Organising health care services for people with an acquired brain injury: an overview of systematic reviews and randomised controlled trials

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background Acquired brain injury (ABI) is the leading cause of disability worldwide yet there is little information regarding the most effective way to organise ABI health care services. The aim of this review was to identify the most up-to-date high quality evidence to answer specific questions regarding the organisation of health care services for people with an ABI. Methods We conducted a systematic review of English papers using MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library. We included the most recently published high quality systematic reviews and any randomised controlled trials, non-randomised controlled trials, controlled before after studies or interrupted time series studies published subsequent to the systematic review. We searched for papers that evaluated pre-defined organisational interventions for adults with an ABI. Organisational interventions of interest included fee-for-service care, integrated care, integrated care pathways, continuity of care, consumer engagement in governance and quality monitoring interventions. Data extraction and appraisal of included reviews and studies was completed independently by two reviewers. Results A total of five systematic reviews and 21 studies were included in the review; eight of the papers (31%) included people with a traumatic brain injury (TBI) or ABI and the remaining papers (69%) included only participants with a diagnosis of stroke. We found evidence supporting the use of integrated care to improve functional outcome and reduce length of stay and evidence supporting early supported discharge teams for reducing morbidity and mortality and reducing length of stay for stroke survivors. There was little evidence to support case management or the use of integrated care pathways for people with ABI. We found evidence that a quality monitoring intervention can lead to improvements in process outcomes in acute and rehabilitation settings. We were unable to find any studies meeting our inclusion criteria regarding fee-for-service care or engaging consumers in the governance of the health care organisation. Conclusions The review found evidence to support integrated care, early supported discharge and quality monitoring interventions however, this evidence was based on studies conducted with people following stroke and may not be appropriate for all people with an ABI

Understanding practice: the factors that influence management of mild traumatic brain injury in the emergency department-a qualitative study using the Theoretical Domains Framework

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

Improving the management of mild traumatic brain injury in the emergency department: factors influencing evidence uptake and designing a targeted, theory-informed intervention to improve practice and patient outcomes

Background - Despite the availability of evidence-based guidelines for the management of mild traumatic brain injury (mTBI) in the emergency department (ED), variations in practice exist. Implementation research can contribute to reducing these variations in practice by studying the determinants, processes and effects of implementation efforts and providing evidence about what works when designing, selecting and improving implementation interventions. The ED environment has unique characteristics that can have an impact on its responsiveness to change. An understanding of these factors influencing practice change is essential to develop an effective implementation intervention that is feasible and acceptable. There is limited research on how to develop targeted, theory-informed implementation interventions in this setting. Aims - The aim of this thesis is to describe the process of developing a targeted, theory-informed intervention to increase the uptake of evidence-based recommendations in the management of mTBI in the ED. Specifically to: 1) identify the key evidence-based recommendations to be implemented, 2) explore and identify the influencing factors (barriers and enablers) to change using relevant theoretical frameworks, 3) develop a targeted, theory-informed intervention by identifying intervention components to overcome these factors that is acceptable and feasible to deliver, and 4) describe the process of developing fidelity measures for intervention components. Methods - A systematic scoping review was conducted to assess the volume and scope of implementation research in the ED setting; a systematic review of clinical guidelines for the management of mTBI, followed by a formal stakeholder consultation process, to develop locally applicable evidence-based recommendations for implementation; qualitative interviews with ED clinicians were used to explore the professional and organisational factors influencing uptake of the recommended behaviours using two theoretical frameworks. A systematic, stepped approach was developed to identify and operationalise intervention components to address the influencing factors and was informed by theory, evidence and feasibility considerations. A review of process evaluations of similar tailored interventions to that developed in the thesis was used to inform development of fidelity measures. Results - The scoping review found a significant increase in the volume of implementation research, however most studies focused on identifying evidence-practice gaps or utilised weak study designs to evaluate the effects of implementation interventions. Four key evidence-based recommendations were identified to improve the management of mTBI in the ED. Interviews with 42 ED staff identified professional and organisational factors that influenced these recommendations and presented theoretically based targets for intervention components. The resulting five intervention components consisted of several behaviour change techniques (BCTs). Fidelity measures were developed for two of these intervention components. Conclusions - This thesis provides a systematic, theory- and evidence-informed approach to developing an intervention aiming to improve the management of mTBI in the ED. Theoretical frameworks, evidence-based BCTs, evidence about the effects of modes of delivery and feasibility information were systematically brought together to develop the intervention. Implementation research is a cumulative science and this intervention is currently being evaluated in a national cluster randomised controlled trial, adding to the evidence of the effectiveness of theory-informed interventions to improve clinical practice

Improving the management of mild traumatic brain injury in the emergency department: factors influencing evidence uptake and designing a targeted, theory-informed intervention to improve practice and patient outcomes

