Concussion: A Comprehensive Prevention, Recognition, and Management Program in a School Setting

This project consists of a series of interventions to implement a cost effective concussion prevention, recognition, and management program at a local system of charter schools. Concussions are a common injury among children and adolescents with a significant potential for long-term harm. Every concussion is a brain injury. Appropriate prevention, recognition, and response in the school setting is an important way to reduce the burden of harm. The reported incidence of concussions has risen steadily in the last 15 years in children and adolescents. There is a substantial public knowledge gap about mechanism of injury, symptoms, treatment, and long-term complications. Concussion symptoms evolve over several hours or days, and often initially go unrecognized and therefore undertreated. Children and adolescents typically take longer to recover than adults, and may experience decline in school performance due to persistent symptoms. Laws in all 50 states mandate removal from play and concussion programs for schools and sports, however there is little specification about what the programs should include and many programs are inadequate. Objectives for this project are as follows: • Implement pre-season baseline coordination and cognitive testing for student athletes • Initiate prevention, recognition and management program for aides, coaches, and staff • Educate teachers and nurses about responding to the unique needs of students returning to school after a concussion injury • Increase education to students and families regarding prevention and recognition of concussion • Disseminate findings To accomplish the first three objectives, blended learning training modules were created based on information from the Center for Disease Control's HEADS UP program and the SCAT3 assessment tool. These included original video, interactive powerpoint presentations, reference hand outs, and templates for documentation. The school nurses were trained in baseline assessment technique, demonstrated appropriate competency, and successfully implemented the assessment on a total of 54 student athletes. The head school nurse was mentored through the first of three presentations for both the second and third objectives, and all were completed. Six educational summaries were included in the school newsletter and distributed to the parents. Students attended an assembly on head injury prevention and participated in a poster contest to raise awareness about signs and symptoms of a concussion and prevention strategies. All training materials and templates were gathered into a toolkit and distributed to the Utah Association of Public Charter Schools. A summary article was written and submitted to the Journal of School Nursing. Everyone is at risk for concussion. As a population health promotion strategy, this program reduces preventable morbidity and mortality, addresses risk factors, and creates a sustainable structure for intervention and management in the future. Student health is a critical factor in academic success, and requires a partnership between the student, families, faculty, and staff.

Running head: CONCUSSION MANAGEMENT IN SCHOOLS Concussion: A Comprehensive Prevention, Recognition, and Management Program in a School Setting Heidi Spencer Vawdrey University of Utah College of Nursing In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 CONCUSSION MANAGEMENT IN SCHOOLS 2 Executive Summary This project consists of a series of interventions to implement a cost effective concussion prevention, recognition, and management program at a local system of charter schools. Concussions are a common injury among children and adolescents with a significant potential for long-term harm. Every concussion is a brain injury. Appropriate prevention, recognition, and response in the school setting is an important way to reduce the burden of harm. The reported incidence of concussions has risen steadily in the last 15 years in children and adolescents. There is a substantial public knowledge gap about mechanism of injury, symptoms, treatment, and long-term complications. Concussion symptoms evolve over several hours or days, and often initially go unrecognized and therefore undertreated. Children and adolescents typically take longer to recover than adults, and may experience decline in school performance due to persistent symptoms. Laws in all 50 states mandate removal from play and concussion programs for schools and sports, however there is little specification about what the programs should include and many programs are inadequate. Objectives for this project are as follows: • Implement pre-season baseline coordination and cognitive testing for student athletes • Initiate prevention, recognition and management program for aides, coaches, and staff • Educate teachers and nurses about responding to the unique needs of students returning to school after a concussion injury • Increase education to students and families regarding prevention and recognition of concussion • Disseminate findings To accomplish the first three objectives, blended learning training modules were created based on information from the Center for Disease Control's HEADS UP program and the SCAT3 assessment tool. These included original video, interactive powerpoint presentations, reference hand outs, and templates for documentation. The school nurses were trained in baseline assessment technique, demonstrated appropriate competency, and successfully implemented the assessment on a total of 54 student athletes. The head school nurse was mentored through the first of three presentations for both the second and third objectives, and all were completed. Six educational summaries were included in the school newsletter and distributed to the parents. Students attended an assembly on head injury prevention and participated in a poster contest to raise awareness about signs and symptoms of a concussion and prevention strategies. All training materials and templates were gathered into a toolkit and distributed to the Utah Association of Public Charter Schools. A summary article was written and submitted to the Journal of School Nursing. Everyone is at risk for concussion. As a population health promotion strategy, this program reduces preventable morbidity and mortality, addresses risk factors, and creates a sustainable structure for intervention and management in the future. Student health is a critical factor in academic success, and requires a partnership between the student, families, faculty, and staff. Project Committee Members: Chair - Jennifer Hamilton, DNP, APRN, CPNP-PC; FNP Specialty Track Director - Julie Balk, DNP, APRN, FNP-BC, CNE; Assistant Dean MS and DNP programs- Pamela Hardin, PhD, RN, CNE; Content Expert - Colby Hansen, MD. CONCUSSION MANAGEMENT IN SCHOOLS 3 Table of Contents Executive Summary ........................................................................................................................ 2 Acknowledgements ......................................................................................................................... 5 Problem Statement .......................................................................................................................... 6 Clinical Significance ....................................................................................................................... 7 Purpose and Objectives ................................................................................................................... 9 Literature Review.......................................................................................................................... 10 Search Terms ............................................................................................................................. 10 Defining the Problem ................................................................................................................ 10 Concussion characterization. ................................................................................................. 10 Pathophysiology. ................................................................................................................... 11 Epidemiology......................................................................................................................... 11 Underreporting and confounding variables. .......................................................................... 13 Clinical Management ................................................................................................................ 14 Diagnosis. .............................................................................................................................. 14 Assessment Tools. ................................................................................................................. 15 Pre-season baseline testing. ................................................................................................... 16 Response at the time of injury. .............................................................................................. 17 Treatment. .............................................................................................................................. 18 Barriers to reporting injury. ................................................................................................... 19 Prevention.................................................................................................................................. 20 Annual education. .................................................................................................................. 20 General education campaigns. ............................................................................................... 21 Barriers to safety strategy implementation. ........................................................................... 22 Theoretical Framework ................................................................................................................. 23 Social Ecological Model of Health Promotion ......................................................................... 23 Implementation and Evaluation .................................................................................................... 25 Discussion and Results ................................................................................................................. 26 Objective #1 .............................................................................................................................. 27 Objective #2 .............................................................................................................................. 28 Objective #3 .............................................................................................................................. 30 Objective #4 .............................................................................................................................. 30 CONCUSSION MANAGEMENT IN SCHOOLS 4 Objective #5 .............................................................................................................................. 31 Future Recommendations ............................................................................................................. 31 DNP Essentials.............................................................................................................................. 34 Conclusion .................................................................................................................................... 35 References ..................................................................................................................................... 37 Appendix A - Project Proposal..................................................................................................... 44 Appendix B - IRB Exemption ...................................................................................................... 54 Appendix C - Program Blueprint ................................................................................................. 55 Appendix D - Program Introduction Letter .................................................................................. 56 Appendix E - Baseline Concussion Assessment Toolkit ............................................................. 57 Appendix F - Baseline Assessment Training Module.................................................................. 58 Appendix G - Baseline Assessment Introduction Letter .............................................................. 76 Appendix H - Concussion Notification Letter ............................................................................. 78 Appendix I - Concussion Management and Prevention in Schools Summary ............................ 80 Appendix J - Concussion Management and Prevention in Schools: Training for Coaches and Aides ............................................................................................................................................. 81 Appendix K - Helping Students Recover From a Concussion ................................................... 100 Appendix L - Newsletter Series ................................................................................................. 112 Appendix M - Article for Submission ........................................................................................ 116 Appendix N - Poster Presentation .............................................................................................. 