Emergency Physician Training on Mild Traumatic Brain Injury: A Systematic Review

Abstract

Objectives

Mild traumatic brain injury (mTBI) is the most common emergency department (ED) brain injury presentation worldwide. Despite its frequency, practice variation and care gaps exist among emergency physicians (EPs) in diagnosing and appropriately managing mTBI in the ED. The objective of this review was to identify mTBI‐specific training undertaken to improve the detection and management of mTBIs by EPs and its impact on practice.

Methods

A comprehensive search strategy utilized four bibliographic databases, the gray literature and the keywords concussion, mild traumatic brain injury, medical education, and continuing medical education (CME). To be included, studies were required to report on mTBI training received by practicing EPs at any point during their medical education or career. Studies examining clinical practice guidelines or use of diagnostic tools without active implementation or formal training were not included. Two reviewers screened unique citations for relevance and reviewed the full texts of relevant articles. Two independent researchers extracted data and assessed methodologic quality. At all stages, a third independent reviewer adjudicated discrepancies.

Results

Overall, five studies were included from 409 unique results. None of the included studies were of high quality. Identified training on mTBI consisted of three training toolkits, conference presentations and academic journal articles, and pediatric fellowship training. Training primarily occurred as CME and focused on awareness of and management of mTBI; three studies reported physician practice changes, including increases in the use of evidence‐based return‐to‐school and return‐to‐activity recommendations.

Conclusions

The few studies identified addressing mTBI training targeting EPs demonstrate the limited attention given to this issue. The current evidence‐to‐practice gap in mTBI management places patients at risk for suboptimal care in the ED, and existing mTBI knowledge translation, including education, requires optimization to effectively address the current gap in evidence‐based practice for mTBI diagnosis and management in the ED.

Mild traumatic brain injury (mTBI), or concussion, is a rapid‐onset transient functional impairment resulting from a direct or indirect force to the head.1 Patients with mTBI often present to the emergency department (ED) shortly after their injury event with symptoms of headache, amnesia, dizziness, confusion, nausea, and/or vomiting.2, 3 Many patients recover from mTBI in a 7‐ to 10‐day period;1 however, 10% to 15% of concussions among children and young and professional athletes develop persistent symptoms.1, 4 Additionally, more than half of concussions in general adult ED populations experience concussion‐related symptoms that persist beyond 3 months after their injury,5, 6, 7, 8 and as high as 30% are still affected by their injury 1 year later.8 Roughly a quarter develop postconcussion syndrome (PCS),9 the persistence of three or more symptoms beyond 3 months after the injury. In addition to quality‐of‐life concerns, these long‐lasting symptoms often impact patients’ ability to work.6 Patients with a delayed or missed mTBI diagnosis are at greater risk of cognitive dysfunction (e.g., memory impairment, difficulty learning, emotional lability),10, 11, 12 reinjury,13 and increased recovery time.14, 15, 16, 17 Reinjury while a patient is still symptomatic from a previous mTBI may lead to second impact syndrome, which—although rare—carries a high risk of morbidity and mortality.18, 19, 20, 21 Moreover, repetitive brain injury can lead to increased risk of depression, including suicide, and premature dementia later in life.19, 22, 23, 24, 25, 26 For many patients, the ED is their first and only point of care;27, 28 thus, it is imperative that emergency physicians (EPs) are able to recognize and adequately counsel patients with mTBI to provide appropriate return‐to‐activity instructions, ensure that follow‐up is arranged, and discuss their prognosis. The overall goal is to improve outcomes and reduce the potential for life‐long adverse effects.

Unfortunately, inconsistent mTBI diagnoses and care gaps persist.10, 14, 15, 16 A previous review examining early (within 72 hours of ED presentation) educational interventions to reduce the severity of PCS found mixed results among included studies; however, the information provided by each intervention varied and some interventions included information that is no longer considered evidence‐based (such as a recommendation for 7 days of complete bedrest prior to beginning a graduated return to activity).29

