New evidence-based MTBI discharge form proposed
Authors find too much variation among EDs
Citing a lack of consistency and complete information in ED discharge forms for patients with mild-trauma brain injury (MTBI), researchers at the University of Buffalo (NY) have proposed a new discharge form they say reflects the key risk factors outlined in research literature. Their findings are reported in the August 2006 issue of Brain Injury.1 (proposed new discharge form) The authors studied the discharge forms used in 15 hospital EDs: 10 in western New York, and five in southern Ontario, Canada. They reported that 14 of the 15 forms lacked at least one important sign of a possible hemorrhage (i.e., amnesia, seizure, neurological deficit, headache, vomiting, and rating on the Glasgow Coma Scale of less than 15.)
In addition, they asserted that most of the forms were written at a reading level higher than that recommended in current literature. The mean Flesch-Kincaid reading grade level of the discharge instruction forms was 8.2, while a sixth-grade level is what is recommended.
These findings came as no surprise to Michael Fung, MD, and the study's lead author and a Canadian physician doing a fellowship in the University of Buffalo's Sports Medicine Institute. "We knew most of these forms were not standardized and did not come from a common source," he says.
That lack of standardization, however, is an important weakness that should be addressed, Fung says. "A lot of patients and their families see discharge forms as being endorsed by the physicians who care for them, an extension of the hospital," he explains. "If they were standardized with evidence-based components, it might lead to better quality care."
David Wright, MD, director of research in emergency medicine at the Emory School of Medicine and an ED physician at Emory University Hospital and Grady Memorial Hospital, all in Atlanta, agrees with the Buffalo researchers that there is a lot of variation in ED discharge forms for MTBI. However, he says their new discharge form does not go nearly far enough. "There are two key elements that should be addressed in [an MTBI] discharge form," Wright asserts. "One is to try to prevent patients being sent home who subsequently have intracranial bleeds, which is what this new form addresses."
While that prevention aspect is important, it is of potential value for a small number of such patients, he says. "What's even more important is to give patients information about what to expect and about the most common problems of post-concussive syndrome."
After a concussion, Wright explains, it's not unusual for a patient to have headaches, memory problems, attention span problems, or sleeping problems. "All of those things can actually be fairly devastating to an individual, and while not life-threatening per se, they could be job-threatening, or have very significant impact on a student's ability to perform in school," he says. "If they go undiagnosed, or if the patient doesn't know to expect them, they may get frustrated or depressed."
Discharge instructions should enlighten patients, let them know what may occur, and when they should see a neurologist or neuropsychologist, Wright says. "There is no drug for it yet, no official treatment, but knowing when and who to follow up with if symptoms continue or become persistent is equally important," he says.
Fung does not disagree. "That's a good idea, but our study was looking more at fatality and mortality," he explains. "Still, it makes sense if you are looking more long-term instructions."
However, he continues, the ED setting deals more with acute care and follow-up. "If you want a better, more comprehensive long-term outlook and want to address follow-up with the patient's long-term care provider, then this makes sense," he says.
Much work to do
Wright is in total agreement with the authors on one point: EDs have along way to go in this area.
"I do believe that one of the biggest downfalls for emergency physicians for mild head injury and concussion is that we don't know how to instruct patients," he says. "Discharge instructions are highly variable, and some places don't even have them — it's just what the doc writes or the nurse decides to give."
Wright recommends that ED managers obtain a copy of a CD-ROM from the Centers for Disease Control and Prevention (CDC), Atlanta, which includes a set of discharge instructions. (See resource box below for ordering information.) "The CDC has a task force for mild head injury and concussion, and this is very nice literature," he says.
Finally, Wright concludes, at a minimum, everyone on the ED staff needs to review the information they are giving out. Fung agrees and advises ED practitioners to take a look at their discharge forms. "See if you can make them easier to read, and make sure they are evidence-based," he advises.
Reference
- Fung M, Willer B, Moreland D, et al. A proposal for an evidenced-based emergency department discharge form for mild traumatic brain injury. Brain Injury 2006; 20:889-894.
Sources/Resouce
For more information on discharge forms for patients with mild brain injury, contact:
- Michael Fung, MD, Buffalo's Sports Medicine Institute, University of Buffalo, 160 Farber Hall, Buffalo, NY. Phone: (716) 829-2070. E-mail: [email protected].
- David Wright, MD, Director of Research, Department of Emergency Medicine, Emory School of Medicine, Atlanta. E-mail: [email protected].
- For more information on how to obtain the Centers for Disease Control and Prevention CD-ROM on head injury and concussion, call (800) 232-4636 and ask for a copy of the National Center for Injury Prevention and Control's publication titled "Injury Surveillance Training Manual." It is free.
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