Concussion: clearing athletes to play from the ED?

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Foster23

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With HS football season starting this week, I've noticed quite a few athletes brought into ED with "concussion rule out" or "head trauma" complaints. Most of these injuries are actually very minor, but these athletes are not allowed to return to the play unless they are cleared by a physician. Base on the past few encounters, I do think that these athletic trainers are overzealous on pulling athletes out of the game. But that's just my personal opinion.

Where you do guys stand on clearing these athletes to return to play? Zero tolerance from the ED, send back to PCP for follow up and clearance? If an athlete reports no amnesia to event, no HA, and symptom free at arrival, do you allow him to return to the field after 1 week? 2 weeks? or do you still send them to PCP for clearance to play? Few of my attendings take a hard stand against clearing to play, whereas a few aren't so strict if the story is reliable. I'm curious on your clinical practice on this issue (and supporting evidence?)

Also, I find this issue is a bit more complex when I moonlight at local urgent care. Quite a few local families use the urgent care as their 'family doctor". To pay 75 dollars to be seen by a physician, only to be told to follow up with PCP for clearance anyways is rather frustrating. Also, to find a family physician within 1 or 2 weeks before the next game is next to impossible in my area. (Our Urgent care sees an average of 10 per day in August for Sport Clearance due to lack of PCP)

So far, I've read through a few articles from the American Academy of Neurology (08/2013) and American Academy of Family Physician (01/2012). My take away point is that there is no universal way to manage concussion, and even the definition of concussion is debatable.

Your thoughts and inputs are appreciated! :)
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Minimum of 1 week after symptom resolution.
Cleared by their PCP, team doctor, or some other sports neurologist.

Of course, if they never were knocked out or any other sx of CHI, I simply document that. I still don't clear them for anything. I just say they never had anything. If they want something signed saying "can play sports", then someone else is doing it.
 
Foster23 said:
With HS football season starting this week, I've noticed quite a few athletes brought into ED with "concussion rule out" or "head trauma" complaints. Most of these injuries are actually very minor, but these athletes are not allowed to return to the play unless they are cleared by a physician. Base on the past few encounters, I do think that these athletic trainers are overzealous on pulling athletes out of the game. But that's just my personal opinion.

Where you do guys stand on clearing these athletes to return to play? Zero tolerance from the ED, send back to PCP for follow up and clearance? If an athlete reports no amnesia to event, no HA, and symptom free at arrival, do you allow him to return to the field after 1 week? 2 weeks? or do you still send them to PCP for clearance to play? Few of my attendings take a hard stand against clearing to play, whereas a few aren't so strict if the story is reliable. I'm curious on your clinical practice on this issue (and supporting evidence?)

Also, I find this issue is a bit more complex when I moonlight at local urgent care. Quite a few local families use the urgent care as their 'family doctor". To pay 75 dollars to be seen by a physician, only to be told to follow up with PCP for clearance anyways is rather frustrating. Also, to find a family physician within 1 or 2 weeks before the next game is next to impossible in my area. (Our Urgent care sees an average of 10 per day in August for Sport Clearance due to lack of PCP)

So far, I've read through a few articles from the American Academy of Neurology (08/2013) and American Academy of Family Physician (01/2012). My take away point is that there is no universal way to manage concussion, and even the definition of concussion is debatable.

Your thoughts and inputs are appreciated! :)
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I used to give them the neurology recommendations and advise them to follow up with the PCP or team doctor for final clearance, but lately it's become such a hot button issue, I don't know that I would even speak to the issue in today's environment.

There are massive class action lawsuits going on right now about this issue.

NFL concussion class-action lawsuit:

http://nflconcussionlitigation.com/


NCAA concussion class-action lawsuit:

http://www.al.com/sports/index.ssf/2013/09/ncaa_faces_new_concussion_laws.html

If it's so important, that they need to run to you to completely off load the liability on to you, then they need a team doctor who practices sport medicine full time to assume this responsibility. If it's not important, then they shouldn't be abusing an Emergency Department for for a "go back to football note."

