Abstract
Purpose: The purpose of this quality improvement project was to identify mild traumatic brain injuries (mTBI) and implement a follow up protocol for these patients to ensure all patients are properly identified and receive treatment, education, referral, and follow-up.|Background: There is a lack of a standardized protocol for diagnosis and follow up of mTBI. Missing a mTBI diagnosis or neglecting to recommend follow up therapy at discharge for patients with mTBI symptoms can have long term consequences.|Sample/Setting: This mTBI care algorithm was implemented in a level 1 academic trauma center and included all levels of care. The patients included in the sample were any patient with a mTBI diagnosis admitted to the trauma service. There was an eight-week baseline period and implementation period.|Methods: Data was collected retrospectively with the use of the electronic medical record. The number of patients, before and after implementation, with a mTBI diagnosis, referral to physical, occupational and speech therapy, and attendance to that appointment was calculated.|Results: Before implementation there were 17 patients with a mTBI code diagnosis and after implementation there were 19 patients. Before implementation 90% of indicated referrals to therapy were sent at discharge, 56% of patients attended their therapy appointment, and 57% of patients attended their follow up doctor appointment. After implementation 50% of indicated therapy referrals were sent, 0% of patients made it to their therapy appointments, and 44% of patients made it to their follow up doctor appointment.|Conclusion: A protocol and education can increase the number of mTBI diagnoses made. Consistent education and reminders of the protocol is necessary for successful increase in the number of follow up referrals and appointments.