122 CONCUSSION MANAGEMENT IN SCHOOLS 5 Acknowledgements I am deeply indebted to my husband Alan, and my children Ethan, Rachel, Elizabeth, and Katie. Ethan and Alan were kind enough to star in my training video, and all of them have been supportive and helpful throughout graduate school. Steven Braithwaite gave me the extraordinary gift of his talent with videography and editing for which I am most thankful. He spent many hours filming and creating a professional product for my project that will continue to be used by many. Shelley Cundick and the other nurses on staff at Providence Hall Charter System were fantastic to work with and eagerly embraced this project. Dr. Colby Hansen, MD evaluated my project content and also graciously allowed me to follow him in his concussion clinic to help me better understand the follow up care of this population of patients. Dr. Jennifer Hamilton has spent many hours reviewing my drafts and offering constructive feedback. I am grateful for her expertise and assistance. CONCUSSION MANAGEMENT IN SCHOOLS 6 Concussion: A Comprehensive Prevention, Recognition, and Management Program in a School Setting Problem Statement Concussions are a common injury among children with a significant potential for longterm harm. The reported incidence of concussions has risen steadily in the last 15 years in children and adolescents, due in part to increased public awareness (Centers for Disease Control and Prevention, 2011a). There is a substantial public knowledge gap about mechanism of injury, symptoms, treatment, and long-term complications (Kerr et al., 2014; Kroshus, Baugh, Daneshvar, Nowinski, & Cantu, 2015; Robbins et al., 2014; White et al., 2013). Concussion symptoms evolve over several hours or days, and often initially go unrecognized and therefore undertreated. Children and adolescents typically require a longer recovery period than adults, and may experience decline in school performance, mood and behavioral changes, persistent headaches, memory loss and other troublesome symptoms (CDC, 2016b). Appropriate prevention, recognition, and response in the school setting is an important way to reduce the burden of harm in this age group. CONCUSSION MANAGEMENT IN SCHOOLS 7 Clinical Significance Concussions are a significant public health concern. In 2010, about 2.5 million emergency department visits, hospitalizations or deaths in the United States for people of all ages were attributed all or in part to traumatic brain injury (CDC, 2016a). Each year, a half million school age children are seen in the emergency room for concussion, and an average of just over 21,000 of those visits to the emergency room are attributed to injuries sustained specifically on the playground (CDC, 2016a; Cheng et al., 2016). The reported incidence of concussions has risen steadily in the last 15 years in children and adolescents, due in part to increased public awareness (CDC, 2011b). However, the disease burden is grossly underestimated in current data, which is culled from emergency department visits and hospitalizations, and accounts for as little as 12-15% of the total initial access to health care for concussion injuries (Arbogast et al., 2016). The majority of patients first seek care through primary care clinics, sports medicine, neurology, physical therapy, or not at all, which complicates the data gathering process (Arbogast et al., 2016). Concussion is a substantial enough national health problem that the President of the United States has requested $5 million dollars to establish a National Concussion Surveillance System starting in 2017 in order to better track and understand the epidemiology of this type of injury (CDC, 2016b). An estimate of cost burden of traumatic brain injury from 2000 is $60 billion in direct and indirect costs, a figure that is certainly higher now (CDC, 2011b). A common misconception about concussion is that the person has to have lost consciousness for the injury to be significant. There is a considerable and troubling public knowledge gap about mechanism of injury, symptoms, treatment, and long-term complications (Kerr et al., 2014; Kroshus et al., 2015; Robbins et al., 2014; White et al., 2013). Concussion CONCUSSION MANAGEMENT IN SCHOOLS 8 symptoms evolve over several hours or days, and often initially go unrecognized and therefore undertreated (CDC, 2011a). Young athletes and their coaches are particularly prone to underreporting, putting them at significant risk for another injury and subsequently more severe symptoms and delayed recovery (Register-Mihalik et al., 2013). Children and adolescents typically require a longer recovery period than adults, and may experience decline in school performance, mood and behavioral changes, persistent headaches, memory loss and other troublesome symptoms (CDC, 2016b). Children are especially prone to concussion injuries on playgrounds, during physical education class, and while playing sports (Cheng et al., 2016). Injury data from the Utah State Department of Health demonstrates the highest risk age group for school related injuries between 4th and 8th grades, underscoring the importance of intervention in this population (2015a). The stakeholders for this project include the 2150 students and their families, faculty, staff and volunteer coaches, and the three school nurses at a K-12 charter school system in a suburban area. The school previously collected very limited data about injuries, and did not have a plan in place specifically to address concussions. Therefore, the historical injury impact is unknown. Implementation of a comprehensive concussion prevention, recognition and response plan, in addition to education about how to manage injuries sustained outside of school, will improve the health of the students and their families. CONCUSSION MANAGEMENT IN SCHOOLS 9 Purpose and Objectives The purpose of this project is to develop and implement a comprehensive concussion prevention, recognition and management program for a charter school system. Objectives • Implement pre-season baseline coordination and cognitive testing for students participating in school sports. • Initiate prevention, recognition, and management program for recess aides, physical education teachers, and coaches. • Educate teachers and nurses about how to respond to the unique needs of students returning to school after a concussion injury. • Increase education to students and families regarding prevention and recognition of concussions. • Disseminate findings. CONCUSSION MANAGEMENT IN SCHOOLS 10 Literature Review Search Terms Terms entered in to PubMed, CINAHL and Google Scholar include "concussion", "concussion assessment tool", "adolescent concussion", "concussion recovery", "concussion epidemiology", "concussion management". Additionally, the Centers for Disease Control and Prevention webpage and the Utah Department of Health webpage were searched for epidemiologic data and resources. Defining the Problem Concussion characterization. Concussion, often used interchangeably with the term mild traumatic brain injury (mTBI) refers to a low velocity injury to the brain in which transient clinical symptoms result that are not necessarily related to a gross structural injury (McCrory et al., 2013). Specific defining criteria were updated in the 2012 Zurich Consensus Statement. These include that the concussion may be caused by either direct blow or indirect transmission of forces to the head from other parts of the body, is characterized symptoms of neurological impairment that may evolve in a period of minutes to hours, is a functional disturbance of the neurological system with an absence of abnormalities on imaging, and a graded set of symptoms are present that may involve a temporary loss of consciousness (McCrory et al., 2013). The signs and symptoms of concussion present in four domains: physical, cognitive, emotional, and sleep. Physical symptoms include headache, photophobia, phonophobia, fatigue, nausea, vomiting, alterations in balance, fatigue and visual problems (Halstead, Walter, & Fitness, 2010). Cognitive symptoms include confusion, amnesia, memory and concentration difficulty, and a sensation of feeling slow or mentally cloudy (Halstead et al., 2010). Emotional symptoms may manifest as increased irritability, sadness, lability, and nervousness (Halstead et al., 2010). Sleep disturbances include difficulty initiating sleep, inappropriate drowsiness, and sleeping either CONCUSSION MANAGEMENT IN SCHOOLS 11 more or less than usual (Halstead et al., 2010). Most patients recover within a period of seven to ten days, however about 10-15% percent may have lingering symptoms for weeks to months (Patricios et al., 2016; McCrory et al., 2013). Pathophysiology. Injury from a concussion is on a cellular level. Halstead et al. (2010) describe how concussion changes neurochemistry and produces symptoms based on research on animal models. Physical forces cause a microscopic disruption of the neuron membrane, allowing potassium to rush out of the neuron, stimulating the release of glutamate, which pulls additional potassium out of the cell. The excess extracellular potassium depolarizes and suppresses the neuron, and in an effort to restore balance, the sodium-potassium pump increases activity and therefore glucose and adenosine triphosphate consumption. The increased metabolism rate leads to an accumulation of lactic acid that impairs cellular function and repair (Halstead et al., 2010). Second impact syndrome is a rare but often fatal condition of rapid brain swelling that occurs when an individual sustains a second concussion before fully recovering from the first (Mott & Koroshetz, 2016; Cantu & Gean, 2010). This is a poorly understood phenomenon, and the National Institute of Neurological Disorders and Stroke is exploring this as well as the association between repeated concussions and the development of chronic traumatic encephalopathy (CTE). CTE causes dementia and brain atrophy, and on microscopic examination, widespread tau protein aggregations in neural cells (Mott & Koroshetz, 2016). A firm cause and effect relationship between CTE and sport related concussion remains controversial, but this is an important area of research (McCrory et al., 2013). Epidemiology. About 2.5 million emergency department visits in the United States annually are due all or in part to traumatic brain injury (CDC, 2016). An estimated 1.6-3.8 CONCUSSION MANAGEMENT IN SCHOOLS 12 million concussions occur in all age groups each year as a result of sports and recreational activities, many of which are not seen in the emergency department (Daneshvar, Nowinski, McKee, & Cantu, 2011). Approximately 9% of reported high school athletic injuries are attributed to concussion, with the highest incidence in football, lacrosse, rugby and ice hockey for males, and soccer and basketball for females (Halstead et al., 2010). Of greatest concern is that the incidence of traumatic brain injury visits to the emergency department has increased substantially in the last fifteen years. Some of the recent increase in emergency room visits is attributable to increased public awareness due to campaigns such as the CDC's HEADS UP program, increased coach education, and legislation mandating removal from play after concussion injury, but the remainder of the increase is troublesome and warrants further examination. A survey of the Nationwide Emergency Department Sample database that samples information from more than 950 hospitals each year found an eightfold increase in visits for concussion between 2006 and 2010 (Marin, Weaver, Yealy, & Mannix, 2014). National data for incidence of TBI gleaned from hospitals, emergency departments and death certificates for the period of 2000-2010 started at an incidence of 521.0 per 100,000 population, jumping to 823.7 per 100,000 population by 2010 (CDC, 2016). Statistics from the state of Utah from 2012 reveal a TBI rate statewide consistent with national numbers, at 834.7 per 100,000 population (Utah Department of Health, 2015b). Utah males have a higher incidence of TBI than the national average, ranging from 834.1-896.2 per 100,000 population in the years 2010-2013, while Utah females ranged between 703.4-782.2 per 100,000 population in the same span (Utah Department of Health, 2015b). Children in Utah have particularly alarming rates of TBI. The most recently published data, from 2013, show that males aged 0-17 suffer 1249.8 injuries per 100,000 CONCUSSION MANAGEMENT IN SCHOOLS 13 population and females aged 0-17 suffer 807.9 injuries per 100,000 population, both of which are higher than the national average for this age group (Utah Department of Health, 2015b). In Utah, half of all emergency department visits for concussion are for children between the ages of 10 to 19, underscoring the vulnerability of this age group (Utah Department of Health, 2015b). Healthy People 2020 has set an objective to reduce emergency department visits for nonfatal traumatic brain injuries to 365.3 per 100,000 population, a goal we are far short of (Office of Disease Prevention and Health Promotion, 2016). Underreporting and confounding variables. Statistics on incidence of concussion are clouded by combination with other traumatic brain injuries into a single category, underreporting and poor ability to gather data outside of emergency department and hospital databases (Daneshvar et al., 2011; Kerr et al., 2014; Kroshus et al., 2015; Register-Mihalik et al., 2013). Individual underreporting is multifactorial, and includes lack of knowledge of symptoms or of the potential seriousness of the injury, unwillingness to leave play, or not wanting to let down coaches and fellow athletes in a sports setting (Register-Mihalik et al., 2013). Systemically poor capture of data is due in part to the fact that the majority of persons with a mild traumatic brain injury do not seek care in the emergency department, but may instead access primary care, physical therapy, sports medicine, neurology or urgent care, or simply not seek care at all. A study of a major health system in California found that fewer than 12% of patients in a four-year period ending in 2014 were initially seen in an emergency department for concussion. Rather, 82% sought evaluation in primary care and the remaining percentage were spread among other specialties (Arbogast et al., 2016). CONCUSSION MANAGEMENT IN SCHOOLS 14 Clinical Management Diagnosis. By nature of the injury being a metabolic cascade that can affect any part of the brain, the symptoms of concussion are multifocal, a syndrome composed of a set of possible symptoms (Kutcher & Giza, 2014). The diagnosis is clinical, and other confounding variables must be