In response to an increasing number of nationally reported concussions and limited knowledge about concussion in youth sports, the Washington State Legislature passed the Zackary Lystedt Law in 2009. This law addressed a Washington resident's experience with a concussion in 2006, in which he was allowed to return to competition after a concussion, with life-altering physical and mental consequences. This was the first law in the nation passed in recognition that individuals lack knowledge and education about issues surrounding concussions, leading to incorrect care for athletes. The law mandates medical clearance of youth athletes suspected of sustaining a concussion before resuming activity. Because internationally accepted consensus guidelines and laws in every state have now changed the management of sports-related concussion (SRC), emergency department physicians need updated knowledge and training regarding the management of SRC to provide appropriate care.
The general consensus among sports medicine professionals is that the rates of concussion in contact sports are higher than reported. McCrea et al. suggested that more than 50% of concussions go unreported.1 Failure to recognize and properly manage concussions may be due to lack of knowledge and understanding among physicians of the most current and widely recognized Zurich Consensus Statement on Concussion in Sport from 2012.2 Current estimates of concussion incidence are 1.6 to 3.8 million each year, with 1.2 to 1.3 million being seen in the emergency department and increasing.3–5
Since 1973, more than 17 guidelines have been created regarding concussion diagnosis and management.6 Physicians often struggle with the number of sources available and have difficulty determining which are the most reliable, current, and practical.7 In addition, health care providers may not have the proper training in best practices for SRC. Pediatric patients with SRC in a 2010 emergency department study were provided with discharge instructions specific to provider follow-up appointments only 33% of the time.8 Another study found that only 23% of emergency physicians at a level 1 trauma center used nationally recognized guidelines when treating SRC.6 Even with the rise in media exposure, the Centers for Disease Control and Prevention concussion educational promotion (“Heads Up”), and an increasing number of state concussion laws, many physicians do not follow current guidelines.9
The Washington State Department of Health designates hospitals as level 1 to level 5 trauma centers based on trauma resources. Level 1 trauma centers are most often in urban centers and are highly resourced to care for trauma patients. Washington State has one level 1 trauma center, whereas the more rural Montana has no level 1 trauma center. Each state has a large number of hospitals that carry trauma designations II to V.10,11
Physicians staffing emergency departments comprise those trained in emergency medicine and primary care specialties. Primary care specialists tend to provide staffing in rural hospitals.12 According to the 2000 census, 82% of Washington residents live in urban areas, whereas 54.1% of Montana is considered urban.13 This suggests that many physicians treating concussions in the emergency department setting in Washington and Montana are likely primary care physicians.
Previous research has evaluated concussion management by primary care or sports medicine physicians, but none has focused on emergency department physicians treating SRC. As such, our study focused on physicians treating SRC in the emergency department setting. The goal of our survey was to determine differences in concussion knowledge, referral patterns, and use of return to play (RTP) guidelines among physicians working in an emergency department. We sought to detect if type of training (emergency medicine vs primary care), practice setting (rural vs urban), trauma designation, and years of emergency medicine practice resulted in differences in concussion management among physicians staffing emergency departments in Washington and Montana.
We attempted contact with all emergency department physicians in Washington State and Montana. The Washington State participants were recruited by contacting emergency department medical directors via a listserv maintained by the Washington Chapter of the American College of Emergency Physicians. We then asked the medical directors to forward the survey to their colleagues working in their respective emergency departments. The Montana participants were recruited by members of the Montana Chapter of the American College of Emergency Physicians who forwarded the survey to statewide emergency department medical directors for distribution to their physician groups. This was not done by listserv but rather a list of contacts maintained by members of the organization. The participants were physicians working in emergency department settings across the two states. The survey link was sent to all members of the organization via e-mail and participants were able to complete the survey voluntarily. The survey (Survey Monkey.com; Survey-Monkey, Palo Alto, CA) could be completed on any computer or mobile device. The survey was disseminated to the listservs in November 2013 with several follow-up e-mails throughout the winter.
