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Lubbers VF, van den Hoven DJ, van der Naalt J, Jellema K, van den Brand C, Backus B. Emergency Department Risk Factors for Post-Concussion Syndrome After Mild Traumatic Brain Injury: A Systematic Review. J Neurotrauma 2024; 41:1253-1270. [PMID: 38390830 DOI: 10.1089/neu.2023.0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Approximately 16% of patients with mild traumatic brain injury (mTBI) develop a post-concussion syndrome (PCS) with persistent physical, neurological, and behavioral complaints. PCS has a great impact on a patient's quality of life, often decreases the ability to return to work, and henceforth has a great economic impact. Recent studies suggest that early treatment can greatly improve prognosis and prevent long-term effects in these patients. However, early recognition of patients at high risk of PCS remains difficult. The objective of this systematic review is to assess risk factors associated with the development of PCS, primarily aimed at the group of non-hospitalized patients who were seen with mTBI at the emergency department (ED). We searched PubMed/MEDLINE, Cochrane Library and EMBASE on September 23, 2022, for prospective studies that assessed the risk factors for the development of PCS. Exclusion criteria were: retrospective studies; > 20% computed tomography (CT) abnormalities, <18 years of age, follow-up <4 weeks, severe trauma, and study population <100 patients. The search strategy identified 1628 articles, of which 17 studies met eligibility criteria. Risk factors found in this systematic review are pre-existing psychiatric history, headache at the ED, neurological symptoms at the ED, female sex, CT abnormalities, pre-existent sleeping problems, and neck pain at the ED. This systematic review identified seven risk factors for development of PCS in patients with mTBI. Future research should assess if implementation of these risk factors into a risk stratification tool will assist the emergency physician in the identification of patients at high risk of PCS.
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Affiliation(s)
- Veerle F Lubbers
- Erasmus University Medical Center, Rotterdam, the Netherlands
- Haaglanden Medical Center, the Hague, the Netherlands
| | | | | | - Korné Jellema
- Haaglanden Medical Center, the Hague, the Netherlands
| | - Crispijn van den Brand
- Erasmus University Medical Center, Rotterdam, the Netherlands
- Elisabeth Tweesteden Ziekenhuis, Tilburg, the Netherlands
| | - Barbra Backus
- Franciscus Gasthuis and Vlietland Hospital, Rotterdam, the Netherlands
- Elisabeth Tweesteden Ziekenhuis, Tilburg, the Netherlands
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Trofimov AO, Agarkova DI, Sergeev D, Dubrovin A, Trofimova KA, Novosadova O, Martynov D, Lidji-Goryaev K, Bragin DE. NIRS-Based Study of Local Cerebral Oxygenation During Transcranial Direct Current Stimulation in Patients with Mild Traumatic Brain Injury. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1395:59-63. [PMID: 36527614 PMCID: PMC10042479 DOI: 10.1007/978-3-031-14190-4_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The purpose of our study was to assess the dynamics of local cerebral oxygenation (LCO) by near-infrared spectroscopy (NIRS) during transcranial direct current stimulation (tDCS) in the acute stage of mild traumatic brain injury (mTBI). Fifty-seven mTBI patients (18 women and 39 men, 35 ± 11.7 years old, GCS 13.7 ± 0.7) were treated by tDCS at 3-5 days after head injury. Stimulation parameters were: 1 mA, 9 V, duration-20 min. A cerebral oximeter was used to assess LCO-values in the frontotemporal lobes. Anodal and cathodal LCO values were compared before tDCS and every 2 min until the tDCS end. Significance was preset to p < 0.05. Results: A significant decrease in LCO values on the anodal side was observed at the 8th to 12th minutes of stimulation, compared to the cathodal side (at 8th minute - p = 0.011; at 12th minute - p < 0.00000001) and compared to LCO values before tDCS (p < 0.00001). The LCO on the cathodal side was not significantly different during the whole tDCS. At the end of the procedure, the interhemispheric LCO differences were not statistically significant (p = 0.757). Conclusions: Transcranial DCS in 3-5 days of mTBI leads to a significant decrease in the LCO value on the anodal side between 8 and 12 min and subsequent recovery to baseline values by the end of the procedure.
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Affiliation(s)
- Alex O Trofimov
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia.
- Department of Polytrauma, Regional Hospital named after Semashko, Nizhny Novgorod, Russia.