taken in to account, such as dehydration, migraine, viral illness, and the mechanism of injury in relation to the severity of symptoms (Kutcher & Giza, 2014). Additionally, the presentation of a concussion develops over time, and is therefore often difficult to diagnose immediately after the injury (Kutcher & Giza, 2014). It is appropriate to describe the cluster of symptoms as a possible concussion, allowing the diagnosis to evolve as recovery and treatment run their course. Imaging is rarely useful or warranted unless the patient manifests danger signs, such as alteration in level of consciousness, repeated vomiting, significant confusion, seizures, slurred speech, focal neurological deficits, evidence of a skull fracture, or a headache that gets worse (McCrory et al., 2013). Serial standardized evaluations, starting with a baseline assessment completed pre-season, allows clarification of diagnosis while simultaneously monitoring the patient's ability to return to participation in scholastic and athletic events (Kutcher & Giza, 2014). A few significant variables have been identified that may result in prolonged recovery after concussion. Loss of consciousness for greater than one minute, age younger than 18, and depression are the most significant (McCrory et al., 2013). Other important modifiers that influence diagnosis, prognosis and treatment include the total number of symptoms and their severity, symptom duration longer than 10 days, multiple concussion injuries, concussions spaced closely together, and comorbidities such as migraine, anxiety, attention deficit hyperactivity disorder, learning disabilities and sleep disorders (McCrory et al., 2013). CONCUSSION MANAGEMENT IN SCHOOLS 15 Assessment Tools. Many assessment tools exist for baseline and post injury assessment. None of these tools are a substitute for a full evaluation by a trained medical provider, but they do provide valuable information to support a diagnosis of concussion and to evaluate the progression of recovery. Components that may be included in an assessment tool are balance, coordination, memory, recall, eye movement, attention, cognition, post-concussion symptom scale, and sensory organization (Armstrong, 2014). Individually, the tools have fair to good sensitivity and good to excellent specificity. Combining one or more elements increases the accuracy and validity of the assessment; however, there is presently not enough evidence to support the best combination of specific test components or to recommend one definitive tool (Armstrong, 2014; Giza et al., 2013). Computerized assessments. Commonly used computerized assessments include the ImPACT test, automated neuropsychological assessment metrics (ANAM), Concussion Resolution Index, and CogSport/AXON (Institute of Medicine (IOM) and National Research Council (NRC), 2014). These assessments evaluate concentration, decision-making, attention, visual processing, memory and learning through a variety of methods. Computerized testing may be more sensitive at identifying subtle cognitive decline that is not as readily picked up on paper and physical based assessments (IOM & NRC, 2014). Advantages include being able to complete baseline assessments on a large number of athletes at once depending on the number of computers available, ready comparison of baseline scores against post-injury results, and some versions have the testing available in mobile application form for easy sideline access. The main disadvantage is that many require a purchased subscription to access the test initially as well as to continue to be able to retrieve the data in the future for comparison, in addition to lacking a balance and coordination assessment component. CONCUSSION MANAGEMENT IN SCHOOLS 16 Paper and physical based assessments. There are multiple paper based assessment and screening tools that are free and readily available. These include the SCAT-3/Child SCAT-3, Acute Concussion Evaluation (ACE), concussion symptom inventory, graded symptom checklist, King-Devick test, and Standardized Assessment of Concussion (SAC) (IOM & NRC, 2014). The King-Devick test is unique from the others as it uses cards printed with specially arranged numbers to measure eye movement, attention and language ability (IOM & NRC, 2014). The ACE, concussion symptom inventory, and graded symptom checklist are limited tools, mainly focused on relevant medical history and progression of symptoms post injury (IOM & NRC, 2014). The SCAT-3 and SAC incorporate variations of assessment of concentration, memory, and physical examination, and the SCAT-3 is the most comprehensive of all of them as it also includes a symptom checklist, balance and coordination assessment, neck assessment, and level of consciousness immediately post injury. The Child SCAT-3 modifies the symptom checklist with age appropriate questions as well as incorporating questions for the caregiver to answer based on their observation of the child (IOM & NRC, 2014). The balance portion of the SCAT-3 assessment is the Balance Error Scoring System (BESS), which is a simple method of identifying postural instability. The BESS has been identified as an assessment with high validity and test-retest reliability in children between the ages of 5 and 14, making it an ideal tool for school age athletes (Hansen, Cushman, Chen, Bounsanga, & Hung, 2016). A more sophisticated means of assessing balance uses force plate technology. Both types of assessment identify acute postural stability deficits that commonly last about 3 days post injury, and are an effective way to evaluate neuro motor function (McCrory et al., 2013) Pre-season baseline testing. Baseline assessments are completed using several of the tools mentioned in the previous section, or a combination thereof. Baseline assessment is CONCUSSION MANAGEMENT IN SCHOOLS 17 commonly done in high school, college and competitive league athletics at intervals of one to two years. The American Academy of Neurology advises that baseline assessment allows better interpretation of post-injury scores (Giza et al., 2013). Additionally, baseline testing that includes a detailed relevant medical history that includes prior concussions identifies athletes at higher risk of significant injury and the opportunity for coaching staff to mitigate risk (McCrory et al., 2013). Other concussion recovery modifiers, such as a history of headaches, depression, and sleep problems are important to characterize before an injury occurs. Whatever tool is chosen for baseline assessment should be easily accessible for future assessments in order for the comparison to be valid. The term baseline testing is a bit misleading, as it is simply an assessment of an individual's ability on the day of the test, and does not necessarily reflect the complexity and variability of neurologic function day to day. The outcome and validity of the testing may be negatively impacted by the amount of sleep the person got the night before, pain, anxiety, testing environment, inter-tester variability, as well as intentional suboptimal effort in order to make it easier to return to play after an injury (McCrory et al., 2013). Again, baseline testing should be viewed as a tool to aid in the diagnosis of a concussion, not as the definitive source of diagnosis. Response at the time of injury. All fifty of the United States have legislation in place to protect athletes sustaining a potential concussion during play. Utah state law mandates that any athlete suspected of a concussion must be removed from play and may not return until cleared by a qualified healthcare provider. Additionally all amateur sports organizations are required to adopt a concussion policy that includes informed consent of parents and athletes about concussion and the removal policy (Protection of Athletes with Head Injuries Act, 2011). Immediate removal from play is a critical component of treatment to limit the extent of CONCUSSION MANAGEMENT IN SCHOOLS 18 metabolic injury, since many concussion injuries do not fully manifest for 48-72 hours, and an athlete subjected to further exertion and the possibility of an additional hit risks longer recovery and greater potential for serious consequences such as second impact syndrome (Patricios et al., 2016; Kutcher & Giza, 2014). A normal examination immediately after injury does not rule out a concussion. Assessment by a team athletic trainer on the sideline is appropriate to identify signs that warrant immediate emergency care, but athletes and their guardians must be adequately educated about the evolving nature of the injury, and when and where to seek further care. With these policies, there is a risk of removing uninjured athletes and restricting their ability to continue to play. Inaccurate evaluation and inappropriate withdrawal of an athlete who is uninjured may have detrimental effects on both the athlete's career or the performance of the team (Patricios et al., 2016). However, the risk of brain injury is greater, hence the legislation to mandate removal. "When in doubt, sit them out" (CDC, 2016b). Treatment. The foundation of management of concussion is cognitive and physical rest until symptoms subside, with a graded return to play and academics (McCrory et al., 2013). There is some debate about how strict and how long the period of rest should be for optimal recovery, and research in this area is ongoing. Current recommendations include strict rest in the first 24-48 hours following injury when symptoms are most acute, with a step-wise addition of activity at 24 hour intervals as long as symptoms don't return or worsen (McCrory et al., 2013). A student may return to school with lingering mild symptoms, but may require accommodations such as a shortened school day, reduced workload, reduction of distractions, and the ability to rest during the day (CDC, 2016a). Periodic re-evaluation with the same concussion assessment tool can guide treatment strategy. CONCUSSION MANAGEMENT IN SCHOOLS 19 Most children and adolescents recover fully in a period of about 10 days, but about 1015% have prolonged recovery periods and may require treatment by a neuropsychologist, balance specialist, physical therapist, or other concussion specialist (McCrory et al., 2013). Novak, Aglipay, & Barrowman found that all children experience a decrease in health related quality of life after a concussion, even those who have resolution of symptoms within the normal timeframe (2016). School functioning was significantly lower for months following injury for all children regardless of the length of recovery, which underscores again the importance of appropriate concussion prevention , recognition, treatment, and follow up care (Novak, Aglipay, & Barrowman, 2016). Barriers to reporting injury. In states that were early adopters of removal from play laws, coaches identified that students were reluctant to report injury because they didn't want to be pulled out of play, and that parents often applied pressure to keep their child in the game as well. This behavior was largely attributed to lack of knowledge of the consequences of subsequent injury (CDC, n.d.). This is consistent with the findings of other researchers. A literature review by Kay, Welch & Valovich McLeod (2015) found that knowledge of concussions was the greatest positive influence toward reporting symptoms among young athletes. Negative factors for reporting included the attitude of coaches, and lack of access to appropriate medical personnel. Education that was specifically aimed at teaching symptoms as well as the consequences of not reporting and therefore not treating a concussion injury was found to be the most effective (Kay et al., 2015). Register-Mihalik et al. (2013) specifically studied barriers to reporting concussions in the high school age group of athletes. The most common reasons that concussions were not reported were that the athlete didn't think it was a serious injury, he/she did not want to be removed from CONCUSSION MANAGEMENT IN SCHOOLS 20 the game or to let down their teammates or coaches, and not knowing that the event was actually a concussion. The authors found that both knowledge base and attitude of the coaches and players were important factors for whether a potential concussion was reported, and that a significant knowledge gap still exists, especially of the less common symptoms of concussion (Register-Mihalik et al., 2015). Quite troubling is data that shows that seven out of ten athletes continue to play after a possible concussion, and four of those with the coach knowing of the injury (CDC, 2016a). Prevention Annual education. One of the most frequently used resources for concussion training is the CDC's HEADS UP website. The spectrum of information covers the needs of coaches, parents, teachers, students, and medical providers, and is free to access. Additionally, some limited information is available on the HEADS UP app. Proof of training from the website can be obtained after viewing a series of short training videos in sequence that takes about thirty minutes to complete (CDC, 2016a). Sarmiento, Mitchko, Klein, & Wong (2010) conducted research on the effectiveness of the HEADS UP tool kit for coaches and found that knowledge about concussion and how to manage it was increased after coaches viewed the training and implemented the toolkit. A single exposure to training material is generally insufficient to produce significant culture change in a sports organization, but any effort at education is worthwhile. Bramley, Patrick, Lehman, & Silvis (2012) found that high school soccer players who are educated about concussions are more likely to notify their coach of a suspected concussion than those who are not. These findings were echoed by Echlin et al. (2015). Repeating education at frequent intervals is important to increase knowledge retention. Cusimano, Chipman, Donnelly, & CONCUSSION MANAGEMENT IN SCHOOLS 21 Hutchinson (2014) evaluated two groups of hockey players, one that watched a training video and one that did not. They found an increase in knowledge about concussion immediately after being exposed to the video, but that by two months, knowledge scores were the same in both groups