Our survey was designed to examine the current level of understanding and practice patterns related to SRC among physicians working in the emergency department. The 32-question survey was based on a composite of existing surveys regarding concussion knowledge. These include the Centers for Disease Control and Prevention – ACTive Athletic Concussion Training for Coaches and the Sports Concussion Assessment Tool 2.14,15 We included questions from each source to create the overall survey. These included: signs and symptoms, diagnosis, treatment, return to activity, and referral protocols for SRC. General knowledge questions included 10 Likert scale questions with responses ranging from strongly disagree to strongly agree on a 5-point scale. A similar survey from Chrisman et al. was used as a template for development of this section.9 SRC management questions related to recommended follow-up care, referrals, and whether respondents provide patient education on the graded RTP guidelines at discharge. Referral questions included which health care professionals would be used in the ongoing care of the patient.
Demographics questions included: age, gender, type of training (emergency medicine vs primary care specialty), years of emergency medicine practice, hospital trauma classification (trauma level 1 to 5), and number of concussions diagnosed in the past year. Participants were asked if their practice setting was considered rural or urban defined by a local population of 50,000. Finally, the survey included questions regarding when the respondents last received training in concussion, type of training, and how they would prefer to receive future training. A general question was asked if they see benefit in additional SRC education. Following the survey, links to various assessment tools, including the Sport Concussion Assessment Tool 3 and the Consensus Statement on Concussion in Sport, the 4th International Conference on Concussion in Sport, were provided as an additional resource.2,16 In each state, a $50 Amazon gift card drawing was conducted to encourage involvement. The gift card drawing was funded by an institutional faculty-funding grant that is detailed in the author disclosures.
We computed descriptive statistics to evaluate differences in concussion knowledge for type of physician training, years of clinical experience, SRC training, number of SRCs evaluated, trauma rating, and practice setting (urban vs rural). We also evaluated differences in a respondent's awareness and use of RTP guidelines and their referral patterns. Questions that addressed concussion knowledge were considered correct if answered with “completely agree/disagree” or “agree/disagree” correctly. “Neutral” was considered an incorrect answer. The overall knowledge score was compared between type of physician training, years of clinical experience, SRC training, trauma rating, and practice setting (urban vs rural). We employed cross-tabulation to create contingency tables for each comparison. We then used Pearson chi-square test or Fisher's exact test to evaluate the statistical significance of differences in response rates between groups. The level of significance (α) was set at .05. Human Subjects Committee approval from the authors' affiliated academic institution was obtained prior to the survey. The authors report no conflicts of interest.
We sought responses from all emergency department physicians in two states using listservs of emergency department medical directors as our means of contact. A total of 152 respondents completed our survey. Respondents were not required to answer each question to continue the survey. Thus, some questions were not answered by each of the 152 respondents. Participant demographic information is included in Table 1. Our respondents were predominantly male (78%), trained in emergency medicine (74%), and practiced in an urban setting (68%). Ninety-four percent were either board certified or board eligible. A large portion of respondents (60%) practiced at level 2 or level 3 trauma centers, whereas 10% had no trauma designation. All respondents indicated they had cared for a patient with SRC in the past year, with 63% indicating they had cared for 11 or more. We did not find significant differences between physicians' training or practice setting when evaluating their SRC knowledge score (Table 2). The SRC knowledge score was also independent of how many SRCs they had cared for in the past year.
Characteristics of Physicians Staffing Emergency Departments
Although 63% (92 of 149, P = .266) of respondents were aware of RTP guidelines, only 37% (55 of 149, P = .902) provide them to patients with SRC at discharge from the emergency department. Knowledge of the RTP guidelines was related to their likelihood of providing them because 56% (56 of 94, P = .01) of those aware of the guidelines provide them to their patients with SRC. Awareness and use of RTP guidelines were both independent of physician training, practice setting, and number of SRCs seen in the past year. Whereas SRC training during residency was not predictive of awareness or use of RTP guidelines, if SRC training had occurred since residency it was found to be predictive of both awareness (P = .00) and use of RTP guidelines at discharge (P = .024).