The diagnosis of mTBI is complicated by the use of different definitions across different medical disciplines.30 The often delayed onset of symptoms, as well as their nonspecific, transient nature, also makes accurately diagnosing mTBI in the ED difficult. While consensus statements and clinical practice guidelines (CPGs) are available to assist EPs in the diagnosis and management of mTBI,1, 31, 32 these reference tools are underutilized in the ED.33, 34 For example, the Canadian CT clinical decision rule was designed to guide physicians in identifying patients with a minor head injury who would benefit most from imaging;35 however, an estimated 10% to 35% of head CTs ordered in the ED do not adhere to these rules, resulting in unnecessary radiation exposure, delays in decision making, and potentially needless tests for these patients.36 Many physicians are comfortable diagnosing mTBI in the absence of a tool, thereby devaluing that tool;37 however, once a diagnosis of mTBI is reached, many EPs are uncomfortable managing mTBI and counseling patients on their injury,32, 33 and patients are often discharged without a clear follow‐up plan.38 These care gaps and inconsistencies raise concern about inadequacies in mTBI training for physicians and has been traced back to medical school.27, 39, 40

Given the potential short‐term and long‐term repercussions of missed mTBI and the frequency of its presentation to the ED,41 there is an urgent need to understand the effectiveness of current efforts to educate EPs on mTBI diagnosis and management to optimize ED practices with current evidence‐based care and improve patient outcomes. The objectives of this review were to identify the types of mTBI‐specific training received by EPs at any point during their careers and whether the training available to physicians affects their practice.

Methods

Protocol

A study protocol was developed a priori and registered in the National Institute of Health Research PROSPERO registry (Reg. No. CRD42016052646). This report follows the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. As a systematic review, this study was exempt from requiring institutional ethics approvals.

Inclusion and Exclusion Criteria

Studies reporting on EP mTBI training during medical school, residency or as continuing medical education (CME) were eligible for inclusion. All modes of education/training (e.g., didactic lecture, skills workshop, conference, online module) were included. Since CPGs and decision tools are not typically developed as formal training,42 studies that examined the use of these tools by EPs without describing an active educational implementation strategy were not included, although studies using multimodal toolkits that included a CPG as a component of the educational tool were eligible for inclusion. For the purposes of this review, EPs were any physician with a board certification in emergency medicine (EM) or any physician whose usual setting of care was an ED or urgent care center. Data on retired physicians or physicians who were not practicing clinically were not eligible for inclusion. Studies of physicians of all specialties that included EPs were eligible. Finally, to gain a comprehensive understanding of mTBI training for EPs, neither study design nor study methodology were reasons for exclusion.

Outcomes

The primary outcomes of this study were the identification and description of mTBI‐specific training received by EPs and the proportion of EPs receiving training. Secondary outcomes included measures of physicians’ knowledge uptake and retention reported by included studies and changes in clinical practice following mTBI training.

Search Strategy and Study Selection

An expert librarian (TC) developed a comprehensive search strategy using the thesaurus headings concussion, mild traumatic brain injury, medical education, and continuing medical education and completed the search in April 2017 using four bibliographic databases (i.e., EMBASE, ERIC, MEDLINE, and SCOPUS). The search was not limited by geographic region, year of publication, or language of publication. To ensure that the search was comprehensive, the indices of issues published from 2013 to 2016 of the academic journals listed in Table 1 were searched by hand. The gray literature was also searched by applying the same search strategy as the bibliographic databases to the Proquest Theses and Dissertations database and by hand searching the conference proceedings of the annual meetings from the past 3 years (2013–2016) of the Society for Academic Emergency Medicine, Canadian Association for Emergency Physicians, and the European Society for Emergency Medicine. The first 100 results of a Google Web search, limited to PDF results, were also examined. Finally, the references and citations of all relevant articles were manually reviewed.

Table 1.

List of Journals for Which Issues (2013–2016) Were Hand‐searched for Concussion Education/Training Studies With ED Physicians for a Systematic Review of mTBI Training for Emergency Physicians

Journal Title
Academic Emergency Medicine
Academic Medicine
Advances in Emergency Medicine
American Journal of Emergency Medicine
Annals of Emergency Medicine
BioMed Central Emergency Medicine
Canadian Journal of Emergency Medicine
Canadian Medical Education Journal
Emergency Medicine Journal
Emergency Medicine International
European Journal of Emergency Medicine

mTBI = mild traumatic brain injury.

After duplicate entries were removed, two independent reviewers (SP, LG) screened the titles and abstracts of unique search results for relevance. The full texts of relevant articles were assessed according to the predetermined inclusion/exclusion criteria. A third independent reviewer (LK) resolved all discrepancies.

