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Background Decision aids are patient-focused tools that have the potential to reduce the overuse of head computed tomography (CT) scans. Objective The objective of this study was to create a consensus among Canadian mild traumatic brain injury and emergency medicine experts on modifications required to adapt two American decision aids about head CT use for adult and paediatric mild traumatic brain injury to the Canadian context. Methods We invited 21 Canadian stakeholders and the two authors of the American decision aids to a Nominal Group Technique consensus meeting to generate suggestions for adapting the decision aids. This method encourages idea generation and sharing between team members. Each idea was discussed and then prioritised using a voting system. We collected data using videotaping, writing material and online collaborative writing tools. The modifications proposed were analysed using a qualitative thematic content analysis. Results Twenty-one participants took part in the meeting, including researchers and clinician researchers (n = 9; 43%), patient partners (n = 3; 14%) and decision makers (n = 2; 10%). A total of 84 ideas were generated. Participants highlighted the need to clarify the purpose of the decision aids, the nature of the problem being addressed and the target population. The tools require sociocultural adaptations, better identification of their target population, better description of head CT utility, Prior Presentation Preliminary results were presented as a poster presentation at the

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Introduction: The Institut national d'excellence en santé et en services sociaux in Quebec published guidelines suggesting that emergency physicians should establish emergency department (ED) patients’ goals of care when appropriate. The objective of this study was to explore emergency physicians’ opinions about leading goals of care discussion (GCD) in their daily practice. Methods: This study used a qualitative design based on the Normalisation Process Theory (NPT); a middle-range theory used to explain the sustainability of implementing complex healthcare interventions. It was conducted in a single academic ED in Lévis, Québec. We planned to recruit a minimal convenience sample of 10 participants. Between April and May 2018, we conducted semi-structured interviews and transcribed the audio records verbatims. Deductive thematic analysis based on the NPT was conducted using Nvivo 12.0. Two authors codified the content of each interview under the four NPT macro-level constructs: coherence, cognitive participation, collective action and reflexive monitoring. A kappa score was calculated to measure the coding inter-rater reliability. Results: We interviewed 10 ED physicians (50 % women; 60% certified by the College of Family Physicians of Canada (Emergency Medicine)). No new ideas emerged after the 9th interview. Our thematic analysis identified 13 themes. Inter-rater reliability of coding was substantial (kappa = 0.72). The coherence construct contained the following themes: common concept of interpersonal communication, efficiency of care and anxiety generated by the discussion, the identification of an acute deterioration leading to the GCD, coming together of clinician, patient and family, and the importance of knowing patients’ goals of care before medical handover. The cognitive participation construct involved the following themes: lack of training on the new goals of care form and availability of reminders to promote the recommendation. One theme characterized the collective action construct: heterogeneous prioritization for leading GCD. The reflexive monitoring construct contained 4 themes: need to take action before patients consult in the ED, need to develop education programs, need for legislation and the impossibility of systematic GCD for all patients. Conclusion: Goals of care discussion is possible and essential with selected patients in the ED. Nevertheless, policy-making efforts remain necessary to ensure the systematization of the recommendation.

Introduction: Choosing Wisely Canada has reported rates of unnecessary head computed tomography (CT) scans for low-risk mild traumatic brain injury (mTBI) patients in Ontario and Alberta ranging from 14% to 46%. Local data for Quebec is currently not available. We sought to estimate the overuse of CT scans among adults with mTBI in the emergency department (ED) of a single level II trauma center in Quebec. Methods: We performed a retrospective chart review of adults who visited the ED of Hôtel-Dieu de Lévis from 04/01/2016 to 03/31/2017. Using an administrative database (Med-GPS, Montreal), we randomly sampled ED patients aged over 18 that had an initial Glasgow Coma Scale score of 13 to 15 and had suffered from a mTBI in the last 24 hours. We excluded patients with an unclear history of trauma, a bleeding disorder/anticoagulation, a history of seizure, any acute focal neurological deficit, a return visit for reassessment of the same injury, unstable vital signs, or a pregnancy. Data was extracted by two reviewers who analyzed separate charts. They used the Canadian CT Head Rule (CCHR) to determine relevance of CT scans. Overuse was determined if a patient without any high or medium risk CCHR criteria underwent a scan. A third reviewer verified a 10% random sample of the data extraction for each primary reviewer and inter-rater reliability was assessed using the kappa statistic. Results: From the 942 eligible mTBI patients, we randomly selected 418 patient charts to review, of which 217 met all inclusion and exclusion criteria (56% were men and the mean age was 48 years old (SD = 21)). Among included patients, 101 were determined as low risk. The overuse proportion was 26% (26/101), 95% CI [18-35]. Two CT scans were assessed as abnormal, but none revealed life-threatening injuries and only one was considered clinically significant with a subdural hematoma of 9 mm. Inter-rater reliability was substantial to perfect (kappa = 0.6 and 1.0) for each primary reviewer. Conclusion: We identified head CT scan overuse in this ED. This will support local quality improvement initiatives to reduce unnecessary head CT scans for adults with mTBI.