| | - Darya I Agarkova
- Department of Polytrauma, Regional Hospital named after Semashko, Nizhny Novgorod, Russia
| | - Dmitry Sergeev
- Department of Polytrauma, Regional Hospital named after Semashko, Nizhny Novgorod, Russia
| | - Anton Dubrovin
- Department of Polytrauma, Regional Hospital named after Semashko, Nizhny Novgorod, Russia
| | - Kseniia A Trofimova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Oxana Novosadova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Dmitry Martynov
- State Technical University named after R.E. Alekseev, Nizhny Novgorod, Russia
| | - Kyril Lidji-Goryaev
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Denis E Bragin
- Lovelace Biomedical Research Institute, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, USA
- National Research Saratov State University, Saratov, Russia
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Rowe BH, Yang EH, Gaudet LA, Eliyahu L, Junqueira DR, Beach J, Mrazik M, Cummings G, Voaklander D. Sex-based differences in outcomes for adult patients presenting to the emergency department with a concussion. J Neurosurg 2021; 136:264-273. [PMID: 34298511 DOI: 10.3171/2021.1.jns203753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. Given infrequent study of concussion symptoms in the general adult population, the authors conducted a sex-based comparison of patients with concussion. METHODS Adults (≥ 17 years of age) presenting with concussion to one of three urban Canadian EDs were recruited. Discharged patients were contacted by telephone 30 and 90 days later to capture the extent of persistent postconcussion symptoms using the Rivermead Post Concussion Symptoms Questionnaire (RPQ). A multivariate logistic regression model for persistent symptoms that included biological sex was developed. RESULTS Overall, 250 patients were included; 131 (52%) were women, and the median age of women was significantly higher than that of men (40 vs 32 years). Women had higher RPQ scores at baseline (p < 0.001) and the 30-day follow-up (p = 0.001); this difference resolved by 90 days. The multivariate logistic regression identified that women, patients having a history of sleep disorder, and those presenting to the ED with concussions after a motor vehicle collision were more likely to experience persistent symptoms. CONCLUSIONS In a community concussion sample, inconsequential demographic differences existed between adult women and men on ED presentation. Based on self-reported and objective outcomes, work and daily activities may be more affected by concussion and persistent postconcussion symptoms for women than men. Further analysis of these differences is required to identify different treatment options and ensure adequate care and management of injury.
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Affiliation(s)
- Brian H Rowe
- Departments of1Emergency Medicine.,2School of Public Health; and
| | | | | | | | | | - Jeremy Beach
- 5College of Physicians and Surgeons of Alberta, Edmonton, Alberta, Canada.,6Division of Preventive Medicine, Faculty of Medicine & Dentistry
| | - Martin Mrazik
- 7Department of Educational Psychology, Faculty of Education, University of Alberta; and
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Lumba‐Brown A, Tang K, Yeates KO, Zemek R. Post-concussion symptom burden in children following motor vehicle collisions. J Am Coll Emerg Physicians Open 2020; 1:938-946. [PMID: 33145544 PMCID: PMC7593496 DOI: 10.1002/emp2.12056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Motor vehicle collisions generate considerable transmitted forces resulting in traumatic brain injury in children presenting to emergency departments (EDs). To date, no large study has examined post-concussive symptoms in children sustaining concussions in motor vehicle collisions. This study aimed to compare trends in acute post-concussive symptom burden in children with concussion following motor vehicle collisions as compared to other injury mechanisms. METHODS The study is a secondary analysis of the Predicting Persistent Post-concussive Problems in Pediatrics study, which prospectively recruited a multicenter cohort of 3029 children 5-17 years of age presenting to the ED with concussion from 2013-2015. Post-concussive symptom ratings were obtained at pre-specified time points for 12 weeks post-injury, using the validated Post-Concussion Symptom Inventory (PCSI). Symptom severity and recovery trajectories were measured using delta scores on the PCSI (mean post-injury symptom score minus perceived pre-injury score). A multivariable, longitudinal model evaluated the adjusted effect of mechanism of injury (motor vehicle collisions vs other mechanisms) on mean symptom scores, compared to perceived pre-injury reports, and the temporal change in mean scores over during recovery. RESULTS Of 3029 study participants, 56 (1.8%) sustained concussion from motor vehicle collisions. Children sustaining concussion in a motor vehicle collision had lower post-concussive symptom scores upon ED presentation, measured as differences from their perceived pre-injury reports, as compared to other injury mechanisms (-0.36 [95% confidence interval (CI) = -0.58, -0.15]). However, the motor vehicle collisions group showed the smallest decline in symptom burden over 1 month following injury (-0.54 [95% CI = -0.81, -0.27]). CONCLUSIONS Children sustaining concussions in motor vehicle collisions may have lower initial symptom burdens but slower symptom recovery at 1 month compared to other mechanisms of injury and may represent a distinct population for prognostic counseling in the ED requiring further research.
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Affiliation(s)
| | - Ken Tang
- Children's Hospital of Eastern Ontario Research InstituteOttawaOntarioCanada
| | | | - Roger Zemek
- Children's Hospital of Eastern Ontario Research InstituteOttawaOntarioCanada
- Department of Pediatrics and Emergency MedicineUniversity of OttawaOttawaOntarioCanada
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Abdul Rahman N'I, Nurumal MS, Awang MS, Mohd Shah ANS. Emergency department discharge instruction for mild traumatic brain injury: Evaluation on readability, understandability, actionability and content. Australas Emerg Care 2020; 23:240-246. [PMID: 32713770 DOI: 10.1016/j.auec.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/31/2020] [Accepted: 06/20/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Emergency departments (EDs) routinely provide discharge instructions due to a large number of patients with mild traumatic brain injury (mTBI) being discharged home directly from ED. This study aims to evaluate the quality of available mTBI discharge instructions provided by EDs of Malaysia government hospitals. METHODS All 132 EDs were requested for a copy of written discharge instruction given to the patients. The mTBI discharge instructions were evaluated using the Patient Education Materials Assessment-Printable Tool (PEMAT-P) for understandability and actionability. Readability was measured using an online readability tool of Malay text. The content was compared against the discharge instructions recommended by established guidelines. RESULTS 49 articles were eligible for the study. 26 of the articles met the criteria of understandability, and 3 met the criteria for actionability. The average readability level met the ability of average adult. Most of the discharge instructions focused on emergency symptoms, and none contained post-concussion features. CONCLUSION Majority of the discharge instructions provided were appropriate for average people to read but difficult to understand and act upon. Important information was neglected in most discharge instructions. Thus, revision and future development of mTBI discharge instruction should consider health literacy demand and cognitive ability to process such information.
