342 - Improving concussion evaluation and management in a primary care setting

Poster Number: 342
Publication Number: 342.345

Corinna Rea, Boston Children's Hospital, Boston, MA, United States; Eli Sprecher, Boston Children's Hospital, Boston, MA, United States; Grace Chi, Boston Children's Hospital, Boston, MA, United States; Barbara Hernandez, Boston Children’s Hospital, Brighton, MA, United States; Alison C. Shea, Boston Children's Hospital, North Easton, MA, United States; Patricia Meleedy-Rey, Boston Children's Hospital, Boston, MA, United States; Michael A. Beasley, Harvard Medical School, Brookline, MA, United States; Karameh Kuemmerle, Harvard Medical School, Boston, MA, United States; Michaela E. Nolan, Boston Children's Hospital, Boston, MA, United States; Maria Pearl, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Amy J. Starmer, Boston Children's Hospital, Boston, MA, United States

Background: Pediatric concussion is a common condition that can usually be managed in a primary care setting. However, primary care providers often fail to use standardized tools for assessing symptom severity and monitoring improvement or to give evidence-based instructions for gradual return to school and sports.
 

Objective: To increase to 70% the proportion of patients with concussion presenting to primary care who: (1) complete a standardized concussion symptom scale; (2) receive educational and instructional materials after an initial concussion visit; and (3) are seen for concussion follow-up within 2 weeks.

Design/Methods: At two hospital-affiliated primary care clinics, we implemented a multi-disciplinary process improvement effort to standardize evaluation and management of concussion.  This included the development of a clinical pathway with information about screening tools, physical exam maneuvers, and follow-up instructions. We performed multiple PDSA cycles to enhance provider and nursing completion of these tasks. These PDSA cycles included embedding the concussion symptom scale into the Electronic Medical Record (EMR) and creating AutoText for visit notes, implementing nursing-driven process changes to improve distribution of the concussion symptom scale to patients, creating a comprehensive instructional letter template within the EMR, and educating providers and nurses about the pathway. We measured monthly screening, education/instruction and follow-up rates using statistical process control charts.

Results: Utilization of the standardized concussion symptom scale increased from a baseline of 37% to 56% following implementation, evidenced by a run of eight consecutive points above the centerline. Distribution of education/instructions and follow-up visit completion have not showed consistent improvement from a baseline of 40 and 30%, respectively. Data reflect seasonal variability with higher rates of concussion in the fall, as well as a significant decrease in concussions during the first year of the COVID-19 pandemic.Conclusion(s):
A multi-pronged interdisciplinary improvement effort enabled the development of consistent practices for evaluation and management of concussion in primary care, and increased utilization of a standardized concussion symptom scale. Next steps include fishbone diagraming and process mapping to prioritize additional PDSA cycles to increase distribution of educational materials and follow-up visit completion.

Percentage of concussion patients who completed a Post Concussion Symptom Scale
Percentage of concussion patients who received written educational materials