Does that make for bad Press-Ganey scores? Maybe.

Be sure that if Johnny doesn't get into Harvard 6 years after his second head bonk, they'll certainly have a lawyer comb over your ED report to see of you are ripe to sue because you recommended he can play.

It's a shame that lawyers and lawsuits have to taint everything we do and don't do, but that's the world we live in.
 
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Dr.McNinja said:
Minimum of 1 week after symptom resolution.
Cleared by their PCP, team doctor, or some other sports neurologist.

Of course, if they never were knocked out or any other sx of CHI, I simply document that. I still don't clear them for anything. I just say they never had anything. If they want something signed saying "can play sports", then someone else is doing it.
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Totally agree with mcninja and birdstrike

I find no reason to try to be the hero by clearing someone who's neurotic enough in the first place to come to the ED for minor head trauma

I tell them that they need to be seen by their PMD so that they can look at baseline cognitive testing and explicitly document in my note that I didn't clear them to play and warned about second impact syndrome
 
Clearance for sports participation is outside the scope of the emergency physician. Our job is to rule out and treat emergency conditions. Sports readiness is not what we do - refer to pcp or sports physician.
 
dotcb said:
Clearance for sports participation is outside the scope of the emergency physician. Our job is to rule out and treat emergency conditions. Sports readiness is not what we do - refer to pcp or sports physician.
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Since sports med is technically an official Subspecialty of EM, I suppose you could argue this kind of stuff is "within the scope" but unless you are marketing yourself as such in the outpatient setting, I see no obligation to acquiesce.
 
So, not giving clearance to return to play from the Emergency Room makes sense, I can live with that. But what about from an Urgent Care or Free Standing ED stand point? Are you guys taking the same stand on the issue? Different environment, different setting, same principle?
 
Foster23 said:
So, not giving clearance to return to play from the Emergency Room makes sense, I can live with that. But what about from an Urgent Care or Free Standing ED stand point? Are you guys taking the same stand on the issue? Different environment, different setting, same principle?
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How is it any different?
 
I'm not telling anyone they're clear to do anything.

I'll tell them that based on my evaluation at this time they are not in emergent need of further medical management, but that at anytime things could change and if they experience x/y/z they should immediately return to seek medical care.

I won't see these people again, god willing. I am not a PMD. I'll say, "Guidelines indicate that you should wait 1 week after resolution of symptoms and at that time should be cleared by a neurologist or your primary doctor."

In a court of law they'll argue that you are not the patient's primary doctor and therefore had no right clearing them. It is outside our scope of practice. An EM residency trained physician who completed a sports medicine fellowship and works with an athletic team is a separate legal condition from a EM doc wading through the quagmires of the local ED imo. I don't like this sort of thing because it feels cheap give patients the runaround but it's reality.
 
Foster23 said:
Where you do guys stand on clearing these athletes to return to play?
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We have a affiliated sports medicine fellowship at my shop, and we literally talked about this on Wednesday during our monthly journal club. From our standpoint in the ED, if I diagnose concussion they get referred to our sports med clinic with instructions that they are not to return to play until cleared by them. The director of the fellowship says he won't even clear them on the first follow up visit from the ED. They'll do their eval+neurocog stuff, then clear them as appropriate after the first visit.

Makes it pretty simple for us - no return to play until cleared by sports med (or PMD or neuro or whoever).
 
We've had conversations with our community pediatricians and they have requested that we send the patient to them for clearance, we do not clear in our ER.
 
Tiger26 said:
How is it any different?
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It's slightly different, simply because these people who show up and pay 75 dollar co-pay to be seen for the sole purpose of return-to-play clearance ended up with a referral to PCP for clearance anyways. I rather hang a sign outside and clearly state that we do not clear athletes to return to play to save the family some time and money. At one of the many urgent care gigs, one place turn away all patients (35 y/o+) with cc of chest pain, simply because we more than likely will be sending patient to ED for r/o ACS.