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Affiliation(s)
- Nurul 'Inayati Abdul Rahman
- Department of Critical Care Nursing, Kulliyyah (Faculty) of Nursing, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia.
| | - Mohd Said Nurumal
- Department of Critical Care Nursing, Kulliyyah (Faculty) of Nursing, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Mohamed Saufi Awang
- Neurosurgery Unit, Department of Surgery, Kulliyyah (Faculty) of Medicine, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Aida Nur Sharini Mohd Shah
- Department of Internal Medicine, Kulliyyah (Faculty) of Medicine, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
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Patient Presentations in Outpatient Settings: Epidemiology of Adult Head Trauma Treated Outside of Hospital Emergency Departments. Epidemiology 2019; 29:885-894. [PMID: 30063541 DOI: 10.1097/ede.0000000000000900] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND While deaths, hospitalizations, and emergency department visits for head trauma are well understood, little is known about presentations in outpatient settings. Our objective was to examine the epidemiology and extent of healthcare-seeking adult (18-64 years) head trauma patients presenting in outpatient settings compared with patients receiving nonhospitalized emergency department care. METHODS We used 2004-2013 MarketScan Medicaid/commercial claims to identify head trauma patients managed in outpatient settings (primary care provider, urgent care) and the emergency department. We examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention-defined head trauma diagnoses, and extent of and reasons for postindex visit ambulatory care use within 30/90/180 days by index visit location, as well as annual and monthly variations in head trauma trends. We used outpatient incidence rates to estimate the US nationwide outpatient burden. RESULTS A total of 1.19 million index outpatient visits were included (emergency department: 348,659). Nationwide, they represented a weighted annual burden of 1.16 million index outpatient cases. These encompassed 46% of all known healthcare-seeking head trauma in 2013 (outpatient/emergency department/inpatient/fatalities) and increased in magnitude (+31%) from 2004 to 2013. One fourth (27%) of office/clinic visits led to diagnosis with concussion on index presentation (urgent care: 32%). Distributions of demographic factors varied with index visit location while injury-specific factors were largely comparable. Subsequent visits reflected high demand for follow-up treatment, increased concussive diagnoses, and sequelae-associated care. CONCLUSIONS Adult outpatient presentations of head trauma remain poorly understood. The results of this study demonstrate the extensive magnitude of their occurrence and close association with need for follow-up care.
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The Epidemiology of Pediatric Head Injury Treated Outside of Hospital Emergency Departments. Epidemiology 2019; 29:269-279. [PMID: 29240568 DOI: 10.1097/ede.0000000000000791] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although head trauma-related deaths, hospitalizations, and emergency department visits are well characterized, few studies describe pediatric patients presenting outside of emergency departments. We compared the epidemiology and extent of healthcare-seeking pediatric (0-17 years) patients presenting in outpatient settings with those of patients seeking nonhospitalized emergency department care. METHODS We used MarketScan Medicaid and commercial claims, 2004-2013, to identify patients managed in two outpatient settings (physician's offices/clinics, urgent care) and the emergency department. We then examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention-defined head trauma diagnoses, the extent of and reasons for post-index visit ambulatory care use within 30/90/180 days, and annual and monthly variations in head trauma trends. Outpatient incidence rates in 2013 provided estimates of the nationwide US outpatient burden. RESULTS A total of 1,683,097 index visits were included, representing a nationwide burden in 2013 of 844,660 outpatient cases, a number that encompassed 51% of healthcare-seeking head trauma that year and that substantially increased in magnitude from 2004 to 2013. Two-thirds (68%) were managed in outpatient settings. While demographic distributions varied with index-visit location, injury-specific factors were comparable. Seasonal spikes appeared to coincide with school sports. CONCLUSIONS There is an urgent need to better understand the natural history of head trauma in the >800,000 pediatric patients presenting each year for outpatient care. These outpatient injuries, which are more than double the number of head trauma cases recorded in the hospital-affiliated settings, illustrate the potential importance of expanding inclusion criteria in surveillance and prevention efforts designed to address this critical issue.
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Hart T, Driver S, Sander A, Pappadis M, Dams-O'Connor K, Bocage C, Hinkens E, Dahdah MN, Cai X. Traumatic brain injury education for adult patients and families: a scoping review. Brain Inj 2018; 32:1295-1306. [PMID: 30084694 DOI: 10.1080/02699052.2018.1493226] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Traumatic brain injury (TBI) is increasingly viewed as a chronic condition, bringing long-term needs for patient and caregiver knowledge pertaining to symptom and problem management over time. In light of these needs, we performed a scoping review of the literature on brain injury education provided to adult patients and/ or family members affected by TBI. Objectives were to describe the types of educational interventions that have been developed; to review the effects of these interventions; and to determine gaps that might be filled by future research efforts. Of 88 articles meeting search criteria and subjected to data extraction, 34 concerned education about mild TBI and 54, moderate to severe TBI. Most mild TBI articles focused on education in the Emergency Room, while most moderate/ severe TBI education was directed toward family members/ caregivers and was frequently combined with other treatment components, making the effects of education difficult to discern. Only 1 article incorporated elements of self-management training (SMT), a model proved effective in other chronic health conditions. We recommend further exploration of SMT principles in long-term TBI care, as well as more precise definition of treatment components in all patient and family interventions, so that the specific effects of education and other treatment elements may be more readily evaluated.
