Evaluation of the information fidelity of discharge instructions for pediatric patients with mild traumatic brain injury in emergency departments
Article information
Abstract
We evaluated the content fidelity of written discharge instructions (WDIs) for pediatric patients with mild traumatic brain injury (mTBI). In May 2023, copies of WDIs were collected from 55 academic hospitals across South Korea. Each document was scored for the fidelity of medical advice based on the “Counsel” section of the Pediatric mTBI Guideline Checklist of the Centers for Disease Control and Prevention (maximum 10 points). Among respondent 46 emergency departments, 21 (45.7%) provided WDIs to patients with mTBI. The median score was 6.0 (interquartile range, 4.0-7.0), indicating that the fidelity of the WDIs needs improving.
Traumatic brain injury is a leading cause of emergency department (ED) visits in pediatric patients. Globally, 691 per 100,000 pediatric patients are treated in EDs for traumatic brain injury (1). Even mild traumatic brain injury (mTBI) is a vital public health concern that contributes to both medical and socioeconomic burdens (2,3). Between 35% and 86% of patients with mTBI experience post-traumatic symptoms for more than 3 months following the injury (4-7).
Written discharge instructions (WDIs) for pediatric patients who visit EDs with mTBI can help reduce the burden of mTBI by providing essential guidance on the initial response in emergencies and supporting recovery (8-10). Despite their importance, WDIs for pediatric patients with mTBI vary considerably in content and quality. However, previous studies have primarily used general recommendations for all patients with mTBI, without specific guidance for pediatric patients.
We evaluated information on WDIs for pediatric mTBI provided by emergency medicine (EM) teaching hospitals in South Korea. This cross-sectional observational study was approved by the institutional review board of Dongtan Sacred Heart Hospital (IRB no. HDT 2022-12-013-001). All participants provided written informed consent online before participating in the study.
In May 2023, we sent e-mails requesting copies of WDIs for pediatric mTBI to emergency physicians (EPs) who were responsible for training EM residents at a total of 55 EDs of EM teaching hospitals across South Korea. The hospitals were selected as the recipients for their accessibility as well as for a high likelihood that the hospitals’ EM residency programs included education on mTBI. If no response was obtained after 3 follow-up mails, we attempted to contact the non-responders by phone. In case of still persistent non-response, we contacted another EP at the same hospital.
An experienced EP and a health education research nurse independently reviewed the collected WDIs. The reviewers independently assessed the content of each WDI. Discrepancies between independent assessments were resolved through consensus in a face-to-face meeting.
The score was calculated for the collected WDIs using the “Counsel” section of the Pediatric mTBI Guideline Checklist of the United States Centers for Disease Control and Prevention (CDC) (Table) (11). One point was assigned for the presence of each of the following items, with a maximum score of 10 points: warning signs that injury may be more serious (6 points), typical recovery course (hereafter, 1 point each), how to prevent further injury, gradual reintroduction of activities that do not significantly worsen symptoms, and the need for social and emotional support. A higher score indicated that the WDI reflected these points well and were informative.
Number of written discharge instructions from emergency departments that include items of the “Counsel” section of the Pediatric Mild Traumatic Brain Injury Guideline Checklist of the United States Centers for Disease Control and Prevention (n = 21)
Data were presented using numbers with percentages and medians with interquartile ranges for categorical and continuous variables, respectively. Median values of the content fidelity scores were compared according to the presence of a government-designated pediatric emergency center (PEC) and the annual ED visit in 2022, using the Mann-Whitney U-test or Kruskal-Wallis test. Differences were considered significant if P < 0.05. For this analysis, we used R software version 4.3.3 (R Project for Statistical Computing).
Responses were obtained from 46 of 55 EDs of EM teaching hospitals that were contacted (83.6%). Of these, 21 EDs (45.7%) provided the WDIs to patients with mTBI, while 3 EDs (6.5%) provided such instructions exclusively for pediatric patients.
Table presents the number of WDIs that included individual items of the Counsel section of the Pediatric mTBI Guideline Checklist of the CDC. Most EDs provided information on the warning signs that an injury may be more serious. WDIs from 5 of the 21 EDs (23.8%) each described the typical recovery course and provided additional injury prevention guidance. Each 1 ED (2.1%) provided the gradual reintroduction of activities that do not significantly worsen symptoms, and the need for social and emotional support.
