Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management.

UNLABELLED: Introduction The diagnosis of concussion is a critical step in the appropriate management of patients following minor head trauma. The authors hypothesized that wide practice variation exists among pediatric emergency medicine physicians in the application of physical and cognitive rest recommendations following an acute concussion. METHODS: The authors developed a 35-item questionnaire incorporating case vignettes to examine pediatric emergency physician knowledge of concussion diagnosis, understanding of initial management using return-to-play/school/work guidelines, use of existing concussion protocols, and perceived barriers to protocol use. Using a modified Dillman technique, the authors distributed an online survey to members of Pediatric Emergency Research Canada, a national association of pediatric emergency physicians. RESULTS: Of 176 potential participants, 115 (65%) responded to the questionnaire, 89% (95% confidence interval [CI]: 0.81, 0.93) of whom reported having diagnosed 20 or more concussions annually. Although 90% (95% CI: 0.83, 0.94) of respondents adequately diagnosed concussion, only 64% (95% CI: 0.54, 0.72) correctly applied graduated return-to-play guidelines. Cognitive rest recommendations were also frequently limited: 40% (95% CI: 0.31, 0.49) did not recommend school absence, 30% (95% CI: 0.22, 0.39) did not recommend schoolwork reduction, and 35% (95% CI: 0.27, 0.45) did not recommend limiting screen time. Eighty percent (95% CI: 0.72, 0.87) of respondents reported having used guidelines frequently or always to guide clinical decisions regarding concussion. CONCLUSION: Despite a proficiency in the diagnosis of concussion, pediatric emergency physicians exhibit wide variation in recommending the graduated return to play and cognitive rest following concussion.

Knowledge of paediatric concussion among front-line primary care providers.

OBJECTIVE: To assess the knowledge of paediatric concussion diagnosis and management among front-line primary care providers. METHODS: Experts from the Concussions Ontario Diagnosis and Early Education Working Group developed a 34-item survey incorporating case vignettes with the collaboration of experts in medical education. Electronic surveys were distributed via FluidSurveys using a modified version of Dillman's tailored design method. The survey was distributed to five Ontario professional associations. The target participants were front-line health care providers (family physicians, emergency medicine physicians, general paediatricians, nurse practitioners and physician assistants) in Ontario; only providers who diagnose and/or manage paediatric concussions were eligible to participate. RESULTS: The survey was fully completed by 577 health care providers who treat paediatric concussion. Of the respondents, 78% (95% CI 74% to 81%) reported diagnosing ≥5 concussions annually. Physicians and nonphysicians equally recognized concussion (90% [95% CI 86% to 92%]; 85% [95% CI 77% to 90%], respectively). Only 37% (95% CI 32% to 41%) of physicians correctly applied graduated return to play guidelines. Return to learn recommendations were also insufficient: 53% (95% CI 49% to 58%) neglected to recommend school absence and 40% (95% CI (35% to 44%) did not recommend schoolwork accommodations. Only 26% (95% CI 22% to 30%) of physicians reported regular use of concussion scoring scales. CONCLUSIONS: Considerable gaps in knowledge exist in front-line primary care providers with inadequate application of graduated return to play and return to learn following concussion, as demonstrated by the present broad population-based survey. Consistent application of best evidence-based management using comprehensive guidelines may help to reduce the impact of concussion and persistent postconcussive problems in children and adolescents.

OBJECTIF: Évaluer les connaissances des dispensateurs de soins de première ligne au sujet du diagnostic et de la prise en charge des commotions cérébrales en pédiatrie. MÉTHODOLOGIE: Avec l'aide d'experts en formation médicale, des experts du groupe de travail sur le diagnostic et l'éducation précoce de Concussions Ontario ont préparé un sondage de 34 questions incluant des capsules cliniques. Les sondages électroniques, inspirés d'une version modifiée du modèle conceptuel adapté de Dillman, ont été distribués à cinq associations professionnelles de l'Ontario par l'entremise de FluidSurveys. Les dispensateurs de soins de première ligne (médecins de famille, urgentologues, pédiatres généralistes, infirmières praticiennes et auxiliaires médicaux) de l'Ontario étaient ciblés. Seuls les dispensateurs qui diagnostiquent ou prennent en charge les commotions cérébrales en pédiatrie pouvaient y participer. RÉSULTATS: Ont entièrement répondu au sondage 577 dispensateurs de soins qui soignent les commotions cérébrales en pédiatrie. De ce nombre, 78 % (95 % IC 74 % à 81 %) ont déclaré en diagnostiquer au moins cinq par année. Les médecins et les non-médecins dépistaient tout autant les commotions (90 % [95 % IC 86 % à 92 %]; 85 % [95 % IC 77 % à 90 %], respectivement). Seulement 37 % (95 % IC 32 % à 41 %) des médecins appliquaient correctement les directives sur le retour au jeu graduel. Les recommandations sur la reprise de l'apprentissage étaient également insuffisantes : 53 % (95 % IC 49 % à 58 %) négligeaient de recommander de s'absenter de l'école et 40 % (95 % IC (35 % à 44 %) ne recommandaient pas d'aménagements des travaux scolaires. Seulement 26 % des médecins (95 % IC 22 % à 30 %) déclaraient utiliser régulièrement les échelles de notation des commotions cérébrales. CONCLUSIONS: Les dispensateurs de soins de première ligne présentaient d'importantes lacunes sur le plan des connaissances. En effet, comme le démontre le présent vaste sondage en population, ils n'appliquaient pas correctement les règles de retour au jeu et de reprise de l'apprentissage graduels après une commotion. L'utilisation généralisée de modes de prise en charge exemplaires tirés de directives détaillées pour-rait contribuer à réduire les conséquences des commotions et des problèmes persistants qui en découlent chez les enfants et les adolescents.