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Affiliation(s)
- Tessa Hart
- a Moss Rehabilitation Research Institute , Elkins Park , PA , USA
| | - Simon Driver
- b Department of Rehabilitation Research , Baylor Scott and White Institute for Rehabilitation , Dallas , TX , USA
| | - Angelle Sander
- c Department of Physical Medicine and Rehabilitation , Baylor College of Medicine , Houston , TX , USA.,d Brain Injury Research Center , TIRR Memorial Hermann , Houston , TX , USA
| | - Monique Pappadis
- d Brain Injury Research Center , TIRR Memorial Hermann , Houston , TX , USA.,e Division of Rehabilitation Sciences, School of Health Professions , University of Texas Medical Branch at Galveston , TX , USA
| | - Kristen Dams-O'Connor
- f Department of Rehabilitation Medicine, Department of Neurology Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Claire Bocage
- g American Institutes for Research , Washington , DC , USA
| | - Emma Hinkens
- g American Institutes for Research , Washington , DC , USA
| | - Marie N Dahdah
- b Department of Rehabilitation Research , Baylor Scott and White Institute for Rehabilitation , Dallas , TX , USA.,h Department of Medical Psychology , Baylor Scott and White Medical Center , Plano , TX , USA
| | - Xinsheng Cai
- g American Institutes for Research , Washington , DC , USA
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Brown AM, Twomey DM, Wong Shee A. Evaluating mild traumatic brain injury management at a regional emergency department. Inj Prev 2018; 24:390-394. [PMID: 29866717 DOI: 10.1136/injuryprev-2018-042865] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/14/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Emergency departments (EDs) are usually the first point of contact, and often the only medical service available, for patients with mild traumatic brain injury (mTBI) in rural and regional areas. Clinical practice guidelines (CPGs) have been created to ensure best practice management of mTBI in EDs. Adherence to mTBI CPGs has rarely been evaluated in rural and regional areas. AIM The aim of this paper was to assess a regional health service's adherence to their mTBI CPG. METHODS This was a 12-month retrospective audit of 1280 ED records of patients ≥16 years presenting with mTBI to a regional Australian ED. Case selection used the Victorian Admitted Episodes Dataset codes for suspected head injury: principal diagnosis codes (S00-T98), concussive injury recorded in diagnosis codes (S06.00-S06.05) and unintentional external cause code (V00-X59). The data were collected to determine 4-hour observation rates, CT scan rates, safe discharge and appropriate referral documentation. RESULTS Fewer people received a CT scan than qualified (n=245, 65.3%), only 45% had 4-hour observations recorded, safe discharge was documented in 74.1% of cases and 33% received educational resources. DISCUSSION/CONCLUSION Several key elements for the management of mTBI were under-recorded, particularly 4-hour observations, safe discharge and education. Acquired brain injury clinic referrals were received in overwhelmingly fewer cases than had a CT scan (n=19, 6.3%). Overall, this study suggests that the regional health service does not currently fully adhere to the CPG and that the referral services are potentially underutilised.
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Affiliation(s)
- Ashlee Maree Brown
- School of Health Sciences and Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Dara M Twomey
- School of Health Sciences and Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Anna Wong Shee
- School of Medicine, Deakin Rural Health, Deakin University, Warrnambool, Victoria, Australia
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Cancelliere C, Coronado VG, Taylor CA, Xu L. Epidemiology of Isolated Versus Nonisolated Mild Traumatic Brain Injury Treated in Emergency Departments in the United States, 2006-2012: Sociodemographic Characteristics. J Head Trauma Rehabil 2018; 32:E37-E46. [PMID: 28489698 PMCID: PMC5554936 DOI: 10.1097/htr.0000000000000260] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the frequencies and rates of mild traumatic brain injury (mTBI) emergency department (ED) visits, analyze the trend across the years, and compare sociodemographic characteristics of visits by mTBI type (ie, mTBI as the only injury, or present along with other injuries). DESIGN Population-based descriptive study using data from the Nationwide Emergency Department Sample (2006-2012). METHODS Joinpoint regression was used to calculate the average annual percent changes of mTBI incidence rates. Characteristics between isolated and nonisolated visits were compared, and the odds ratios were reported. RESULTS The rate per 100 000 population of mTBI ED visits in the United States increased significantly from 569.4 (in 2006) to 807.9 (in 2012). The highest rates were observed in 0- to 4-year-olds, followed by male 15- to 24-year-olds and females 65 years and older; the lowest rates were among 45- to 64-year-olds. The majority (70%) of all visits were nonisolated and occurred more frequently in residents of metropolitan areas. Falls were the leading external cause. Most visits were privately insured or covered by Medicare/Medicaid, and the injury occurred on weekdays in predominantly metropolitan hospitals in the South region. CONCLUSIONS The burden of mTBI in US EDs is high. Most mTBI ED visits present with other injuries. Awareness of sociodemographic factors associated with nonisolated mTBI may help improve diagnosis in US EDs. This information has implications for resource planning and mTBI screening in EDs.