Data Extraction and Analysis

Two reviewers (SP, LG) independently extracted data from included studies onto standardized forms and the third reviewer (LK) adjudicated discrepancies. Data were extracted under three domains: study and ED characteristics, physician demographics, and training details. The following study characteristics were collected, where available: publication year, study location (i.e., country), and ED setting (e.g., rural, urban, community, academic) including number of visits per year. Details on physician demographics and previous education (e.g., certifications/training, subspecialization) as well as their practice exposure to mTBI (i.e., number of mTBIs seen/treated in the past year) were also extracted, where available. Finally, data extracted under the training domain included details on the mTBI training program such as specific tools used for knowledge uptake; education delivery; when during the physician's career the training occurred; and any reported measures of knowledge uptake, retention, and changes in physicians’ practice.

Analysis was predominantly narrative because of the expected high level of heterogeneity among studies and the low number of relevant studies identified. While a meta‐analysis examining mTBI‐specific training on physician knowledge was planned, it was not carried out because sufficient data were not available.

Quality Assessment

A critical appraisal of the methodologic quality of each included study was performed by two independent reviewers (SP, LG) using the validated Methodological Index for Nonrandomized Studies (MINORS) tool, which reports good inter‐reviewer agreement and high test–retest reliability.43, 44 MINORS assesses studies based on the domains listed in Data Supplement S1 (available as supporting information in the online version of this paper, which is available at https://doi.org/onlinelibrary.wiley.com/doi/10.1002/aet2.10053/full), with the highest possible MINORS score being 16 or 24 for noncomparative or comparative studies, respectively. To date, no validated cutoff scores have been set for this tool to denote high, medium, or low quality. A third independent reviewer (LK) adjudicated disagreements.

Results

Search Results

Overall, 722 results were retrieved from the bibliographic databases, and 12 results were identified through the gray literature search. Following the removal of duplicates and screening of 453 unique citations, assessment of the full texts of 35 studies resulted in five studies being included in this review. Figure 1 presents the search results and reasons for study exclusion.

Figure 1.

PRISMA flow diagram for a systematic review of mTBI training for emergency physicians. mTBI = mild traumatic brain injury.

Study Characteristics

Table 2 summarizes the included studies. All included studies were conducted in North America and reported some form of comparison. Study designs included two before‐and‐after studies,45, 46 two cross‐sectional studies,47, 48 and one randomized controlled trial.49 Each study was conducted at multiple sites45, 46, 48 and/or using professional mailing lists (i.e., Canadian Association of Emergency Physicians47 and the American Medical Association49) for recruitment. One of the included studies was conducted in pediatric settings,46 one was conducted in mixed adult/pediatric settings,48 and three did not report details on the study setting.45, 47, 49 Studies generally did not report on physician demographics (i.e., sex, age) and additional certifications (e.g., additional residencies); however, two studies reported on subspecialty training.47, 48 The proportion of EPs with previous mTBI training was not reported in any of the studies.

Table 2.

Summary of Study Characteristics of Studies Included in a Systematic Review of mTBI Training for EPs

Author, Year	Country	Study Design	MINORS Scorea	Setting	Subspecialties	Outcome Measure(s)	Results
Babul et al., 201445	Canada	Before‐and‐after	3	Multiple urban EDs	NR	Self‐report survey sent to EPs on: mTBI knowledge Treatment practices Attitudes about mTBI	Improved mTBI knowledge in physicians treating > 10 mTBI/year Improved mTBI practice Negative change in physician attitudes to mTBI
Carson et al., 201647	Canada	Cross‐sectional	10	Two community teaching hospitals	Sports medicine	Self‐report survey sent to SEMPs and EPs on: Usefulness and awareness of mTBI information sources Use of diagnostic tools Treatment strategies	Compared to SEMPs, EPs were: Less aware of consensus guidelines Less likely to use SCAT‐2 More likely to prescribe nonopioid analgesics and NSAIDs Less likely to advise cognitive rest
Chrisman et al., 201149	United States	Randomized control trial	19	NR	NR	Self‐report survey sent to physicians including EPs on: mTBI experience mTBI knowledge Vignettes assessed: EPs diagnosis RTA instructions	Survey reported: Better understanding of helmet's limitations to prevent mTBI Vignettes found: No change in diagnosis patterns Decrease in recommendations for next‐day RTA
Wang‐Flores et al., 201548	United States	Cross‐sectional	9	Seven EDs: children's hospitals, community hospitals, urgent care centers	Pediatrics	Case‐based survey send to EPs with and without pediatric fellowship training on: Discharge instructions	Compared to without, EPs with pediatric fellowship training: Reported more appropriate discharge instructions
Zuckerbraun et al., 201446	United States	Before‐and‐after	14	Two urban pediatric Level I trauma centers with > 70,000 ED visits/year	Pediatrics	Patient caregivers surveyed on: Rates of follow‐up Recall of discharge instructions Adherence to discharge instructions	After implementation of ED‐ACE, caregivers reported: Improved follow‐up with PCP or mTBI specialist Recall of mTBI symptoms and activity restrictions Improved patient adherence to recommendations

EPs = emergency physicians; MINORS = Methodologic Index for Nonrandomized Studies; mTBI = mild traumatic brain injury; NR = not reported; NSAID = nonsteroidal anti‐inflammatory drug; PCP = primary care provider; RTA = return to activity; SCAT‐2 = Sport Concussion Assessment Tool version 2; SEMP = sport and exercise medicine physician.

