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Headache Clinical Recommendation Internal Training

Training Workbook

November 16, 2016

Table of ContentsAssessment Activity 1.1.................................................................................................................2

Activity Question 1.................................................................................................................2

Knowledge Check 1................................................................................................................4

History Activity 1.2.........................................................................................................................5


Knowledge Check 2................................................................................................................6

Red Flag Activity 1.3.......................................................................................................................7


Knowledge Check 3................................................................................................................7

Group Activity 2.1..........................................................................................................................8

Creating a Presentation at DVBIC..............................................................................................8

Rationale:...............................................................................................................................8

Instructions............................................................................................................................8

Answer Key.................................................................................................................................... 9

Headache Clinical Recommendation Knowledge Survey...........................................................9

Assessment Activity 1.1.............................................................................................................9

History Activity 1.2.....................................................................................................................9

Red Flag Activity 1.3...................................................................................................................9

Checklist.......................................................................................................................................10

Appendix......................................................................................................................................12

Why do presentations; are they really important?..................................................................12

What do you do about difficult questions?..............................................................................14

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TRAINING EXCERCISESNovember 16, 2016

Assessment Activity 1.1This activity provides an opportunity to apply the knowledge you are learning from the Management of Headache Following Concussion/mTBI; Guidance for Primary Care Management in Deployed and Non-Deployed Settings to a clinical scenario. Read the assessment activity, then turn and talk with a partner to discuss how best to answer the questions.

PFC Tonya Ray (age 20) waits in the exam room rubbing her neck.

PFC Tonya Ray complains of a headache with light sensitivity; she has been treated for headaches in the past.

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Activity Question 1How might a provider approach PFC Ray’s case using typical assessment methods? If a provider used the Management of Headache Following Concussion Clinical Recommendation (CR) instead, how might they asses PFC Ray?

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If directed to do so by your instructor, select the answer that most closely reflects the CR’s content (even if the knowledge check is not assigned, you may wish to answer the question later as a review).

Knowledge Check 1How can the Performed Focused Post-Traumatic Headache (PTH) History and Exam Algorithm help providers diagnose the patient’s type of headache correctly?

A) The algorithm assists in assessing symptoms, location, description of pain, frequency and duration of pain and associated symptoms.

B) The algorithm assists in assessing the head, neck, face, ears, nose, throat, neurological areas and mental status.

C) The algorithm assists in determining if the patient has had a concussion. D) A, B & C are correctE) A & B are correct

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History Activity 1.2This activity is intended to transfer the knowledge you are learning to a clinical scenario. Read the activity, then turn and talk with a partner to answer the questions.

The provider takes PFC Ray’s patient history

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During the injury history questions, the primary care provider (PCP) learns that PFC Ray was in a car accident about a week ago. In the accident she experienced whiplash and a contusion to the left side of her head. Since then PFC Ray has had a mild headache, light sensitivity and neck pain. Her headache has become noticeably worse in the last 2 days

Activity Question 2How might the Management of Headache Following Concussion CR help direct a Primary Care Provider in diagnosing PFC Ray?

If directed to do so by your instructor, select the answer that most closely reflects the CR’s content.

Knowledge Check 2Why does the Management of Headache Following Concussion CR offer a better approach to diagnosing headache symptoms than typical treatment?

A) The Management of Headache Following Concussion CR is developed using evidenced-based reviews, current clinical practice guidelines and a multidiscipline expert panel so the guidance is vetted and well presented.

B) The Management of Headache Following Concussion CR is designed specifically to assist with acute and sub-acute post-traumatic headache so the guidance is targeted and easily accessible for Providers.

C) The Management of Headache Following Concussion CR offers specific guidance to specialty care providers.

D) A and B are correctE) C is correct

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Red Flag Activity 1.3Read the activity, then turn and talk with a partner to answer the questions.

Examining pupil size

Since PFC Ryan’s accident, her headaches have become progressively worse. During the exam, the PCP notices that her pupils are asymmetric. According to the Management of Headache Following Concussion CR, what should the PCP do next?

Activity Question 3What advice would you give to a provider using the Table 2.0 and 3.0 (C & D in treatment algorithm) Concussion Red Flags?