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Affiliation(s)
- Carol Cancelliere
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (Dr Cancelliere); and National Center for Injury Prevention and Control (Drs Taylor and Xu), Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Coronado)
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Cooksley R, Maguire E, Lannin NA, Unsworth CA, Farquhar M, Galea C, Mitra B, Schmidt J. Persistent symptoms and activity changes three months after mild traumatic brain injury. Aust Occup Ther J 2018; 65:168-175. [PMID: 29498077 DOI: 10.1111/1440-1630.12457] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND/AIM Approximately, 80% of traumatic brain injuries are considered mild in severity. Mild traumatic brain injury (mTBI) may cause temporary or persisting impairments that can adversely affect an individual's ability to participate in daily occupations and life roles. This study aimed to identify symptoms, factors predicting level of symptoms and functional and psycho-social outcomes for participants with mTBI three months following injury. METHOD Patients discharged from the Emergency Department of a major metropolitan hospital with a diagnosis of mTBI were contacted by telephone three months after injury. An interview with two questionnaires was administered: The Concussion Symptom Inventory (CSI) Scale and the Rivermead Head Injury Follow-Up Questionnaire (RHIFUQ). Data obtained were used to determine the type and prevalence of post-concussion symptoms and their impact on activity change. RESULTS Sixty-three people with mTBI participated in the study. The majority of participants (81%) reported that all symptoms had resolved within the three-month time frame. Of those still experiencing symptoms, workplace fatigue (22%) and an inability to maintain previous workload/standards (17%) were reported. CONCLUSION There is a small, but clinically significant, subgroup of patients who continue to experience symptoms three-month post-mTBI. Symptoms experienced beyond the expected three-month recovery timeframe have the potential to adversely affect an individual's ability to participate in daily occupation and return to work.
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Affiliation(s)
- Rebecca Cooksley
- Occupational Therapy, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia
| | | | - Natasha A Lannin
- Occupational Therapy, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia.,Alfred Health, Melbourne, Victoria, Australia
| | - Carolyn A Unsworth
- Occupational Therapy, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia.,Occupational Therapy, School of Health, Medical and Applied Sciences, Central Queensland University, Melbourne, Victoria, Australia
| | | | - Claire Galea
- Cerebral Palsy Alliance, The University of Sydney, Sydney, New South Wales, Australia
| | - Biswadev Mitra
- Alfred Health, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Julia Schmidt
- Occupational Therapy, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia.,Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Brown AM, Twomey DM, Wong Shee A. Are patients with concussion getting optimal discharge advice at a regional emergency department? Aust J Rural Health 2017; 26:134-135. [PMID: 29105939 DOI: 10.1111/ajr.12397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Ashlee M Brown
- School of Health Sciences & Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Dara M Twomey
- School of Health Sciences & Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Anna Wong Shee
- Ballarat Health Services, Drummond Street North, Ballarat, Victoria, Australia
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Abstract
Education to improve symptom management is an agreed-upon strategy to reduce the impact of symptoms on the quality of life for persons with mild traumatic brain injury. The purpose of this study was to investigate whether current discharge education practices are deemed adequate by persons treated and released from the emergency department with concussion. A review of current literature identified a need for patient education improvements in emergency departments. Strategies for improving information retention in the mild traumatic brain injury patient population for effective symptom management are identified. A concussion symptom management booklet was created using current scientific information. The concussion education booklet along with standardized postconcussion education was provided to patients with mild traumatic brain injuries who were discharged from a level I trauma center emergency department. A prospective small-scale study was performed to establish the ease of use and usefulness of the newly created concussion education booklet and determine whether patients preferred the booklet of information over the standard discharge instructions.
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de Amorim RLO, Brunoni AR, de Oliveira MAF, Zaninotto ALC, Nagumo MM, Guirado VMDP, Neville IS, Benute GRG, de Lucia MCS, Paiva WS, de Andrade AF, Teixeira MJ. Transcranial Direct Current Stimulation for Post-Concussion Syndrome: Study Protocol for a Randomized Crossover Trial. Front Neurol 2017; 8:164. [PMID: 28512443 PMCID: PMC5411433 DOI: 10.3389/fneur.2017.00164] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/07/2017] [Indexed: 01/13/2023] Open
Abstract
Background Mild traumatic brain injury (MTBI) represents 70–80% of all treated brain injuries. A considerable proportion of MTBI patients experience post-concussion symptoms for a prolonged period after MTBI, and these symptoms are diagnosed as persistent post-concussion syndrome (PPCS). PPCS is defined as a range of physical, cognitive, and emotional symptoms. However, memory and executive dysfunction seems to be one of the most debilitating symptoms. Recently, non-invasive brain stimulation has been studied as a potential treatment method for traumatic brain injury (TBI) patients. Therefore, our primary goal is to verify the effects of transcranial direct current stimulation (tDCS) in patients with PPCS who demonstrate cognitive deficits in long-term episodic memory, working memory, and executive function following MTBI. Methods/design This is a randomized crossover trial of patients with a history of MTBI with cognitive deficits in memory and executive function. Thirty adult patients will be randomized in a crossover manner to receive three weekly sessions of anodal tDCS (2 mA) at left dorsolateral prefrontal cortex, left temporal cortex, and sham stimulation that will be performed at 7-day intervals (washout period). The clinical diagnosis of PPCS will be determined using the Rivermead Post-Concussion Symptoms Questionnaire. Patients who meet the inclusion criteria will be assessed with a neuropsychological evaluation. A new battery of computerized neuropsychological tests will be performed before and immediately after each stimulation. Statistical analysis will be performed to determine trends of cognitive improvement. Discussion There is paucity of studies regarding the use of tDCS in TBI patients, and although recent results showed controversial data regarding the effects of tDCS in such patients, we will address specifically patients with PPCS and MTBI and no brain abnormalities on CT scan other than subarachnoid hemorrhage. Moreover, due to the missing information on literature regarding the best brain region to be studied, we will evaluate two different regions to find immediate effects of tDCS on memory and executive dysfunction. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT02292589 (https://register.clinicaltrials.gov).