When evaluating the concussion knowledge assessment (Table 3), most questions were answered correctly a high percentage of the time. Two notable exceptions were “Most (> 80%) concussions resolve in 7 to 10 days” and “Most (> 80%) concussions last a few weeks to a month.” These were answered correctly only 60% (88 of 146) and 56% (83 of 147) of the time, respectively.
General Concussion Knowledge Assessment
Most emergency department physicians (89%, 132 of 149) routinely refer their patients with SRC for follow-up care. Primary care physicians (86%, 128 of 149) are the most commonly used. Emergency department physicians also refer to neurologists (40%, 59 of 149), sports concussion clinics (46%, 68 of 149), and traumatic brain injury clinics (15%, 23 of 149). Interestingly, emergency department physicians also refer to non-physician providers such as athletic trainers (17%, 26 of 149) and neuropsychologists (11%, 16 of 149).
We conducted a survey of physicians staffing emergency departments in two states and used descriptive statistics to examine our data. Our primary goal was to determine differences in concussion knowledge, use of RTP guidelines, and referral patterns among physicians staffing emergency departments across Washington State and Montana. We found that neither the type of training (primary care vs emergency medicine) nor the practice setting of emergency department physicians predicted successful scoring of 90% or greater on the concussion knowledge assessment tool. There was a trend toward those who had received SRC training since residency answering at least 90% correct, but this did not reach statistical significance (P = .098). Chris-man et al. reported that only 65% correctly answered the question “More than 80% of concussions resolve in 7 to 10 days “and only 55% answered the question “More than 80% of concussions last a few weeks to a month” correctly in their survey of 414 physicians.9 Both were similar to our results to these questions. This suggests that future SRC education should be focused on the chronology of symptoms and the natural history of concussion because these data indicate a gap in physician knowledge.
We found that 94 of 149 (63%) of respondents were aware of RTP guidelines. Despite this, only 55 of 149 (37%) include RTP information at discharge. Use of RTP discharge instructions was independent of how long a respondent had been in practice and the increased awareness associated with passage of the Lystedt Law in 2009. It was also not associated with concussion knowledge. These data are similar to the reported use of discharge instructions for SRC by DeMaio et al.17 (42% to 50%) and Sarsfield et al.18 (46% to 53%).
The discrepancy between awareness and provision of RTP guidelines at discharge may indicate that RTP guidelines are not routinely available within a physician's electronic medical record. The typical practice is for physicians to pick from a predetermined list of vetted discharge instructions within their electronic medical record. If RTP guidelines are not readily available, physicians are required to search outside the electronic medical record, which slows their work-flow and potentially violates institutional expectations. However, we found that respondents who were aware of RTP guidelines were also more likely to provide them, signifying a willingness to overcome barriers with increased awareness. Emergency department physicians may not perceive the use of RTP guidelines at discharge as necessary because 89% indicated that they refer to another health care professional. This health care professional would then be expected to assist in determining return to play. As such, emergency department physicians may choose to use general instructions specific to mild traumatic brain injury rather than the more specific RTP guidelines.
Recently, there has been increased attention on referral patterns for SRC and an increasing number of specialty clinics for concussion management.19,20 Our findings indicate that primary care physicians are the primary referral preference for emergency department physicians (86%), followed by sports concussion specialty clinics (46%) and neurologists (40%). This indicates a willingness to refer to a variety of professionals and may indicate variation in local practice and resources. Eighty-nine percent of respondents indicated they refer patients with SRC for ongoing care as recommended by the consensus guidelines.2,21 Nearly one-third of respondents indicated they refer to non-physician providers, including athletic trainers (17%) and neuropsychologists (11%).