In the ED, we have to abide by EMTALA, so, it's not much of a choice for these patients to be seen or turn away. From a stand point of UC or Free Standing ED, we have a choice. We choose to not evaluate chest pain because of our limited capability. Return-to-play is no different when it is not in the scope of our practice.
 
pinipig523 said:
We've had conversations with our community pediatricians and they have requested that we send the patient to them for clearance, we do not clear in our ER.
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The pediatricians are willing to see them within 1 week? That's impossible in my area.
 
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What would you do with a 40-year-old male with chest pain who says, "I'm just here to rule out MI and then discharge home with instructions that I can continue my usual activities?" It's the same field as far as I am concerned. As we are usually not the final stop for anyone, concussions are no different. I even tell teenagers that they are not allowed to send text messages until cleared by their PCP.
 
Foster23 said:
It's slightly different, simply because these people who show up and pay 75 dollar co-pay to be seen for the sole purpose of return-to-play clearance ended up with a referral to PCP for clearance anyways. I rather hang a sign outside and clearly state that we do not clear athletes to return to play to save the family some time and money. At one of the many urgent care gigs, one place turn away all patients (35 y/o+) with cc of chest pain, simply because we more than likely will be sending patient to ED for r/o ACS.

In the ED, we have to abide by EMTALA, so, it's not much of a choice for these patients to be seen or turn away. From a stand point of UC or Free Standing ED, we have a choice. We choose to not evaluate chest pain because of our limited capability. Return-to-play is no different when it is not in the scope of our practice.
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ummm i work in a "freestanding ED" that is part of a hospital system... we are absolutely bound by EMTALA, just be be clear... not all FSED's are in a strip mall and more similar to an urgent care. we have automatic transfer agreements, etc.

as far as the OP... i NEVER clear for sports, especially after head injury. it's so prevalent in the news and has become such a talking point in sports that i really get no pushback. plus, i never HAVE cleared anyone so i can claim total ignorance, which is absolutely true. i can clear you kid to go HOME, but not to get hit in the head again.... no responsible MD would the day of injury anyway!
 
We just had a grand rounds on this topic last week. Looks like, as a group, we aren't clearing anyone to go back to sports from the ED. What we can do though is keep them from getting a CT scan (PECARN).
 
la gringa said:
ummm i work in a "freestanding ED" that is part of a hospital system... we are absolutely bound by EMTALA, just be be clear...
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Because you are hospital affiliated.

Free standing EDs are not EMTALA bound if they are,

1) Independently owned,
2) Not affiliated with a hospital,
3) Are in a state without its own EMTALA-like statute, and
4) Opt out of Medicare and Medicaid.

http://www.ucaoa.org/docs/Article_Freestanding.pdf

(“A freestanding emergency center that is affiliated with a hospital and accepts Medicare and/or Medicaid is generally subject to EMTALA while an independently owned facility may forego the federal requirement by opting out of the government insurance schemes.”)
 
fahimaz7 said:
We just had a grand rounds on this topic last week. Looks like, as a group, we aren't clearing anyone to go back to sports from the ED. What we can do though is keep them from getting a CT scan (PECARN).
Click to expand...

Texas has a law saying you can't get cleared from the ED. Cheeses off some parents but makes it easy for us.
 
Birdstrike said:
Because you are hospital affiliated.

Free standing EDs are not EMTALA bound if they are,

1) Independently owned,
2) Not affiliated with a hospital,
3) Are in a state without its own EMTALA-like statute, and
4) Opt out of Medicare and Medicaid.

http://www.ucaoa.org/docs/Article_Freestanding.pdf

(“A freestanding emergency center that is affiliated with a hospital and accepts Medicare and/or Medicaid is generally subject to EMTALA while an independently owned facility may forego the federal requirement by opting out of the government insurance schemes.”)
Click to expand...

there is no such thing as a NON-hospital affiliated freestanding ED that i am aware of in the middle atlantic or southeast... they are all built in nicer areas to bring patients into the hospital system!!!
 