indicating that the effect was transient (Cusimano et al., 2014). General education campaigns. Educational theory demonstrates that ongoing education that incorporates repeated exposure to a concept, reassessment of knowledge level, and identification of barriers is far more effective than a single passive exposure to a topic (Echlin et al., 2014). Increased awareness of mechanisms of injury and symptoms improves identification of concussion and better adherence to treatment (Echlin et al., 2014). Legislation mandates implementation of a concussion plan for schools and amateur sport organizations, but does not define what the plan must include. For some organizations, the concussion plan is as minimal as a short information sheet available to read at the beginning of the season and for others there is a robust coach, parent and athlete education plan in place for pre-assessment and follow up care. Many concussion education campaigns have been largely focused only on groups of athletes participating in high risk sports, belying the fact that everyone is at risk for a concussion and reducing the burden of injury requires a population wide intervention. The age group with the highest rate of traumatic brain injury is children four years and younger, so clearly education on prevention and recognition of symptoms is needed more broadly than just young athletes (CDC, 2011b). There has been extensive media coverage of concussion in recent years, spurred on largely by emerging evidence of repeated sports related concussions leading to long term cognitive impairment, such as chronic traumatic encephalopathy. There are many websites and phone applications available with concussion information and assessment tools, but it can be CONCUSSION MANAGEMENT IN SCHOOLS 22 difficult for consumers to identify accurate information sources (Provvidenza et al., 2013). Formal training on early identification of injury, treatment strategy, and return to play guidelines in the school setting is an effective way to reach a vulnerable and impressionable sector of the population that has the potential to reduce the morbidity from this type of injury (Echlin et al., 2014). Barriers to safety strategy implementation. The use of various safety equipment, such as face guards, headgear, and mandibular orthotics as strategies to reduce the harm from sport related concussion has shown mixed results (Rodolfo, 2011). Bicycle helmets do not necessarily reduce the incidence of concussion, but do protect against skull fracture and more severe cranial and intracranial injuries. Barriers to using bicycle helmets includes lack of access and perception of negative peer response, though Howland, Sargent, & Weitzman (1989) described that children tended to respect other children who wear helmets. An important strategy to reduce injury is to enforce rules about risky types of athletic play. Difficulty lies in challenging practices of allowing athletes to do headers in ball sports, curtailing aggressive play, and convincing parents, coaches and athletes of the wisdom of sitting out after an injury to monitor for manifestation of concussion symptoms. Evidence shows that eliminating aggressive play in youth hockey leagues was effective at reducing concussion injuries (Benson et al., 2013). Unfortunately, legislative efforts to mandate concussion safety have so far shown little evidence of benefit on morbidity rates due to lack of uniformity of implementation (Benson et al., 2013). CONCUSSION MANAGEMENT IN SCHOOLS 23 Theoretical Framework Social Ecological Model of Health Promotion The Social Ecological Model of Health Promotion is a model describing the process of change from macro to micro level that encompasses the influence of public policy, community relationships, organizations, interpersonal associations and an individual's own knowledge and attitudes on a particular health behavior (McLaren & Hawe, 2005). Each one of these determinants interacts with and causes reactions and behavior on the other levels, so goals must be developed with specific strategies to target each level. Concussion has been identified as a significant problem on international level (McCrory et al., 2013). Legislation exists in all 50 states that addresses return to play, implementation of concussion policies in youth sports, and other similar laws (National Conference of State Legislatures, 2015). The Centers for Disease Control and Prevention has developed a comprehensive concussion program called HEADS UP that includes freely available resources for athletes, parents, teachers, coaches, and healthcare providers in the form of printable training materials, posters, videos, and a phone application for mobile access (CDC, 2016). On a local level, the Brain Injury Alliance of Utah links services from multiple organizations to provide education, discounted helmets, and post-injury support for patients and their caregivers (BIAU, 2016). Additionally, multiple clinics that specialize in concussion care partner with local sports organizations to provide baseline assessment of athletes, education for the coaches and parents, and post injury care. Despite the wealth of information and resources from international, national, state, and local organizations, concussion remains vastly underreported and therefore undertreated (Register-Mihalik et al., 2013; White et al., 2013). Currently, the type of prevention and CONCUSSION MANAGEMENT IN SCHOOLS 24 recognition training varies significantly between schools and recreational sport leagues, and charter schools typically have little or no programming in place to address concussion management. The national education and assessment resources that are validated and readily available, coupled with support from local organizations have laid the foundation for a successful intervention at the charter school system. The intent of this project is to enact change on the interpersonal level at the school as well as individual behavior regarding concussion prevention practices and appropriate response to a concussion injury. CONCUSSION MANAGEMENT IN SCHOOLS 25 Implementation and Evaluation Objective Implementation Evaluation #1 - Implemented pre-season baseline coordination and cognitive testing for students participating in school sports 1. Developed training video to demonstrate proper baseline testing technique based on the SCAT-3 concussion assessment tool 1. Successfully developed training video and packet that was approved by content expert and project chair 2. Training session 2. Developed training packet completed with all nurses to accompany video demonstrating consistency in assessment technique 3. Completed live training session with school nurse 3. Successfully completed team including training first implementation of video baseline assessment 4. Assisted nurses with baseline assessment of a single sport team #2 - Initiated prevention, recognition and management program for recess aides, physical education teachers, and coaches 1. Developed power point presentation based on the Centers for Disease Control and Prevention's HEADS UP campaign that is designed to be reused for future trainings 1. Presentation and handout developed as approved by content expert and project chair 2. Training of head nurse completed 2. Created handout to accompany power point presentation 3. Trained head nurse on delivery of presentation #3 - Educated teachers and nurses about how to respond to the unique needs of students returning to school after a concussion injury 1. Developed a fact sheet and checklist based on materials available on CDC's HEADS UP website 2. Combined fact sheet and checklist with in depth materials available on 1. Training materials developed as approved by content expert and project chair 2. Information was distributed to all teachers CONCUSSION MANAGEMENT IN SCHOOLS 26 CDC's HEADS UP website 3. Head nurse trained to distribute information to all teachers at all three schools #4 - Increased education to students and families regarding prevention and recognition of concussions 1. Developed short fact summaries on prevention and recognition of concussion based on CDC's HEADS UP website that were included in the schools' electronic newsletter 2. Participated in a school wide event with the Brain Injury Alliance of Utah followed by a poster contest for the students. #5 - Disseminated information 1. Packaged the educational materials created, including video, power points, and handouts, and disseminated it the state charter school organization 1. Six summaries created and disseminated in sequence to the school population by the school nurse by the end of March 2017 2. Brain Injury Alliance of Utah assemblies and student poster contest completed. 1. Article written and reviewed by content experts and project chair, with revisions done as needed 2. Submission completed by March 31st 2. Wrote a summary article of project, and submitted article to a journal focused on school nursing Discussion and Results The implementation of this project was intentionally multifaceted, in order to spread the information and cultural change over the entire target school population. Focusing only on a handful of students perceived to be at highest risk due to their chosen sport ignores that CONCUSSION MANAGEMENT IN SCHOOLS 27 concussion can occur anywhere and to anyone, and all people deserve the same attention to prevention and management. Objective #1 The first portion of the project involved implementation of a baseline assessment program for the student athletes. The SCAT-3 tool incorporates relevant medical history, cognitive assessment, balance, coordination and focused physical examination. It is free and readily available, making it an ideal choice for application where budget is a concern. Inter-rater reliability is important to the validity of this assessment, so a training video that includes real time scoring feedback as well as reference sheets were created to train the school nurses for this year, and may be used for future reference. The training video may be viewed at https://www.youtube.com/watch?v=r8a6YyU13T4. The three school nurses were trained in the assessment technique on November 10, 2016. Baseline assessments were completed on 34 high school basketball players, with six not completed due to failure to return a signed consent form. For the spring soccer season, 20 additional athletes were screened, with plans to incorporate this in to all of the secondary level athletic teams by the end of next school year. The timing of the beginning of the project rollout was two weeks after the beginning of the basketball season, so the opportunity to present information on baseline assessments at the pre-season parent meeting was missed. Explanation and consent forms were sent home with the athletes at a practice, but it proved to be difficult to get the students to return the forms. The nurses reported that several students were reluctant to have the assessment done because they misunderstood the intent of the assessment and feared that they would be disqualified from play if they were found to have poor balance or memory at baseline. The nurses were able to overcome this with individualized explanation, and the CONCUSSION MANAGEMENT IN SCHOOLS 28 education and rollout for the soccer team went much more smoothly. All of the soccer players were informed that they would not be allowed to participate in practice until the form was turned in. All 20 forms were returned within a handful of days and the assessments were completed quickly by the school nurses. The head nurse is working on a strategy with the athletic director to manage rollouts for the remaining sport teams. The nurses were able to perform the majority of the assessments during the school day over the course of two weeks by simply pulling students out of elective class periods for the 1015 minutes needed to complete it. All three nurses demonstrated competence and interrater reliability in the scoring technique. The nurses noted wide variability between the students in terms of their baseline scores, solidifying the importance of completing the assessment pre-injury so that post-injury assessment is a valid method of evaluating individualized recovery. An additional benefit of performing the baseline assessment was the opportunity to discuss safety and recognition of concussion symptoms with each athlete. Objective #2 The second portion of the project was a training module that was implemented in collaboration with the head school nurse in a series of training sessions held at each of the three schools on November 29, 2016, December 2, 2016, and December 14, 2016. The content of this module is applicable for all school faculty and staff that supervise children on the playground, during physical education classes, and coach after school sports, with an emphasis on recognizing and reporting any possible concussion injuries so that appropriate follow up care needs are identified. Fifteen coaches from the junior high and high school and 25 recess and classroom aides from the elementary school completed the training module on prevention, recognition, and CONCUSSION MANAGEMENT IN SCHOOLS 29 management of concussion. This training included reporting forms with symptom education, a workflow for how to notify parents, and follow up standards for the school nurses to carry out. One high school coach noted that he had a student sustain a concussion injury a week prior to the training and he was unsure of how to handle it. He and the other coaches expressed that they were grateful to now have a standard method of managing injuries with appropriate follow up by the school nurses. All had previously completed the HEADS UP online coach training, but had limited understanding about management and reporting of injuries prior to completing the new training course. A key conversation point was that athletes may be cleared prematurely by their healthcare provider, so the coaches and nurses are now more knowledgeable about how to spot problem symptoms that would warrant reassessment with the SCAT3 tool and referral back to the primary care provider. The recess aides were enthusiastic participants in the training session. Just a