Mild traumatic brain injury: improving quality of care in the paediatric emergency department setting

Challenges in the acute identification of mild traumatic brain injuries: results from an emergency department surveillance study

OBJECTIVES

To establish the proportion of mild traumatic brain injury (mTBI) diagnosis among people presenting to an emergency department (ED), to determine the accuracy of recorded ED diagnoses. We also aimed to describe challenges in mTBI case identification and its acute hospital management.

DESIGN AND SETTING

A retrospective chart review of all ED attendances to a major trauma hospital, over a 9-month period (June 2015-February 2016).

PARTICIPANTS

Adults aged 18-65 years consecutively presenting to an ED.

PRIMARY OUTCOME MEASURES

Proportion of mTBI diagnosis among ED attendances (ie, confirmed mTBI based on the WHO criteria or indeterminate mTBI based on secondary criteria), and proportion of accurately recorded mTBI diagnosis by ED clinicians (ie, 'mTBI', 'concussion').

RESULTS

Of 30 479 ED attendances, 351 (1.15%) confirmed mTBI diagnosis and 180 (0.6%) indeterminate diagnosis were identified. Only 81 (23.1%) individuals with a confirmed mTBI had a 'mTBI diagnosis' clearly recorded in the medical notes. Of the allocated discharge diagnosis codes to the two identified cohorts, 89.8% were not indicative of mTBI. Intracranial injuries were found in 31 (8.5%) confirmed cases. Glasgow Coma Scale scores were consistently assessed in the ED but identified only 117 (33.3%) confirmed mTBI cases. Post-traumatic amnesia (PTA) testing was able to confirm acute cognitive impairment in 113 (62.1%) of those who were tested (182, 51.3%).

CONCLUSIONS

mTBI is a common, but an under-recognised cause for ED attendance. Despite challenges, the use of an operational definition such as the WHO diagnostic criteria can improve accuracy in mTBI identification. Acute management may be enhanced by rapid assessment of PTA.

Implementing evidence-based recommended practices for the management of patients with mild traumatic brain injuries in Australian emergency care departments: study protocol for a cluster randomised controlled trial

Background

Mild head injuries commonly present to emergency departments. The challenges facing clinicians in emergency departments include identifying which patients have traumatic brain injury, and which patients can safely be sent home. Traumatic brain injuries may exist with subtle symptoms or signs, but can still lead to adverse outcomes. Despite the existence of several high quality clinical practice guidelines, internationally and in Australia, research shows inconsistent implementation of these recommendations. The aim of this trial is to test the effectiveness of a targeted, theory- and evidence-informed implementation intervention to increase the uptake of three key clinical recommendations regarding the emergency department management of adult patients (18 years of age or older) who present following mild head injuries (concussion), compared with passive dissemination of these recommendations. The primary objective is to establish whether the intervention is effective in increasing the percentage of patients for which appropriate post-traumatic amnesia screening is performed.

Methods/design

The design of this study is a cluster randomised trial. We aim to include 34 Australian 24-hour emergency departments, which will be randomised to an intervention or control group. Control group departments will receive a copy of the most recent Australian evidence-based clinical practice guideline on the acute management of patients with mild head injuries. The intervention group will receive an implementation intervention based on an analysis of influencing factors, which include local stakeholder meetings, identification of nursing and medical opinion leaders in each site, a train-the-trainer day and standardised education and interactive workshops delivered by the opinion leaders during a 3 month period of time. Clinical practice outcomes will be collected retrospectively from medical records by independent chart auditors over the 2 month period following intervention delivery (patient level outcomes). In consenting hospitals, eligible patients will be recruited for a follow-up telephone interview conducted by trained researchers. A cost-effectiveness analysis and process evaluation using mixed-methods will be conducted. Sample size calculations are based on including 30 patients on average per department. Outcome assessors will be blinded to group allocation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12612001286831 (date registered 12 December 2012).

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

OBJECTIVE

Accurate diagnosis, treatment and follow up of children suffering mild traumatic brain injury (MTBI) is important as post-concussive symptoms and long-term disability might occur. This research explored the decisions clinicians make in their assessment and management of children with MTBI in acute care settings, and identified barriers and enablers to the delivery of best-practice care.

METHODS

A purposeful sample of 29 clinicians employed in two metropolitan paediatric EDs and one Urgent Care clinic was surveyed using a vignette-based questionnaire that also included domains of guideline awareness, attitudes to MTBI care, use of clinical decision support systems, and knowledge and skills for practising evidence-based healthcare.

RESULTS

Overall, the evaluation and management of children presenting acutely with MTBI generally followed best-practice guidelines, particularly in relation to identifying intracranial injuries that might require surgical intervention, observation for potential deterioration, adequate pain management and the provision of written head injury advice on discharge. Larger variation emerged in regard to follow-up care and referral pathways. Potential barriers to best- practice were lack of guideline awareness, attitudes to MTBI, and lack of time or other priorities.

CONCLUSIONS

Opportunities exist to improve care for children who present in acute care settings following mild traumatic brain injury. These include having up-to-date guidelines that are consistent across acute care settings; providing clearer pathways for referral and follow up; targeting continuing medical education towards potential complications; and providing computerised decision support so that assessment and management are conducted systematically.

Diagnostic approach to children with minor traumatic brain injury

STUDY PURPOSE

To analyse the management of minor traumatic brain injury (MTBI) in paediatric hospitals in Germany.

METHODS

An electronic survey was sent to 72 children hospitals.

RESULTS

All participating (45/72; 62.5 %) hospitals had facilities to perform an electroencephalogram (EEG), 98 % cranial ultrasonography, 94 % MRI studies, and 87 % a CT scan. The initial Glasgow Coma Scale, the clinical presentation/neurological deficits, the intensity of the trauma and external/visible injuries were most important for initial assessment. The main reason for in-patient monitoring was initial clinical neurologic presentation (44 %). X-ray scans were used routinely in only 2.2 %, cMRI scans in 6.7 % and cCT scans in 13.3 %; approximately one third employed ultrasonography. In 22.2 % was an EEG part of the routine diagnostic work-up. Inpatient monitoring for 24-48 h was done in 80 %.

CONCLUSIONS

Children with MTBI are often monitored clinically without resorting to potentially harmful and expensive diagnostic procedures (cCT scans).