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Affiliation(s)
| | - André Russowsky Brunoni
- Division of Psychiatry and Psychology, University Hospital of São Paulo University, São Paulo, Brazil
| | | | | | - Marcia Mitie Nagumo
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Iuri Santana Neville
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
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15
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Watson CE, Clous EA, Jaeger M, D’Amours SK. Introduction of the Abbreviated Westmead Post-Traumatic Amnesia Scale and Impact on Length of Stay. Scand J Surg 2017; 106:356-360. [DOI: 10.1177/1457496917698642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Aims: Mild traumatic brain injury is a common presentation to Emergency Departments. Early identification of patients with cognitive deficits and provision of discharge advice are important. The Abbreviated Westmead Post-traumatic Amnesia Scale provides an early and efficient assessment of post-traumatic amnesia for patients with mild traumatic brain injuries, compared with the previously used assessment, the Modified Oxford Post-traumatic Scale. Material and Methods: This retrospective cohort study reviewed 270 patients with mild traumatic brain injury assessed for post-traumatic amnesia over a 2-year period between February 2011 and February 2013. It identified those assessed with Abbreviated Westmead Post-traumatic Amnesia Scale versus Modified Oxford Post-traumatic Scale, the outcomes of these post-traumatic amnesia assessments, the hospital length of stay for patients, and their readmission rates. Results: The Abbreviated Westmead Post-traumatic Amnesia Scale was used in 91% of patient cases (and the Modified Oxford Post-traumatic Scale in 7%), and of those assessed with the Abbreviated Westmead Post-traumatic Amnesia Scale, 94% cleared post-traumatic amnesia testing within 4 h. Of those assessed with the Abbreviated Westmead Post-traumatic Amnesia Scale, 56% had a shorter length of stay than had they been assessed with the Modified Oxford Post-traumatic Scale, resulting in 295 bed-days saved. Verbal and written discharge advice was provided to those assessed for post-traumatic amnesia to assist their recovery. In all, 1% of patients were readmitted for monitoring of mild post-concussion symptoms. Conclusion: The Abbreviated Westmead Post-traumatic Amnesia Scale provides an effective and timely assessment of post-traumatic amnesia for patients presenting to the Emergency Department with mild traumatic brain injury compared with the previously used assessment tool. It helps identify patients with cognitive impairment and the need for admission and further investigation, resulting in appropriate access to care. It also results in a decreased length of stay and decreased hospital admissions, with subsequent cost savings to the hospital.
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Affiliation(s)
- C. E. Watson
- Occupational Therapy Department, Liverpool Hospital, Liverpool, NSW, Australia
| | - E. A. Clous
- Trauma Department, Liverpool Hospital, Liverpool, NSW, Australia
- Trauma Unit, Department of Surgery, Academisch Medisch Centrum, Amsterdam, The Netherlands
| | - M. Jaeger
- Neurosurgery Department, Liverpool Hospital, Liverpool, NSW, Australia
- Neurosurgery Department, Wollongong Hospital, Wollongong, NSW, Australia
| | - S. K. D’Amours
- Trauma Department, Liverpool Hospital, Liverpool, NSW, Australia
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16
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Jodoin M, Rouleau DM, Charlebois-Plante C, Benoit B, Leduc S, Laflamme GY, Gosselin N, Larson-Dupuis C, De Beaumont L. Incidence rate of mild traumatic brain injury among patients who have suffered from an isolated limb fracture: Upper limb fracture patients are more at risk. Injury 2016; 47:1835-40. [PMID: 27291349 DOI: 10.1016/j.injury.2016.05.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study compares the incidence rate of mild traumatic brain injury (mild TBI) detected at follow-up visits (retrospective diagnosis) in patients suffering from an isolated limb trauma, with the incidence rate held by the hospital records (prospective diagnosis) of the sampled cohort. This study also seeks to determine which types of fractures present with the highest incidence of mild TBI. PATIENTS AND METHODS Retrospective assessment of mild TBI among orthopaedic monotrauma patients, randomly selected for participation in an Orthopaedic clinic of a Level I Trauma Hospital. Patients in the remission phase of a limb fracture were recruited between August 2014 and May 2015. No intervention was done (observational study). MAIN OUTCOME MEASUREMENTS Standardized semi-structured interviews were conducted with all patients to retrospectively assess for mild TBI at the time of the fracture. Emergency room related medical records of all patients were carefully analyzed to determine whether a prospective mild TBI diagnosis was made following the accident. RESULTS A total of 251 patients were recruited (54% females, Mean age=49). Study interview revealed a 23.5% incidence rate of mild TBI compared to an incidence rate of 8.8% for prospective diagnosis (χ(2)=78.47; p<0.0001). Patients suffering from an upper limb monotrauma (29.6%; n=42/142) are significantly more at risk of sustaining a mild TBI compared to lower limb fractures (15.6%; n=17/109) (χ(2)=6.70; p=0.010). More specifically, patients with a proximal upper limb injury were significantly more at risk of sustaining concomitant mild TBI (40.6%; 26/64) compared to distal upper limb fractures (20.25%; 16/79) (χ(2)=7.07; p=0.008). CONCLUSIONS Results suggest an important concomitance of mild TBI among orthopaedic trauma patients, the majority of which go undetected during acute care. Patients treated for an upper limb fracture are particularly at risk of sustaining concomitant mild TBI.
