Are pediatric concussion patients compliant with discharge instructions?

BACKGROUND: Concussions are commonly diagnosed in pediatric patients presenting to the emergency department (ED). The primary objective of this study was to evaluate compliance with ED discharge instructions for concussion management. METHODS: A prospective cohort study was conducted from November 2011 to November 2012 in a pediatric ED at a regional Level 1 trauma center, serving 35,000 pediatric patients per year. Subjects were aged 8 years to 17 years and were discharged from the ED with a diagnosis of concussion. Exclusion criteria included recent (past 3 months) diagnosis of head injury, hospital admission, intracranial injury, skull fracture, suspected nonaccidental trauma, or preexisting neurologic condition. Subjects were administered a baseline survey in the ED and were given standardized discharge instructions for concussion by the treating physician. Telephone follow-up surveys were conducted at 2 weeks and 4 weeks after ED visit. RESULTS: A total of 150 patients were enrolled. The majority (67%) of concussions were sports related. Among sports-related concussions, soccer (30%), football (11%), lacrosse (8%), and basketball (8%) injuries were most common. More than one third (39%) reported return to play (RTP) on the day of the injury. Physician follow-up was equivalent for sport and nonsport concussions (2 weeks, 58%; 4 weeks, 64%). Sports-related concussion patients were more likely to follow up with a trainer (2 weeks, 25% vs. 10%, p = 0.06; 4 weeks, 29% vs. 8%, p < 0.01). Of the patients who did RTP or normal activities at 2 weeks (44%), more than one third (35%) were symptomatic, and most (58%) did not receive medical clearance. Of the patients who had returned to activities at 4 weeks (64%), less than one quarter (23%) were symptomatic, and most (54%) received medical clearance. CONCLUSION: Pediatric patients discharged from the ED are mostly compliant with concussion instructions. However, a significant number of patients RTP on the day of injury, while experiencing symptoms or without medical clearance. LEVEL OF EVIDENCE: Care management, level IV. Epidemiologic study, level III.

Clinician's checklist for reading and using an article about patient-reported outcomes.

Clinicians need evidence-based medicine to help them make clinical decisions with their patients. For many health problems, the goal of treatment is to help the patient to function and feel better. To measure patient functioning, well-being, and symptoms, questionnaires referred to as patient-reported outcome (PRO) measures are often used. Clinicians are generally not trained in survey design, scale development, and questionnaire administration, making it difficult for them to interpret and effectively use PROs as clinical evidence. It is increasingly important that clinicians be able to understand and use outcomes measured from both the clinical and patient perspectives to inform their practice. We aim to provide a "Clinician's Checklist" to help practicing clinicians understand clinical research articles that include PROs so that the information can be used for decision making. This checklist provides an itemization of important areas for the reader to consider in evaluating research articles. We propose that clinicians consider 5 elements when reading a study using PROs: study design and PRO assessment strategy, PRO measure performance, validity of results, context of the findings, and generalizability to their own patient population. Patient-reported outcomes play an increasingly prominent role in clinical research and practice, and this trend has the potential to improve the patient-centeredness of care. Clinicians will need to understand how to use PROs to partner with patients and help them function and feel better. The proposed Clinician's Checklist can help clinicians systematically evaluate PRO studies by determining whether the study design was appropriate and whether the measurement approach was adequate and properly executed as well as by assisting in the interpretation and application of the results to a specific patient population.

The development and validation of the readiness to engage in self-management after acute traumatic injury questionnaire.