few short weeks prior to the training session, a first grader collided with another student and subsequently crashed into the wall. Later that day he went in to cardiac arrest at home due to increased intracranial pressure from a bleed sustained during his accident. Quick intervention and transfer to the local children's hospital resulted in a full recovery. The staff were very motivated by this experience to learn how to better assess students after head injuries. Since the implementation of the process of reporting all head injuries and having the nurses assess and follow up, the nurses have noted an increase in the number of referrals for evaluation, mostly from the PE teachers and recess aides. They have identified a handful of concussions. One student was assessed by the nurse and seemed well enough to go back to class, then developed nausea and a headache two hours later. His parent picked him up and took him CONCUSSION MANAGEMENT IN SCHOOLS 30 to the doctor where he was indeed diagnosed with a concussion. He spent a week recuperating at home before returning to school. Objective #3 The third portion of the project was a short training module designed to disseminate the information on the CDC's HEADS UP webpage regarding interventions and scholastic modifications to assist children who are returning to school after a concussion. This included a presentation to complement reference materials from HEADS UP. Presentations were given at the three schools on the following dates: November 30, 2016, December 2, 2016, and January 4, 2017. A total of 110 teachers between all three schools participated in this training module, which was integrated in to their staff meetings. The elementary teachers were the most receptive and participative, largely due to how supportive their principal was of the project. The principals of the junior high and high schools were present at the trainings, but less engaged. In hindsight, it would have been beneficial to have a formal meeting with the principals before the project was rolled out to explain the scope and intent rather than relying on email communication and the head nurse to relay the information. Objective #4 The fourth portion of the project was an education campaign designed to increase the knowledge and understanding of the students and their families of how to prevent, identify and respond to a concussion. Six concise summaries were released sequentially through the school's electronic weekly newsletter reaching an additional population of an estimated 1,000 adults in January and February of 2017. Approximately 2,150 students attended the assemblies put on by the Brain Injury Alliance of Utah (BIAU) in February, then students were invited to participate CONCUSSION MANAGEMENT IN SCHOOLS 31 in a poster contest about prevention and identification of a concussion. The contest fliers were handed out immediately after the assembly and then posted around the school. The nurses noted that while many students expressed interest, in the end, just 10 submissions were received. The presenter from BIAU had technical difficulties during the high school presentation, so it did not go as well as hoped. BIAU brought in a motocross racer who had a career ending concussion after a crash while not wearing a helmet to speak to the junior high, and it was well received. The final presentation to the elementary aged children was presented at a level above the understanding of many of the younger children, which is an issue BIAU will work to remedy in the future. Objective #5 The fifth and last portion of the project was dissemination of findings. The completed toolkit was disseminated electronically to the Director of Training at the Utah Association of Public Charter Schools (UAPCS), which serves 127 schools across the state and a total population of just over 71,000 students (Utah State Charter School Board, 2017). The toolkit will be released online to members through the UAPCS resource library. Additional training on utilizing the toolkit will be completed June 2017 in breakout sessions at the annual charter school conference. An article describing the implementation of this project was submitted to the Journal of School Health. The Journal of School Health accepts submissions in a variety of categories, including health service applications in schools, which was suitable for the scope of this project. Future Recommendations While the rollout went well overall, we learned lessons that will improve future implementations. One of the key factors that made this a successful intervention was the CONCUSSION MANAGEMENT IN SCHOOLS 32 significant support and flexibility of the nursing staff. This school system is unusual for having a much higher nurse to student ratio than the statewide average. In schools where a nurse is not on location the majority of the time, the nurse can still schedule and lead the training, but the framework for reporting and follow up will need to be modified. The school should designate another person at the school to use the standardized checklists on the HEADS UP form as a method to screen students for development of symptoms at 1-2 days post injury, then refer the student to the nurse and/or their medical provider for a more detailed evaluation if any of the symptoms are present. The implementation process went more smoothly at the elementary school because the principal was vocally supportive of it and attended both of the training meetings. For future rollout opportunities, a meeting with the school leadership and nursing staff would be beneficial in advance. The second round of athlete assessments went very well compared with the first, due to the way the information was given at the beginning of the season and the coach requiring the athletes to turn in the permission forms before being allowed to play. Schools that adopt the baseline assessment module will have better success if the coaches, parents, and athletes are well informed in advance of the purpose and expectations of baseline screening. The content of the toolkit is modular and designed to be customizable to fit the needs of individual schools. Schools that do not have athletic programs may choose to use just the training segments for PE teachers, aides, and teachers. Templates for letters to the parents and the educational summaries in the toolkit are written at a 7th-8th grade level and can easily be modified to suit the needs of each school. CONCUSSION MANAGEMENT IN SCHOOLS 33 The time commitment is most significant for the school nurse as he/she must go through the baseline assessment training, implement the rollout of the athlete screenings, and learn then teach the training sessions for the faculty and staff. This may consist of several hours of work, though the athlete screenings can be integrated into the normal workflow of the school day to avoid incurring overtime hours. The baseline assessment training is approximately 90 minutes in length, the coach/recess aide training 30-45 minutes, and the teacher training 20-30 minutes. The assemblies were under an hour in duration, and in areas where the BIAU is not available, school staff may choose someone from their community to speak on helmet safety and concussion recognition. The BIAU will improve the flow of their assemblies the more opportunity they have to present them. The other printed resources can be made electronically or in print form for long-term access for review. CONCUSSION MANAGEMENT IN SCHOOLS 34 DNP Essentials VI: Interprofessional collaboration for improving patient and population health outcomes The goal of reducing morbidity and mortality from concussion requires a multidisciplinary approach. The DNP prepared nurse practitioner is uniquely qualified and well prepared to construct the framework for and oversee the implementation of such public health interventions. This project involved cooperation between the school nurses, teachers, coaches, ancillary school staff, local healthcare providers and community organizations, including BIAU and the UAPCS. Collaboration with BIAU and UAPCS will allow dissemination of the project to a much wider audience, numbering in the tens of thousands, with the potential to make a significant impact in reducing morbidity from concussion injuries in school age children. VII - Clinical prevention and population health for improving the nation's health. Implementation of a concussion prevention, recognition and management program for a school system falls directly in line with this essential in terms of health promotion and risk reduction. Concussion is an issue of significant national public health concern, and the local incidence in school age children is higher than the national average. The DNP prepared nurse practitioner has the research and development skills necessary to create a public health intervention. School nurses are well positioned to have a positive impact on the health of children and adolescents by implementing a structured concussion program, with a ripple effect to their families. CONCUSSION MANAGEMENT IN SCHOOLS 35 Conclusion Public health interventions are population based, guided by an assessment of community health, and consider all levels of prevention and practice. Concussion is well identified as a growing public health problem, and previous efforts focused on small groups of athletes deemed to be at most risk has proven to be an ineffective way to reduce the incidence and morbidity of this type of injury. The intent of this project was to spread awareness of concussion widely across the whole school population, in addition to implementing a structured program for prevention, recognition, and management that is self-contained and robust enough to be used for years to come. The CDC's HEADS UP curriculum provided an excellent basis for the toolkit, and the additional customization to include the SCAT-3 baseline assessment and powerpoint presentations suitable for large group training led to a final product that is simple and flexible enough to implement in a variety of school settings. Using the free SCAT-3 assessment tool is a cost effective approach for charter schools to address athlete safety, and the time required to train the staff throughout the school with the modules is minimal. Repeated exposure to the topic through the training sessions, newsletter, assemblies and poster contest solidifies learning. The total reach of this project numbers in the tens of thousands of people who were directly trained during rollout and who will have access to the toolkit in the future. It is not possible to measure a reduction in morbidity or incidence directly influenced by this project, but the charter school system where it was implemented has enacted culture and practice changes that will certainly enhance the health of their students. These include baseline assessment for their student athletes, systematic training of the entire staff, focused education on concussion prevention and recognition to the student body and parents, and implementation of a consistent method for reporting, tracking and follow up on injured students. The scope of the project CONCUSSION MANAGEMENT IN SCHOOLS encompasses primary, secondary, and tertiary prevention, across individual, community and systems focused practice change, which are the cornerstones of public health interventions. 36 CONCUSSION MANAGEMENT IN SCHOOLS 37 References Arbogast K. B., Curry A. E., Pfeiffer M. R., Zonfrillo, M., Haarbauer-Krupa, J., Breiding, M., …Master, C. L. (2016). Point of health care entry for youth with concussion within a large pediatric care network. JAMA Pediatrics, e160294. http://doi.org/10.1001/jamapediatrics.2016.0294 Armstrong, C. (2014). Evaluation and management of concussion in athletes: Recommendations from the AAN. 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Sports-related concussions in youth: Improving the science, changing the culture. Washington, D.C., The National Academies Press. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK169016/pdf/Bookshelf_NBK169016.pdf CONCUSSION MANAGEMENT IN SCHOOLS 40 Kerr, Z. Y., Register-Mihalik, J. K., Marshall, S. W., Evenson, K. R., Mihalik, J. P., & Guskiewicz, K. M. (2014). Disclosure and non-disclosure of concussion and concussion symptoms in athletes: Review and application of the socio-ecological framework. Brain Injury, 28(8), 1009-1021. http://doi.org/10.3109/02699052.2014.904049 Kroshus, E., Baugh, C. M., Daneshvar, D. H., Nowinski, C. J., & Cantu, R. C. (2015). Concussion reporting intention: A valuable metric for predicting reporting behavior and evaluating concussion education. Clinical Journal of Sport Medicine, 25(3), pp. 243-247. http://doi.org/10.1097/JSM.0000000000000137 Kutcher, J. S., & Giza, C. C. (2014). Sports Concussion Diagnosis and Management. 