CONCUSSION & INJURY MANAGEMENT POLICY

Transcription

1 CONCUSSION & INJURY MANAGEMENT POLICY February 2014

2 Table of Contents 1. Background Management Team Recognition of concussion Management steps for employees Academic Progression Protocol (AP) Six Step Return to Play Protocol (RTP) Follow up Care during School References

3 1. Background A concussion is a reaction by the brain to a jolt or force that can be transmitted to the head by an impact or blow occurring anywhere on the body. Essentially a concussion results from the brain moving back and forth or twisting rapidly inside the skull (CDC, 2014) Medical management of concussion is evolving. It has been proven that with the proper cognitive rest and earliest detection the student has a better chance with their recovery and the length of their recovery. The key issue is the need for individualized assessment, management, and monitoring of cognitive exertion as tolerated over time. Emma Willard School (EWS has established a concussion management to provide education about concussions for the school employees (faculty and staff) and Parents to follow in managing head injuries. This policy outlines the return to academics and return to play steps after a concussion/or head trauma. EWS seeks to provide a safe return to all forms of physical activities (including Sports and dance) as well as classroom activity after a concussion. To respond to these injuries effectively and consistently procedures have been developed to identify and treat concussed students and refer the student to the appropriate medical care. They should receive appropriate medical follow-up during the academic school day and be fully recovered prior to returning to physical activity. Concussions affect everyone differently and recovery is person specific. Students with a history of concussion may take longer to recover. Children and adolescents are more susceptible to concussions and take longer than adults to recover (NYSPHSSA, 2014) This protocol will be reviewed on an annual basis, by the Concussion Management Team. Any change or modification will be reviewed and advised accordingly. 2. Concussion Management Team River View Pediatrics Henry Tomiak, MD William Kostun, MD Lori Caruso, MD Lead Nurse Jennifer Bliss, RN Director of Cognitive Skills De Shan Lett Director of Athletics and Wellness Shelley Maher, MS, B.Ed Athletic Trainer Debbie Fonseca, MS, ATC 3

4 3. Recognition of concussion Signs observed by employees Appears dazed or stunned Is confused about assignment or position Forgets an instruction Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness (even briefly) Shows mood, behavior, or personality changes Can t recall events prior to hit or fall Can t recall events after hit or fall Symptoms reported by the student Headache or pressure in head Nausea or vomiting Balance problems or dizziness Double or blurry vision Sensitivity to light Sensitivity to noise Feeling sluggish, hazy, foggy, or groggy Concentration or memory problems Confusion Just not feeling right or feeling down Symptoms that constitute emergency One pupil larger than the other Is drowsy or cannot be awakened A headache that not only does not diminish, but gets worse Weakness, numbness, or decreased coordination Repeated vomiting or nausea Slurred speech Convulsions or seizures Cannot recognize people or places Becomes increasingly confused, restless, or agitated Has unusual behavior Loses consciousness (even a brief loss of consciousness should be taken seriously) Adapted from NYSPHSAA (2014) 4

5 4. Management steps for employees Injury management steps for injury on campus 1. The Faculty/Staff member will perform the initial assessment to determine if emergency medical personnel are needed (see page 4). 2. If the student has ANY symptoms of concussion they must stop physical activity for at least 24 hours. 3. Call 911 if deemed an emergency or with any loss of consciousness. 4. If the injury requires emergency medical attention, the emergency chain of command will be call 911 and then alert the health center. Please note the HC hours of operation Monday Thursday 7:30-8:00pm, 7:30-4:00pm Friday. If after the HC hours please notify to contact the on call nurse. 5. If the injury does not require emergency medical attention the HC will be notified and the proper course of treatment will be determined. 6. The HC will notify parents and all appropriate parties of the current status of the student. 7. Once a student has been diagnosed with a concussion the EWS Concussion Management Protocol will be initiated. 8. The Academic Progression (AP) will be initiated and the stages will be determined by the physician in coordination with the HC and the Director of Cognitive Skills. 9. Once the Academic Progression Protocol has been completed to Stage 2 and clearance has been received from the physician, the HC will send the student to the Athletic Trainer (AT) to start Stage 2 of the Six Step Return to play protocol. 10. The physician determines the clearance to start RTP protocol in coordination with the HC and Director of Cognitive Skills. 11. The implementation of the protocol, daily evaluation and progression of activity and academic participation are managed through the HC in coordination with the Director of Cognitive Skills. 12. Once the Six Step RTP has been completed the student will report to the HC and pick up her medical clearance note (green note) to give to her teacher, dance teacher, or coach. 13. The HC will notify all appropriate parties the student s physical activity level along with any academic accommodations daily. Injury management guidelines for injury off campus 1. The Faculty/Staff will determine if medical treatment is needed. 2. If the injury requires emergency medical care call The Faculty/Staff should contact the to inform the student s status, en route to Emergency Department or returning to school. 4. The HC will notify parents and all appropriate parties of the current status of the student. 5. The student will report to the HC when she returns to campus. 5

