O2129: Improving Concussion Evaluation and Management in a Primary Care Setting

Purpose/Objectives: Pediatric concussions frequently present to primary care settings for initial evaluation and follow-up, as well as follow-up after emergency department evaluation. Standardized tools and procedures for caring for children with concussions in the primary care setting exist but are often underutilized. This phenomenon leads to gaps in formal assessment, care, and follow-ups for concussion patients. The growth of virtual visits during the COVID-19 pandemic provides additional challenges and opportunities for providing standardized concussion care. In this quality improvement project, our goals were to increase to 70% the proportion of patients with concussion presenting to primary care who: 1) complete a standardized concussion symptom scale (the post-concussive symptom scale, or PCSS); 2) receive educational materials after an initial concussion visit; 3) are seen for a concussion follow-up within 2 weeks.

Design/Methods: At two outpatient clinics, we implemented a multi-disciplinary process improvement effort to standardize evaluation and management of concussions. We developed a clinical pathway with information about screening tools and instructions for care and follow-up, and implemented PDSA cycles to target gaps in nurse and provider knowledge as well as system-related barriers. We measured monthly screening, education/instruction and follow-up rates using statistical process control charts. The concussion pathway launched in April 2021. PDSA cycles have included multi-faceted education for residents and providers, inclusion of the PCSS as a powerform in the Electronic Medical Record, creation of autotext for visit notes and discharge instructions, nursing-driven process changes to improve distribution and entry of the concussion symptom scale, and personalized feedback for providers and nurses who miss measures.

Results: Utilization of the standardized concussion symptom scale increased from a baseline of 36% to 77% following implementation, evidenced by a run of eight consecutive points above the centerline. Distribution of education/instructions increased from a baseline of 42% to a mean of 74%. Follow-up visit completion increased from a mean of 43% to 66%, showing improvement but not yet meeting the goal of 70%. Data reflect seasonal variability with higher rates of concussion in the fall, as well as a significant decrease in concussions during the first year of the COVID-19 pandemic.

Conclusion/Discussion: A multi-pronged interdisciplinary improvement effort enabled the development of consistent practices for evaluation and management of concussion in primary care, and increased utilization of a standardized concussion symptom scale, and provision of educational materials and follow-up care. Future PDSA cycles will include a focus on virtual visits for concussion follow-ups, including spreading awareness for the virtual assessment procedures to providers and increasing virtual visit availability for concussion follow-ups to increase accessibility of follow-up care for families.