Evaluation of a targeted, theory-informed implementation intervention designed to increase uptake of emergency management recommendations regarding adult patients with mild traumatic brain injury: results of the NET cluster randomised trial

Abstract

BackgroundEvidence-based guidelines for management of mild traumatic brain injury (mTBI) in the emergency department (ED) are now widely available; however, clinical practice remains inconsistent with these guidelines. A targeted, theory-informed implementation intervention (Neurotrauma Evidence Translation (NET) intervention) was designed to increase the uptake of three clinical practice recommendations regarding the management of patients who present to Australian EDs with mild head injuries. The intervention involved local stakeholder meetings, identification and training of nursing and medical local opinion leaders, train-the-trainer workshops and standardised education materials and interactive workshops delivered by the opinion leaders to others within their EDs during a 3 month period. This paper reports on the effects of this intervention.MethodsEDs (clusters) were allocated to receive either access to a clinical practice guideline (control) or the implementation intervention, using minimisation, a method that allocates clusters to groups using an algorithm to minimise differences in predefined factors between the groups. We measured clinical practice outcomes at the patient level using chart audit. The primary outcome was appropriate screening for post-traumatic amnesia (PTA) using a validated tool until a perfect score was achieved (indicating absence of acute cognitive impairment) before the patient was discharged home. Secondary outcomes included appropriate CT scanning and the provision of written patient information upon discharge. Patient health outcomes (anxiety, primary outcome: Hospital Anxiety and Depression Scale) were also assessed using follow-up telephone interviews. Outcomes were assessed by independent auditors and interviewers, blinded to group allocation.ResultsFourteen EDs were allocated to the intervention and 17 to the control condition; 1943 patients were included in the chart audit. At 2 months follow-up, patients attending intervention EDs (n = 893) compared with control EDs (n = 1050) were more likely to have been appropriately assessed for PTA (adjusted odds ratio (OR) 20.1, 95%CI 6.8 to 59.3; adjusted absolute risk difference (ARD) 14%, 95%CI 8 to 19). The odds of compliance with recommendations for CT scanning and provision of written patient discharge information were small (OR 1.2, 95%CI 0.8 to 1.6; ARD 3.2, 95%CI − 3.7 to 10 and OR 1.2, 95%CI 0.8 to 1.8; ARD 3.1, 95%CI − 3.0 to 9.3 respectively).A total of 343 patients at ten interventions and 14 control sites participated in follow-up interviews at 4.3 to 10.7 months post-ED presentation. The intervention had a small effect on anxiety levels (adjusted mean difference − 0.52, 95%CI − 1.34 to 0.30; scale 0–21, with higher scores indicating greater anxiety).ConclusionsOur intervention was effective in improving the uptake of the PTA recommendation; however, it did not appreciably increase the uptake of the other two practice recommendations. Improved screening for PTA may be clinically important as it leads to appropriate peri...

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

“…This study is unique in its way of screening for PTA in ED by means of a validated measure. However, standard PTA testing was only available in about half of confirmed mTBI cases (51.9%), though this was considerably higher than previously reported PTA screening rates (up to 31%) 10 23. Also, optimal scores of 18/18 on the A-WTPAS were obtained in 17.8% of those who were tested.…”

“…Though the A-WPTAS has been shown to assist with a safer discharge of people with mTBI, by identifying cases with a GCS of 15/15 who remain acutely cognitively impaired,20 and reducing hospitalisation and direct costs,22 its implementation to date appears inconsistent. Unpublished Australian data showed that rates of PTA screening in ED range from 0% to 31%,10 while findings from a recent randomised controlled trial showed lower rates (ie, below 13%) 23. This highlights the need for further studies to investigate the extent and possible benefit of A-WPTAS implementation in emergency settings.…”

Understanding factors that contribute to variations in bronchiolitis management in acute care settings: a qualitative study in Australia and New Zealand using the Theoretical Domains Framework

“…This framework has been successfully trialled in the Australian ED environment to understand factors influencing the management of mild traumatic brain injury in adults and guide intervention development [32,33]. A subsequent cluster randomised controlled trial of this intervention resulted in improvement in the uptake of practice recommendations [34]. The TDF has also been used to develop implementation interventions in the acute care setting of stroke management [35,36].…”

Review article: A primer for clinical researchers in the emergency department: Part VIII. Implementation science: An introduction

“…Authors have recommended more high‐quality rigorous research that uses theory‐based approaches to identify the key factors influencing practice variation to inform the design and evaluation of targeted implementation interventions. Implementation research in Australia is emerging with several large multi‐centre cluster randomised controlled trials evaluating the effectiveness of implementation strategies recently completed or close to completion in the clinical areas of head injuries, stroke and bronchiolitis …”