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'Quarterbacksí of care

Nurses guide, educate growing number of patients with concussions

Monday March 25, 2013
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Dennis Cardone, DO
Concussions have captured more attention in recent years as education spreads about what they are and the technology and tools that make them easier to detect. New York and New Jersey are among states responding to heightened awareness of concussions with new laws and care plans.

No longer are athletes who have signs of concussion cleared in minutes to return to the field with a few perfunctory tests. Better education has taught coaches, athletes, patients and families that you donít have to lose consciousness to have a concussion and that brain injuries of any type may have long-term consequences.

Laws in recent years have helped emphasize the seriousness of immediate and proper care for people suspected of having a concussion. According to the National Conference of State Legislatures, at least 41 states passed laws between 2009 and 2012 to address traumatic brain injury or TBI, primarily regarding youth sports-related concussions.

In New York and New Jersey, for example, if an athlete is suspected of having a concussion, he or she must be taken off the field and get clearance from a physician to return to play.

Heightened awareness and a need to approach concussion care in a more coordinated, systematic way were among the reasons NYU Langone Medical Center in Manhattan developed its concussion center, which launched this month.

The centerís goal is to coordinate care across departments and make sure patients are seen quickly and are followed throughout the spectrum of care.

At the start, the center will primarily be for athletes but will grow to include all people who have sustained traumatic brain injuries, said Dennis Cardone, DO, associate professor in orthopedic surgery.

Departments including neurology, rehabilitation medicine, orthopedics, pediatrics and physical therapy will consult patients and develop care plans.


Catherine Manley-Cullen, RN
"Potentially the biggest role player in all of this is our RN clinical coordinator," Cardone said. "She or he will take the history and, accordingly, truly quarterback the care."

That means the nurse will determine which services the patient needs and whether the patient needs to go right to the ED or another department.

"Anybody who calls or seeks an appointment through the NYU concussion center will get seen within 24 to 48 hours at the latest," Cardone said.

Once the patient enters the centerís system, the RN clinical coordinator will coordinate the care plan from consulting to treatments to follow-ups.

The new center will offer community educational programs and provide an on-call physician on weekends.

"Itís a nice service for the community," Cardone said. "They donít have to feel that on the weekend they have nowhere to go to after such a head injury. Football games, as we know, are often Friday nights and Saturdays."

Development of the center will enhance the work of healthcare providers at Langoneís urgent care center, often the first stop for someone who has sustained a blow to the head.

"A lot of times in the emergency department, you make referrals and you just hope the patient makes the right connections," said Catherine Manley-Cullen, RN, MS, CEN, director of nursing at the urgent care center. "Now we can make sure that patients get seen quickly and get the right level of care when they are discharged."


Barry Jordan, MD
Barry Jordan, MD, MPH, is director of Burke Rehabilitation Hospitalís traumatic brain injury program as well as medical director of the hospitalís sports concussion management program in White Plains, N.Y.

The outpatient sports concussion program, started in 2011, targets professional and amateur athletes from age 13 and older. It expands the rehabilitation program and includes neurological evaluation, neuropsychological testing, physical, occupational and speech therapy and referrals for neuroimaging, when necessary.

Education is a huge part of the program, Jordan said, with particular emphasis on making sure an athleteís first concussion is treated correctly to avoid the more serious consequences if another concussion occurs.

Every year 1.7 million people sustain a traumatic brain injury nationally, and 75% of those are concussions or other mild forms of TBI, according to the Centers for Disease Control and Prevention.

TBI is a contributing factor to nearly one-third (30.5%) of all injury-related deaths in the U.S., according to the CDC.

With those numbers in mind, the Burke program works to educate families and schools to prevent Second Impact Syndrome, a rare but devastating occurrence when a first concussion is mismanaged and a second head trauma brings an intensified response, possibly resulting in death.

"In cases of high school athletes dying on the football field, itís usually Second Impact Syndrome," said Jordan, who has been evaluating athletes with concussions for more than 30 years. "Thatís why itís extremely important to properly recognize and manage these concussions."

Itís also important that nurses, particularly in schools, have input along with athletic directors in evaluating athletes for playing fitness, he said.

Jordan also works with athletic programs in the preseason, encouraging athletes to take a computerized neuropsychological test that measures problem-solving and memory skills. Having those baseline readings can help measure recovery if that athlete gets injured, he said.

Treatment for concussions is constantly evolving, and Jordan said he is interested in pursuing rehabilitation exercises for the small percentage of athletes who donít recover from concussions within a month. Cognitive rest, the primary method of treating concussions, would be followed by stimulation exercises right up until they develop symptoms.

Jordan works with parents, athletes and athletic trainers to help them recognize what constitutes a concussion.

"Previously, people used to think that in order to have a concussion, you needed to have loss of consciousness," he said. "When it relates to sports, actually loss of consciousness is less than 10% of the cases."

Cecilia Pagkalinawan, RN, nurse manager in the brain injury unit at Kessler Institute for Rehabilitation, West Orange, N.J., said patients with mild brain injuries are often referred to Kessler after they have been to an ED or another physician.

Kessler nurses, physicians and neuropsychologists dig more deeply, she said, screening and assessing for dizziness, sensitivity to light, balance issues, irritability, visual blurriness, mood changes, memory issues and trouble concentrating or sleeping.

Pagkalinawan said nurses often have to educate families on the importance of keeping stimuli to a minimum when a patient has a brain injury. Patients need a break from TV, video games, loud noises, too much conversation, text messaging, etc., for the brain to heal.

That can be hard for families when they canít see the injury as they could with a broken leg or a wound, Pagkalinawan said.

"If I am the parent or the brother of someone whoís sustained a mild brain injury, I donít really see that thereís anything wrong," Pagkalinawan said. So, for instance, family members might try too hard to get a patient to remember something, thus possibly causing the patient further harm, she said.


Cecilia Pagkalinawan, RN
Because education is a major part of preventing and managing concussions, nurses are in a unique position to improve outcomes.

In the past, according to NYUís Manley-Cullen, when a patient bumped his or her head, the emphasis was on waking the patient periodically during the night.

"Now, weíre all learning that there are long-term sequelae from concussion, so I think weíve certainly become more involved in preventive education," she said.

Nurses get more individual time to talk with patients about their lifestyles and activities and about safety measures, such as wearing a helmet.

Nurses also are often the last providers to see a patient walk out the door and often follow up with calls at home. Thatís when they can emphasize and explain discharge instructions.

"Thatís where nurses shine — in education," Manley-Cullen said.

Marcia Frellick is a freelance writer.


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