An Evaluation of Post-Concussion Return to School Guidelines: A Survey of Massachusetts School Nurses.

Although all states have legislation pertaining to youth sports concussion, most of these laws focus on return-to-play procedures; only a few address return-to-learn (RTL) accommodations for students who have experienced a concussion. To address this gap in the legislation, some states and nongovernmental organizations have developed RTL guidelines to advise school personnel, parents, and health care providers on best practices for accommodating students' postconcussion reintegration into academic activity. In 2018, the Massachusetts Department of Public Health (MDPH) developed RTL guidelines which were disseminated to school nurses (SNs) at all public and nonpublic middle and high schools in the state. In 2020, the MDPH engaged the Injury Prevention Center at Boston Medical Center to survey Massachusetts SNs to assess the usefulness of the guidelines. The response rate was 63%; 92% found the booklet extremely useful or moderately useful; and 70% endorsed that the booklet fostered collaboration among stakeholders.

It is time to rewrite state youth sports concussion laws.

Between 2009 and 2014, all 50 states and the District of Columbia passed legislation to improve the recognition and management of youth concussed in sports. These laws can include requirements for concussion training for school athletic personnel, concussion education for children and their parents, return-to-play (RTP) procedures, and medical clearance to for RTP. Concussion can impact academic learning and performance in children and adolescents. Postconcussion academic accommodations during recovery can be an important component of secondary prevention for mitigating the sequalae of head injury. Few state youth concussion laws, however, include provision of postconcussion return-to-learn (RTL) accommodations and most of those that do address RTL apply to student athletes only. Concussions may occur in youth who are not participating in organised sports (eg, falls, traffic crashes) and thus may not be subjected to RTL accommodations, even if the state mandates such procedures for athletes. Low income and students of colour may be more likely to have non-sports concussions than their more affluent and white peers, thus potentially creating demographic disparities in the benefits of RTL procedures. State youth sports concussion laws should be revised so that they include RTL provisions that apply to all students, athletes and non-athletes alike.

Disparities in baseline neurocognitive testing for student concussion management in Massachusetts high schools.

PURPOSE: There is evidence of socioeconomic disparities with respect to the implementation of student-sports concussion laws nationally. The purpose of this study was to examine school sociodemographic characteristics associated with the provision of computerised baseline neurocognitive testing (BNT) in Massachusetts (MA) high schools, and to assess whether the scope of testing is associated with the economic status of student populations in MA. METHODS: A cross-sectional secondary analysis of surveys conducted with MA athletic directors (n=270) was employed to investigate school characteristics associated with the provision of BNT. Correlation and regression analyses were used to assess whether the scope of testing is associated with the economic status of student populations in MA. RESULTS: The scope of BNT was independently associated with the economic disadvantage rate (EDR) of the student population (ß=-0.02, p=0.01); whether or not the school employs an athletic trainer (AT) (ß=0.43, p=0.03); and school size (ß=-0.54, p=0.03). In a multivariable regression model, EDR was significantly associated with the scope of baseline testing, while controlling for AT and size (ß=-0.01, p=0.03, adj-R2=0.1135). CONCLUSION: Among public high schools in MA, disparities in the provision of BNT for students are associated with the economic characteristics of the student body. Schools that have a greater proportion of low-income students are less likely to provide comprehensive BNT. The clinical implications of not receiving BNT prior to concussion may include diminished quality of postconcussive care, which can have short-term and long-term social, health-related and educational impacts.

Evaluation of Implementation of Massachusetts Sports Concussion Regulations: Results of Focus Groups with Athletic Directors.

