A simple checklist and better handouts helped clinicians transform how concussions are handled in primary care — boosting symptom tracking, family education, and follow-up care.
The intervention, implemented at two clinics affiliated with Boston Children’s Hospital, Boston, increased use of the post-concussion symptom scale from 37% to 85% and of educational materials from 42% to 83%. Follow-up visits to primary care physicians among concussion patients rose from 47% to 71%. The findings were published in Pediatrics.
Caring for children with concussions can be daunting for pediatricians because these visits usually involve checking mental status and neurologic exams, said Corinna Rea, MD, MPH, pediatrician at Boston Children’s Hospital, who led the study.
To streamline the process, she and her colleagues built a clinical care pathway into the electronic medical record to guide decision-making.
“The idea is that we were managing these kids more safely and effectively so they would have fewer symptoms, their symptoms wouldn’t last as long, and they would return to their school and sports more quickly or more safely,” she said.
The pathway recommended using a post-concussion symptom scale at every visit and provided treatment options based on symptoms such as headache, nausea, and sleep disturbances. The system also noted red flags that would prompt referral to specialty care or the emergency room and included instructions for families on what to do at home and when children could return to the classroom and participate in sports.
The initiative has been so successful, she added, that her colleagues have stopped her in the hallways to tell her “how much better they felt it made their care and how much easier it made their visits,” she said.
Improving Communication
In 2022 in the US, 2.3 million children and adolescents younger than 18 years were diagnosed with a concussion or brain injury. Research indicates that most of these patients are initially treated by primary care clinicians.
Rea and her colleagues conducted their project between 2021 and 2024, during which 704 unique patients were seen for concussion visits. Their pathway recommendations are from current clinical guidelines, including those from the International Conference on Concussion in Sports and the US CDC.
Rea said the hardest measure to improve was the rate of follow-up visits.
“Oftentimes, they just didn’t realize they were supposed to” come back for another visit, she said.
To improve how many families came back for follow-up, the Boston researchers created a checklist in English and Spanish on the next steps to take after initial visits and standardized the scheduling by sending caregivers an email rather than relying on patients to call the front desk. They also encouraged clinicians to make follow-up visits virtual when possible.
They also held educational sessions for clinicians and nurses and gave them individual feedback via email if they did not use the concussion tools in the electronic medical record or give out written instructions.
Rea and her colleagues found in their baseline data that non-English-speaking families and those with public insurance were less likely to complete the symptom scale or receive written instructions than those who spoke English or had commercial insurance. After the intervention, these differences were no longer statistically significant, she said.
Rea said that patients did not report that the visits were more burdensome than usual care, and rates of children being sent to the emergency department did not increase.
“By building a few simple things into our electronic medical record, we saw a really significant improvement in standardization without really making anything worse,” she said.
Christina Master, MD, co-director of the Minds Matter Concussion Program at the Children’s Hospital of Philadelphia, Philadelphia, said one of the strengths of the study is that each step in the quality improvement project was clearly defined, which may be helpful for other clinicians who want to better care for patients with potential concussions.
“Half of the treasure that you’re getting out of this is actually the process,” Master said.
The study was funded by a grant from the Boston Children’s Hospital Program for Patient Safety and Quality. Master reported receiving grant funding from the US Department of Defense, the National Collegiate Athletic Association, and Toyota’s Way Forward Fund, among others.
Brenda Sandburg is a freelance writer for Medscape Medical News. She has written about the biopharmaceutical industry and legal issues for the Pink Sheet and American Lawyer Media.
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