Improving the diagnosis and management of paediatric TBI
Bridget Kool
Outline Improving the diagnosis and management of mild TBI among children presenting to the emergency department
Bridget Kool, Sarah Sharpe, Michael Shepherd,
Stuart Dalziel, Shanthi Ameratunga
INJURY 2010 Conference
MTBI background
* "Silent Epidemic"
* 90% of all TBI among children = "mild"
* 1:5 children experience 1 MTBI < 16 years
* 3 to 5 times as many seen in 10 care
* Significance:
- Complications e.g. somatic symptoms, cognitive deficits, behavioural problems
- Large burden on individuals, families, and the healthcare system
Recent research
Aim: To determine if children with head injuries, who are discharged home from
ED, are managed according to best practice standards
Objectives:
- Collection of data for determining the diagnosis of TBI
- Application of criteria for safe discharge
- Provision of information and advice about TBI
- Description of follow-up practices
Methods
* Clinical audit of ED records
* Children aged 0-14 years discharged in 2007 from Starship Hospital ED
following a head injury
* Stratified purposeful sampling strategy: 60 patients, 15 from four ethnic
groups
* Processes of care relating to the objectives were compared with best practice
standards derived from guidelines
Key findings
* Data elements were documented to a high standard
* Diagnosis of MTBI:
- Not evident that data elements were applied systematically to diagnose MTBI or
estimate the probability of MTBI
- 30 of 60 cases filled criteria for definite or possible TBI
- Discharge codes used interchangeably
Documentation of data elements: 0-4 years (n=20)
Additional findings relating to documentation
* Criteria for safe discharge
- 80% did not specifically document the adequacy of support structures
* Information and advice
- 88% had documentation that information was given
- 1 record - consideration of language needs
- 4 records - consideration of prevention issues
* Follow-up
- Discharge summary letter to GP
- 14 children referred to GP
- 20 patients with definite/possible brain injury had no specific follow-up
plans
Discussion points
* Possible contributors to variability in documentation
- Main aim of ED management of TBI is detection of clinically significant acute
complications
- Recognition and identification of MTBI is a challenge
* Actions to improve quality of care
- Improve recognition and appropriate follow-up of MTBI
- Develop integrated services
- Prevention advice
- Cultural support
* Further research
- An improved evidence base about MTBI among children is required
Translational Research Project
Aim
To develop and implement a computerised decision support system (CDSS) tool
to improve the diagnosis, management, and follow-up of acute MTBI among children
in the ED setting
Objectives
* To explore the management of children with MTBI in other settings
* To identify barriers to current best practice
* To develop a CDSS for the diagnosis, management, and follow-up of children
with MTBI
* To follow-up children with MTBI assessed using the CDSS tool
Computerised (clinical) Decision Support System(CDSS)
"Clinical Decision Support systems link health observations with health
knowledge to influence health choices by clinicians for improved health care".
R. Hayward, Centre for Health Evidence
Methods
Phase One: Identifying barriers to best practice
* Retrospective audit of 60 children presenting with MTBI to a Whitecross A & M
clinic and Kidz First ED
* Interviews with Clinicians to identify barriers to care
Phase Two: Translation of knowledge into best practice
* Development of the evidence-based CDSS tool. Focus on "when to CT/refer" and
identifying and managing MTBI.
Methods continue
Phase Three: Evaluation
* Follow-up study of 40 children who have been assessed by the CDSS
* Detailed interviews with 20 clinicians who have piloted and used the CDSS
* Retrospective audit of 60 cases to establish if CDSS resulted in best-practice
care
Phase Four: Cohort Study Foundation
* The CDSS will allow development of a detailed long-term cohort of children who
have suffered MTBI
Investigators & Study Advisory Group
* Principal Investigators: Dr Bridget Kool & Dr Stu Dalziel
* Co investigators: Dr Mike Shepherd, Dr Hine Elder, Prof. Shanthi Ameratunga,
Dr Sue Wells, Prof. Jim Warren
Study Advisory Group
White Cross Accident and Medical, Brain Injury New Zealand; Kaiatawhai,
Starship; Dr Jocelyn Neutze (Paediatric emergency care specialist) Dr Kathryn
Edward and EeWei Lim (paediatric rehab specialists), Pip Bishop (paediatric OT);
paediatric neuropsychologist (TBC); Dr Matire Harwood, (Clinical Director for
T?maki Healthcare); ACC
Acknowledgements
Starship Children's Emergency Department
White Cross Accident and Medical
Kidz First
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Ministry of Health