6 5. Academic Progression - 4 Stage Protocol Academic Key/Goals Stage 1 Complete Rest 2 Gradual introduction of cognitive activity as tolerated Expected Educational Actions Duration 2-6 days Health Center provides an explanation of injury and current plan of care to ALL appropriate parties 2-14 days In coordination with Physician, HC and Director of Cognitive Skills: Develop list of 3 categories for all assignments: 1. Excused-not to be made up 2. Accountable-responsible for content not process. May be notes or worked shared by a classmate or may be covered in a review sheet 3. Responsible-Must be completed by student and will be graded Student s Actions Out of school No physical activity (No sports/pe/dance) No electronics-(no cell phone, ipod, texting, video games,computer) No off campus and social activities In class as tolerated (attempt to attend ½ of each class) No physical activity When present in class, observing not participating, get copies of notes, handouts etc. Meets with advisor to discuss challenges and progress and upcoming assessments or exams Remind to be patient with slow recovery and no assessments 3 Gradual increase in time and energy, slowly resuming a full work load Variable 3-7 days Prioritize completion of assignments with both make up and New York State Continue to utilize lists with the 3 above categories for assignments until work is completed Assist in setting a timeline for completion of assignments In class full time No physical activity Exams postponed/rescheduled Communicates with teachers/advisors, health center on the pace of resuming a full workload and completing make up work 4 Complete presumption of normal activities Monitor competition, assignments /exams in the following order: language, arts,history,science and math Director of Cognitive skills will notify parents and all appropriate parties when the student is caught up and is working at the same pace as classmates Resume all normal activities Resume assessments per make up exam schedule Begin Six Step Return to Play Progression CDC (2014) 6

7 6. Six Step Return to Play (RTP) Progression Protocol (*protocol is for all injury types, students with concussion like symptoms must first complete the Academic Progression Protocol) Six Step Return to Play(RTP) Progression Protocol begins with medical clearance from the Health Center. Implementation, daily student evaluation and progression of activity are managed by the Health Center in coordination with the Athletic Trainer. Students involved in the Six Step RTP Progression Protocol must be evaluated by the health center every 24 hours. Any discomfort or swelling student returns to previous rehabilitation stage at which no symptoms are present. Rehabilitation Stage Key Idea- Goal Functional exercise Objective of Stage 1. No activity Complete rest Complete rest Recovery 2. Light (non-impact) aerobic exercise Activity as tolerated A) Walking, swimming or stationary bike keeping intensity less than 70% Max. Performance Heart Rate (MPHR) - no resistance training B) Interval workout stationary (nonimpact) Increase heart rate for minutes steady rate. Progress to activity B for next workout if asymptomatic and pain free after completing A. 3. Moderate (impact) aerobic exercise. Gradual increase in activity A) Jogging on treadmill workout. Dynamic Warm- up. Running drills with complex turns and sprints B) Team warm up and Sport specific drillsnon contact Add movement and impact activities progressing from A to B if symptom free and pain free. 4. Non- person to person contact training drills. *** Non head contact activities for students recovering from concussion Gradual increase in activity and resistance Progression to more complex training drills- passing drills. May start progressive resistance training Exercise, coordination and cognitive load 5. Full contact practice and drills Gradual increase in activity, resistance and full practice routine and scrimmage Participate in full practice schedule and scrimmages Restore confidence and assess functional skills by coaching staff 6. Return to competition Full Activity Normal Game Participation CDC (2014) 7

8 7. Follow- Up Care during School after the injury has occurred Responsibilities of the School Nurse 1. Evaluate and monitor the student daily during the school day. 2. Provide an individualized health care plan based on the student s current condition, recommendations from the student s physician and the student s medical and educational needs. 3. The HC in coordination with the Director of Cognitive Skills will decide the academic expectations and will notify all appropriate parties any restrictions and academic expectations. 4. The HC will notify all appropriate parties any changes or updates in the student s current status. 5. Once the student has completed the AP and has been cleared medically by a physician the student will report to the AT to start the Six Step RTP. 6. Once the student has completed the Six Step RTP She will report to the HC who will then notify all appropriate parties that she is cleared to RTP and may participate in competition. Responsibilities of the Director of Cognitive Studies 1. Monitor the student closely and recommend appropriate academic accommodations when she exhibits symptoms of post-concussion syndrome. 2. Communicate with the school health center on a regular basis, to provide the most effective care for the student. 3. Devise a plan for make- up work-develop a list of 3 categories for all assignments. Excused-not to be made up Accountable-responsible for content not process. May be notes or worked shared by a classmate, or may be covered in a review sheet Responsible-Must be completed by a student and will be graded 4. Do not rush the student to make up assignments (essential vs non-essential 5. Allow oral examinations 6. Make up classes or academic tutoring Depending on the student s symptoms, it may be necessary to reduce the number of classes the athlete attends while recovering. In order to fully heal, the student needs to rest-both physically and cognitively. It is also important that the athlete pace herself while cognitively active. While in class or doing homework, encourage the athlete to take frequent breaks. A good rule of thumb is work minutes, rest minutes. Allow students who are recovering from a concussion extra time to complete assignments and tests Encourage teachers to provide written instructions on assignments when possible and encourage the student to tape record the class lectures. Obtaining notes from class peers might also help. Give written notes for when SMART board or overhead projector is being used. Utilize quiet environments for studying Refrain from standardized tests or significant tests while symptomatic Encourage the student to get sufficient sleep Responsibilities of the Athletic Trainer 1. Implement the RTP Progression Protocol including notifying the HC of any changes in the student s current status. 8

