The lack of effective knowledge use by professionals in trauma care increases mortality, morbidity and associated costs. There is evidence of overuse of tests that unnecessarily expose patients to side effects, especially the use of computed tomography (CT scan) in victims of mild traumatic brain injury (mTBI) for which about 10-35 % of scans are done inappropriately. In Canada, there is significant variability in the rate of use of CT scans for mTBI ranging up to a fourfold higher use in some centers. In prescribing a brain CT scan for patients who do not show signs or symptoms of serious injuries, physicians are unnecessarily exposing patients to ionizing radiation that can increase their risk of developing cancer during their lifetime (1 cancer per 1,000 brain CTs for mTBI for children and 1 in 10 000 for adults). One factor for this overuse is social pressure exerted by patients. Several studies have shown that the Shared Decision Making (SDM) can decrease the overuse of resources. There exists two shared decision support tools (children and adult) developed in the United States to reduce the use of CT scans for mTBI.
We have four goals: 1) Translate two decision support tools for the use of CT scans for mTBI (pediatric and adult) developed in the United States and adapt them to the Québec context; 2) Create a training program on the adoption of SDM in EDs to inform the decision to conduct a CT scan for mTBI; 3) Implement the tools and training in three Québec EDs and; 4) Assess the impact of the decision aids and the training program on the appropriate use of CT scans for mTBI.
First, we will translate into French the US-produced shared decision support tools on the use of CT scans for mTBI (pediatric and adult). We will then adapt the translated tools to the local context of three hospitals: CHU Ste-Justine (version for children), Hôpital de l’Enfant-Jésus (version for adults) et Hôtel-Dieu de Lévis (two versions). We will employ user-centered design to perform rapid prototyping with mTBI patients. The first step will comprise a consensus meeting with patient partners and clinical experts to list the necessary adaptations to the two American DAs to be used in the first rounds of prototyping with patients. This consensus meeting will use a Nominal Group Technique to create consensus about the two DAs to be then tested with patients. We will then conduct three separate focus groups with 5 patient partners, 5 doctors and 5 nurses to better understand the barriers in connection with the use of tools and find solutions to these barriers. The data from the content analysis will allow us to further adapt the DAs (pediatric and adult). These will be placed on a collaborative web platform, called WikiTrauma (https://goo.gl/WS92Od), to serve as a document management system for three rapid prototyping cycles whereby 5 emergency physicians will meet 1 patient each to present them the tool and correct problems of use, producing a final version.
We will develop training on SDM and the tools (in class and online versions) for physicians and nurses working in EDs based on the results of the first phase. Phase III: In the same three centers, we will train emergency physicians either in-person or on-line through WikiTrauma. Prior to the training, we will analyze the medical records of all cases of mTBI who visited the three centers to calculate the rate of CT scan use. Two reviewers will independently judge the appropriateness of having done a CT scan based on explicit criteria. We will measure the impact of the training on practices by administering the same questionnaire developed during Phase 1, measuring intention of physicians to adopt the SDM. In addition, for the 6 months following the training, we will prospectively identify cases of mTBI to assess : 1) the decision to order a CT scan; 2) the justification to prescribe the CT scan; 3) the result of the CT scan. All patients will be called one week after their visit to check if a CT scan was performed elsewhere and to evaluate if their decision was congruent with their values and preferences.
This project will allow: 1) adaptation of two new support tools for shared decision making for the use of CT scans for MTBI in the Québec context; 2) the production of a unique training program for the adoption of SDM in traumatology; 3) sharing of new tools in a knowledge management system, WikiTrauma, which will allow all those involved in trauma care to get free access to these tools which could be adapted to their local context; 4) increased appropriate use of brain CT scans for MTBI; and 5) efficiencies in costs and human resources with the more appropriate use of brain CT scanning and sharing tools that can be adapted to several contexts.