Mild traumatic brain injury in children: management practices in the acute care setting

Qualitative study of emergency clinicians to inform a national guideline on the management of children with mild-to-moderate head injuries

BACKGROUND

Head injury is a common reason children present to EDs. Guideline development to improve care for paediatric head injuries should target the information needs of ED clinicians and factors influencing its uptake.

METHODS

We conducted semi-structured qualitative interviews (November 2017-November 2018) with a stratified purposive sample of ED clinicians from across Australia and New Zealand. We identified clinician information needs, used the Theoretical Domains Framework (TDF) to explore factors influencing the use of head CT and clinical decision rules/guidelines in CT decision-making, and explored ways to improve guideline uptake. Two researchers coded the interview transcripts using thematic content analysis.

RESULTS

A total of 43 clinicians (28 doctors, 15 nurses), from 19 hospitals (5 tertiary, 8 suburban, 6 regional/rural) were interviewed. Clinicians sought guidance for scenarios including ED management of infants, children with underlying medical issues, delayed or representations and potential non-accidental injuries. Improvements to the quality and content of discharge communication and parental discussion materials were suggested. Known risks of radiation from head CTs has led to a culture of observation over use of CT in Australasia (TDF domain: beliefs about consequences). Formal and informal policies have resulted in senior clinicians making most head CT decisions in children (TDF domain: behavioural regulation). Senior clinicians consider their gestalt to be more accurate and outperform existing guidance (TDF domain: beliefs about capabilities), although they perceive guidelines as useful for training and supporting junior staff. Summaries, flow charts, publication in ED-specific journals and scripted training materials were suggestions to improve uptake.

CONCLUSION

Information needs of ED clinicians, factors influencing use of head CT in children with head injuries and the role of guidelines were identified. These findings informed the scope and implementation strategies for an Australasian guideline for mild-to-moderate head injuries in children.

Involving end-users in the design of an audit and feedback intervention in the emergency department setting - a mixed methods study

BACKGROUND

Long length of stays (LOS) in emergency departments (ED) negatively affect quality of care. Ordering of inappropriate diagnostic tests contributes to long LOS and reduces quality of care. One strategy to change practice patterns is to use performance feedback dashboards for physicians. While this strategy has proven to be successful in multiple settings, the most effective ways to deliver such interventions remain unknown. Involving end-users in the process is likely important for a successful design and implementation of a performance dashboard within a specific workplace culture. This mixed methods study aimed to develop design requirements for an ED performance dashboard and to understand the role of culture and social networks in the adoption process.

METHODS

We performed 13 semi-structured interviews with attending physicians in different roles within a single public ED in the U.S. to get an in-depth understanding of physicians' needs and concerns. Principles of human-centered design were used to translate these interviews into design requirements and to iteratively develop a front-end performance feedback dashboard. Pre- and post- surveys were used to evaluate the effect of the dashboard on physicians' motivation and to measure their perception of the usefulness of the dashboard. Data on the ED culture and underlying social network were collected. Outcomes were compared between physicians involved in the human-centered design process, those with exposure to the design process through the ED social network, and those with limited exposure.

RESULTS

Key design requirements obtained from the interviews were ease of access, drilldown functionality, customization, and a visual data display including monthly time-trends and blinded peer-comparisons. Identified barriers included concerns about unintended consequences and the veracity of underlying data. The surveys revealed that the ED culture and social network are associated with reported usefulness of the dashboard. Additionally, physicians' motivation was differentially affected by the dashboard based on their position in the social network.

CONCLUSIONS

This study demonstrates the feasibility of designing a performance feedback dashboard using a human-centered design approach in the ED setting. Additionally, we show preliminary evidence that the culture and underlying social network are of key importance for successful adoption of a dashboard.

Factors that predict discharge recommendations following paediatric mild traumatic brain injury

PRIMARY OBJECTIVE

To investigate factors that predict discharge recommendations for children and adolescents who present to an Australian paediatric Emergency Department (ED) following a mild traumatic brain injury (mTBI).

RESEARCH DESIGN

Retrospective data base analysis.

METHODS

The study retrospectively analysed an ED database to test the relationship between injury risk factors (symptoms, Glasgow Coma Scale, prior TBI, mechanism of injury and Computed Tomography scan), non-injury risk factors (sex, age, socio-economic status (SES)) and discharge recommendations of 2807 children and adolescents (0-18 years) who presented to a children's hospital ED over a three year period with mTBI.

RESULTS

Univariate analyses indicated a statistically significant association of discharge recommendations with age, SES, mechanism of injury and vomiting. However, multivariate analyses indicated vomiting and mechanism of injury were the only statistically significant risk factor associated with discharge recommendations, when controlling for other risk factors.

CONCLUSIONS

The current study suggests vomiting and mechanism of injury are the only risk factors predicting discharge recommendations for children and adolescents with mTBI.