In 2018, the Massachusetts Department of Public Health (MDPH) conducted focus groups with athletic directors (ADs) from Massachusetts middle and high schools to assess the implementation of legislated regulations relative to the management of concussion (mild traumatic brain injuries; mTBI) among students engaged in extracurricular sports. Two tape-recorded focus groups were conducted with a facilitator. Lists of themes were synthesized by investigators. Overall, participating ADs expressed that the law and accompanying regulations were necessary and important for protecting student athletes, despite some burdensome aspects of implementation. Emerging themes included support for the law, some implementation problems, impact on workload, and recommendations for improving mandated procedures. ADs assume an important role in the management of middle and high school students' mTBI when given the authority to do so through legislation and regulation. Nonetheless, challenges to the daily application of legislated protocols exist and should continue to be evaluated.

Perceptions of implementation of Massachusetts sports concussion regulations: results of a survey of athletic directors.

BACKGROUND: In 2011 the Massachusetts Department of Public Health issued regulations pursuant to 2010 Massachusetts youth sports concussion legislation that provided policies and procedures for persons engaged in the prevention, training, management, and return-to-activity for students who sustain head injury during interscholastic athletics, including Athletic Directors (ADs). METHODS: A survey instrument was developed with participation from injury prevention experts at the Boston University School of Medicine, the Massachusetts Department of Public Health, and ADs. An electronic survey was sent to all AD members of the Massachusetts Interscholastic Athletic Association to assess their perceptions of implementation of the sports concussion law. RESULTS: Response rate was 75% (260/346). The mean rating on a 0-10 scale (10 being "very important") on importance of the law for student safety was 9.24, and the mean rating of the law's impact on workload was 5.54. Perceived impact on workload varied as a function of whether or not the school also employed an athletic trainer (t = 2.24, p = 0.03). Most respondents (88%) reported that their school had a concussion management team, and 74% reported that they were informed "always" (31%) or "often" (43%) when a student-athlete experienced a head injury in a venue other than extracurricular sports. Most respondents (95%) endorsed that "all" or "most" school nurses were "very knowledgeable" about the law and regulations. Approximately half of all respondents endorsed that "all" or "most" teachers and guidance counselors were "very knowledgeable" about the law and regulations; 76% endorsed that "all" or "most" of students' physicians were "very knowledgeable" about the law and regulations; 59% endorsed that "all" or "most" parents were "very knowledgeable" about the law and regulations. Sixty-six percent endorsed that student-athletes with concussion "often" (10%) or "sometimes" (56%) misrepresent their symptoms to accelerate return-to-play; and, 70% perceived that student-athletes with concussion "often" (15%) or "sometimes" (55%) misrepresent their symptoms to avoid academics. CONCLUSIONS: ADs perceive the sports concussion legislation as very important to student safety and positively assess implementation of the law and associated regulations. More effort is needed to increase understanding of the law among stakeholders including teachers, parents, and physicians.

Application of Components of the Massachusetts' Sports Concussion Regulations to All Students With Concussion: A Survey of School Nurses.

Appropriate management by schools of all students with a concussion, regardless of the cause, has not received the same attention as sports-related concussions. Focus groups conducted with Massachusetts School Nurses in 2015 found that some had applied protocols required in the state's sports concussion regulations to all students with concussion, not just student athletes. We surveyed high school nurses in Massachusetts to examine (1) the extent of this practice and (2) the extent to which protocols for all students with concussion are included in school policies. Of 168 (74%) responding, 94% applied the return-to-learn and play, and medical clearance requirements to all students with concussion, regardless of how or where the concussion occurred and 77% reported their school's policy required these protocols for all students with concussion. A significant association (odds ratio: 13.3, 95% confidence interval [2.4, 72.8], p <.01) existed between the two measures. These findings have important clinical and academic implications.

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments.

