Variability in Discharge Instructions and Activity Restrictions for Patients in a Children’s ED Postconcussion

Abstract

The objective of this study was to describe discharge instructions given to school-aged patients evaluated in a children's emergency department (ED) following concussion. This was a retrospective cohort study of children 6 to 18 years evaluated in a dedicated children's ED at a level I trauma center in 2008 following acute head trauma regardless of mechanism, identified by any of 27 International Classification of Disease, Ninth Revision diagnoses for head injury, concussion, or skull fracture. Included were those presentations consistent with the Zurich definition for concussion. Excluded were hospital admission, death before admission, evidence of intoxication, or structural abnormality on imaging. Univariate and multivariate analyses determined adjusted odds ratios (ORs) for receipt of concussion-specific discharge instructions and activity restrictions. Of 350 eligible patients, the 218 included patients were mostly male (68%) with mean age 12.8 (SD, 3.4) years. Injury characteristics included sports-related, 42%; fall, 23%; loss of consciousness, 33%; headache, 75%; dizziness, 29%; amnesia, 25%; and vomiting, 19%. Most patients underwent imaging (81%). Discharge characteristics included concussion stated in final diagnosis, 31%; concussion-specific instructions, 62%; and activity restrictions, 34%. Concussion-specific discharge instructions were more likely for loss of consciousness (OR, 1.7; 95% confidence interval [CI], 1.22-2.36), and activity restrictions were more likely for sport-related injury (OR, 1.31; 95% CI, 1.02-1.76) and amnesia (OR, 1.42; 95% CI, 1.01-1.98). Most children meeting diagnostic criteria for concussion were discharged without concussion-specific diagnoses or activity restrictions. Given the risks associated with untimely return to both physical and cognitive activity after concussion, improved awareness and standardization of disposition are imperative for the management of these young patients in the ED.