OBJECTIVE: Although the management of acute traumatic injury has improved, long-term functional outcomes remain poor. Data suggest major improvements in outcome will require comprehensive, self-management (SM) interventions. However, little is known about trauma survivors' willingness to participate in such interventions. The goal of this study was to create and validate an instrument based on the stages of change (SOC) framework to assess readiness to engage in SM programs following acute traumatic injury. METHOD: The Readiness to Engage in Self-Management after Acute Traumatic Injury (RESMATI) was developed based on SOC theory. Participants (N = 150) were admitted to a Level I trauma center for treatment of severe trauma and completed the RESMATI 3 to 12 months postinjury. A random sample (n = 60) completed a reassessment 1 month later to determine item stability. A principal components analysis and an exploratory factor analysis were conducted. RESULTS: The analyses of the 34 RESMATI items yielded a 5-factor model, collapsed into 3 domains based on SOC theory. Two factors were classified as "precontemplation," 2 factors were classified as "contemplation," and 1 factor was classified as "action/maintenance." All 3 domains had good internal consistency reliability (.71 to .92) and moderate test-retest reliability (.56 and .73). CONCLUSIONS: The exploratory factor analysis yielded 3 domains that were consistent with the SOC model. Two notable exceptions were the lack of a "preparation" domain and lack of distinction between the action and maintenance stages. The RESMATI is a reliable instrument that requires further testing to establish validity and utility in identifying individuals' readiness to engage in SM following acute traumatic injury.

Barriers to implementation of a hospital-based program for survivors of traumatic injury.

The Trauma Survivors Network is a multimodal program for trauma patients and their families. Despite training representatives of 30 trauma centers, only 3 have fully implemented the program. The purpose of this study was to identify barriers to program implementation among trainees through in-depth phone interviews and an electronic survey. Although interviewees were positive about the Trauma Survivors Network concept, they identified numerous barriers to implementation. Trainee confidence in their ability to implement program components was predictive of their success. We recommend that future trainings include program advocacy, implementation skills, and an assessment of trainees' roles in the hospital.

Improving outcomes at Level I trauma centers: an early evaluation of the Trauma Survivors Network.

BACKGROUND: The Trauma Survivors Network (TSN), a program developed to help patients and families manage the psychosocial impact of their injuries, combines information access, self-management training, peer support, and online social networking. The purpose of this study was to evaluate the effectiveness of the TSN in improving patient reported outcomes among orthopedic trauma patients at a Level I trauma center. METHODS: We prospectively enrolled 251 patients with either severe lower-extremity injuries or polytrauma in two cohorts: one group (n = 125) before implementation of the TSN and one group (n = 126) after implementation. Participants were interviewed during their initial hospital stay and at 6 months. Outcomes evaluated at 6 months included depression, anxiety, self-efficacy, health status, and patient activation. RESULTS: Participation in the individual components of the TSN was low, ranging between 3% for the NextSteps self-management program and 27% for receipt of the Patient and Family Handbook. There were no statistically significant differences between treatment and control groups in self-efficacy, anxiety, health status, or activation. There were statistically significant differences in depression (24% of patients with probable depression in the TSN group vs. 40% in the control group, p = 0.02). However, the groups were not balanced with respect to sex, education, and baseline social support. After controlling for these differences, the TSN group still had 49% lower odds (95% confidence interval, 0% to 74%) of depression (p = 0.05). CONCLUSION: The TSN represents a potentially important step toward the development of comprehensive psychosocial support programs for trauma survivors. Despite improvements in one important outcome, a key finding of this evaluation is the low rate of use of program components. This finding highlights the need for greater understanding of use barriers and efforts to increase adoption. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The trauma survivors network: Survive. Connect. Rebuild.

BACKGROUND: Despite substantial improvements in trauma care, severe injuries often result in significant long-term consequences for otherwise young, healthy individuals. Providing patient-centered care and extensive psychosocial support services is difficult for trauma centers. METHODS: In collaboration with researchers and clinicians, the American Trauma Society has developed the Trauma Survivors Network, a program incorporating self-management, peer support, timely access to information, and online social networking. RESULTS: Individually, these components have been proven effective in improving outcomes and quality of life and are widely used in nontrauma settings. To date, 70 representatives from 30 trauma centers have participated in training sessions conducted by the American Trauma Society. CONCLUSION: The Trauma Survivors Network provides a critical component of trauma care that can be adapted for local needs throughout the country. Implementation of these services is a necessary step in the development of comprehensive trauma systems that not only save lives but also reduce long-term disability among survivors.