Evidence-based clinical practice guidelines can facilitate proper evaluation and management of concussions in the emergency department (ED), often the initial and primary point of contact for concussion care. There is no universally adopted set of guidelines for concussion management, and extant evidence suggests that there may be variability in concussion care practices and limited application of clinical practice guidelines in the ED. This study surveyed EDs throughout New England to examine current practices of concussion care and utilization of evidence-based clinical practice guidelines in the evaluation and management of concussions. In 2013, a 32-item online survey was e-mailed to 149/168 EDs throughout New England (Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine). Respondents included senior administrators asked to report on their EDs use of clinical practice guidelines, neuroimaging decision-making, and discharge instructions for concussion management. Of the 72/78 respondents included, 35% reported absence of clinical practice guidelines, and 57% reported inconsistency in the type of guidelines used. Practitioner preference guided neuroimaging decision-making for 57%. Although 94% provided written discharge instructions, there was inconsistency in the recommended time frame for follow-up care (13% provided no specific time frame), the referral specialist to be seen (25% did not recommend any specialist), and return to activity instructions were inconsistent. There is much variability in concussion care practices and application of evidence-based clinical practice guidelines in the evaluation and management of concussions in New England EDs. Knowledge translational efforts will be critical to improve concussion management in the ED setting.

Current Trends in Geriatric Emergency Medicine.

The number of geriatric visits to United States emergency departments continues to rise. This article reviews demographics, statistics, and future projections in geriatric emergency medicine. Included are discussions of US health care spending, geriatric emergency departments, prehospital care, frailty of geriatric patients, delirium, geriatric trauma, geriatric screening and prediction tools, medication safety, long-term care, and palliative care.

Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke.

Dizzy patients present a significant diagnostic challenge to the emergency clinician. The discrimination between peripheral and central causes is important and will inform subsequent diagnostic evaluation and treatment. Isolated vertigo can be the only initial symptom of a posterior circulation stroke. The sensation of imbalance especially raises this possibility. Research involving strokes of the posterior circulation has lagged behind that of the anterior cerebral circulation. Investigations of the last 20 years, using new technologies in brain imaging in combination with detailed clinical studies, have revolutionized our understanding of the clinical presentation, causes, treatments, and prognosis of posterior circulation ischemia.

Time series analysis of emergency department length of stay per 8-hour shift.

INTRODUCTION: The mean emergency department (ED) length of stay (LOS) is considered a measure of crowding. This paper measures the association between LOS and factors that potentially contribute to LOS measured over consecutive shifts in the ED: shift 1 (7:00 am to 3:00 pm), shift 2 (3:00 pm to 11:00 pm), and shift 3 (11:00 pm to 7:00 am). SETTING: University, inner-city teaching hospital. PATIENTS: 91,643 adult ED patients between October 12, 2005 and April 30, 2007. DESIGN: For each shift, we measured the numbers of (1) ED nurses on duty, (2) discharges, (3) discharges on the previous shift, (4) resuscitation cases, (5) admissions, (6) intensive care unit (ICU) admissions, and (7) LOS on the previous shift. For each 24-hour period, we measured the (1) number of elective surgical admissions and (2) hospital occupancy. We used autoregressive integrated moving average time series analysis to retrospectively measure the association between LOS and the covariates. RESULTS: For all 3 shifts, LOS in minutes increased by 1.08 (95% confidence interval 0.68, 1.50) for every additional 1% increase in hospital occupancy. For every additional admission from the ED, LOS in minutes increased by 3.88 (2.81, 4.95) on shift 1, 2.88 (1.54, 3.14) on shift 2, and 4.91 (2.29, 7.53) on shift 3. LOS in minutes increased 14.27 (2.01, 26.52) when 3 or more patients were admitted to the ICU on shift 1. The numbers of nurses, ED discharges on the previous shift, resuscitation cases, and elective surgical admissions were not associated with LOS on any shift. CONCLUSION: Key factors associated with LOS include hospital occupancy and the number of hospital admissions that originate in the ED. This particularly applies to ED patients who are admitted to the ICU.

Impact of an emergency department closure on the local emergency medical services system.