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Concussion research at the National Institutes of Health: an update from the National Institute of Neurologic Disorders and Stroke. Future Medicine, 1(2). doi: 10.2217/cnc.15.10 CONCUSSION MANAGEMENT IN SCHOOLS 41 National Conference of State Legislatures. (2015, November 18). Traumatic brain injury legislation [webpage]. Retrieved from http://www.ncsl.org/research/health/traumaticbrain-injury-legislation.aspx Novak, Z., Aglipay, M., & Barrowman, N. (2016). Association of persistent postconcussion symptoms with pediatric quality of life. JAMA Pediatrics. Advance online publication. doi: 10.1001/jamapediatrics.2016.2900 Office of Disease Prevention and Health Promotion. (2016). IVP-2.3 Reduce emergency department (ED) visits for nonfatal traumatic brain injuries. Retrieved from https://www.healthypeople.gov/node/4747/data_details Patricios, J., Kutcher, J., Raftery, M., Makdissi, M., Ellenbogen, R., Putukian, M., McCrea, ...., & Fuller, G. (2016, March 29). What are the critical elements of side-line screening that can be used to establish the diagnosis of concussion? A systematic review. Paper presented at the 5th International Consensus Conference on Concussion in Sport, Berlin, Germany. Retrieved from http://www.crd.york.ac.uk/PROSPEROFILES/37831_PROTOCOL_20160315.pdf Protection of Athletes with Head Injuries Act, Utah Code, 26-53-1, sections 101, 102, 201, 301, 401 (2011). Provvidenza, C., Engebretson, L., Tator, C., Kissick, J., McCrory, P., Sills, A., & Johnston, K. (2013). From consensus to action: Knowledge transfer, education and influencing policy on sports concussions. British Journal of Sports Medicine, 47(5), pp. 332-338. doi: 10.1136/bjsports-2012-092099 CONCUSSION MANAGEMENT IN SCHOOLS 42 Register-Mihalik, J. K., Guskiewicz, K. M., McLeod, T. C. V., Linnan, L. A., Mueller, F. O., & Marshall, S. W. (2013). Knowledge, attitude, and concussion-reporting behaviors among high school athletes: A preliminary study. Journal of Athletic Training, 48(5), pp. 645- 653. http://doi.org/10.4085/1062-6050-48.3.20 Robbins, C., Daneshvar, D., Picano, J., Gavett, B., Baugh, C., Riley, D., … McKee, A. (2014). Self-reported concussion history: Impact of providing a definition of concussion. Open Access Journal of Sports Medicine, 99. http://doi.org/10.2147/OAJSM.S58005 Navarro, R. (2011). Protective equipment and prevention of concussion - what is the evidence? Head and Neurologic Conditions, 10(1), pp. 27-31. doi: 10.1249/JSR.0b013e318205e072 Sarmiento, K., Mitchko, J., Klein, C., & Wong, S. (2010). Evaluation of the Centers for Disease Control and Prevention's concussion initiative for high school coaches: "Heads Up: Concussion in high school sports". Journal of School Health, 80(3), pp. 112-118. doi: 10/1111/j.1746-1561.2010.00491.x Utah Department of Health. (2015a). Health Indicator Report of Student Injuries. Retrieved from https://ibis.health.utah.gov/indicator/view/StuInj.InjType.html Utah Department of Health. (2015b). Traumatic Brain Injury. Retrieved from https://ibis.health.utah.gov/indicator/view/TBI.html Utah State Charter School Board. (2017, January). Utah's Public Charter Schools Report, January 2017. Retrieved from http://www.schools.utah.gov/charterschools/AnnualReports/2017JanuaryCharter.aspx CONCUSSION MANAGEMENT IN SCHOOLS 43 White, P. E., Newton, J. D., Makdissi, M., Sullivan, S. J., Davis, G., McCrory, P., … Finch, C. F. (2013). Knowledge about sports-related concussion: Is the message getting through to coaches and trainers? British Journal of Sports Medicine, 48, pp. 119-124. doi: http://doi.org/10.1136/bjsports-2013-092785 CONCUSSION MANAGEMENT IN SCHOOLS Appendix A - Project Proposal 44 CONCUSSION MANAGEMENT IN SCHOOLS 45 CONCUSSION MANAGEMENT IN SCHOOLS 46 CONCUSSION MANAGEMENT IN SCHOOLS 47 CONCUSSION MANAGEMENT IN SCHOOLS 48 CONCUSSION MANAGEMENT IN SCHOOLS 49 CONCUSSION MANAGEMENT IN SCHOOLS 50 CONCUSSION MANAGEMENT IN SCHOOLS 51 CONCUSSION MANAGEMENT IN SCHOOLS 52 CONCUSSION MANAGEMENT IN SCHOOLS 53 CONCUSSION MANAGEMENT IN SCHOOLS 54 Appendix B - IRB Exemption To: HEIDI SPENCER VAWDREY Inbox Thursday, October 06, 2016 11:03 AM Heidi, My name is Anna Shirley and I am an administrator at the IRB. Ann Johnson asked that I respond to you. At the moment, we are under-staffed and I am helping Ann with some of her workload so that she can focus on her duties as Associate Director. From what you've described I would agree with you and your advisor that your project doesn't require an IRB submission. It sounds like you are implementing a program rather than research. We define research as "A systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge." I don't see from your description that you are conducting an investigation and you mentioned you are not collecting data. If I am missing something, please feel free to correct me. If you want to have an official determination however, you will still need to make a submission to the IRB. We do have the option for you to submit a Request for Non-Human Subject Research Review. This is a shorter version of our New Study Application. Once complete, it will be reviewed and a determination will be made. To make this request, there will be a question on the first page of our application ( question 7) asking what type of application is being submitted and you would answer "Request for Non-Human Subject Research Review". Please let me know if you have any additional questions or concerns. I am best reached by e-mail as I work remotely from home. Good luck! Anna University of Utah IRB CONCUSSION MANAGEMENT IN SCHOOLS 55 Appendix C - Program Blueprint • Program introduction letter template • Baseline Assessment Module o Introduction letter template for parents and athletes o Training module for nurses - 90-120 minutes •  Summary sheet  Training session outline  Power Point module  SCAT3 training video - may also access online at https://www.youtube.com/watch?v=r8a6YyU13T4  SCAT3 and Child SCAT3 forms  BESS reference sheet  Injury reporting forms - HEADS UP assessment form for serious injuries and mild injury notification letter template Concussion Prevention and Recognition Module o Training module for coaches, aides and school support staff - 30 - 40 minutes •  Summary sheet  Power Point module  HEADS UP Coaches guide  Report of injury form for parent/guardian for mild injuries  HEADS UP Concussion assessment form for serious injuries  HEADS UP information sheet to accompany report of injury form Return to School Toolkit o Training module for teachers - 15-20 minutes •  Power Point module  HEADS UP fact sheet for schools  HEADS UP 2 page summary sheets  HEADS UP 12 page detailed information sheets School Wide Education Toolkit o Series of six information bulletins for school newsletter o Poster contest flier sample • Additional documentation o Concussion Training Session Rolls CONCUSSION MANAGEMENT IN SCHOOLS 56 Appendix D - Program Introduction Letter Date {…..} Dear parents and students, We will be introducing a school wide concussion program over the next few months. Did you know that half a million children and teens in the United States are treated in an emergency room each year for a concussion? Utah has a higher than average rate of concussions in young people. Concussions can be tricky to identify because the symptoms may not show up right away. The good news is that most people recover completely in a few days. However, about 10-15% of people can have troublesome symptoms for weeks or even months after a concussion. Children and adolescents take longer to recover than adults. Concussion is an important health risk for every student, not just those who are playing sports. We will be training our staff on ways to reduce harm and to identify potential concussion injuries at school. If your child sustains a hit to the head or neck, you will receive a letter home that has details about the warning signs to watch for and when to seek treatment. We are also beginning a program to do a baseline concussion assessment in our athletes. If they do become injured, post injury scores can be compared with pre injury scores to guide the recovery process. If your athlete is on a team that will be screened, you will receive separate notification of this process. All students will have the opportunity to participate in educational events and a poster contest to increase awareness about concussion. We look forward to the next few months as we incorporate this concussion program in to our school. Please contact our school nurse {…….} if you have any questions or concerns. Warm Regards, {………………..} CONCUSSION MANAGEMENT IN SCHOOLS 57 Appendix E - Baseline Concussion Assessment Toolkit Concussion Baseline Assessment Training for School Nurses Summary Sheet • Concussion is a serious health problem - every concussion is a brain injury o Symptoms include physical, cognitive, emotional, and sleep problems o Often not recognized and therefore undertreated because the symptoms develop over hours to days o Kids take longer to heal than adults o 85% heal within about 10 days, but 15% may have symptoms for weeks to months • Comprehensive Concussion Prevention, Recognition, and Management Program o Nurse oversees administration of the program, including baseline screening, management of injuries, follow up, documentation, and training staff o Coaches, staff, PE teachers - prevention, recognize and report o Teachers - prevention, recognize and report, and learning accommodations o Students and parents - obey safety rules, report injuries, follow treatment plan • Baseline assessment o Done every 1-2 years at the beginning of the season to establish healthy baseline o Repeat assessments using the same tool track the recovery process o Athletes returned to play too soon are at risk for a second injury o No single tool has been identified as the best, but tools that assess multiple aspects of cognitive function are better o Baseline screenings offer an important opportunity to educate the athlete about concussion o SCAT3 tool is free, completed in about 15 minutes, and validated for ages 13+ o Younger athletes can be assessed using the Child SCAT3 • Resource links o SCAT3 Tool: http://bjsm.bmj.com/content/47/5/259.full.pdf o Training video: https://www.youtube.com/watch?v=r8a6YyU13T4 o Balance pad example: https://www.amazon.com/PROCIRCLE-Balance-PadExercise-Physical/dp/B014GYDSPO/ o HEADS UP: http://www.cdc.gov/headsup/ CONCUSSION MANAGEMENT IN SCHOOLS Appendix F - Baseline Assessment Training Module 58 CONCUSSION MANAGEMENT IN SCHOOLS 59 CONCUSSION MANAGEMENT IN SCHOOLS 60 CONCUSSION MANAGEMENT IN SCHOOLS 61 CONCUSSION MANAGEMENT IN SCHOOLS 62 CONCUSSION MANAGEMENT IN SCHOOLS 63 CONCUSSION MANAGEMENT IN SCHOOLS 64 CONCUSSION MANAGEMENT IN SCHOOLS 65 CONCUSSION MANAGEMENT IN SCHOOLS 66 CONCUSSION MANAGEMENT IN SCHOOLS 67 CONCUSSION MANAGEMENT IN SCHOOLS 68 CONCUSSION MANAGEMENT IN SCHOOLS 69 CONCUSSION MANAGEMENT IN SCHOOLS 70 CONCUSSION MANAGEMENT IN SCHOOLS 71 CONCUSSION MANAGEMENT IN SCHOOLS 72 CONCUSSION MANAGEMENT IN SCHOOLS 73 CONCUSSION MANAGEMENT IN SCHOOLS 74 CONCUSSION MANAGEMENT IN SCHOOLS 75 CONCUSSION MANAGEMENT IN SCHOOLS 76 Appendix G - Baseline Assessment Introduction Letter Date {….} Dear parents and student athletes, The health and safety of our student athletes is our top priority. State law requires that schools and amateur sport associations have a concussion plan and that athletes suspected of a concussion must be removed from play and may not return until cleared by a medical provider. We will be implementing baseline concussion screenings at the beginning of our season as part of our safety program. The screening is based on the SCAT3 tool and takes about 15 minutes to complete. The assessments will be done during normal practice time by the school nursing staff, and the results will be kept on file to be retrieved if the athlete is injured. The assessment includes a brief medical history, symptom checklist, and evaluation of orientation, memory, concentration, balance, and coordination. Concussion is common injury that can be serious. Concussions effect each person differently, and it is important to assess all areas of brain function. A person who has had one concussion is at increased risk of sustaining another. It usually takes longer to recover after a second injury. An athlete is more likely to get another concussion if they return to play too soon. Baseline assessment also provides an important opportunity to educate the student athlete. The first portion of the assessment is a brief health history. Please fill out the health history information below, which we will transfer to the assessment tool. If you do not want your student athlete to participate in baseline testing, please indicate below, and do not complete the health history questions. Please contact our school nurse {…….} if you have any questions or concerns. Forms MUST BE RETURNED BY {…date…} at regular practice. Athlete name _______________________________________ Sport____________________________ Grade _______ Date of birth _________________ Parent/Guardian phone number_______________________________________ Parent/Guardian name_______________________________ Signature _______________________________________ ____ I hereby give my permission for my athlete to participate in concussion baseline assessment ____ I DO NOT give my permission for my athlete to participate in concussion baseline assessment CONCUSSION MANAGEMENT IN SCHOOLS How many concussions do you think you have had in the past? When was the most recent concussion? How long was the recovery from the most recent concussion? Have you ever been hospitalized or had medical imaging done for a head injury? Have you ever been diagnosed with headaches or migraines? Do you have a learning disability, dyslexia, ADD/ADHD? Have you ever been diagnosed with depression, anxiety or other psychiatric disorder? Has anyone in your family ever been diagnosed with any of these problems? Are you on any medications? List medications: 77 CONCUSSION MANAGEMENT IN SCHOOLS 78 Appendix H - Concussion Notification Letter Date ______________ To the parent or guardian of _____________________, This letter is to inform you that your child sustained an injury to the head or neck today while at school that may result in a concussion. As part of our concussion protocol, we notify the parents or guardians so that the child can be monitored for symptoms that may develop over the next few days. Most concussions are relatively minor and resolve with rest after a few days. However, some children and teens may have symptoms that last longer than normal. This may cause problems with school and sports. People who have had one concussion are at greater risk for a second one and it takes longer to heal after the next injury. Please follow up with your child's primary care provider if you have any concerns about their health. Please read the attached information from the Centers for Disease Control about symptoms of concussion and how to take care of your child at home. Pay close attention to the warning signs that mean you should take your child directly to the emergency room for evaluation. If you have any questions, please contact the school nurse at {…….