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Affiliation(s)
- Marianne Jodoin
- Research Center in Neuropsychology and Cognition (CERNEC), Department of Psychology, University of Montreal, Montreal, Quebec, Canada; Montreal Sacred Heart Hospital Research Centre, Montreal, Quebec, Canada
| | - Dominique M Rouleau
- Montreal Sacred Heart Hospital Research Centre, Montreal, Quebec, Canada; Department of Surgery, University of Montreal, Montreal, Quebec, Canada, Canada.
| | | | - Benoit Benoit
- Montreal Sacred Heart Hospital Research Centre, Montreal, Quebec, Canada; Department of Surgery, University of Montreal, Montreal, Quebec, Canada, Canada
| | - Stéphane Leduc
- Montreal Sacred Heart Hospital Research Centre, Montreal, Quebec, Canada; Department of Surgery, University of Montreal, Montreal, Quebec, Canada, Canada
| | - G-Yves Laflamme
- Montreal Sacred Heart Hospital Research Centre, Montreal, Quebec, Canada; Department of Surgery, University of Montreal, Montreal, Quebec, Canada, Canada
| | - Nadia Gosselin
- Research Center in Neuropsychology and Cognition (CERNEC), Department of Psychology, University of Montreal, Montreal, Quebec, Canada; Montreal Sacred Heart Hospital Research Centre, Montreal, Quebec, Canada
| | - Camille Larson-Dupuis
- Research Center in Neuropsychology and Cognition (CERNEC), Department of Psychology, University of Montreal, Montreal, Quebec, Canada; Montreal Sacred Heart Hospital Research Centre, Montreal, Quebec, Canada
| | - Louis De Beaumont
- Montreal Sacred Heart Hospital Research Centre, Montreal, Quebec, Canada; Department of Psychology, University of Quebec at Trois-Rivieres, Trois-Rivieres, Quebec, Canada
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17
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Stern RA, Seichepine D, Tschoe C, Fritts NG, Alosco ML, Berkowitz O, Burke P, Howland J, Olshaker J, Cantu RC, Baugh CM, Holsapple JW. Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments. J Neurotrauma 2016; 34:861-868. [PMID: 27112592 DOI: 10.1089/neu.2016.4475] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Evidence-based clinical practice guidelines can facilitate proper evaluation and management of concussions in the emergency department (ED), often the initial and primary point of contact for concussion care. There is no universally adopted set of guidelines for concussion management, and extant evidence suggests that there may be variability in concussion care practices and limited application of clinical practice guidelines in the ED. This study surveyed EDs throughout New England to examine current practices of concussion care and utilization of evidence-based clinical practice guidelines in the evaluation and management of concussions. In 2013, a 32-item online survey was e-mailed to 149/168 EDs throughout New England (Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine). Respondents included senior administrators asked to report on their EDs use of clinical practice guidelines, neuroimaging decision-making, and discharge instructions for concussion management. Of the 72/78 respondents included, 35% reported absence of clinical practice guidelines, and 57% reported inconsistency in the type of guidelines used. Practitioner preference guided neuroimaging decision-making for 57%. Although 94% provided written discharge instructions, there was inconsistency in the recommended time frame for follow-up care (13% provided no specific time frame), the referral specialist to be seen (25% did not recommend any specialist), and return to activity instructions were inconsistent. There is much variability in concussion care practices and application of evidence-based clinical practice guidelines in the evaluation and management of concussions in New England EDs. Knowledge translational efforts will be critical to improve concussion management in the ED setting.