BACKGROUND: On July 12, 2010, Boston Medical Center (BMC), the busiest emergency department (ED) in Massachusetts, with more than 100,000 adult patient visits per year, consolidated its two fully functional EDs into one. In preparation for this consolidation, BMC implemented systems changes to mitigate potential negative effects on both BMC and emergency medical services (EMS) providers, including Boston Emergency Medical Services (Boston EMS), the provider of 9-1-1 EMS to the City of Boston. OBJECTIVE: To examine the impact of the closure of an ED on an urban EMS system in a setting where ambulance diversion is not allowed. METHODS: We performed a before-and-after study that examined the effects of an ED closure on BMC and Boston EMS. We examined ED and Boston EMS volumes and ambulance turnaround intervals from June 1, 2010, to July 11, 2010 (preclosure) as compared with July 12, 2010, to August 26, 2010 (postclosure). Mean ED and Boston EMS volumes and Boston EMS turnaround intervals were calculated in four-hour shifts. We used multivariate analysis to analyze electronic medical systems data from BMC and Boston EMS and linear regression. We used autoregressive integrated moving average (ARIMA) models to determine the effect of the ED closure on turnaround intervals, ED volumes, and transport volumes. All analyses were adjusted for shift, ED volume, day of the week, and citywide EMS transport volumes. RESULTS: After ED closure, there was a statistically significant increase of 0.89 minutes (p = 0.02) in the mean EMS turnaround intervals. Additionally, the total ED volume decreased by 3.67 visits per shift (p < 0.001). The ratio of patients transported by Boston EMS to BMC remained unchanged (p = 0.11) for two weeks before and two weeks after the closure. CONCLUSIONS: The closure of one ED resulted in a statistically significant increase in turnaround intervals and a significant decrease in ED volume independent of EMS volumes. In the absence of ambulance diversion, ratios of EMS turnaround intervals and EMS volumes according to hospital destination can be used as alternatives to ambulance diversion times to examine the effects of system-level changes such as closure of an ED on an urban EMS system.

Managing emergency department overcrowding.

Emergency department (ED) crowding and ambulance diversion has been an increasingly significant national problem for more than a decade. More than 90% of hospital ED directors reported overcrowding as a problem resulting in patients in hallways, full occupancy of ED beds, and long waits, occurring several times a week. Overcrowding has many other potential detrimental effects including diversion of ambulances, frustration for patients and ED personnel, lesser patient satisfaction, and most importantly, greater risk for poor outcomes. This article gives a basic blueprint for successfully making hospital-wide changes using principles of operational management. It briefly covers the causes, significance, and dangers of overcrowding, and then focuses primarily on specific solutions.

Response to hepatitis A epidemic: emergency department collaboration with public health commission.

In 2004, a hepatitis A outbreak occurred in Boston, Massachusetts with an incident rate of 14.8 per 100,000, compared to 4.2 in 2003. The majority of cases had risk factors of homelessness, injection drug use, or incarceration. In September 2004, the Boston Public Health Commission began an immunization campaign partnering with health centers, detoxification centers, homeless shelters, and our Emergency Department (ED) to increase the number of hepatitis A vaccinations and stem the epidemic. The ED rapidly developed (within days) a vaccination protocol. Hepatitis A vaccinations were offered to patients over age 21 years who were homeless, substance users, or incarcerated. From October 2004 through January 2005, the ED vaccinated 122 patients notable for 64% male, 61% homeless, 28% substance users, and 11% incarcerated. No reported vaccination reactions occurred. There was a 51% decrease in the number of cases of Hepatitis A in Boston in the first 4 months of 2005. As a partner, the ED helped stem the epidemic by rapidly providing vaccinations to those most vulnerable. This project provides a model for future collaborations between EDs and local, state, and federal organizations to address epidemics.

Time series analysis of variables associated with daily mean emergency department length of stay.

