1. Discharge Instructions for Youth Sports-Related Concussions in the Pediatric Emergency Department 2004-2012 Mark Riederer, MD, FAAP Joseph Boyle Elise Martin Clint Morgan George Yang Allison Umfress Cam Upchurch

2. 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).

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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%

10. Note: Chart does not include 2012 data

14. Note: Includes follow up with VSCC , VSM, ATC, Neurology

15. 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

16. 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

17. Questions? Please contact Dr. Mark Riederer: mark.riederer@vanderbilt.edu