Abstract
BackgroundMild 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/designThe 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 registrationAustralian New Zealand Clinical Trials Registry ACTRN12612001286831 (date registered 12 December 2012).
Highlights
Mild head injuries commonly present to emergency departments
Post-traumatic amnesia (PTA) is defined as "an interval during which the patient is confused, amnestic for ongoing events and likely to evidence behavioural disturbance" [13]. It may manifest as repetitive questioning or short-term memory deficits [14] and has been shown to have better predictive ability with clinical outcomes compared with Glasgow Coma Scale (GCS) [15,16,17,18] (GCS assesses consciousness but not whether the patient is able to lay down new memories)
Evidence Translation (NET) programme [48], is to test the effectiveness of a targeted, theory- and evidence-informed implementation intervention to increase the uptake of three key clinical evidence-based clinical practice guideline (EBCPG) recommendations regarding the management of adult patients (18 years of age or older) who present to Australian emergency department (ED) with mild head injuries, compared with passive dissemination of the EBCPG
Summary
Head injuries are a frequent presentation to emergency departments (EDs) worldwide. They are caused by external forces to the head (such as sport, falls, motor vehicle accidents, assaults or blast injuries) [1]. Post-traumatic amnesia (PTA) is defined as "an interval during which the patient is confused, amnestic for ongoing events and likely to evidence behavioural disturbance" [13] It may manifest as repetitive questioning or short-term memory deficits [14] and has been shown to have better predictive ability with clinical outcomes compared with Glasgow Coma Scale (GCS) [15,16,17,18] (GCS assesses consciousness but not whether the patient is able to lay down new memories). The Institute for Trauma and Injury Management, New South Wales, developed simple recommendations for the identification of high risk patients based on the presence of single criteria that are applicable in the Australian setting [14]. There was no statistical difference between the groups on formal neuropsychological assessment
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