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Individuals with concussion should have access to care at the following time points, according to the attached pathway.

Diagnostic assessment:

T1: as soon as it is recognized that the individual has incurred a suspected concussion.

Education, resource information and follow-up:

T1: at diagnosis
T2: at 1-2 weeks when follow-up occurs

T3: at 3-4 weeks when flagged for further assessment and symptom management follow-up occurs.

T4: in an ongoing fashion as symptoms are monitored through follow-up

T5: upon referral to an interdisciplinary concussion clinic and in an ongoing fashion through involvement with the clinic.

Therapies and interventions once symptoms are deemed persistent

T5: upon referral to an interdisciplinary concussion clinic

Background:

Delineation of a clear pathway and components of care is a necessary step in ensuring the right care is delivered at the right time. The goal of a pathway of care is to improve patient flow and access. Waitlists are currently viewed as too lengthy and detrimental to patient care. Pathways that include timelines inform the system about changes that need to be made in order to improve patient flow.

There are three key stages to the pathway that have been identified through review of the evidence and consensus among experienced healthcare practitioners: 1. diagnosis; 2. education and follow-up; and 3. treatment from an interdisciplinary concussion clinic.

A diagnosis will clearly identify a course of recovery and suggested treatments. Risk factors and potential confounding conditions can be identified and managed. Current evidence suggests it is more appropriate to flag patients who may have protracted or difficult recovery and to monitor them so that the decision to refer for therapy can occur without delay. Research has shown that the risk of persistent symptoms can be flagged earlier than previously believed. This will hopefully facilitate an earlier entry into receiving interdisciplinary care for those who are, or will be, at risk for a longer recovery.

Educational material about recovery, risk factors, trajectory of care and appropriate treatments and resources has not been provided to patients quickly, comprehensively and consistently over time. This has caused unnecessary anxiety and confusion among patients and their families. Educational information must be provided to patients and families, so that they can begin to know and understand concussion from the outset. This should include directions for the initial few days, as well as reassurance that most concussions recover over time, and reasonable expectations for recovery.

What this standard means:

There have been practices that have become entrenched based on out-of-date evidence, or others that have been adopted but that may not be appropriate within scope of practice or evidence. The timeline and patient flow proposed in this standard will require changing and clarifying some existing practices. The development of the pathway is grounded in evidence. Education of healthcare providers will be required to ensure that current practices are brought into line with this standard and current evidence.

While it is optimal that diagnosis occurs shortly following the concussive event, it is acknowledged that some individuals may only seek care or diagnosis after some time has passed if symptoms do not resolve. Regardless of when diagnosis actually occurs, the pathway should be adhered to, as diagnosis is the first in many steps of an appropriate care flow.

It is important for patients to understand how to manage their activities post-concussion, while not inundating or overstimulating them with too much detail in the initial few days. Education is best provided in multiple formats, to allow patients to learn in the medium they can tolerate and are comfortable with, while providing clear sources for more information, as wanted or needed.

The majority of individuals who sustain concussion will recover spontaneously without need for medical or other healthcare involvement, but there is a percentage of individuals who do not. Patients who are living with persistent symptoms need to receive coordinated, collaborative, interdisciplinary care as defined in the post-concussion care pathway. By following the trajectory of care, patients should get to qualified care quickly, avoid long waitlists and experience less time struggling with symptoms for a protracted period of time.