Qmetis West 57th Newsletter

Concussion Diagnosis and Documentation

Arthur Maerlender, PhD, ABPP-CN & Andrew Verreaux, BA

Introduction

Concussion diagnosis is a clinical categorization that rests on symptom reporting. However, diagnostic criteria require certain signs and symptoms to be either ruled in or ruled out. Without an accepted biomarker the variability in clinical practices influences the quality of diagnoses. The quality and completeness of documentation through the course of injury are important factors for driving appropriate treatment and care. It is not unusual for an athlete to be diagnosed in an emergency department, seen by their primary care physician or specialty concussion clinic, and then followed more closely by a school athletic trainer; thus, continuity of care is a critical need in concussion diagnosis and management and documentation becomes the link to create the continuity needed. Further, because the natural course of the injury can be on the order of a week or two, timeliness is important.  Yet documentation practices for diagnosis and care are not standardized and are variable.  Making matters more challenging is that patients do not always present on-time while circumstances can interfere in best-practices.

This survey of clinical diagnostic reports was undertaken to demonstrate the utility of quantification of guideline adherence in concussion diagnosis.

Methods

A scoping review of guidelines and standards for diagnosis of concussion was undertaken to identify the best diagnostic practices based on evidence and expert consensus. Multiple expert panel reports, consensus conferences, and professional guidelines have been published and were used to survey a sample of existing diagnostic reports for completeness of documentation (see Appendix).  The review identified 16 best-practice principles with seven specific diagnostic criteria.  Within the 16 guidelines the criteria for diagnosis are represented.

The diagnosis of concussion relies on seven items: a likely mechanism of injury, an alteration of consciousness, symptom presentation that is consistent with concussion, a Glasgow Coma scale of greater than 12, no loss of consciousness less than 30 minutes, no post traumatic amnesia for more than 24 hours, and a rule-out of confounding factors that could explain the presentation*.

The sample consisted of 62 case reports generated by 10 athletic trainers in their standard clinical practice. The athletic trainers were all certified and employed by a large athletic training service and worked at several high schools. The reports were randomly selected from cases from the 2020-22 school years.  Although the reports were generated during the pandemic period, cases were felt to be assessed as per usual. All materials were deidentified prior to review other than the date of injury and date of report. One independent reviewer reviewed each of the reports for documentation that reflected consideration of the 16 guidelines.  If a guideline were mentioned as having been addressed, it received 1-point.

A matrix table was created that identified the report with a system generated identification number by each of the 16 items.  A sum of represented items was calculated for each report and for each item.  Percent of completeness per report and percent of representation of each item were also calculated.

Results

While there was considerable variability in the completeness of the documentation, across the sample the overall rate of criteria representation was 52% with an average of 8 items per case (range of 1-13 items). No report met all 16 guidelines (see Table 1 for summary data).

Table 1. Guidelines and Results from 62 Diagnostic Reports

GuidelineSumAvg
1.     Red Flags acknowledged230.37
2.     Glasgow Coma Scale60.10
3.     Head Physical Examination150.24
4.     Likely Mechanism of Injury520.84
5.     Alteration of Consciousness200.32
6.     LOC ruled out80.13
7.     PTA ruled out30.05
8.     Cervical Spine Examination180.29
9.     Health History430.69
10.  Symptom Examination550.89
11.  Neurological Examination410.66
12.  Confounding Factors250.4
13.  Recommendations600.97
14.  SAC590.81
15.  mBESS440.71
16.  Dx <49 hours510.82

Notes. LOC = loss of consciousness; PTA = Post-traumatic amnesia; SAC = Standardized Assessment of Concussion; mBESS = modified Balance Error Scoring System; Dx = diagnosis.

Providing recommendations (97%), completing symptom examinations (89%), identifying the likely mechanism of injury (84%), administering the Standardized Assessment of Concussion (SAC 81%:  McCrea, 2001; McCrea et al., 1998)and the modified Balance Error Scoring System (mBESS 71%: Guskiewicz, 2011; Guskiewicz et al., 2013) were the guidelines most frequently met. Diagnoses were more often made within 48-hours than not, with the average time under 2-days. Less complete documentation was identified for rule-outs of loss of consciousness greater than 30 minutes (13%) and post traumatic amnesia greater than 24 hours (5%). Documenting cervical spine examinations (29%) and head trauma examinations (24%), together with the lack of reporting of the Glasgow Coma Scale (10%) represented important gaps in documentation.

