1
|
Wickbom F, Berghog W, Bernhardsson S, Persson L, Kunkel S, Undén J. Pediatric head injury guideline use in Sweden: a cross-sectional survey on determinants for successful implementation of a clinical practice guideline. BMC Health Serv Res 2024; 24:965. [PMID: 39169324 PMCID: PMC11340051 DOI: 10.1186/s12913-024-11423-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 08/09/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND The Scandinavian Neurotrauma Committee guideline (SNC-16) was developed and published in 2016, to aid clinicians in management of pediatric head injuries in Scandinavian emergency departments (ED). The objective of this study was to explore determinants for use of the SNC-16 guideline by Swedish ED physicians. METHODS This is a nationwide, cross-sectional, web-based survey in Sweden. Using modified snowball sampling, physicians managing children in the ED were invited via e-mail to complete the validated Clinician Guideline Determinants Questionnaire between February and May, 2023. Baseline data, data on enablers and barriers for use of the SNC-16 guideline, and preferred routes for implementation and access of guidelines in general were collected and analyzed descriptively and exploratory with Chi-square and Fisher's tests. RESULTS Of 595 invitations, 198 emergency physicians completed the survey (effective response rate 33.3%). There was a high reported use of the SNC-16 guideline (149/195; 76.4%) and a strong belief in its benefits for the patients (188/197; 95.4% agreement). Respondents generally agreed with the guideline's content (187/197; 94.9%) and found it easy to use and navigate (188/197; 95.4%). Some respondents (53/197; 26.9%) perceived a lack of organizational support needed to use the guideline. Implementation tools may be improved as only 58.9% (116/197) agreed that the guideline includes such. Only 37.6% (74/197) of the respondents agreed that the guideline clearly describes the underlying evidence supporting the recommendation. Most respondents prefer to consult colleagues (178/198; 89.9%) and guidelines (149/198; 75.3%) to gain knowledge to guide clinical decision making. Four types of enablers for guideline use emerged from free-text answers: ease of use and implementation, alignment with local guidelines and practice, advantages for stakeholders, and practicality and accessibility. Barriers for guideline use were manifested as: organizational challenges, medical concerns, and practical concerns. CONCLUSIONS The findings suggest high self-reported use of the SNC-16 guideline among Swedish ED physicians. In updated versions of the guideline, focus on improving implementation tools and descriptions of the underlying evidence may further facilitate adoption and adherence. Measures to improve organizational support for guideline use and involvement of patient representatives should also be considered.
Collapse
Affiliation(s)
- Fredrik Wickbom
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden.
- Lund University, Lund, Sweden.
| | - William Berghog
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden
| | - Susanne Bernhardsson
- Region Västra Götaland, Research, Education, Development, and Innovation Primary Health Care, Gothenburg, Sweden
- School of Public Health and Community Medicine, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Linda Persson
- Department of Orthopedics, Halland Hospital, Halmstad, Sweden
| | - Stefan Kunkel
- Department of Medicine, Växjö Hospital, Växjö, Sweden
| | - Johan Undén
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden
- Lund University, Lund, Sweden
| |
Collapse
|
2
|
Wickbom F, Persson L, Olivecrona Z, Undén J. Management of paediatric traumatic brain injury in Sweden: a national cross-sectional survey. Scand J Trauma Resusc Emerg Med 2022; 30:35. [PMID: 35551626 PMCID: PMC9097395 DOI: 10.1186/s13049-022-01022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Previous studies have shown variations in management routines for children with traumatic brain injury (TBI) in Sweden. It is unknown if this management has changed after the publication of the Scandinavian Neurotrauma Committee guidelines in 2016 (SNC16). Also, knowledge of current practice routines may guide development of an efficient implementation strategy for the guidelines. The aim of this study is therefore to describe current management routines in paediatric TBI on a hospital/organizational level in Sweden. Secondary aims are to analyse differences in management over time, to assess the current dissemination status of the SNC16 guideline and to analyse possible variations between hospitals. Methods This is a sequential, cross-sectional, structured survey in five sections, covering initial management routines for paediatric TBI in Sweden. Respondents, with profound knowledge of local management routines and recommendations, were identified for all Swedish hospitals with an emergency department managing children (age 0–17 year) via phone/mail before distribution of the survey. Responses were collected via an on-line survey system during June 2020–March 2021. Data are presented as descriptive statistics and comparisons were made using Fisher exact test, when applicable. Results 71 of the 76 identified hospitals managed patients with TBI of all ages and 66 responded (response rate 93%). 56 of these managed children and were selected for further analysis. 76% (42/55) of hospitals have an established guideline to aid in clinical decision making. Children with TBI are predominately managed by inexperienced doctors (84%; 47/56), primarily from non-paediatric specialities (75%; 42/56). Most hospitals (75%; 42/56) have the possibility to admit and observe children with TBI of varying degrees and almost all centres have complete access to neuroradiology (96%; 54/56). In larger hospitals, it was more common for nurses to discharge patients without doctor assessment when compared to smaller hospitals (6/9 vs. 9/47; p < 0.001). Presence of established guidelines (14/51 vs. 42/55; p < 0.001) and written observation routines (16/51 vs. 29/42; p < 0.001) in hospitals have increased significantly since 2006. Conclusions TBI management routines for children in Sweden still vary, with some differences occurring over time. Use of established guidelines, written observation routines and information for patients/guardians have all improved. These results form a baseline for current management and may also aid in guideline implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01022-4.