STUDY OBJECTIVE: We measure the effect of various input, throughput, and output factors on daily emergency department (ED) mean length of stay per patient (daily mean length of stay). METHODS: The study was a retrospective review of 93,274 ED visits between April 15, 2002, and December 31, 2003. The association between the daily mean length of stay and the independent variables was assessed with autoregressive moving average time series analysis (ARIMA). The following independent variables were measured per 24-hour period: number of elective surgical admissions, ED volume, number of ED admissions, number of ED ICU admissions, number of ED clinical attending hours, hospital medical-surgical occupancy (hospital occupancy), and day of the week. RESULTS: Three factors were independently associated with daily mean length of stay in time series analysis: number of elective surgical admissions, number of ED admissions, and hospital occupancy. The daily mean length of stay increased by 0.21 minutes for every additional elective surgical admission, 2.2 minutes for every additional admission, and 4.1 minutes for every 5% increase in hospital occupancy. Elective surgical admissions were associated with a maximum of 35 hours of additional ED dwell time. The model accounted for 31.5% of the variability in daily mean length of stay. The final model parameters for the ARIMA analysis were autoregressive term (1) moving average (1). CONCLUSION: Hospital occupancy and the number of ED admissions are associated with daily mean length of stay. Every additional elective surgical admission prolonged the daily mean length of stay by 0.21 minutes per ED patient. Autocorrelation exists between the daily mean length of stay of the current day and the previous day.

Brief interventions to reduce harmful alcohol use among military personnel: lessons learned from the civilian experience.

Unhealthy alcohol use is among the leading causes of morbidity and mortality in the United States. Among military personnel, service members between the ages 18 and 25 had a 27.3% prevalence of heavy drinking in the previous 30 days, compared to 15.3% among civilians in the same age group. In the civilian world, > 100 million patients are treated in U.S. emergency departments (ED) annually; 7.9% of these visits are alcohol related. Alcohol is associated with a broad range of health consequences that may ultimately present in the ED setting: traumatic injuries (e.g., motor vehicle crashes, intentional violence, falls); environmental injuries (e.g., frostbite); cardiovascular problems (e.g., hypertension, dilated cardiomyopathy); gastrointestinal disorders (e.g., hepatitis, pancreatitis, gastrointestinal bleeding); neurological problems (e.g., encephalopathy, alcohol withdrawal, withdrawal seizures), as well as psychological problems (e.g., depression, suicide). Seminal work has been done to create behavioral interventions for at-risk drinkers. These motivational interventions have been found to be successful in encouraging clients to change their risky behaviors. We present such a technique, called the Brief Negotiated Interview as performed in a civilian ED setting, in hopes of adapting it for use in the military context. Military health care providers could easily adapt this technique to help reduce risky levels of alcohol consumption among service members, retirees, or military dependents.

Emergency Department overcrowding and ambulance diversion: the impact and potential solutions of extended boarding of admitted patients in the Emergency Department.

Emergency Department (ED) crowding and ambulance diversion have been increasingly significant national problems for more than a decade. Surveys of hospital directors have reported overcrowding in almost every state and 91% of hospital ED directors report overcrowding as a problem. The problem has developed because of multiple factors in the past 20 years, including a steady downsizing in hospital capacity, closures of a significant number of EDs, increased ED volume, growing numbers of uninsured, and deceased reimbursement for uncompensated care. Initial position statements from major organizations, including JCAHO and the General Accounting Office, suggested the problem of overcrowding was due to inappropriate use of emergency services by those with no urgent conditions, probably cyclical, and needed no specific policy response. More recently, the same and other organizations have more forcefully highlighted the problem of overcrowding and focused on the inability to transfer emergency patients to inpatient beds as the single most important factor contributing to ED overcrowding. This point has been further solidified by initial overcrowding research. This article will review how overcrowding occurred with a focus on the significance and potential remedies of extended boarding of admitted patients in the Emergency Department.

Elder abuse.

Elder abuse and neglect is a prevalent, underrecognized problem among today's senior citizens. Fortunately, awareness is increasing, and services are being provided to elders on a more ready basis. Still, the emergency care provider must act as a patient advocate and assume responsibility for the detection, treatment, and safe disposition of unfortunate victims.