iPad-Based Neurocognitive Testing (ImPACT-QT) in Acute Adult Mild Traumatic Brain Injury/Concussion: Study on Practicality and Bedside Cognitive Scores in a Level-1 Trauma Center

Background There lacks rapid standardized bedside testing to screen cognitive deficits following mild traumatic brain injury (mTBI). Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test (ImPACT-QT) is an abbreviated-iPad form of computerized cognitive testing. The aim of this study is to test ImPACT-QT utility in inpatient settings. We hypothesize ImPACT-QT is feasible in the acute trauma setting. Method Trauma patients ages 12-70 were administered ImPACT-QT (09/2022-09/2023). Encephalopathic/medically unstable patients were excluded. Mild traumatic brain injury was defined as documented-head trauma with loss-of-consciousness <30 minutes and arrival Glasgow Coma Scale 13-15. Patients answered Likert-scale surveys. Bivariate analyses compared demographics, attention, motor speed, and memory scores between mTBI and non-TBI controls. Multivariable logistic regression assessed memory score as a predictor of mTBI diagnosis. Results Of 233 patients evaluated (36 years [IQR 23-50], 71% [166/233] female), 179 (76%) were mTBI patients. For all patients, mean test-time was 9.3 ± 2 minutes with 93% (73/76) finding the test “easy to understand.” Mild traumatic brain injury patients than non-TBI control had lower memory scores (25 [IQR 7-100] vs 43 [26-100], P = .001) while attention (5 [1-23] vs 11 [1-32]) and motor score (14 [3-28] vs 13 [4-32]) showed no significant differences. Multivariable-regression (adjustment: age, sex, race, education level, ISS, and time to test) demonstrated memory score predicted mTBI positive status (OR .96, CI .94-.98, P = .004). Discussion Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test is feasible in trauma patients. Preliminary findings suggest acute mTBIs have lower memory but not attention/motor scores vs non-TBI trauma controls.


Introduction
Mild traumatic brain injury (mTBI, "concussions") represents the most common form of TBI, with a 100 per 100,000 annual incidence worldwide. 1Despite its classification as "mild," mTBI encompasses a spectrum of cognitive, physical, and affective symptoms.In particular, cognitive symptoms such as memory problems, 2 reduced attention span, and slower motor speed are significant causes of difficulty returning to work 3 and self-reported patient disability. 4iagnosing mTBI is challenging due to the subtlety of clinical symptoms, the ambiguity of radiographic findings, and the absence of identifiable biomarkers. 5A challenge in the trauma setting is the acute triage of mTBI patients, as these patients may not require hospitalization but may have substantial early cognitive impairment. 6owever, the diagnosis of mTBI is likely underreported in acute settings, as many patients underreport symptoms and/or hospital systems may not capture cognitive deficits in patients who are discharged directly from the emergency department.The number of patients discharged has even more recently increased due to increased data on the safety of this practice. 7In addition, formal cognitive evaluations are time-consuming and require highly specialized providers such as occupational therapists and/or speech therapists to administer these tests. 7To date, there is a paucity of standardized, validated bedside exams that can be administered by nursing staff to screen for cognitive deficits in mTBI patients.
This study aimed to evaluate this gap with the administration of the Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test (ImPACT-QT), an FDAapproved iPad variant of the computerized ImPACT test 8 for triaging trauma patients for mTBI-related cognitive symptoms.This test has previously been utilized for outpatient testing and sports-related injuries. 9,10However, no studies tested this as a method for cognitive evaluation in acute adult TBI patients within the Emergency Department.
Therefore, the primary aim of this study is to demonstrate the feasibility of implementing ImPACT-QT in the acute emergency and inpatient setting of a level-1 trauma center.We hypothesize in mTBI acute trauma populations the test can be performed rapidly with minimal negative impact on patient symptoms or workflow.As a secondary exploratory aim, we compare score differences between mTBI vs those without mTBI, hypothesizing that patients with mTBI would have worse performance of memory score.

Methods
The study adhered to ethical guidelines with protocol and consent exemption approval from our local Institutional Review Board (Protocol #3070).