^aAll studies were comparative, and have a maximum MINORS score of 24.

Study Quality

Overall, the included studies were not of high quality, and MINORS scores ranged from 3 to 19 out of a maximum of 24 for comparative studies (Table 2). Figure 2 presents a summary of the quality assessment for all studies, and detailed scores for each study are available in Data Supplement S1. All studies had a clearly stated aim, and a majority adequately reported endpoints and follow‐up periods appropriate to the aim of the study and selected appropriate statistical analyses. Study quality was limited by inadequate reporting of physician inclusion strategy, prospective collection of data, unbiased assessment of the study endpoint, loss to follow‐up less than 5%, prospective calculation of study size, and an adequate control group, as well as baseline equivalence between the two groups.

Figure 2.

MINORS quality assessment scores for studies included in a systematic review of mTBI training for emergency physicians, stratified by criterion. mTBI = mild traumatic brain injury.

Primary Outcome: Training Types

The review identified a variety of mTBI training resources including three educational toolkits, the use of conference presentations and academic journal articles as CME, and fellowship training in pediatrics. The choice of training resource and its delivery varied across studies.

Overall, the included training resources focused on the recognition and management of mTBI and often occurred as part of CME. Table 3 presents a summary of each training resource. This review identified three formal educational toolkits: 1) the Concussion Assessment Training Tool (CATT), 2) the Centers for Disease Control and Prevention (CDC) Heads Up toolkit, and 3) the ED‐adapted Acute Concussion Evaluation (ACE) toolkit. The CATT is an online toolkit consisting of CPGs, online learning modules, patient handouts, a pocket mTBI recognition card that physicians can print out to use as a reference in the clinic, journal articles, mTBI study cases, and links to additional clinical resources such as websites and videos. The CDC's Heads Up toolkit contains a CPG, patient and physician handouts, a quick reference palm card, information booklet, and a CD‐ROM with additional resources. The third formalized tool identified was the ED‐adapted ACE toolkit, which included an assessment form to aid in the evaluation and diagnosis of mTBI and a patient discharge handout. Implementation of ACE also included additional mTBI training that consisted of a general mTBI education session for clinical staff, informational posters placed around the clinic, and informational e‐mails. The CATT and Heads Up toolkits both aim to provide comprehensive training on mTBI and include components on awareness, assessment/diagnosis, and management of mTBI, while the ACE toolkit lacked a general awareness component and focused on assessment and management.

Table 3.

Summary of mTBI Education and Training Outcomes From Studies Included in a Systematic Review of mTBI Training for Emergency Physicians

Education/Training Tool	Education Components							Scope	Type
	CPG	Teaching sessions	Info. handout	Reminder cards	Academic articles/ presentations	Vignettes/ case studies	Other resources
CATT online toolkit45	✓ SCAT‐3; pediatric postconcussive score	✓ online	✓ patient	✓ recognition tool	✓	✓	✓	Awareness, assessment	CME
Journal articles/ conference presentations47	✓ SCAT‐2				✓			NR	CME
Heads Up toolkit49	✓ ACE tool		✓ patient; physician	✓ palm card			✓	Diagnosis, management	CME
ED‐modified ACE tool46	✓ ACE tool	✓	✓ poster; e‐mails					Awareness, diagnosis, management	CME
Pediatric EM fellowship48	N/A			NR				NR	Subspecialty training

ACE = Acute Concussion Evaluation; CATT = Concussion Assessment Training Tool; CME = continuing medical education; CPG = clinical practice guideline; EM = emergency medicine; mTBI = mild traumatic brain injury; N/A = not applicable; NR = not reported; SCAT‐2 = Sport Concussion Assessment Tool version 2; SCAT‐3 = Sport Concussion Assessment Tool version 3.