If directed by your instructor, select the answer that most closely reflects the CR’s content.

Knowledge Check 3How does Table 4.0 (E in treatment algorithm) Headache Red Flags and Indications for Referral assist providers in determining the urgency of potentially important PTH diagnoses?

A) The table lists all possible red flagsB) The table lists all red flags for the four common PTH typesC) The table makes good use of an algorithmD) The table separates indications for emergency and specialty referrals

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Group Activity 2.1Creating a Presentation at DVBIC

Rationale:

This exercise is designed to help you create a presentation based on the Management of Headache Following Concussion/mTBI; Guidance for Primary Care Management in Deployed and Non-Deployed Settings. You will work in teams. The purpose of this teamwork approach is to imitate the DVBIC work environment and the reach-back resources available here at headquarters for any topic. For the purposes of this exercise, you will simulate the act of working with subject matter experts at headquarters, putting together a presentation on the Headache CR and then delivering it.

For example: If a team includes a social worker, a nurse and a physician, members of the team may or can play different roles on their team. Not all team members must present, some may just provide professional expertise and resources. There can be more than one presenter; if you’d like to share the duties, or have just a single presenter.

Instructions:

Using the Headache CR, develop a presentation with your team based on the downloaded slide deck that accompanied this training.

Please create your presentation and be prepared to present to larger group, using the presentation checklist in the workbook.

The presentation should be 45 minutes or less.

Please come back at 13:00 prepared to make your team’s presentation.

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Answer KeyHeadache Clinical Recommendation Knowledge Survey 1. 22. 13. 34. 15. 4.

Assessment Activity 1.11. Activity Question Answer:

Provider would follow the algorithm guidance to determine the recommended treatment and first line interventions, instead of going with their ‘usual migraine medication’ and 2 week follow up- etc.

2. Knowledge Check Answer:D

History Activity 1.23. Activity Question Answer:

Get thorough history to include concussion history, perform PTH specific physical exam, narrow to most likely headache type, begin first line recommended care, and proceed with follow-up guidance.


Red Flag Activity 1.35. Activity Question Answer:

See if groups come up with these suggestions:

a. Don’t memorizeb. Target distinguishing areas- ex) photophobiac. Use as a soft guide- headaches don’t really fit in neatly boxed categories


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Use the table below as a structure on which to build your presentation.

ChecklistSlide Presentation Guidelines

Cover Slide/IntroductionIncludes name (s)Includes name of locationIncludes key speaker’s introductionIncludes speaker’s credentialsDVBIC overviewReference to germane resourcesImpact of TBI on Service MembersDescribe how TBI impacts SM, using WWNPresent specific objective of the Headache CRCRs at DVBICProvide overview/purpose of all CR’s at DVBICDescribe/Explain each agenda objectivePurpose and Scope of Headache CRDescribe goal of CRDescribe common occurrence of PTH after concussionDescribe state-of-the-science information within CRDescribe interventions/pharmacologic and non- pharmacologicHow do we develop CRs at DVBIC?Explain multidisciplinary process used to develop all CRs.Type; Case SpecificDescribe how PTH is diagnosed Diagnosis/ClassificationDescribe all types of PTHTreatment OptionsDescribe non-pharmacologic options Describe Concussion Management AlgorithmExplain Progressive Return to ActivityDescribe Pharmacologic options Evaluation/Treatment Algorithm

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Describe how to use DVBIC AlgorithmsFocused ExamDescribe the concept of a focused examConcussion Red FlagsDescribe the concept of a “red flag” within the AlgorithmHeadache TypesDescribe all headache PTH typesSummarySummarize all key points from presentationClinical Support ToolsDescribe appropriate CST Patient ResourcesHighlight appropriate DVBIC resources PTH Working GroupExplain the purpose and scope of the PTH working groupConclusion SlideProvide follow up resourcesProvide Professional contacttake questions

1.