}. You will receive a follow up phone call or email in 2-3 days as well. Below are details of your child's injury: Time: _______________ Location: ______________________________________ Witness(es): __________________________________________________________________ Description of incident: _________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Symptoms: (circle all that apply) Loss of consciousness Headache Nausea Balance problems Confusion Sensitivity to light Sensitivity to noise Changes in vision "Not feeling right" Mood changes Unusual behavior Slurred speech Poor memory Actions/Treatment: _________________________________________________________ ______________________________________________________________________________ CONCUSSION MANAGEMENT IN SCHOOLS 79 Follow up plan: _______________________________________________________________ ______________________________________________________________________________ Assessed by: __________________________________________________________________ For additional information about concussion prevention, recognition and management, please visit www.cdc.gov/headsup/index.html CONCUSSION MANAGEMENT IN SCHOOLS 80 Appendix I - Concussion Management and Prevention in Schools Summary Concussion Management and Prevention in Schools Summary Sheet • Comprehensive Concussion Prevention, Recognition, and Management Program o Nurse oversees administration of the program, including baseline screening, management of injuries, follow up, documentation, and training staff o Coaches, staff, PE teachers - prevention, recognize and report o Teachers - prevention, recognize and report, and learning accommodations o Students and parents - obey safety rules, report injuries, follow treatment plan • Concussion is a serious health problem - every concussion is a brain injury o Symptoms include physical, cognitive, emotional, and sleep problems o Often not recognized and therefore undertreated because the symptoms develop over hours to days o 85% heal within 10 days, but 15% may have symptoms for weeks to months • Treatment o Immediately remove from play - It's the law! o Cognitive rest - no screens, reading, or school work initially o Physical rest - no physical exertion initially o Step-wise return to school and play activities o May need academic accommodations o If symptoms return with increase in activity, step back for 24 hours and try again o Recovery can occur faster in one area of brain function than another o Return to play too soon = increased risk for another injury and longer recovery • Prevention o Culture of safety - talk about reporting, concussion plan, use of safety equipment, rules about player contact, baseline assessment for athletes o Soft surfaces on playgrounds, adequate supervision, correctly fitting helmets, car seats • Reporting o Every head or neck injury must be reported so that parents can monitor for concussion symptoms and the nurse can follow up o Standard notification letter and information packet • Resource: HEADS UP: http://www.cdc.gov/headsup/ CONCUSSION MANAGEMENT IN SCHOOLS 81 Appendix J - Concussion Management and Prevention in Schools: Training for Coaches and Aides CONCUSSION MANAGEMENT IN SCHOOLS 82 CONCUSSION MANAGEMENT IN SCHOOLS 83 CONCUSSION MANAGEMENT IN SCHOOLS 84 CONCUSSION MANAGEMENT IN SCHOOLS 85 CONCUSSION MANAGEMENT IN SCHOOLS 86 CONCUSSION MANAGEMENT IN SCHOOLS 87 CONCUSSION MANAGEMENT IN SCHOOLS 88 CONCUSSION MANAGEMENT IN SCHOOLS 89 CONCUSSION MANAGEMENT IN SCHOOLS 90 CONCUSSION MANAGEMENT IN SCHOOLS 91 CONCUSSION MANAGEMENT IN SCHOOLS 92 CONCUSSION MANAGEMENT IN SCHOOLS 93 CONCUSSION MANAGEMENT IN SCHOOLS 94 CONCUSSION MANAGEMENT IN SCHOOLS 95 CONCUSSION MANAGEMENT IN SCHOOLS 96 CONCUSSION MANAGEMENT IN SCHOOLS 97 CONCUSSION MANAGEMENT IN SCHOOLS 98 CONCUSSION MANAGEMENT IN SCHOOLS 99 CONCUSSION MANAGEMENT IN SCHOOLS Appendix K - Helping Students Recover From a Concussion 100 CONCUSSION MANAGEMENT IN SCHOOLS 101 CONCUSSION MANAGEMENT IN SCHOOLS 102 CONCUSSION MANAGEMENT IN SCHOOLS 103 CONCUSSION MANAGEMENT IN SCHOOLS 104 CONCUSSION MANAGEMENT IN SCHOOLS 105 CONCUSSION MANAGEMENT IN SCHOOLS 106 CONCUSSION MANAGEMENT IN SCHOOLS 107 CONCUSSION MANAGEMENT IN SCHOOLS 108 CONCUSSION MANAGEMENT IN SCHOOLS 109 CONCUSSION MANAGEMENT IN SCHOOLS 110 CONCUSSION MANAGEMENT IN SCHOOLS 111 CONCUSSION MANAGEMENT IN SCHOOLS 112 Appendix L - Newsletter Series Dear staff, students, and parents, As part of our comprehensive concussion program, we will be featuring a series of six informational spotlights in our newsletters. The health of our students is important to us, and we feel it is vital for every family to know how to identify a concussion. We hope you learn from this series, and encourage you to direct any questions you may have to your healthcare provider or our school nurses, {……..}. Warm regards, {……………..} 1) What is a concussion? Did you know that more than half a million kids per year are treated in the emergency department for traumatic brain injury, including concussions? Most concerning is that that nationally, the rate of head injuries has been steadily increasing for the last 15 years. Every concussion is a brain injury, and a person who has had one concussion is at greater risk for another. A concussion is an injury to the brain caused by a bump, blow or jolt to the head, or a hit on the body that causes the head to quickly move back and forth. These forces and movements cause the brain to bounce around inside the skull, which damages the brain cells. The damage cannot be seen on an x-ray or CT scan since it happens inside the cells. Children and teens take longer to heal from a concussion because their brains are still developing. Each concussion injury is unique and different areas of brain function are effected. A common myth is that you have to lose consciousness for a head injury to be a concussion. This is not true! Very few people are "knocked out" when they sustain a concussion, and you can have very severe symptoms without having lost consciousness. For more information about concussion, please visit www.cdc.gov/headsup/. 2) Signs and Symptoms of a concussion/danger signs Concussions can be difficult to identify because the symptoms can take a few hours or even days to develop and they may change over time. For example, a person may be stunned briefly at the time of injury but otherwise seem fine. They may wake up the next morning with a bad headache, blurry vision, fatigue, and nausea. Over the course of a few days, the vision problems and nausea may clear up, but then problems with concentration and sleep can set in. Because it can take time for the symptoms to show up, it is important to remove athletes from play any time you suspect a concussion and not let them return to play the same day. Knowing the signs and CONCUSSION MANAGEMENT IN SCHOOLS 113 symptoms of concussion can help you identify when you need to have someone seen by a medical provider after an injury. Concussions cause symptoms in four major categories: physical, cognitive, emotional, and sleep. Physical symptoms include headache, fatigue, nausea, vomiting, problems with balance, changes in vision, numbness, tingling, and sensitivity to light or sound. Cognitive symptoms include feeling mentally foggy or slow, trouble with concentration and learning new information, confusion, and amnesia. Emotional symptoms include irritability, sadness, anxiety, depression, and nervousness. Sleep symptoms include trouble falling asleep, sleeping more or less than usual, and sleeping at inappropriate times. Warning signs that mean you should take someone to the emergency room right away for evaluation include the following: loss of consciousness of any length of time, restlessness, agitation, increased confusion, unusual behavior, seizures, repeated vomiting, slurred speech, weakness, decreased coordination, a headache that gets worse and won't go away, inability to wake up, and one pupil larger than the other. Anyone suspected of having a concussion should be evaluated by a medical provider. Every concussion is a brain injury! For more information about the signs and symptoms of concussion, please visit www.cdc.gov/headsup/. 3) Recovery from a concussion The prescription for recovery from a concussion is simple: rest. This means resting your brain and your body until your symptoms improve. Brain rest means no screens (TV, computer, tablet, phone), reading, school work, or anything that takes concentration initially. Physical rest means getting a lot of sleep and rest, and avoiding any exertion initially. As your symptoms improve, your medical provider can guide you through the process of adding back cognitive and physical activities a little at a time. If your symptoms get worse at any point, then you must step back for 24 hours and rest, and then try again. It is common for symptoms to get better in one area of brain function more quickly than another. Returning to sports or full days of school too soon can make the healing process take longer. The good news is that about 85% of kids and teens recover fully within 10 days. The bad news is that the remaining 15% can have symptoms that linger for weeks or even months! In these cases, the help of concussion specialists is needed for full recovery. Save the brain. You only get one! Take the time you need for full recovery. For more information about recovering from a concussion, please visit www.cdc.gov/headsup/. 4) Concussions and Sports Seven out of ten athletes reported that they continued playing after they hit their head hard enough to sustain a concussion. The most common reasons included not knowing that they were CONCUSSION MANAGEMENT IN SCHOOLS 114 hurt, not recognizing the symptoms of concussion, not wanting to disappoint their coach or team, and simply not wanting to leave the game. Keeping athletes safe is a team effort between coaches, referees, parents, and the athletes themselves. It is far better for an athlete to miss one game than to miss a whole season or more due to an undertreated brain injury. When in doubt, sit them out. It is the law for young athletes to be removed from play when a concussion is suspected, and to not return to play until cleared by a medical provider. When an athlete is diagnosed with a concussion, return to play is a six step process. It starts with complete physical rest. The second step is 10-15 minutes of light aerobic activity. The third step is sport-specific exercise that does not involve impact, such as running drills. The fourth step adds more complex training drills and resistance training. The fifth step allows return to normal training activity once medically cleared. The sixth and final step is complete return to play once they have been cleared by a medical provider. For an uncomplicated concussion, the athlete may move up a step each day and potentially return to full play as soon as a week after the injury. If symptoms return with an increase in activity, then step back to the previous level for 24 hours and try again. Take the time you need to recover. Your brain is worth it! For more information about returning to sports after a concussion, please visit www.cdc.gov/headsup/. 5) Returning to school Many students have problems with concentration, learning new material, and functioning in the classroom environment after a concussion. Since most students recover from a concussion within 10 days, the teacher may only need to make temporary, informal learning accommodations. For students who have symptoms lasting longer than 10 days, the school nurse and teacher can help determine if a formal 504 plan is needed. Students struggling with symptoms after a concussion may need periodic breaks, a quiet place to take tests, or a lighter work load. If memory is a problem, written instructions or the ability to record class may help. Symptoms that last longer than 10 days should be evaluated by a concussion specialist to determine the best therapy and approach to recovery. Be kind to your brain. You only get one! For more information about returning to school after a concussion, please visit www.cdc.gov/headsup/. 6) Brain injury prevention By law, all schools and amateur sport teams must have a concussion plan in place. A culture of safety starts with talking about concussions regularly. Most athlete concussions happen as a result of physical contact with another player. Coaches and referees must enforce rules about player contact and the use of safety equipment. Many sport teams perform baseline concussion assessments at the beginning of the season. If an athlete is injured, they are re-assessed using the CONCUSSION MANAGEMENT IN SCHOOLS 115 same screening tool to help assess the recovery process. Baseline assessments also offer an important opportunity to educate the athlete about concussion safety and symptoms to report. General head injury prevention includes wearing appropriately fitting helmets and other safety gear during recreation and sports, using age and size appropriate car seats, soft surfaces underneath playground equipment, and home safety devices such as stair gates and window well guards. Equally important is appropriate adult supervision. For more information about concussion prevention, please visit www.cdc.gov/headsup/. For information on discounted helmets, please visit www.biau.org. CONCUSSION MANAGEMENT IN SCHOOLS Appendix M - Article for Submission 116 CONCUSSION MANAGEMENT IN SCHOOLS 117 Implementation of a Cost Effective Comprehensive Concussion Program in a Charter School System By Heidi Vawdrey, BSN, RN, CCRN, DNP student Reviewed by Jennifer Hamilton, DNP, APRN, CPNP-PC, Shelley Cundick, RN, and Colby Hansen, MD Concussions are a common injury among children with a significant potential for longterm harm. The reported incidence of concussions has risen steadily in the last 15 years in children and adolescents, due in part to increased public awareness.1 In 2010, about 2.5 million emergency department visits, hospitalizations or deaths in the United States for people of all ages were attributed all or in part to traumatic brain injury.2 Each year, a half million school age children are seen in the emergency room for concussion, and an average of just over 21,000 of those visits to the emergency room are attributed to injuries sustained specifically on the playground.2,3 However, the disease burden is grossly underestimated in current data, which is culled from emergency department visits and hospitalizations, and accounts for as little as 1215% of the total initial access to health care for