Figure shows the distribution of the content fidelity scores of each ED. The median content fidelity score was 6.0 (interquartile range, 4.0-7.0). The hospitals with PEC had a lower median fidelity score than those without PEC (6.0 [4.6-6.0] vs. 6.0 [6.0-7.0]; P = 0.049). Among the hospitals, 4 had 20,001-40,000 annual ED visits, 7 had 40,001-60,000, and 10 had 60,001 or more. This distinction per the annual ED visits showed no difference in median fidelity scores (6.0 [6.0-6.0] vs. 6.0 [6.0-7.0] vs. 7.0 [7.0-7.0]; P = 0.230).
Distribution of the content fidelity scores of the written discharge instructions in each participating emergency department.
In this study, we evaluated the fidelity of information in WDIs for pediatric patients with mTBI in South Korea and identified 3 main findings. First, only 3 EDs (14.3%) provided specific WDIs for pediatric mTBI. Second, the fidelity of information on injury prevention and recovery in WDIs for pediatric mTBI was relatively low. Third, the fidelity of data was not associated with proxy measures for hospital capacity for pediatric patients.
In contrast to previous studies that reported that the majority of hospitals analyzed provided WDIs to patients with mTBI (12), our study found that more than half of the EDs in South Korea did not provide such instructions. Insufficient use of WDIs for patients with mTBI may influence the knowledge of guardians or caregivers of affected children. A recent meta-analysis showed that WDIs are more effective than verbal communication in promoting comprehension and recall of WDIs (13). A previous survey of Korean guardians reported that hospital visits due to mTBI were not associated with their knowledge levels regarding mTBI (14). Although medical advice was considered a potential facilitating factor for awareness about mTBI, the lack of WDI use in Korea may reduce the depth of guardians’ knowledge about mTBI.
The importance of tailored WDIs for pediatric mTBI should not be underestimated, given the differences in clinical manifestations between children and adults (15). In our study, only 3 EDs used WDIs for pediatric mTBI separately from those for adult mTBI. Symptom profiles of mTBI in children differ by age, with irritability or drowsiness in preschool-aged children (16). Post-concussive signs and symptoms have been reported in young children; however, their clinical presentation and manifestations differ from those observed in older children, necessitating a developmental approach for detection. A previous study reported that children under 2 years of age manifested more sleep- and comfort-seeking symptoms than older children (17). Given the limited verbal and cognitive abilities typical of early childhood, the use of developmentally appropriate manifestations and behaviors could aid in diagnosis of young children’s concussion (18).
Furthermore, less than one-third of the WDIs for pediatric mTBI included information on the recovery process, including the post-concussive symptom profile for the pediatric patients. EDs should consider providing WDIs to guardians or caregivers of children with mTBI based on the children’s age and developmental stage.
Why PECs had lower median fidelity scores than non-PECs in WDIs for pediatric mTBI remains unclear. The emphasis on PECs’ mission as institutions responsible for definitive treatment of critically ill pediatric patients may be 1 possible explanation (19). PECs in South Korea do not have sufficient readiness for a comprehensive and functional assessment of the subtle concussion symptom profile. Their leadership needs to develop and implement guidelines for pediatric mTBI in South Korea.
This study had some limitations. First, the results of the evaluation of EM teaching hospitals cannot be generalized to represent evaluations of all EM centers, mainly because this study included only a few local emergency institutions. The overall EM center usage rate or fidelity score of WDIs for pediatric patients with mTBI may be lower than those reported in this study. Second, the content evaluation was based on the U.S. CDC guidelines, as comparable guidelines were not available in South Korea. We hypothesize that crucial information, such as red flags, is unlikely to vary across countries. Better standardization and pediatric-tailored materials are urgently needed to support safe at-home management of patients with mTBI. Third, the fidelity score has not been validated yet. However, a previous study used similar means to evaluate fidelity in WDIs for ED patients with mTBI (14). Finally, we could not assess the specific hospital capacity for pediatrics, such as the annual number of pediatric patient visits or the allocation of pediatric emergency staff, as measures of hospital capacity.
In conclusion, we evaluated WDIs for pediatric mTBI in EDs in South Korea, of which content fidelity could be improved. Additional research is needed to establish guidelines for WDIs by relevant academic societies and governments.
Notes
Author contributions
Conceptualization, Data curation, and Formal analysis: KO Ahn
Funding acquisition: HA Park
Investigation: JN Yang and HA Park
Methodology: JN Yang and KO Ahn
Writing-original draft: KO Ahn
Writing-review and editing: JN Yang and HA Park
All authors read and approved the final manuscript.
Conflicts of Interest
No potential conflicts of interest relevant to this article were reported.
Funding sources
This work was supported by the National Research Foundation of Korea grant (grant no. RS-2022-00166487) funded by the Korean Ministry of Science and ICT.
Data availability statement
The data that support the findings of this study are available from the corresponding author, Ki Ok Ahn, upon reasonable request.