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Affiliation(s)
- Robert A Stern
- 1 Boston University Alzheimer's Disease and CTE Center; Departments of Neurology, Neurosurgery, and Anatomy and Neurobiology, Boston University School of Medicine , Boston, Massachusetts
| | - Daniel Seichepine
- 2 Boston University Alzheimer's Disease and CTE Center , Boston, Massachusetts
| | - Christine Tschoe
- 3 Department of Neurosurgery, Boston University School of Medicine , Boston, Massachusetts
| | - Nathan G Fritts
- 2 Boston University Alzheimer's Disease and CTE Center , Boston, Massachusetts
| | - Michael L Alosco
- 4 Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine , Boston, Massachusetts
| | - Oren Berkowitz
- 5 Departments of Neurosurgery and Medicine, Boston University School of Medicine , Boston, Massachusetts
| | - Peter Burke
- 6 Section of Acute Care & Trauma Surgery, Division of General Surgery, Department of Surgery, Boston Medical Center, Boston University School of Medicine , Boston, Massachusetts
| | - Jonathan Howland
- 7 Injury Prevention Center, Boston Medical Center; Department of Emergency Medicine, Boston University School of Medicine , Boston, Massachusetts
| | - Jonathan Olshaker
- 8 Department of Emergency Medicine, Boston University School of Medicine; Department of Emergency Medicine , Boston Medical Center, Boston, Massachusetts
| | - Robert C Cantu
- 9 Boston University Alzheimer's Disease and CTE Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine , Boston, Massachusetts
| | - Christine M Baugh
- 10 Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts; Interfaculty Initiative in Health Policy, Harvard University , Cambridge, Massachusetts
| | - James W Holsapple
- 3 Department of Neurosurgery, Boston University School of Medicine , Boston, Massachusetts
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18
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Bosch M, Tavender EJ, Brennan SE, Knott J, Gruen RL, Green SE. The Many Organisational Factors Relevant to Planning Change in Emergency Care Departments: A Qualitative Study to Inform a Cluster Randomised Controlled Trial Aiming to Improve the Management of Patients with Mild Traumatic Brain Injuries. PLoS One 2016; 11:e0148091. [PMID: 26845772 PMCID: PMC4742078 DOI: 10.1371/journal.pone.0148091] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 01/12/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Neurotrauma Evidence Translation (NET) Trial aims to design and evaluate the effectiveness of a targeted theory-and evidence-informed intervention to increase the uptake of evidence-based recommended practices for the management of patients who present to an emergency department (ED) with mild head injuries. When designing interventions to bring about change in organisational settings such as the ED, it is important to understand the impact of the context to ensure successful implementation of practice change. Few studies explicitly use organisational theory to study which factors are likely to be most important to address when planning change processes in the ED. Yet, this setting may have a unique set of organisational pressures that need to be taken into account when implementing new clinical practices. This paper aims to provide an in depth analysis of the organisational context in which ED management of mild head injuries and implementation of new practices occurs, drawing upon organisational level theory. METHODS Semi-structured interviews were conducted with ED staff in Australia. The interviews explored the organisational context in relation to change and organisational factors influencing the management of patients presenting with mild head injuries. Two researchers coded the interview transcripts using thematic content analysis. The "model of diffusion in service organisations" was used to guide analyses and organisation of the results. RESULTS Nine directors, 20 doctors and 13 nurses of 13 hospitals were interviewed. With regard to characteristics of the innovation (i.e. the recommended practices) the most important factor was whether they were perceived as being in line with values and needs. Tension for change (the degree to which stakeholders perceive the current situation as intolerable or needing change) was relatively low for managing acute mild head injury symptoms, and mixed for managing longer-term symptoms (higher change commitment, but relatively low change efficacy). Regarding implementation processes, the importance of (visible) senior leadership for all professions involved was identified as a critical factor. An unpredictable and hectic environment brings challenges in creating an environment in which team-based and organisational learning can thrive (system antecedents for innovation). In addition, the position of the ED as the entry-point of the hospital points to the relevance of securing buy-in from other units. CONCLUSIONS We identified several organisational factors relevant to realising change in ED management of patients who present with mild head injuries. These factors will inform the intervention design and process evaluation in a trial evaluating the effectiveness of our implementation intervention.
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Affiliation(s)
- Marije Bosch
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia
- * E-mail:
| | - Emma J. Tavender
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia
| | - Sue E. Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jonathan Knott
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Russell L. Gruen
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia
- The Alfred Trauma Service, The Alfred Hospital, Melbourne, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Sally E. Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Understanding practice: the factors that influence management of mild traumatic brain injury in the emergency department--a qualitative study using the Theoretical Domains Framework. Implement Sci 2014; 9:8. [PMID: 24418161 PMCID: PMC3895840 DOI: 10.1186/1748-5908-9-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 08/12/2013] [Indexed: 11/25/2022] Open
Abstract
Background Mild traumatic brain injury is a frequent cause of presentation to emergency departments. Despite the availability of clinical practice guidelines in this area, there is variation in practice. One of the aims of the Neurotrauma Evidence Translation program is to develop and evaluate a targeted, theory- and evidence-informed intervention to improve the management of mild traumatic brain injury in Australian emergency departments. This study is the first step in the intervention development process and uses the Theoretical Domains Framework to explore the factors perceived to influence the uptake of four key evidence-based recommended practices for managing mild traumatic brain injury. Methods Semi-structured interviews were conducted with emergency staff in the Australian state of Victoria. The interview guide was developed using the Theoretical Domains Framework to explore current practice and to identify the factors perceived to influence practice. Two researchers coded the interview transcripts using thematic content analysis. Results A total of 42 participants (9 Directors, 20 doctors and 13 nurses) were interviewed over a seven-month period. The results suggested that (i) the prospective assessment of post-traumatic amnesia was influenced by: knowledge; beliefs about consequences; environmental context and resources; skills; social/professional role and identity; and beliefs about capabilities; (ii) the use of guideline-developed criteria or decision rules to inform the appropriate use of a CT scan was influenced by: knowledge; beliefs about consequences; environmental context and resources; memory, attention and decision processes; beliefs about capabilities; social influences; skills and behavioral regulation; (iii) providing verbal and written patient information on discharge was influenced by: beliefs about consequences; environmental context and resources; memory, attention and decision processes; social/professional role and identity; and knowledge; (iv) the practice of providing brief, routine follow-up on discharge was influenced by: environmental context and resources; social/professional role and identity; knowledge; beliefs about consequences; and motivation and goals. Conclusions Using the Theoretical Domains Framework, factors thought to influence the management of mild traumatic brain injury in the emergency department were identified. These factors present theoretically based targets for a future intervention.
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