The clinical utility of a written point-of-care Concussion Action Plan (CAP) in facilitating recovery from a concussive injury, and improve outcomes following emergency department discharge

Abstract

Background: The majority of concussion injuries in children and adolescents are sports and/or recreational-related. Most have a typical clinical trajectory, making a full recovery by 3 weeks. This process however can be long and drawn-out as many practitioners are reluctant to move too quickly due to a lack of guidance. Post-concussion, many injured patients are robust enough to commence escalation of their activity earlier than is current suggested, with excessive rest often prolonging recovery. A tool that outlines a consistent and clear plan of action or CAP for patients recovering from a concussion has the potential to improve outcomes, increase parental satisfaction and may even reduce the burden of unscheduled visits to medical service providers such as General Practitioners or Emergency Departments. Method: A non-randomised controlled study was conducted in the emergency department of a single tertiary paediatric trauma centre over a 3-month period. Children aged 12-16 years presenting with a simple concussion (no hospitalisation or co-morbidity) were eligible to participate. On discharge from the emergency department, families were given, in addition to an education leaflet, a CAP with instruction on its use at home. CAP is a colour coded activity progression plan, with compatible cognitive and physical activities prescribed at each sequential stage. CAP includes a daily symptom diary to be recorded by the parent and/or caregiver to assist progression through the plan, in addition to having a record of symptom recovery should they need to visit their GP for advice. All participants were followed until full recovery. Outcomes of interest were; patient compliance, adverse events and unscheduled representations, with parental and/or caregiver satisfaction a secondary outcome. Results: During the study, 132 patients with a simple concussion were evaluated in the emergency department. Of these, 69 participated in the study, and the remaining 63 managed with education alone. The mean age was 12.8 years, 70% male, with recreation-related falls accounting for 68%. Non-compliance with instruction was reported in 4.3% of participants using CAP and 48% undergoing education. Deviation from CAP was reported in 3.4% of participants who made a rapid recovery. In all cases, parents were satisfied with CAP. Dissatisfaction was reported in 38% of those having education alone due to confusing or mis-information. No adverse outcomes were reported in either group. Unscheduled visits were reported in 11% of those undergoing education alone as the parent and/or caregiver was often unclear on how to progress a child toward normal activity. Discussion: The use of CAP improves outcome and streamlines the discharge process in a busy acute-care setting. Parents also need to understand the disease and what to do if expectations are not met. Education before discharge tailored to meet this need in addition to CAP is important. Conflict of interest statement: My co-authors and I acknowledge that we have no conflicts of interest of relevance to the submission of this abstract.