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AppendixWhy do presentations; are they really important? Are there reasons beyond the obvious answer that DVBIC’s mission is to serve active-duty service members, veterans and their family members with traumatic brain injury through state-of-the-science medical care and care coordination, and innovative clinical research and educational programs? Yes! Regardless of its specific clinical subject, anytime you make a presentation you represent our organization and can contribute to promoting and positioning DVBIC. Your training presentation will introduce the products we work so hard to produce to our target population, and encourage their use by providers. Try to consider these underlying goals in the examples below:

DVBIC is a trusted source: Tell providers why; emphasis our history and partnerships. Assure providers that DVBIC’s information will be consistent, accurate, and reliable. Providers may not remember all the details, but they should retain the message that DVBIC is a knowledgeable, up-to-date and accessible authority. If you are successful in conveying this message, the remainder of these goals will fall in place naturally.

DVBIC is current: Providers, especially in primary care providers, rarely have time to do all the reading required to keep current on medical recommendations. However, falling behind can mean practicing outside of accepted medical guidelines. This may result not only in harming patients, but can lead to legal consequences. Talk about how we develop tools using teams of experts in the field, which are based on validated clinical research. Mention our products are regularly reviewed and updated, ensuring they contain the best guidance available today.

DVBIC puts the patient first: Stress that our clinical tools incorporate conservative and non-pharmacologic treatment options, which are also based on evidence validated research. Try to emphasize to your audience that we always consider the patient’s long-term health, even when focusing on immediate symptom relief. To effect changes in clinical practice, we must convince providers that if follow they DVBIC recommendations they will make valid decisions-in-care, because DVBIC CRs are based on what is safe and what works.

DVBIC tools are ready-to-use and accessible in many forms: Discuss all the different types of tools we offer (website links, apps, fact sheets, CRs, CPGs etc.). Providers may not always retain the specific items you list, but they should get the impression that DVBIC has multiple free tools

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tailored to their needs. We want them to come back to DVBIC and seek other products of interest, even if your presentation was not on that specific topic.

DVBIC tools are user-friendly: When showing PowerPoint slides of algorithms and charts, explain they were not designed to be memorized, because guides are subject to change when recommendations are revised. A data-dense algorithm or chart may intimidate a provider. Make sure they know you are just demonstrating what product looks like and how it is navigated. Providers should feel they can easily integrate DVBIC tools into their practice.

DVBIC values provider opinion: Getting first-hand product feedback historically has not been easy for our organization. Demonstrate we want feedback and are willing to create the tools providers need. Show empathy for the provider’s daily challenges such as; time constraints, argumentative patients (who may resist non-pharmacologic options), and the sometimes awkward learning-curve of using a new tool with patients for the first time. Your audience should feel that DVBIC products will help with patient/provider relationships in the following ways:

Better patient symptom control Overlapping relief of other symptoms Access to educational tools patients can actively use between appointments Confidence in a treatment model from validated medical authority Fewer appointments per patient opening up time for other practice areas

As DVBIC educators try keep these presentation tips in mind to enhance our reputation as a validated authority, so that providers can justify to the service member why they are applying our treatment recommendations.

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What do you do about difficult questions?It is alright if you don’t know the “right answer,” because it is an opportunity to make new connections and relationships by emphasizing the expansive expertise within DVBIC. For example:

Q: “Are you aware of (any research/treatments/ tools/programs) that shows….”

A: “That is a great question for our [insert best resource here: i.e. ‘research division’, ‘clinical experts,’ ‘education leadership’, ‘outreach specialist’ etc.], I would be more than happy to connect you with them. Please see me after this presentation to provide your contact information.”

If you are unsure which resource is most appropriate just say you will connect them to “the best resource.”

Occasionally a person in the audience will challenge DVBIC statistics and recommendations, especially if they conflict with their own research or treatment approaches. In cases like this it may be helpful to explain how the guidelines were created, but try to discourage arguments about the presentation, particularly discussions about specific treatment theories. You must be sure you have enough time to make your entire presentation, and often the subject of argument does not benefit the whole audience. For example:

Q: “DVBIC guidelines say that … but in my experience…works much better…”

A: You may need to politely interrupt with- “I appreciate your interest in [DVBIC guidelines/recs/etc.] and your passion about [their subject]. I want to be sure to provide all my prepared presentation material today, so if you have time, please see me later and we can talk more about this offline.”

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