Background - Despite the availability of evidence-based guidelines for the management of mild traumatic brain injury (mTBI) in the emergency department (ED), variations in practice exist. Implementation research can contribute to reducing these variations in practice by studying the determinants, processes and effects of implementation efforts and providing evidence about what works when designing, selecting and improving implementation interventions. The ED environment has unique characteristics that can have an impact on its responsiveness to change. An understanding of these factors influencing practice change is essential to develop an effective implementation intervention that is feasible and acceptable. There is limited research on how to develop targeted, theory-informed implementation interventions in this setting. Aims - The aim of this thesis is to describe the process of developing a targeted, theory-informed intervention to increase the uptake of evidence-based recommendations in the management of mTBI in the ED. Specifically to: 1) identify the key evidence-based recommendations to be implemented, 2) explore and identify the influencing factors (barriers and enablers) to change using relevant theoretical frameworks, 3) develop a targeted, theory-informed intervention by identifying intervention components to overcome these factors that is acceptable and feasible to deliver, and 4) describe the process of developing fidelity measures for intervention components. Methods - A systematic scoping review was conducted to assess the volume and scope of implementation research in the ED setting; a systematic review of clinical guidelines for the management of mTBI, followed by a formal stakeholder consultation process, to develop locally applicable evidence-based recommendations for implementation; qualitative interviews with ED clinicians were used to explore the professional and organisational factors influencing uptake of the recommended behaviours using two theoretical frameworks. A systematic, stepped approach was developed to identify and operationalise intervention components to address the influencing factors and was informed by theory, evidence and feasibility considerations. A review of process evaluations of similar tailored interventions to that developed in the thesis was used to inform development of fidelity measures. Results - The scoping review found a significant increase in the volume of implementation research, however most studies focused on identifying evidence-practice gaps or utilised weak study designs to evaluate the effects of implementation interventions. Four key evidence-based recommendations were identified to improve the management of mTBI in the ED. Interviews with 42 ED staff identified professional and organisational factors that influenced these recommendations and presented theoretically based targets for intervention components. The resulting five intervention components consisted of several behaviour change techniques (BCTs). Fidelity measures were developed for two of these intervention components. Conclusions - This thesis provides a systematic, theory- and evidence-informed approach to developing an intervention aiming to improve the management of mTBI in the ED. Theoretical frameworks, evidence-based BCTs, evidence about the effects of modes of delivery and feasibility information were systematically brought together to develop the intervention. Implementation research is a cumulative science and this intervention is currently being evaluated in a national cluster randomised controlled trial, adding to the evidence of the effectiveness of theory-informed interventions to improve clinical practice

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

New research findings may not lead to change in practice, or a change at the front line may be delayed by years. A number of terms have been used to describe efforts and strategies to speed a change in evidence‐based practice, such as: implementation science, knowledge translation, research translation and others. In contrast to traditional clinical research, implementation science generally aims to understand and change health professional behaviour to promote evidence uptake as opposed to attempting to change patient behaviour. There are now theoretical frameworks and evolving evidence providing guidance how to change clinician behaviour and, specifically, emerging evidence on how to achieve this in the emergency setting. This review will provide an introduction to implementation science and illustrate how to target evidence practice gaps using ED examples

Identification, classification and assessment of dyskinesia in children with cerebral palsy : A survey of clinicians

Aim The aims of this study were to investigate clinicians’ knowledge, and barriers they perceive exist, relating to the identification and measurement of dyskinesia (dystonia/choreoathetosis) in children with cerebral palsy (CP) and to explore educational needs regarding improving identification and assessment of dyskinesia. Methods This was a cross-sectional online survey of clinicians working with children with CP. Data analysis was descriptive, with qualitative analysis of unstructured questions. Results In total, 163 completed surveys from Australian clinicians were analysed. Respondents were allied health (n = 140) followed by medical doctors (n = 18) working mainly in tertiary hospitals and not-for-profit organisations. Hypertonia subtypes and movement disorders seen in children with CP appear to be identified by clinicians, although limited knowledge about dyskinesia and access to training were reported as significant barriers to accurate identification. Despite knowledge of available measurement scales, only a small percentage were used clinically and reported to be only somewhat useful or not useful at all. Barriers identified for use of scales included limited training opportunities and knowledge of scales and lack of confidence in their use. Conclusion A lack of confidence in identifying and measuring movement disorders in children with CP was reported by Australian clinicians. It was identified that a greater understanding of dyskinetic CP and the tools available to identify and measure it would be valuable in clinical practice. The results of this survey will inform the development of a ‘Toolbox’ to help identify, classify and measure dyskinetic CP and its impact on activity and participation using the framework of the International Classification of Functioning, Disability and Health

Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials

Objective To evaluate the most appropriate surgical method of hysterectomy (abdominal, vaginal, or laparoscopic) for women with benign disease. Design Systematic review and meta-analysis. Data sources Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, and Biological Abstracts. Selection of studies Only randomised controlled trials were selected; participants had to have benign gynaecological disease; interventions had to comprise at least one hysterectomy method compared with another; and trials had to report primary outcomes (time taken to return to normal activities, intraoperative visceral injury, and major long term complications) or secondary outcomes (operating time, other immediate complications of surgery, short term complications, and duration of hospital stay). Results 27 trials (total of 3643 participants) were included. Return to normal activities was quicker after vaginal than after abdominal hysterectomy (weighted mean difference 9.5 (95% confidence interval 6.4 to 12.6) days) and after laparoscopic than after abdominal hysterectomy (difference 13.6 (11.8 to 15.4) days), but was not significantly different for laparoscopic versus vaginal hysterectomy (difference -1.1 (-4.2 to 2.1) days). There were more urinary tract injuries with laparoscopic than with abdominal hysterectomy (odds ratio 2.61 (95% confidence interval 1.22 to 5.60)), but no other intraoperative visceral injuries showed a significant difference between surgical approaches. Data were notably absent for many important long term patient outcome measures, where the analyses were underpowered to detect important differences, or they were simply not reported in trials. Conclusions Significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it brings a higher chance of bladder or ureter injury

Review article: A primer for clinical researchers in the emergency department: Part XII. Sustainability of improvements in care: An introduction

Despite an increased focus on ways to improve implementation of evidence and de-implementation of practices with no known benefit, there is limited guidance on how to sustain these improvements. This review provides an introduction to sustainability of improvements in care and sustainability research, discussing how to support sustainability in practice and detailing a sustainability research agenda for the emergency medicine setting