Concussion Misdiagnosis Associated With Emergency Department Stay, Injury Type

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The investigators suggest the development of validated diagnostic criteria to minimize variation in physician practice.
The investigators suggest the development of validated diagnostic criteria to minimize variation in physician practice.

A study published in the American Journal of Emergency Medicine demonstrates that misdiagnosis of concussion in adults is somewhat common in the emergency department (ED), despite patients presenting with known concussion signs and symptoms. Longer length of ED stay, involvement in a motor vehicle collision, and variation in physician experience and practice may partially explain these misdiagnoses in the ED setting.

Investigators enrolled a total of 250 adult patients who met the World Health Organization's criteria for concussion and who were seen at 1 academic and 2 community EDs in an urban area of Canada. The proportion of patients who received an accurate diagnosis of concussion by the treating emergency physician comprised the primary outcome. 

Data were collected by means of a patient-focused structured baseline interview as well as by a physician-facing questionnaire regarding assessment of patients' severity of injuries. The investigators obtained diagnoses of concussion from the physician questionnaire. Investigators also assessed patients' symptoms at 30 days and 90 days following admission to the ED.

Approximately 16% of head injuries that met the World Health Organization's concussion criteria did not result in a concussion diagnosis. Patients with a longer length of ED stay were less likely to receive a concussion diagnosis (odds ratio [OR] 0.71; 95% CI, 0.60-0.83). Similarly, patients not receiving a concussion diagnosis had a significantly longer ED stay compared with patients who did receive a concussion diagnosis (Mann-Whitney Z =−2.850, P =.004). Additionally, a concussion diagnosis was less likely among those presenting to an ED at a non-academic center (OR 0.21; 95% CI, 0.08-0.58 and OR 0.07; 95% CI, 0.02-0.24) and among those receiving a concussion in a motor vehicle collision (OR 0.11; 95% CI, 0.03-0.46).

Limitations of this study include the small number of patients as well as the inclusion of only patients presenting to an urban ED in Canada.

Considering a diagnosis of concussion “appears to be related to the mechanism of injury and institution-related factors,” the investigators suggest. The development of validated diagnostic criteria to minimize variation in physician practice as well as strategies “to increase awareness and use of current consensus-based concussion guidelines among emergency physicians” are needed, the authors concluded.

Reference

Rowe BH, Eliyahu L, Lowes J, et al. Concussion diagnoses among adults presenting to three Canadian emergency departments: Missed opportunities [published online March 20, 2018]. Am J Emerg Med. doi: 10.1016/j.ajem.2018.03.040

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