In our cohort, only 31 of 148 (21%) received training on SRC during their residency training. Because 78% of our respondents indicated they finished residency more than 5 years ago, this reflects the lack of SRC training emphasis in the past. It is encouraging that 92 of 148 (62%) indicated they had received training since residency completion, indicating an increased awareness of the need for ongoing SRC education. Significantly, training since residency was found to be predictive of both awareness and provision of RTP guidelines at discharge.
Most of our respondents (135 of 148, 91%) indicated they would welcome and see value in additional SRC education. The preferred method (93 of 148, 63%) was to receive training online, followed by lecture format (54 of 148, 36%) and printed material (26 of 148, 18%). This is similar to what Lebrun et al. reported with family medicine physicians, where 84% to 94% desired additional training with lecture format and online education being the preferred modality.22
We also attempted to determine if SRC training during or after residency was associated with an increased number of SRCs diagnosed in clinical practice. It would seem that those with training would be more attentive to this diagnosis. However, our results were mixed because those who received residency training reported seeing a higher number of SRCs (P = .016), whereas those who received training after residency did not (P = .158).
Our study must be viewed in light of several limiting factors. The survey was sent to a single point of contact, the emergency department medical director, for each physician group staffing emergency departments in the two states. The points of contact were then asked to forward our request to their group members. As such, we are unsure how many total physicians received our survey request. According to the Association of American Medical Colleges, there were a total of 1,056 emergency physicians in the states of Washington and Montana in 2013.23 Although our survey certainly did not reach every emergency department physician in the two states, the 152 responses represents a response rate of 14% of all emergency department physicians in the two states. In addition, the cohort appears to represent an oversampling of physicians staffing level 1 to level 3 trauma centers. According to the Washington and Montana trauma registries, 34% of hospitals are level 1 to level 3 trauma centers, whereas 77% of our respondents indicated they staff emergency departments associated with level 1 to level 3 trauma centers.10,11 However, what is unknown is the percent of the 1,056 total emergency department physicians who work at each level of trauma center. Because higher level trauma centers also represent higher volume emergency departments, they will have a much larger emergency department physician workforce when compared to lower level trauma centers that see fewer patients. Thus, the degree of perceived oversampling is unknown. Although all of our respondents indicated they cared for patients with SRC in the past year and 58% indicated they had cared for at least 11 cases, further work with physicians staffing lower level trauma centers is warranted.
Implications for Clinical Practice
From these data, it appears there are barriers to the use of RTP guidelines at discharge in emergency departments because few physicians use RTP guidelines despite being aware of their existence. Recent SRC educational efforts appear to be addressing this issue. Future research regarding the presence of RTP guidelines within hospital electronic medical records would help inform this issue. These data also suggest increasing awareness of SRC and a desire to refer patients with SRC for ongoing management to a variety of health care professionals. It appears that most emergency departments staffing physicians would welcome educational opportunities focused on SRC.
- McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA. 2003;290:2556–2563. doi:10.1001/jama.290.19.2556 [CrossRef]
- McCrory P, Meeuwisse WH, Aubry M, et al. Concensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, Zurich, November 2012. J Athl Train. 2013;48:554–575. doi:10.4085/1062-6050-48.4.05 [CrossRef]
- McCrea M, ed. Mild Traumatic Brain Injury and Postconcussion Syndrome. New York: Oxford University Press; 2008.
- Macpherson A, Fridman L, Scolnik M, Corallo A, Guttmann A. A population-based study of paediatric emergency department and office visits for concussions from 2003 to 2010. Paediatr Child Health. 2014;10:543–546.
