Awareness of Concussion Guidelines in Primary Care
I work as a GP and as a Sport & Exercise Medicine Physician. The recognition and management of concussion has been very topical in the field of Sport & Exercise Medicine for a number of years.
There have now been 4 major international conferences on the recognition and management of concussion, the last being in Zurich in 2012. Following each conference there has been a consensus statement released, advising on the recognition and management of concussion. Each consensus statement supersedes the previous one.
In Northern Ireland, there has been increased media attention on concussion due to the tragic death of Benjamin Robinson, a 14yr old schoolboy, who died from second impact syndrome as a result of sustaining a double concussion during a school rugby match. Following the Coroner’s investigation into Benjamin Robinsons death there were several newspaper articles, radio and TV interviews discussing concussion. Many of these advised players and parents to seek medical attention from their GP if they suspected concussion.
This advice concerned me. As a doctor who has worked as a GP since 2002, I have never had any formal GP training on concussion recognition or management. During my sport & exercise medicine training I have had training on concussion, have attended several meetings and have read extensively on the subject.
I decided to do a survey of GPs in Northern Ireland, asking 4 questions:
- Have you ever had any formal training on the recognition and management of concussion?
- Have you ever seen a patient with concussion?
- Are you aware of the SCAT guidelines?
- Are you aware of the return to play guidelines?
I emailed these questions to each person that I could find on the Secure Practice GP Email System with the title “Dr”. I purposely kept the survey brief and kept the questions in the main body of the email to try to improve the response rate.
Weaknesses of this method are that not all GPs use their email address on a regular basis; if “Dr” did not prefix their name then I did not know that person was a GP and so did not include them; some retired GPs addresses were still on the system; it was not anonymous so GPs may have been reluctant to reply.
I emailed the survey to 1,409 GP addresses. I received 132 responses which was only a 9.4% response rate. I have not followed this up with repeat emails. The response rates to the questions were as follows:
1. Have you ever had any formal training on the recognition and management of concussion?
YES – 17
No – 115
2. Have you ever seen a patient with concussion?
YES – 62
No – 70
3. Are you aware of the SCAT guidelines?
YES – 19
No – 113
4. Are you aware of the return to play guidelines?
YES – 19
No – 113
The response rate was low but the figures above show there is an obvious need for concussion training for GPs. Several of the GPs requested training in their email response to me. It is concerning that 47% of GPs have seen at least one patient who they thought had concussion but 87% have never had any formal training and 86% are not aware of the guidelines on management.
So how were these patients managed?
- Were the patients referred to the Emergency Dept? Was this an appropriate referral? It is not appropriate to overload Emergency Depts that are already under pressure with patients who they often do not need to see.
- Were the patients referred to a local neurologist? – the waiting time for this appointment could take several months. What advice was the patient given in the meantime?
- Were the patients given advice? If so, was it appropriate? If allowed to return to play too early then the patient may have been put at risk of second impact syndrome. If kept off sport for an unnecessarily long period this could have effects on their physical fitness, mental health and social life.
With 87% not having any training on concussion, it also raises the concern that patients could be attending with concussion which is not being recognised.
Actions as a result of this study
Whilst GPs can and do update their knowledge on a regular basis and have access to the Zurich guidelines on the management of concussion, I feel that a training course should be organised on the recognition and management of concussion for GPs.
Before entering General Practice I worked for 15 months in 3 different Emergency Departments. Whilst I received training on structural head injury management in each of these posts, I didn’t receive any formal training on concussion in any of the posts. It would be interesting to study if Emergency Dept staff currently receive formal training on concussion in keeping with the Zurich Guidelines.