concussion injuries.4 There is a substantial public knowledge gap about mechanism of injury, symptoms, treatment, and long-term complications.5-8 Concussion symptoms evolve over several hours or days, and often initially go unrecognized and therefore undertreated. About 85% of people of all ages recover fully from a concussion in a week to 10 days, but the remaining 15% can have lingering symptoms for weeks to months. Children and adolescents typically require a longer recovery period than adults, and may experience decline in school performance, mood and behavioral changes, persistent headaches, memory loss and other troublesome symptoms.9 All children experience a prolonged decrease in health related quality of life after a concussion, even those who have resolution of symptoms within the expected timeframe.10 Appropriate prevention, recognition, and response in the school setting is an important way to reduce the burden of harm in this age group. Laws in all of the 50 United States mandate removal from play and concussion programs for schools and sports, however there is little specification about what the programs should include. Many programs are inadequate, or are only focused on subcategories of students deemed to be at risk due to the nature of their sport.11 This belies the fact that everyone is at risk for concussion, and education about prevention and recognition is more beneficial and likely to reduce morbidity when spread across the whole population. There are a wealth of resources online for concussion education, including the CDC's HEADS UP webpage, but it can be difficult to sift through the content and identify the portions that are most appropriate for a specific population.2 Additionally, few of the resources are structured for group training. School budgets are notoriously stretched thin, so a cost effective solution that is sustainable for future use is critical. Many products for baseline assessments and athletic program training require ongoing paid subscriptions and can be cost prohibitive. Charter schools in Utah rely on pooled resources through the state charter association for supplemental training and materials. There is currently no recommended concussion training material on the association's resource page. A K-12 suburban charter school system with CONCUSSION MANAGEMENT IN SCHOOLS 118 approximately 2,150 students and three nurses on staff was chosen to pilot a project with a series of interventions to implement a robust low cost concussion prevention, recognition, and management program. Prior to the intervention, the school did not have a systematic way of tracking and following up on concussion injuries. Training for the coaches consisted only of the short self-paced learning module on the CDC's HEADS UP website. There was no additional training for students, parents, or staff. Objectives for this project were as follows: • • • • • Implement pre-season baseline coordination and cognitive testing for student athletes Initiate prevention, recognition and management program for aides, coaches, and staff Educate teachers and nurses about responding to the unique needs of students returning to school after a concussion injury Increase education to students and families regarding prevention and recognition of concussion Disseminate findings The program is structured to place the school nurses in charge of overseeing the implementation, conducting baseline concussion screenings, managing immediate injuries, and performing appropriate follow up and documentation. The nurses use the formulated curriculum to train the coaches and staff on how to prevent, recognize and respond to injuries, in addition to monitoring students once they return to school and athletic activities. The teachers also undergo annual training from the nurses on prevention, recognition and reporting, and a special focus on meeting the learning needs of students who return to school after a concussion injury. Students and parents are educated annually on safety rules, recognizing symptoms, reporting injuries, and following the treatment plan. To accomplish the first three objectives, blended learning training modules were created based on information from the Center for Disease Control's HEADS UP program and the freely available SCAT-3 assessment tool. These included original video, interactive powerpoint presentations, reference hand outs, and templates for documentation. The three school nurses were trained in baseline assessment technique and demonstrated appropriate competency. They successfully implemented the assessment on the high school basketball teams and boys soccer team, a total of 54 athletes, with plans to do the remaining student athletes incrementally over the next year. The head nurse was mentored on the presentations for the coaches, recess aides and teachers, and a total of 120 teachers, 15 coaches, and 25 recess aides completed the training sessions. Six educational summaries were included in the school newsletter and distributed to the parents. The student body in all grades participated in assemblies presented by the local Brain Injury Alliance chapter, then took part in a poster contest to raise awareness about signs and symptoms of a concussion and injury prevention strategies. All training materials and templates were gathered into a toolkit and distributed electronically to the Utah Association of Public Charter Schools for unrestricted use. The Utah public charter school system serves greater than 70,000 students.12 During implementation, the nurses found that some students were reluctant to undergo baseline screening. A common reason was that the students were afraid that the assessment could potentially disqualify them from playing their sport, not understanding that the intent of it to have an evaluation to compare to in the event of future injury. The nurses were able to CONCUSSION MANAGEMENT IN SCHOOLS 119 overcome this in most cases with individualized explanation. Indeed, baseline screenings offer a very important opportunity for athlete education about recognizing symptoms of concussion and the importance of reporting an injury to coaching and nursing staff. The nurses found wide variability between students in the balance portion of the assessment, underscoring the necessity of individualized baseline assessments in order to have a reliable way to track improvement after an injury.13,14 Timing of the initial rollout unfortunately missed the beginning of the basketball season and the opportunity to explain the baseline assessment process to the parents, which would have alleviated much of the students' misunderstanding. The second rollout went much more smoothly because the coach announced at the pre-season parent meeting that the athletes would not be allowed to participate until they turned in their baseline assessment permission slip. All of the forms were returned very quickly and the nurses were able to complete the assessments within the first week or so of the season. Due to the small size of the athlete population, the nurses found that it was relatively easy to pull students out of elective classes for 10 minutes to complete the assessment during the school day. This eliminated the need for the nurses to clock overtime hours to stay to pull students out for assessment during sport practices. Getting the high school and junior high school coaches to attend the training meetings proved a bit challenging, as many of them felt they were already knowledgeable enough in concussion management. After completing training, several made comments that they were glad to have a concise set of rules to follow after injury, and that the interactive training and discussion was helpful and expanded their understanding. The playground aides for the elementary school were very engaged in the process due to a recent severe head injury sustained at school by one of the first graders. The teacher training sessions were integrated into their usual staff meetings, and were well received. Since the program was implemented, the nurses have noted a significant increase in the number of students referred to them for evaluation after a collision or impact on the playground or during physical education class. Most of the students have had no lasting injury, but they have identified a handful of students that did in fact sustain a concussion. A very important point emphasized throughout the training is that the baseline assessment and school staff response to injury is not a substitute for a formal medical evaluation. The nurses follow a model that includes referral for care to the student's usual medical provider for uncomplicated injuries, or to a concussion specialist for persistent or severe symptoms. In cases where the athlete is cleared prematurely, the nurse may reassess with the SCAT-3 tool and refer the athlete back to the medical provider if deficits are still present. Overall, the implementation was quite successful, as we were able to educate the entire faculty, staff, student body, and parents at this charter school system. Spreading the implementation over the course of about three months allowed for repeated exposure to the information, an important factor in increasing knowledge retention.15,16 The nurses now have a set of reporting forms to use for both minor and major injuries and a system of tracking and following up with students 1-2 days after injury to determine if concussion symptoms have evolved Concussion is well identified as a growing public health problem, and previous efforts focused on small groups of athletes deemed to be at most risk has proven to be an ineffective way to reduce the incidence and morbidity of this type of injury. This project successfully spread awareness of concussion across the whole school population, in addition to implementing CONCUSSION MANAGEMENT IN SCHOOLS 120 a structured program for prevention, recognition, and management that is self-contained and robust enough to be used for years to come. The CDC's HEADS UP curriculum provided an excellent basis for the toolkit, and the additional customization to include the SCAT-3 baseline assessment and powerpoint presentations suitable for large group training led to a final product that is simple and flexible enough to implement in a variety of school settings. Using the free SCAT-3 assessment tool is a cost effective approach for charter schools to address athlete safety, and the time required to train the staff throughout the school with the modules is manageable. As a population health promotion strategy, this program reduces preventable morbidity and mortality, addresses risk factors, and creates a sustainable structure for intervention and management in the future. References: 1. Centers for Disease Control and Prevention [webpage on the Internet]. HEADS UP: Brain injury basics. 2011. Available from http://www.cdc.gov/headsup/basics/index.html. Accessed March 8, 2017. 2. Centers for Disease Control and Prevention [homepage on the Internet]. HEADS UP. 2016. Available from http://www.cdc.gov/headsup/index.html. Accessed March 8, 2017. 3. Cheng TA, Bell JM, Haileyesus T, Gilchrist J, Sugerman DE, Coronado, VG. Nonfatal playground-related traumatic brain injuries among children, 2001-2013. Pediatrics. 2016; e20152721. doi: http://doi.org/10.1542/peds.2015-2721 4. Arbogast KB, Curry AE, Pfeiffer MR, et al. Point of health care entry for youth with concussion within a large pediatric care network. JAMA Pediatrics. 2016; 170(7):e160294. doi: http://doi.org/10.1001/jamapediatrics.2016.0294 5. Kerr ZY, Register-Mihalik JK, Marshall SW, et al. Disclosure and non-disclosure of concussion and concussion symptoms in athletes: Review and application of the socio-ecological framework. Brain Injury. 2014;28(8):1009-1021. doi: http://doi.org/10.3109/02699052.2014.904049 6. Kroshus E, Baugh CM, Daneshvar DH, et al. Concussion reporting intention: A valuable metric for predicting reporting behavior and evaluating concussion education. Clin J Sport Med. 2015;25(3):243-247. doi: http://doi.org/10.1097/JSM.0000000000000137 7. Robbins C, Daneshvar D, Picano J, et al. Self-reported concussion history: Impact of providing a definition of concussion. Open Access J Sports Med. 2014;99. doi: http://doi.org/10.2147/OAJSM.S58005 8. White PE, Newton JD, Makdissi M, et al. (2013). Knowledge about sports-related concussion: Is the message getting through to coaches and trainers? Br J Sports Med. 2014;48:119-124. doi: http://doi.org/10.1136/bjsports-2013-092785 9. Centers for Disease Control [webpage on the Internet]. TBI: Get the facts. 2016. Available from http://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Accessed March 8, 2017. CONCUSSION MANAGEMENT IN SCHOOLS 121 10. Novak Z, Aglipay M, Barrowman N. Association of persistent postconcussion symptoms with pediatric quality of life. JAMA Pediatrics. 2016. Advance online publication. doi: 10.1001/jamapediatrics.2016.2900 11. National Conference of State Legislatures [webpage on the Internet]. Traumatic brain injury legislation. 2015. Available from http://www.ncsl.org/research/health/traumatic-braininjury-legislation.aspx. Accessed March 8, 2017. 12. Utah State Charter School Board [webpage on the Internet]. Public Charter Schools Report, January 2017. 2017. Available from http://www.schools.utah.gov/charterschools/Annual-Reports/2017JanuaryCharter.aspx. Accessed March 8, 2017. 13. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sport. Neurology. 2013;80(24):2250-2257. doi: http://dx.doi.org/10.1212/WNL.0b013e13828d57dd= 14. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47(5):250-258. doi: http://doi.org/10.1136/bjsports-2013-092313 15. Cusimano M, Chipman M, Donnelly P, Hutchison M. Effectiveness of an educational video on concussion knowledge in minor league hockey players: a cluster randomised controlled trial. Br J Sports Med. 2014;48:141-146. doi: 10.1136/bjsports-2012-091660 16. Echlin P, Johnson A, Holmes J, et al. (2014). The sport concussion education project: A brief report on the educational initiative from concept to curriculum. J Neurosurg. 2014;121(6): 1331-1336. doi: 10.3171/2014.8JNS132804 CONCUSSION MANAGEMENT IN SCHOOLS Appendix N - Poster Presentation 122