Collapse
Affiliation(s)
- Fredrik Wickbom
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden. .,Lund University, Lund, Sweden.
| | - Linda Persson
- Department of Orthopaedics, Halland Hospital, Halmstad, Sweden
| | - Zandra Olivecrona
- Department of Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Örebro, Sweden
| | - Johan Undén
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden.,Lund University, Lund, Sweden
| |
Collapse
|
3
|
Undén J, Dalziel SR, Borland ML, Phillips N, Kochar A, Lyttle MD, Bressan S, Cheek JA, Neutze J, Donath S, Hearps S, Oakley E, Dalton S, Gilhotra Y, Babl FE. External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC Med 2018; 16:176. [PMID: 30309392 PMCID: PMC6182797 DOI: 10.1186/s12916-018-1166-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/07/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Clinical decision rules (CDRs) aid in the management of children with traumatic brain injury (TBI). Recently, the Scandinavian Neurotrauma Committee (SNC) has published practical, evidence-based guidelines for children with Glasgow Coma Scale (GCS) scores of 9-15. This study aims to validate these guidelines and to compare them with other CDRs. METHODS A large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, we compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13-15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT. RESULTS The SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1-100.0; 32/32), 97.8% (94.5-99.4; 179/183) and 95% (95% CI 91.6-97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs. CONCLUSION The SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI.
Collapse
Affiliation(s)
- Johan Undén
- Department of Operation and Intensive Care, Hallands Hospital, Halmstad, Sweden.,Lund University, Lund, Sweden
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Health, 2 Park Rd, Grafton, Auckland, 1023, New Zealand.,Liggins Institute, University of Auckland, 85 Park Ave, Grafton, Auckland, 1023, New Zealand
| | - Meredith L Borland
- Emergency Department, Princess Margaret Hospital for Children, Roberts Rd, Subiaco, Perth, Western Australia, 6008, Australia.,Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, 6009, Australia
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, 501 Stanley St, South Brisbane, Queensland, 4101, Australia
| | - Amit Kochar
- Emergency Department, Women's & Children's Hospital, Adelaide, 72 King William St, North Adelaide, South Australia, 5006, Australia
| | - Mark D Lyttle
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Emergency Department, Bristol Children's Hospital, Paul O'Gorman Building, Upper Maudlin St, Bristol, BS2 8BJ, UK.,Academic Department of Emergency Care, University of the West of England, Blackberry Hill, Bristol, BS16 1XS, UK
| | - Silvia Bressan
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Women's and Children's Health, University of Padova, Via Giustiniani3, 2, 35128, Padova, Padova, Italy
| | - John A Cheek
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Emergency Department, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, 3186, Australia
| | - Jocelyn Neutze
- Emergency Department, Kidzfirst Middlemore Hospital, 100 Hospital Rd, Auckland, 2025, New Zealand
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, Victoria, 3010, Australia
| | - Stephen Hearps
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, Victoria, 3010, Australia
| | - Sarah Dalton
- Emergency Department, The Children's Hospital at Westmead, 212 Hawkesbury Rd, Westmead, New South Wales, 2145, Australia
| | - Yuri Gilhotra
- Emergency Department, Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, 501 Stanley St, South Brisbane, Queensland, 4101, Australia
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia. .,Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia. .,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, Victoria, 3010, Australia.
| | | |
Collapse
|
4
|
Astrand R, Rosenlund C, Undén J. Scandinavian guidelines for initial management of minor and moderate head trauma in children. BMC Med 2016; 14:33. [PMID: 26888597 PMCID: PMC4758024 DOI: 10.1186/s12916-016-0574-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 02/02/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim. METHODS General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders. RESULTS The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children. CONCLUSIONS We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma.
Collapse
Affiliation(s)
- Ramona Astrand
- Department of Neurosurgery, Neurocenter 2091, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Christina Rosenlund
- Department of Neurosurgery, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | - Johan Undén
- Department of Intensive Care and Perioperative Medicine, Institute for Clinical Sciences, Skåne University Hospital, Södra Förstadsgatan 101, 20502, Malmö, Sweden.
| | | |
Collapse
|