- Nalliah RP, Anderson IM, Lee MK, Rampa S, Allareddy V, Allareddy V. Epidemiology of hospital-based emergency department visits due to sports injuries. Pediatr Emerg Care. 2014;30:511–515. doi:10.1097/PEC.0000000000000180 [CrossRef]
- Giebel S, Kothari R, Koestner A, Mohney G, Baker R. Factors influencing emergency medicine physicians' management of sports-related concussions: a community-wide study. J Emerg Med. 2011;41:649–654. doi:10.1016/j.jemermed.2011.03.021 [CrossRef]
- Christakis DA, Rivara FP. Pediatricians' awareness of and attitudes about four clinical practice guidelines. Pediatrics. 1998;101:825–830. doi:10.1542/peds.101.5.825 [CrossRef]
- Meehan WP 3rd, Mannix R. Pediatric concussions in United States emergency departments in the years 2002 to 2006. J Pediatr. 2010;157:889–893. doi:10.1016/j.jpeds.2010.06.040 [CrossRef]
- Chrisman SP, Schiff MA, Rivara FP. Physician concussion knowledge and the effect of mailing the CDC's “Heads Up” toolkit. Clin Pediatr (Phila). 2011;50:1031–1039. doi:10.1177/0009922811410970 [CrossRef]
- Washington State Department of Health Trauma Facility Designation website. Available at: http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/EmergencyMedicalServicesEMSSystems/TraumaSystem/TraumaDesignation. Accessed November 1, 2015.
- Montana State Department of Public Health and Human Services website. Available at: http://dphhs.mt.gov/publichealth/EMSTS/traumasystems/designation.aspx. Accessed November 1, 2015.
- Lew E, Fagnan LJ, Mattek N, Mahler J, Lowe RA. Emergency department coverage by primary care physicians in a rural practice-based research network: incentives, confidence, and training. J Rural Health. 2009;25:189–193. doi:10.1111/j.1748-0361.2009.00216.x [CrossRef]
- Census of Population and Housing 2010. U.S. Census Bureau website. Available at: http://www.census.gov/prod/www/decennial.html. Accessed May 20, 2015.
- Heads Up Concussion in Youth Sports. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/concussion/HeadsUp/Training/. Accessed May 20, 2015.
- McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the second International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med. 2005;15:48–55. doi:10.1097/01.jsm.0000159931.77191.29 [CrossRef]
- Sport Concussion Assessment Tool – 3rd edition. British Journal of Sports Medicine website. Available at: http://bjsm.bmj.com/content/47/5/259.full.pdf. Accessed May 20, 2015.
- De Maio VJ, Joseph DO, Tibbo-Valeriote H, et al. Variability in discharge instructions andactivity restrictions for patients in a children's ED postconcussion. Pediatr Emerg Care. 2014;30:20–25. doi:10.1097/PEC.0000000000000058 [CrossRef]
- Sarsfield MJ, Morley EJ, Callahan JM, Grant WD, Wojick SM. Evaluation of emergency medicine discharge instructions in pediatric head injury. Pediatr Emerg Care. 2013;29:884–887. doi:10.1097/PEC.0b013e31829ec0d9 [CrossRef]
- Upchurch C, Morgan CD, Umfress A, Yang G, Riederer MF. Discharge instructions for youth sports-related concussions in the emergency department, 2004 to 2012. Clin J Sport Med. 2015;25:297–299. doi:10.1097/JSM.0000000000000123 [CrossRef]
- Kinnaman KA, Mannix RC, Comstock RD, Meehan WP 3rd, . Management of pediatric patients with concussion by emergency medicine physicians. Pediatr Emerg Care. 2014;30:458–461. doi:10.1097/PEC.0000000000000161 [CrossRef]
- Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Clin J Sport Med. 2013;23:1–18. doi:10.1097/JSM.0b013e31827f5f93 [CrossRef]
- Lebrun CM, Mrazik M, Prasad AS, et al. Sport concussion knowledge base, clinical practises and needs for continuing medical education: a survey of family physicians and cross-border comparison. Br J Sports Med. 2013;47:54–59. doi:10.1136/bjsports-2012-091480 [CrossRef]
- State Physician Workforce Data Book 2013. Association of American Medical Colleges website. Available at: https://www.aamc.org/data/workforce/reports/profiles/. Accessed November 1, 2015.
