Remote Patient Monitoring from the ED for Concussion Care Continuity

Concussion is a common injury in the emergency department (ED) setting, accounting for more 200,000 annual visits in the US. While many pediatric concussion symptoms resolve within one month, approximately 30 percent of children will experience persistent post-concussion symptoms (PPCS), defined as symptoms above baseline beyond 28 days. The majority of pediatric patients with PPCS continue to be symptomatic multiple months after injury, with symptoms persisting for months to years. 

Today, novel active concussion rehabilitation strategies exist that can reduce symptom burden and possibly prevent PPCS, but these therapies are limited since they are nearly exclusively prescribed from the specialty setting. Of particular concern, less than half of youth concussion patients have a follow-up visit with any medical provider after visiting the ED. A potential opportunity exists during ED concussion visits to identify patients at high risk of experiencing PPCS and, for those patients, provide an expedited care hand-off to specialists who can initiate active rehabilitation strategies.

Risk Stratification Using Physiologic Markers and Mobile Health-Facilitated Specialist Management to Improve Outcomes in Pediatric Concussion Patients

Study Objectives

Currently, there are limited methods to predict, early in-the-course of the injury, which concussed children will develop persistent symptoms. For those determined to be high risk of PPCS, multiple barriers exist to accessing concussion specialists who can prescribe active therapies shown to improve recovery time. By incorporating objective visio-vestibular deficits into risk models, and utilizing a remote patient monitoring (RPM) tool to improve specialist access and care continuity, we plan to begin the process of matching novel therapies to those most in need of their benefits. Ultimately, our objective is to reduce recovery times and the related physical, cognitive, and emotional morbidity for pediatric concussion patients.

Investigational Plan

Over a five-year study period, researchers are pursuing the following aims:

Aim 1: Improve accuracy of concussion risk using physiologic markers of injury. 

  • We will take advantage of the Minds Matter Concussion Registry, a data repository that includes over 5,000 injured children, to develop risk models that will assist providers in identifying children at high risk for PPCS shortly after injury. This will build on prior work by the Pediatric Emergency Research Canada (PERC) Concussion Team (the 5P rule), augmenting prior risk scores by including visio-vestibular examination (VVE) deficits that have shown significant promise in identify youth who will develop PPCS.

Aim 2: Assess the feasibility of a remote patient monitoring mobile eHealth tool to facilitate specialist access and care continuity.

  • We will prospectively enroll 100 concussed youth from the ED deemed moderate-to-high risk for PPCS using validated risk scores (the 5P rule) and equip them with an RPM tool to facilitate early specialist care. We will monitor both symptoms and activity of participants in this pilot study, with data forwarded to our Minds Matter Concussion Team, and methodologically evaluate our intervention in an implementation-based design.
  • An earlier study by the Minds Matter Team piloted ecological momentary assessment (EMA) techniques to conduct remote patient monitoring of concussion patients from the ED. Overall, the study of 30 concussed adolescents age 13-18 found tracking step count using wearable devices and monitoring symptoms via tridaily surveys is feasible from the ED setting. Specifically, more than 90% of participants interacted with our RPM tool, with more than 75% responding to prompts on at least 14 of 21 study days. We found a dynamic incentivization strategy (re-numeration dependent on response rates) led to higher overall responses than a flat-rate strategy, and that there was improved ability to discern outcomes using RPM as compared to prospective monitoring using the electronic health record.

Principal Investigator: Daniel Corwin, MD, MSCE

Funding: National Institutes of Health: National Institute of Neurological Disorders and Stroke