9 8. References Centers for Disease Control and Prevention (2014) Injury Prevention & Control: Traumatic Brain Injury Retrieved 15 December January 2013 from New York State Public High School Athletic Association (2014) Guidelines for Concussion Management Retrieved 10 December 2013 from 9

10 CHECKLIST - New York State Public High School Athletic Association (NYSPHSAA) endorsed Name Age Grade Activity Date of Injury Time of injury On Site Evaluation Description of Injury: Has the student ever had a concussion? Yes No Unclear Was there a loss of consciousness today? Yes No Unclear Does he/she remember the injury? Yes No Unclear Does he/she have confusion after the injury? Yes No Unclear Symptoms observed at time of injury: check yes or no (If symptoms worsen or deteriorate call EMS immediately). Symptoms Yes No Symptoms Yes No Dizziness Ringing in Ears Drowsy/Sleepy Don t feel right Seizure (call EMS) Memory problems Blurred vision Vacant stare/glassy eyed Headache Nausea/vomiting Fatigue/low energy Feeling dazed Poor balance-coordination Loss of orientation Sensitivity to light Sensitivity to noise Other Findings/Comments: Final action taken: Parents notified.. Sent to Hospital Evaluator s Signature:. Address:. Date: Phone No.: 10

11 Physician Evaluation Date of Evaluation: Time of Evaluation: Symptoms Observed: Please check Symptoms Yes No NA Dizziness Headache Tinnitus Nausea Fatigue Drowsy/Sleepy Sensitivity to Light Sensitivity to Noise Anterograde Amnesia (after impact) Retrograde Amnesia (backwards in time from impact) Did the athlete sustain a concussion? Please circle Yes No Additional Findings/Comments:... Recommendations/Limitations: *** Student must be completely symptom free in order to begin the return to play progression. If student still has symptoms more than seven days after injury, referral to a concussion specialist/clinic should be strongly considered. Athlete is asymptomatic and is ready to begin the return to play progression. Athlete is still symptomatic more than seven days after injury. Signature Phone Date 11

12 Emma Willard School Post Concussion Home Care Instructions I believe that sustained a concussion on. To make sure she recovers, please read the following information as it will help to answer some of your questions & provide directions for follow-up care. If you have any questions, please contact: Jenn Bliss RN Lead Nurse jbliss@emmawillard.org What is a concussion? A concussion is a disturbance in brain function that occurs following either a blow to the head or as a result of the violent shaking of the head. Please seek immediate medical attention if your daughter exhibits any of the following: Develops a worse headache Becomes dizzy, drowsy or cannot be aroused Mental confusion Slurred speech Repeated vomiting Pupils unequal size Ringing in the ears Seizures Clear fluid coming from nose and/or ears Change in the state of consciousness Anything you find unusual 12

13 Cognitive rest: An additional cornerstone of concussion management is cognitive rest. Acute Phase- Immediately after (Goal: get as much rest as possible) a. No text messaging b. No video games c. No computer use d. No school or homework e. No reading f. No parties, concerts, dances, trips, attending games, visiting friends g. No TV, or limited to very short period of non-visually stressful/intense programming Recovery Phase-when symptoms start to subside a. No physical activity b. Academic accommodations However, Cocoon therapy, or keeping the concussed athletes in a quiet, dark room, is NOT recommended, as isolation can affect emotional well-being. Emotional SupportA student with a concussion has a temporarily malfunctioning brain, and therefore may not act like themselves. Of particular concern are changes in emotion and impulse control, including engaging is risky behavior. New recommendations advise that parents provide a calm, supportive environment and monitor their children s emotional state. This abnormal emotional state is temporary. In the following days: She is NOT allowed to participate in sports/physical education classes until she/he has been cleared by a physician and/or Judy Dignum RN for returning to play will include: no symptoms at rest, no symptoms with exertion & post-concussion ImPACT results must be at or near baseline scores. ImPACT Testing: At EWS, we use the ImPACT Concussion Management system which is a computer based testing program that takes about 20 minutes and measures attention, verbal and visual memory, processing speed and reaction time. A baseline test is taken, prior to the season, to measure a baseline score of these items. In the event a student receives a concussion, a follow up test will be performed to compare the baseline results to the student s current state. This is yet another tool we can use in assessing an athlete s readiness to return to play. Please know that the ImPACT system does NOT diagnose concussions. EWS will use this program in conjunction with the student s history, physical exams, other physician ordered special testing (CT scans, etc.) and physician guidance in returning athletes to play/activity. Second Impact Syndrome: Second Impact Syndrome is a dangerous condition which can occur if a student returns to sports/physical activity before full recovery. If you receive a second blow to your head (even a relatively minor one) before the symptoms of the initial concussion have cleared, there can be more serious complications. 13