The remaining two studies both examined differences between EPs and another specialty or subspecialty. Two studies reported on mTBI management and subspecialty training; one found that management of pediatric mTBI differed between EPs with and without additional pediatric training.48 Finally, one study described the differences between EPs and sports medicine physicians (SMPs) in mTBI CME, including use and perceived usefulness of mTBI informational resources (i.e., expert consensus statements, websites) and the use of the Sport Concussion Assessment Tool (SCAT)‐2.47

Most studies reported on use of a CPG in the management of mTBI, either alone47 or as part of one of the identified toolkits.45, 46, 49 In several studies, the CPG tools were presented alongside additional training or mTBI awareness education,45, 46, 49 and one study described the use of the SCAT‐2 between EPs and SMPs.

Secondary Outcomes

Knowledge Uptake And Retention

Knowledge uptake and retention among EPs was primarily measured by physician self‐report,45, 48, 49 and all three studies that reporting this outcome noted positive changes in knowledge uptake, with improvement most commonly seen in mTBI management (i.e., return‐to‐activity recommendations).45, 48, 49 No study commented on short‐ or long‐term knowledge retention.

While a significant positive change in knowledge was reported by Babul et al.,45 more specific details about the domains of mTBI knowledge assessed were unavailable. The Heads Up toolkit led to significantly improved discharge instructions and increased knowledge about the limitations of helmets to prevent mTBI.49 Overall, no change in mTBI identification and diagnosis of mTBI was found using vignettes, although a decrease in next‐day return‐to‐activity discharge instructions was reported.49 Using a case‐based survey, physicians with pediatric EM fellowship training responded with appropriate mTBI discharge instructions significantly more often than EPs without pediatric training.48

Reported Practice

Several studies measured physician practice, including both medical and nonmedical management, generally using self‐reporting methods (Table 2). Using a self‐reported survey, one study examined treatment strategies for mTBI and found that a larger proportion of EPs “usually or always” prescribed nonopioid analgesics (71% vs. 30%) and nonsteroidal anti‐inflammatory drugs (65% vs. 18%) for mTBI compared with sports and exercise medicine physicians;47 however, the role of mTBI training in this practice variation was not directly addressed.

Most studies (four of five) reported positive changes in the management of mTBI. Implementation of the CATT reportedly led to significant improvement in mTBI practice, especially for EPs who saw greater than 10 mTBIs in a year, although more specific details were not available.45 Training physicians on the use of the ED‐modified ACE tools with additional mTBI‐specific training was assessed through patient interviews and led to improvements in patient‐reported follow‐up with a primary care provider or mTBI specialist; additionally, pediatric patients’ caregivers were more likely to correctly recall mTBI symptoms, recall being given appropriate activity restrictions, and report adhering to discharge instructions.46 The CDC's Heads Up toolkit reduced the likelihood of physicians recommending next‐day return to activity, as assessed through a self‐report survey. Two studies assessed practice differences between EPs and other specialties using self‐report surveys. Compared with sports and exercise medicine physicians, EPs were significantly less likely to advise cognitive rest as part of their discharge instructions.47 Finally, physicians with pediatric subspecialty training more often provided appropriate restriction of screen time and reading/writing post‐mTBI.48

Discussion

Using a comprehensive and systematic search strategy, this review identified only five studies assessing mTBI training programs administered to EPs at any point during their career. This highlights the dearth of research in this area and raises concerns that physicians may not be receiving adequate training on the detection and management of mTBI. The included studies were not of high quality and were too few and too heterogeneous for a meta‐analysis. Resources for mTBI training for EPs identified by this review included three educational toolkits, the use of conference presentations, journal articles, and pediatric subspecialty training.

While previous studies have identified the deficiencies in mTBI information included in North American medical school curricula,39 no studies screened in this review examined the impact of medical school mTBI training on EP practice. CME on mTBI may fill the knowledge gaps left by the medical school curricula, but only if physicians engage in it it. Other tools, such as audit and feedback or real‐time interventions employing computerized physician order entry (CPOE) guidelines or electronic medical records, may help to reduce practice variation among physicians treating concussions; however, these types of interventions were outside the scope of this review.