Conclusion

This project intended to identify specific strengths and weaknesses in documentation of best-practice diagnostic guidelines. In this convenience sample of diagnostic reports, many best-practice guidelines were regularly reported in documentation. However, multiple gaps existed throughout these case reports. It is important to note that in some, gaps may not be due to clinical oversight, but due to typical challenges in clinical care or failure to document procedures completely. This exercise highlights several items that were routinely missing from reports that could call a specific diagnosis into question.

There are several important caveats to these data. First, only one reviewer reviewed the reports. Although that work was checked, multiple raters would have been better. Further, this was data from only one athletic training service and may not represent others. The cases were examined during the pandemic; however, it was surprising that confounding factors such as COVID were not explicitly ruled out. Finally, and importantly, items may have been addressed and simply not reported. Thus, the findings do not suggest poor practice per se.

Complete documentation of diagnosis is important for both continuity and quality of clinical care. Based on multiple published papers, this survey provided a structured framework for identifying gaps in diagnostic procedures demonstrated the value of reviewing documentation in concussion diagnostic procedures. The ability to identify strengths and gaps in documentation about clinical concussion practice can help improve both the continuity of care and the quality of care, that in turn should lead to more certain diagnoses and better outcomes. At an organizational level, such a procedure can identify systematic omissions and potential policy needs.

References

Carney, N., Ghajar, J., Jagoda, A., Bedrick, S., Davis-O’Reilly, C., duCoudray, H., Hack, D., Helfand, N., Huddleston, A., Nettleton, T., & Riggio, S. (2014, Sep). Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery, 75 Suppl 1, S3-15. https://doi.org/10.1227/NEU.0000000000000433

Giza, C. C., Kutcher, J. S., Ashwal, S., Barth, J., Getchius, T. S., Gioia, G. A., Gronseth, G. S., Guskiewicz, K., Mandel, S., Manley, G., McKeag, D. B., Thurman, D. J., & Zafonte, R. (2013, Jun 11). Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology, 80(24), 2250-2257. https://doi.org/10.1212/WNL.0b013e31828d57dd

Guskiewicz, K. M. (2011). Balance Assessment in the Management of Sport-Related Concussion. Clinics in Sports Medicine, 30(1), 89–102. https://doi.org/10.1016/j.csm.2010.09.004

Guskiewicz, K. M., Register-Mihalik, J., McCrory, P., McCrea, M., Johnston, K., Makdissi, M., Dvořák, J., Davis, G., & Meeuwisse, W. (2013). Evidence-based approach to revising the SCAT2: Introducing the SCAT3. British Journal of Sports Medicine, 47(5), 289–293. https://doi.org/10.1136/bjsports-2013-092225

Harmon, K. G., Clugston, J. R., Dec, K., Hainline, B., Herring, S. A., Kane, S., Kontos, A. P., Leddy, J. J., McCrea, M. A., Poddar, S. K., Putukian, M., Wilson, J. C., & Roberts, W. O. (2019, Mar). American Medical Society for Sports Medicine Position Statement on Concussion in Sport. Clinical Journal of Sports Medicine, 29(2), 87-100. https://doi.org/10.1097/JSM.0000000000000720

Herring, S., Kibler, W. B., Putukian, M., Solomon, G. S., Boyajian-O’Neill, L., Dec, K. L., Franks, R. R., Indelicato, P. A., LaBella, C. R., Leddy, J. J., Matuszak, J., McDonough, E. B., O’Connor, F., & Sutton, K. M. (2021, Nov). Selected issues in sport-related concussion (SRC|mild traumatic brain injury) for the team physician: a consensus statement. British Journal of Sports Medicine, 55(22), 1251-1261. https://doi.org/10.1136/bjsports-2021-104235

Herring, S. A., Cantu, R. C., Guskiewicz, K. M., Putukian, M., Kibler, W. B., Bergfeld, J. A., Boyajian-O’Neill, L. A., Franks, R. R., Indelicato, P. A., & American College of Sports, M. (2011, Dec). Concussion (mild traumatic brain injury) and the team physician: a consensus statement–2011 update. Medicine and Science in Sports and Exercise, 43(12), 2412-2422. https://doi.org/10.1249/MSS.0b013e3182342e64

