Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America; Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America.
Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States of America; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America.
Am J Emerg Med. 2019 Jul;37(7):1219-1223. doi: 10.1016/j.ajem.2018.09.008. Epub 2018 Sep 5.
Concussion guidelines recommend a vestibular and oculomotor (VOM) examination be performed for all patients with concern for concussion, however the feasibility of performing testing is unknown. We aimed to measure rates of exam performance after implementation of training and support tools in a pediatric emergency department.
We conducted a retrospective study of patients age 6 to 18 years old presenting over a 12-month period. Charts were obtained via natural language processing, where concussion was suggested as a diagnosis in the electronic health record, and then manually reviewed to record patient and provider factors. A multivariable logistic regression was performed to determine factors associated with exam performance, and a classification and regression tree (CART) analysis was performed to determine if a specific patient type was at risk for not having testing performed.
Four hundred patients were included in the analysis. Sixty-four percent received a VOM examination (including 73% of those diagnosed with concussion). Provider type, concussion history, symptom burden, injury mechanism, and final diagnosis were all significantly associated with exam performance. CART analysis determined patients with a non-concussion diagnosis, a non-sports injury mechanism, no prior history of concussion, and two or fewer symptoms had the lowest likelihood (46%) of receiving the exam.
Performing a VOM examination for concussion is feasible in the acute setting following provider education and using clinical support tools. The exam is more likely to be performed on those children with history or exam findings associated with perceived risk for ongoing symptoms.
concussion 指南建议对所有疑似 concussion 的患者进行前庭和眼动（VOM）检查，然而进行测试的可行性尚不清楚。我们旨在测量在儿科急诊部门实施培训和支持工具后进行检查的比例。
我们进行了一项回顾性研究，研究对象为 6 至 18 岁的患者，研究时间为 12 个月。通过自然语言处理获取图表，电子健康记录中提示 concussion 作为诊断，然后手动审查以记录患者和提供者因素。进行多变量逻辑回归以确定与检查表现相关的因素，并进行分类和回归树（CART）分析以确定是否存在特定患者类型进行检查的风险。
共纳入 400 名患者进行分析。64%的患者接受了 VOM 检查（包括 73%被诊断为 concussion 的患者）。提供者类型、concussion 病史、症状负担、损伤机制和最终诊断均与检查表现显著相关。CART 分析确定了具有非 concussion 诊断、非运动损伤机制、无既往 concussion 病史和两个或更少症状的患者接受检查的可能性最低（46%）。
在提供者教育和使用临床支持工具后，在急性环境中进行 VOM 检查对于 concussion 是可行的。对于那些具有与持续症状相关的既往或检查结果相关的风险感知的儿童，更有可能进行检查。