|CHARACTERISTICS||ALL RESPONDENTS (%)|
| Male||114 (78)|
| Female||33 (22)|
| 26 to 40||55 (36)|
| 41 to 55||56 (36)|
| 56 to 70||36 (23)|
|Years of clinical practice|
| 0 to 5||28 (18)|
| 6 to 10||40 (26)|
| 11 to 15||27 (17)|
| 16 to 20||47 (31)|
| > 20||11 (7)|
| Emergency medicine||102 (74)|
| Family medicine||16 (12)|
| Internal medicine||7 (5)|
| Pediatrics||3 (2)|
| Other||9 (7)|
|Board certified/board eligible|
| Yes||138 (94)|
| No||9 (6)|
| Urban (> 50,000)||98 (68)|
| Rural (< 50,000)||47 (32)|
| Level 1||24 (17)|
| Level 2||36 (25)|
| Level 3||50 (35)|
| Level 4||18 (12)|
| Level 5||3 (2)|
| No designation||14 (10)|
|Number of SRCs cared for in past year|
| 1 to 5||17 (12)|
| 6 to 10||37 (26)|
| 11 to 15||36 (25)|
| > 15||55 (38)|
Characteristics of Physicians Staffing Emergency Departments
|PARAMETER||90% OR > ON SRC KNOWLEDGE TESTA||P||AWARE OF RTP GUIDELINES||P||USE RTP GUIDELINES||P|
| Emergency meda||55 (53.4%)||.720||64 (62%)||.266||39 (38%)||.902|
| Primary careb||15 (52%)||23 (77%)||12 (40%)|
| Otherc||6 (68%)||5 (56%)||4 (44%)|
|SRC training in residency?|
| Yes||20 (65%)||.161||19 (61%)||.835||13 (42%)||.682|
| No||60 (50%)||78 (65%)||45 (38%)|
|Concussion training since residency?|
| Yes||55 (58%)||.098||75 (79%)||.00||43 (46%)||.024|
| No||25 (44%)||22 (39%)||15 (26%)|
| Rural (< 50,000)||28 (55%)||.863||35 (69%)||.473||15 (30%)||.154|
| Urban (> 50,000)||51 (52%)||60 (61%)||42 (43%)|
| Level 1||9 (38%)||.676||10 (42%)||.087||8 (33%)||.799|
| Level 2||20 (54%)||28 (76%)||18 (49%)|
| Level 3||29 (57%)||34 (67%)||18 (35%)|
| Level 4||10 (52%)||11 (58%)||6 (33%)|
| Level 5||2 (67%)||3 (100%)||1 (33%)|
| No trauma designation||9 (60%)||9 (60%)||6 (40%)|
|SRC cared for in past year|
| 1 to 5||11 (69%)||.485||10 (63%)||.404||7 (44%)||.572|
| 6 to 10||21 (58%)||22 (61%)||10 (29%)|
| 11 to 15||18 (50%)||27 (75%)||13 (36%)|
| > 15||28 (49%)||33 (58%)||24 (42%)|
General Concussion Knowledge Assessment
|CONCUSSION KNOWLEDGE QUESTIONS (CORRECT ANSWER)||NUMBER (% CORRECT)|
|Most (> 80%) concussions resolve in 7 to 10 days (agree)||88 of 146 (60%)|
|Most (> 80%) concussions last a few weeks to a month (disagree)||83 of 147 (56%)|
|Safe to go back in game if symptoms < 15 minutes (disagree)||138 of 146 (95%)|
|Computed tomography normal in majority of patients with concussion (agree)||131 of 148 (89%)|
|Concussion can cause permanent cognitive deficits (agree)||134 of 146 (92%)|
|After concussion, higher risk for second concussion (agree)||129 of 146 (88%)|
|Loss of consciousness required for diagnosis of concussion (disagree)||144 of 147 (98%)|
|Most concussions involve loss of consciousness for at least a few seconds (disagree)||114 of 146 (78%)|
|Return to play with symptoms prolongs recovery (agree)||142 of 149 (95%)|
|Should not return to play until symptom free (agree)||142 of 145 (98%)|