Lumba-Brown, A., Yeates, K. O., Sarmiento, K., Breiding, M. J., Haegerich, T. M., Gioia, G. A., Turner, M., Benzel, E. C., Suskauer, S. J., Giza, C. C., Joseph, M., Broomand, C., Weissman, B., Gordon, W., Wright, D. W., Moser, R. S., McAvoy, K., Ewing-Cobbs, L., Duhaime, A. C., Putukian, M., Holshouser, B., Paulk, D., Wade, S. L., Herring, S. A., Halstead, M., Keenan, H. T., Choe, M., Christian, C. W., Guskiewicz, K., Raksin, P. B., Gregory, A., Mucha, A., Taylor, H. G., Callahan, J. M., DeWitt, J., Collins, M. W., Kirkwood, M. W., Ragheb, J., Ellenbogen, R. G., Spinks, T. J., Ganiats, T. G., Sabelhaus, L. J., Altenhofen, K., Hoffman, R., Getchius, T., Gronseth, G., Donnell, Z., O’Connor, R. E., & Timmons, S. D. (2018). Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatrics, 172(11), e182853. https://doi.org/10.1001/jamapediatrics.2018.2853

Marshall, M., Bayley, M., McCullagh, S., Velikonja, D.,   Berrigan, L., Ouchterlony, D., Weegar, K. (2015) Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms, Brain Injury, 29:6, 688-700, DOI: 10.3109/02699052.2015.1004755

McCrea, M. (2001). Standardized Mental Status Assessment of Sports Concussion: Clinical Journal of Sport Medicine, 11(3), 176–181. https://doi.org/10.1097/00042752-200107000-00008

McCrea, M., Kelly, J. P., Randolph, C., Kluge, J., Bartolic, E., Finn, G., & Baxter, B. (1998). Standardized assessment of concussion (SAC): On-site mental status evaluation of the athlete. Jornal of Head Trauma Rehabilitation, 13(2), 27–35.

McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., Cantu, R. C., Cassidy, D., Echemendia, R. J., Castellani, R. J., Davis, G. A., Ellenbogen, R., Emery, C., Engebretsen, L., Feddermann-Demont, N., Giza, C. C., Guskiewicz, K. M., Herring, S., Iverson, G. L., Johnston, K. M., Kissick, J., Kutcher, J., Leddy, J. J., Maddocks, D., Makdissi, M., Manley, G. T., McCrea, M., Meehan, W. P., Nagahiro, S., Patricios, J., Putukian, M., Schneider, K. J., Sills, A., Tator, C. H., Turner, M., & Vos, P. E. (2017, Jun). Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine, 51(11), 838-847. https://doi.org/10.1136/bjsports-2017-097699

Silverberg, N. D., Iaccarino, M. A., Panenka, W. J., Iverson, G. L., McCulloch, K. L., Dams-O’Connor, K., Reed, N., McCrea, M., & American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group Mild, T. B. I. T. F. (2020, Feb). Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines. Archives of  Physical Medicine and Rehabilitation, 101(2), 382-393. https://doi.org/10.1016/j.apmr.2019.10.179

West, T. A., & Marion, D. W. (2014, Jan 15). Current recommendations for the diagnosis and treatment of concussion in sport: a comparison of three new guidelines. Journal of Neurotrauma, 31(2), 159-168. https://doi.org/10.1089/neu.2013.3031

World Health Organization. (‎2004)‎. ICD-10 : international statistical classification of diseases and related health problems: tenth revision, 2nd ed. World Health Organization. https://apps.who.int/iris/handle/10665/42980

 Appendix. Guideline Reference Matrix

StudyCarney 2014Giza 2013Harmon 2019Herring 2021Herring 2011Lumba-Brown 2018Marshall 2015McCrory 2017Silvervberg  2020West 2014World Health 2004
Diagnostic guideline
1Red Flags reported33333
2Glasgow Coma Scale33331
3Head Trauma Physical Examination333333
4Likely MoI33323331
5Alteration of Consciousness or Memory33313131
6Loss of Consciousness < 20 min.1
7Post Trauma Amnesia < 24 hours1
8Cervical Spine Exam13133
9Diagnosis <48 hrs33133131
10Health History331321333
11Concussion Symptom Screening313313331
12Neurological Exam3231333333
13Confounding Factors33333331
14SAC (sports only)33333333
15mBESS (sports only)333333
16Care Plans provided331333333

Notes: (1)- Consistent and broad evidence in support, (2)- Inconsistent or limited evidence, (3)- Expert consensus; Blank – no data or not mentioned; MoI-Mechanism of injury; AOC – Alteration of consciousness; PTA – Post-traumatic amnesia; LOC – Loss of consciousness;  sports only – recommendation for sports-related concussions, not necessarily general mTBI.

 

* There are slight differences in specific diagnostic criteria depending on the organization or framework.  Probably the most used standard is the International Classification of Diseases (ICD-10) (World Health Organization, 2004), used in this exercise.

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