Study Design Prospective cohort study
ImPACT-QT neurocognitive testing.The test outputs a composite score in three domains, representing percentile performance compared to a normative data set.This normative data set consists of a 772person cohort across various ages and races without known neurologic, psychiatric, or drug use history.Im-PACT testing also took place in a research environment as specified by the ImPACT-QT manual. 8,11Manufacturer recommendations include a testing environment free of noise/distraction, no alcohol or recreational drug use, testing in one sitting, and taking the test in an upright position using a table.
Participants, Procedure, and Outcomes.Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test was sequentially administered to trauma activations at our level-1 trauma center.This prospective and sequential administration aimed at evaluating cognitive functions within 72 hours of patient arrival.A convenience sample encompassed both ED and admitted trauma patients.To identify suitable participants, daily trauma service patient lists were scrutinized on weekdays.Test administrators, independent of the study's design and blind to its analysis, conducted this review.Testing was restricted to a single attempt per patient, during which the administrators refrained from interaction or assistance.The duration of the ImPACT cognitive modules was recorded.Following testing, patients were given an optional post-test paper survey.Patient demographics, hospital metrics, and Rancho Los Amigos Scores were manually extracted from the electronic medical record.
The primary outcome was self-reported survey metrics by patients after performing ImPACT testing.Secondary outcomes were a clinical diagnosis of concussion and Rancho Los Amigos Score.
Inclusion and Exclusion Criteria.mTBI was classified using specific criteria: a Glasgow Coma Scale of 13-15 at initial assessment, loss of consciousness less than 30 minutes, witnessed or reported head trauma, high-risk mechanism (MVC, peds vs adult, fall), and a clinical mTBI diagnosis in the trauma attending physician's note.This definition shares clinical definitions with updated American Congress of Rehabilitation Medicine Diagnostic Criteria 12 and was intentionally broad in order to achieve sample size.We utilize a TBI definition that includes both radiographically (CT) negative and positive TBI because of a priori determination that CT-positive TBI accounts for a small minority of our population and radiographically negative TBI is most common and is known to cause disability and cognitive symptoms. 13on-head trauma controls were identified as trauma activations not meeting the aforementioned mTBI criteria upon chart review.
Inclusion criteria were trauma activations, age 12 to 70, and proficiency in reading Spanish or English.We excluded encephalopathic patients, active alcohol withdrawal, recent sedation/analgesia, and physical impediments barring the use of an iPad.Test administrators were at discretion to exclude patients determined to be medically or surgically unstable or with bodily injury (eg, eye and arm) that would not be compatible with using an iPad.Patients unable to complete testing despite selection were excluded.
Statistical Analysis.Descriptive statistics and univariate analysis were performed.Continuous variables were assessed using Student's t test, while categorical variables were analyzed using Chi-Square or ANOVA.Normality was determined with the Shapiro-Wilk Test.Nonparametric testing was used for the Kruskal

Univariate Analysis of mTBI vs Trauma Patients
There were no differences in age, sex, race, ethnicity, AIS, and ISS between cohorts (all P > .05).The mTBI group had increased emergency department lengths of stay (11 hours vs 9 hours, P = .032)and rates of ED discharge to home (66% vs 27%, P < .001)compared to the control.Time from admission to ImPACT administration was lower in the mTBI group than in the control (9 hours vs 17 hours, P < .001)(Table 1).
Regardless of TBI status, average cognitive scores were below the 50 th percentile.There was no difference in motor (14 vs 13 percentile, P = .755)or attention scores mTBI (5 vs 11 percentile, P = .081)between mTBI and control groups.Memory scores were significantly lower in the mTBI group vs control (25 vs 43 percentile, P < .001)(Figure 1).

Post-Testing Survey Results
A total of 76 (32%) participants completed post-ImPACT surveys.Highest level of education in 53 percent (41/76) of surveyors was college-graduate or above.Of those surveyed, testing was deemed easy to understand, and the iPad easy to use in more than 90% of participants regardless of cohort (Table 1).Only 1 patient (4%) in the mTBI group felt symptoms worsened post-testing, and both groups had minimal disruption to nursing care.More control patients felt distracted during testing than patients in the mTBI group (22% vs 4%, P = .019).Median test completion time for all participants was 9 minutes.

Multivariable Analysis
On multivariable analysis, when controlling for age, sex, race, highest education level, ISS, and time to test administration, an increased memory score predicted a lower