In this review, actively disseminated multimodal educational toolkits that included components integrated into physicians’ practice, such as pocket cards, appeared to have positive effects on ED‐based practice.45, 46, 49 Unfortunately, no study directly compared any of these tools or measured sustained practice change, so the comparative effectiveness of each tool and sustainability of practice changes over time remain unknown. Despite the existence of the five different training resources identified in this review, their weak implementation and unknown fidelity and/or effectiveness limits their potential application.47, 50, 51 Practice variation and evidence‐to‐practice gaps among EPs management of mTBI has been documented,52 and suboptimal implementation strategies have previously been held responsible for this variation.31, 51, 52, 53 In this review, the measurement of both knowledge‐based and patient‐centered outcomes was suboptimal; thus, the most effective methods for EP knowledge uptake and practice change remain to be identified. Active and multifaceted approaches are generally recommended to overcome the barriers to translating educational interventions into bedside improvements,54, 55 but further validation of the CATT, ED‐modified ACE, and Heads Up toolkits in changing physician practice is needed. The search identified several in‐progress mTBI‐specific knowledge translation (KT) projects.37, 45, 56 While these projects could not be included in this review due to a lack of data, they highlight that research in this area is currently ongoing.

The other two identified training resources (pediatric subspecialty EM training and CME journal articles and conference presentations) also present challenges. While EPs who had completed both pediatric and EM training more often provided appropriate recommendations for cognitive rest compared with EPs with only EM training,48 training in an additional subspecialty is not readily accessible for all EPs. Although EPs with additional pediatric training may be more familiar with concussion literature,32 and therefore more likely to be aware of the current consensus‐based best practice, it is unclear whether this familiarity comes through pediatric EM fellowship training or pediatric residency training. Pediatric specialty training may emphasize conditions such as shaken baby syndrome or sports injuries, where mTBI identification and management apply. Identification of components within pediatric training that address diagnosis and management of mTBIs may be useful, as those components could then be adapted to other subspecialties or built into a stand‐alone educational CME module. Journal articles and conference presentations are readily available forms of CME; however, their ability to independently change practice and improve care or patient outcomes is questionable.50 While most physicians in North America are required to complete a minimum number of CME credits every year, there are no requirements relating to the educational topic. In other words, the availability of mTBI‐centered articles and conference presentations does not necessarily correlate with their uptake by physicians.

Limitations

There are several limitations in this review. First, the heterogeneity among included studies and a lack of direct comparisons among tools precluded simple or network meta‐analysis to identify the overall effectiveness of each training resource or their components. Second, the included studies did not report data on physician characteristics. Data on physician characteristics, such as their previous experience treating mTBI and number of years in practice, and their association with the effectiveness of mTBI training tools may be important to identifying successful KT strategies. Third, in most studies, EPs self‐reported their change in practice as a measure of mTBI knowledge uptake; only one study externally validated its self‐reported survey through patient interviews.47 These self‐reported outcomes may be biased and inaccurately reflect a physician's practice.57, 58 As a result, the positive changes in EP practice attributed to each tool may overestimate the effect due to social desirability bias. Fifth, we did not assess fidelity of any of the included training programs or educational toolkits; the limited data presented in the included studies would have made this a fruitless endeavor. Last, publication and selection biases can affect all systematic reviews. To limit publication bias, a comprehensive search strategy utilized multiple primary literature databases with no restrictions, as well as extensively searching the gray literature. The potential publication bias in this review is low as there were a number of abstracts not yet published in journals that were included. Similarly, two independent reviewers reviewed relevant studies and extracted data, and a third independent reviewer adjudicated disagreements, all of which acted to reduce the likelihood of selection bias.

Conclusions

This systematic review identified five studies that addressed mTBI training resources or training programs accessible to emergency physicians at some point during their medical career. Each study assessed a different educational toolkit or training program and used different outcome measures. Although most of the tools identified resulted in knowledge uptake and retention regarding mTBI, due to insufficient high‐quality evidence on emergency physician mTBI training, this review cannot make specific recommendations regarding the most effective type of delivery. Additionally, no study examined objective changes in emergency physician practice highlighting a deficiency in current mTBI–specific KT research. Direct comparisons of the effectiveness of mTBI educational toolkits are required to identify those tools successful at improving diagnostic accuracy, to aid in the establishment of standardized mTBI medical school curricula, and to identify optimal KT methods for effectively translating new knowledge to changes in physician practice. While most patients with mTBI recover within 7 to 10 days, in the absence of a standardized training tool with an objective outcome measure, practice variation, care gaps, and the prevalence of the serious sequelae of mTBIs will likely persist.

The authors thank Drs. Shelina Babul, Angela Colantonio, Isabelle Gagnon, Cameron Marshall, Laura Purcell, Emma Tavender, James Carson, and Noel Zuckerbraun for responding to requests for additional information.

Supporting information

Data Supplement S1. Methodological Index for Non‐Randomized Studies quality assessment for studies included in a systematic review of mTBI training received by emergency physicians.

AEM Education and Training 2017;1:346–356.