1. Every patient who sustains a concussion should be assessed by a qualified practitioner able to make a diagnostic decision (physician, nurse practitioner, neuropsychologist).
Background:
A diagnosis will clearly identify a course of recovery and potential treatments. As part of the diagnostic process it is important that an initial medical assessment occurs to rule-out conditions requiring medical follow up. There are other injuries that can look like a concussion that can be more severe, so a physician or nurse practitioner must conduct an initial assessment.
Medical assessment is the first part of the diagnostic process. A full diagnosis also involves an evaluation of the mechanism of injury, potential risk factors that may have a negative impact on recovery, clinical history and current symptom presentation.
There are only three types of practitioners who are regulated in Ontario to make a concussion diagnosis: physician, nurse practitioner and neuropsychologist. Each practitioner has a distinct role in the diagnostic process; one not replacing the other.
What this standard means:
Diagnosis can only be made those qualified and regulated to do so; other healthcare providers can suspect a concussion but cannot diagnose one. The diagnosis of concussion is a clinical diagnosis based on observed symptoms, mechanism of injury and clinical history. Symptoms after concussion can be physical, cognitive and social/emotional and all must be assessed to inform a concussion diagnosis. Physicians, nurse practitioners and neuropsychologists are able to diagnose concussion; however it is necessary that a medical assessment occur first to ensure medical stability.
A physician or nurse practitioner must complete the initial medical assessment to identify the key diagnostic elements of concussion and identify and act on any symptoms indicating other potentially serious issues that may need urgent and/or specialized medical care.
A physician is responsible for ruling out other medical diagnoses, considering co-morbidity or pre-morbidity, treatment decisions for medical issues and symptoms, medication management, specialist referral, and later providing clearance for return to work/school/play.
In some cases a nurse practitioner (NP) will be the available medical provider. Nurse practitioners are primary care providers who can diagnose concussion. There are some limitations to NPs that preclude them for having all of these responsibilities without an involved physician, namely independently ordering imaging (MRI, CT, cervical spine x-rays) when required, and prescription medications that may be off label.
For those patients whose symptoms are not resolving quickly (within 2 weeks), neuropsychologists can be brought into the diagnostic process to provide a more a detailed assessment, corroborate the diagnosis and assist in the identification of appropriate symptom management strategies. They can assess for readiness and supports required for return to work/school/play but clearance must be provided by a medical practitioner.
In making a concussion diagnosis, practitioners should consider and instruct the patient on necessary follow-up steps. This sets in motion the post-concussion care pathway. Patients and families will thus be able to have confidence that other diagnoses or potential complications can be ruled out and/or managed.