Discussion
This is the first study to demonstrate that ImPACT-QT, an iPad-based neurocognitive test, is in a busy trauma setting.Notably, the test is safe, performed under 10 minutes, understandable by patients, and does not disrupt clinical care.In our exploratory second analysis, we found the test demonstrates lower memory scores in mTBI than in non-TBI trauma patients.This rapid bedside tool may be useful for triaging post-mTBI cognitive deficits in resource-limited environments without access to speech-language pathologist, psychologist, or specialty concussion care.We show in this study that ImPACT-QT is feasible once a patient obtains the device, nevertheless a key next step in practical implementation is better understanding the effect and barriers of patient flow.The barriers to implementation are seen by the fact that time to testing was longer in the non-concussion group.This may reflect our hospital and research screening bias.For example, non-head trauma may be deemed lower priority for cognitive assessment because of need for extra-axial care or pending discharge.In contrast, our hospital protocol prioritizes cognitive screening for primary head trauma, especially if intracranial abnormalities are identified.Patient location may also be a factor in testing implementation.mTBI patients had longer ED stays and higher proportion of discharge from the ED.In contrast, non-mTBI patients had higher admission rates and more testing was performed in the ward setting rather than ED.This suggests complexities intrinsic to some groups of trauma patients, and the movement and disposition of patients may delay identification or testing of appropriate patients.There were no differences in ISS or AIS between groups, but the effect of imbalances in hospital setting on scoring will need to be studied.
Memory scores were lower in clinical TBI patients vs non-head trauma patients, while attention and motor scores were low in both TBI and non-head trauma patients.This exploratory study sought to evaluate the score ranges of ImPACT-QT in a "real-world" setting.Patients in the emergency room and trauma settings in contrast to manufacturer recommendations are in an uncontrolled setting.The trauma setting has multiple distractors including hospital sound, medical care/intervention, medications, and psychological stressors.ImPACT reports scores as percentile outputs which are performance percentile from a reference group that took the test in a highly controlled setting and it is common for healthy populations to score below 25 th percentile on one score parameter. 11Unsurprisingly, cognitive scores of even non-TBI trauma patients were below the 50 th percentile.This suggests all scores are to some extent confounded by the trauma setting.Nevertheless, the finding of significantly lower memory scores in TBI patients despite this uncontrolled test setting suggests memory score may be an objective biomarker in clinical mTBI.
To date, only two other studies have tested ImPACT-QT in non-normative populations, both in athletic populations. 9,14The iPad interface is appealing in a trauma setting due to its mobility and user-friendly interface compared to traditional cognitive batteries which often require trained personnel.Though ImPACT-QT shares similarities with the computerized ImPACT, the effect of mobile device interfaces on reported scores is not known.In a comparison between ImPACT Computerized vs ImPACT-QT batteries, a study found the latter had significantly higher scores in four speed-based motor subtests.Furthermore, ImPACT testing in non-sports populations lacks rigorous evaluation and is more robust with a pre-testing baseline, which is not practical in an acute concussion population.ImPACT testing is known to have a high rate of baseline invalidity 15 and varying retest reliability, 16 and it is unknown what general trauma population factors may contribute to the known limitations of ImPACT.
Our findings are important because the current literature on neurocognitive testing in the acute non-sport TBI setting is mixed and limited.Lunter et al successfully implemented the Cambridge Neuropsychological Test Automated Battery iPad application in an emergency department and found differences in reaction time and executive functioning among concussion vs trauma control. 17Similarly, computerized ImPACT was implemented in a pediatric emergency department with no disruption to workflow and showed most pediatric mTBI patients performed below the 25th percentile across neurocognitive domains. 18In contrast, a battery of computerized neurocognitive tools including ImPACT failed to differentiate between mTBI and trauma controls. 19Though we did not find a relationship between ImPACT-QT scores and the Rancho Los Amigos Scale or investigate long-term cognitive outcomes, studies found early acute neurocognitive changes predict risk for persistent postconcussion syndrome. 20The heterogeneity of study findings likely reflects the heterogeneity of methodology, test batteries utilized, and study outcomes.Future randomized head-to-head testing across rapidneurocognitive batteries and gold-standard neuropsychology testing in acute adult mTBI is still needed.Key limitations in our study include the small sample size, lack of pre-injury testing, serial testing, lack of health control, and dependence on normative percentiles.We utilized a clinician definition of mTBI, relied on EMR chart extraction, and performed convenience sampling of ED trauma patients fitting a pre-determined criterion.Though we found no difference among number of patients cared for by the providers, we acknowledge possible diagnosis bias from different clinicians.Therefore, this study may not reflect the true incidence of mTBI.We did not investigate the role of radiographic positive head trauma on findings due to small sample size.We did not perform patient matching such as propensity given limitations of study design, though we are conducting an ongoing study to address this.Our findings reflect an academic level-1 trauma center in Southern California which may limit generalizability.Though we noted no differences in baseline demographics and education level between mTBI and trauma controls, we did not account for all socioeconomic or baseline patient factors that may influence cognitive testing performance.Our study was underpowered to assess the validity of the device in screening cognitive deficits, relationship between test scores, and standard inpatient cognitive testing (Rancho Score) and lacks long-term outcomes.Finally, patients only had one attempt at testing, and we did not control for all confounding neurological, medications, and hospital environment factors, which may account for poor performance on testing.

Conclusion
In this study, we demonstrate the feasibility of an iPadbased neurocognitive in adult patients at a level-1 trauma center.We show lower memory scores in clinical mTBI than non-head trauma controls.This study suggests ImPACT-QT as one possible adjunct tool to screen for mTBI in acute trauma and assist in triaging mTBI patients for further cognitive workup.Future studies will investigate the impact on quality metrics and long-term patient cognitive outcomes.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figure 1 .
Figure 1.Violin plots of scores in mild traumatic brain injury (mTBI) versus non-traumatic brain injury trauma controls.
-Wallis Test for continuous variables or Fischer's Test for categorical variables.Multivariable logistical regression identified potential confounders in acute cognitive testing informed by literature review and group consensus.Statistical significance was defined as P < .05.Statistical Analysis was performed with R Studio v. 4.3.2(Boston, MA).Data Statement: Anonymized data source is available per request.

Table 1 .
Demographic and Cognitive Scoring in Mild Traumatic Brain Injury (mTBI) Versus Non-traumatic Brain Injury Trauma Controls.