the mTBI group performed significantly worse than the OIC on nearly all measures of psychomotor speed and reaction time. Further, cognitive functioning appears to worsen as more time passes since the mTBI. Neurocognitive deficits are detectable in youth with an mTBI who present to the ED, despite having a Glasgow Coma Scale score of 15/15 and normal neuroimaging (or their presentation does not warrant neuroimaging). Their profile appears to include preserved accuracy on cognitive measures, but at the expense of slower psychomotor speed and longer reaction time.