I don't ever clear them to return to play. In fact, I make it perfectly clear to non-sports-related head injuries that "If you were a high school football player, there is no way I would let you play... (or even: "...this would be a season-ending injury.)" That actually means something in football-crazed Florida.

I actually got to discuss IMPACT with a kid and mom who'd just moved here... and had just sustained concussion #3 in 2 years in a freak impact. It had taken him a year to get back to baseline after #1, and had bonked his head playing a usually-low-contact sport. Oops. And they knew what it meant. High school nurse insisted he come in, but I wasn't going to scan him, nor would I clear him, which they totally understood.
 
la gringa said:
there is no such thing as a NON-hospital affiliated freestanding ED that i am aware of in the middle atlantic or southeast... they are all built in nicer areas to bring patients into the hospital system!!!
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Yet, the opportunity is there for the taking. Surgeons build surgery centers and with that comes a lot of power, control and independence. Yet, Emergency Physicians as a rule don't think to build their own independent free-standing emergency care centers (ECC), and therefore have none of the independence, and every bit of the tail wagging the dog.

Free-standing, non-hospital affiliated ED = freedom from Press-Ganey, EMTALA, hospital admin and the like.

If surgeons can build their own ASCs, EPs can build their own ECCs.

Why don't more do so?
 
Birdstrike said:
Yet, the opportunity is there for the taking. Surgeons build surgery centers and with that comes a lot of power, control and independence. Yet, Emergency Physicians as a rule don't think to build their own independent free-standing emergency care centers (ECC), and therefore have none of the independence, and every bit of the tail wagging the dog.

Free-standing, non-hospital affiliated ED = freedom from Press-Ganey, EMTALA, hospital admin and the like.

If surgeons can build their own ASCs, EPs can build their own ECCs.

Why don't more do so?
Click to expand...

Time and money?
 
I haven't and probably would not clear anyone from the ED, I explain the "1 week after symptom free" rule to the parents and follow it up with I don't know if he is going to still have a headache tomorrow so I can't say when he will be able to return, haven't gotten any angry parents about this. They all understand that I can't predict if their son will feel totally normal the next day or have a headache for a few days. I even told a boy he couldn't play video games for mental rest because he brought it up. good thing its not testing season because its so much worse when this happens at the end of semester and I start giving notes saying they have to be excused from a test - I'm sure the teachers hate trying to work around that, but I sure wouldn't want to have a test grade based on a concussed fog! I tell every parent they need to call their pediatrician ASAP to schedule an appointment for the following week - either to get the RTP form filled out or to get rechecked for continued symptoms of concussion. either way they all need to be seen in a week.
 
Here is MA, we actually CAN'T clear kids from the ED anymore (fine with me... though sometimes kids come in with cc: "someone brushed against my head, I have no symptoms, can I play...")

See below:

The Department of Public Health (DPH) has asked MACEP to communicate to our members that as of September 2013, Regulations 105 CMR 201: Head Injuries and Concussions in Extracurricular Activities require medical clearance for return to play only by practitioners that have received department-approved training in traumatic head injury assessment and management.

MACEP feels that post sports-related head injury medical clearance is not the role of an emergency physician or a decision to be made in the emergency department. By definition, determination to clear a patient for return to sports cannot be made on the day the injury occurs. Patients that have a sports-related head injury should be informed of the need to have medical clearance and instructed to visit their primary care physician for the required form.

Please note that MACEP's message is to inform you of this new training requirement and to communicate that the training is not needed if you do not plan to sign the medical clearance form. If you or providers in your department are involved in following-up or clearing patients with head injuries and concussions you will need to be aware of the DPH guidelines around required training. If you are interested in completing the training in traumatic head injury assessment and management the information on the training available is below.
 
Our state law said "appropriate health professional"

“Appropriate health professional” means a health professional who is licensed or otherwise authorized to engage in a health profession under article 15 and whose scope of practice within that health profession includes the recognition, treatment, and management of concussions.

I guess it does eliminate EP now that I read it over more than once.... :)
 
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