Abstract:
Context: The number of young athletes presenting to the emergency department (ED) with head injury has skyrocketed. Many of these patients are referred to a concussion clinic or to their Athletic Trainer for follow-up care. Objective: To compare characteristics and early outcomes at first concussion clinic visit between patients referred from the ED (with or without Emergency Medical Services (EMS) transport) vs. those with no-ED referral. Design: Retrospective cohort. Setting: Concussion clinic. Patients and Other Participants: Pediatric patients (age 10-18 years), with a goal of returning to sport, presenting to a hospital system’s dedicated concussion clinic from August 2009-July 2011, within 10 days of their concussion (n = 245; age = 14.2 ± 2.1 years; 78% male). Intervention(s): Patients completed a systematic concussion assessment including a clinical interview, symptom assessment (Graded Symptom Checklist – GSC), neurocognitive (Immediate Postconcussion Assessment and Cognitive Test – ImPACT) and balance testing (Balance Error Scoring System – BESS), and physician evaluation. ED Referral vs. no-ED referral to the clinic and EMS transport vs. no-EMS transport served as the comparators. Main Outcome Measure(s): Demographic factors (age, gender, sport contact level, race, family history of headache/migraine, previous history of head trauma); injury factors (mechanism, loss of consciousness (LOC), amnesia); first clinic visit and time of injury (TOI) symptoms endorsed and total symptom severity (GSC); first clinic visit ImPACT composite domain scores, BESS total scores and management recommendations were examined for univariate associations with ED referral and/or EMS transport using independent Student’s t-tests for continuous variables and Chi-Square tests for categorical variables (a priori α < .05). Results: Of the 245 patients, 59% reported a previous history of head trauma and 55% were ED referrals. Twenty percent of ED referrals were transported by EMS. ED referrals were more likely to be in the younger age group (OR = 2.1; 95% CI: 1.3,3.5; P = .004) and more likely to report TOI numbness (OR = 3.5; 95% CI: 1.6,7.7; P < .001), greater TOI symptom severity (OR = 2.0; 95% CI: 1.0, 4.0; P = .043), LOC (OR = 2.1; 95% CI: 1.1, 3.9; P = .018), and amnesia (OR = 2.3; 95% CI: 1.3, 3.9; P = .004). There were no other associations with ED referral for demographics, injury factors, symptom severity, cognitive outcomes, or balance outcomes at TOI or first clinic visit. (P>.05) Those transported by EMS to the ED were more likely to have a nonsport related mechanism, report LOC, TOI numbness, confusion, neck pain, first visit balance problems, dizziness, photophobia, memory problems and neck pain (P < .05). Conclusions: Overall, patients referred from the ED were more symptomatic at TOI but at initial follow-up looked clinically similar to those without ED referral. However, those transported by EMS to the ED were more symptomatic upon first clinic evaluation and may represent a group with more severe injury. Further study is required to determine if outcome differences exist beyond the first follow-up visit.