mild traumatic brain injury: improving quality of care in the paediatric emergency department...

ORIGINAL ARTICLE

Mild traumatic brain injury: Improving quality of care in thepaediatric emergency department settingjpc_2068 170..176

Sarah Sharpe,1 Bridget Kool,1 Michael Shepherd,2 Stuart Dalziel2 and Shanthi Ameratunga1

1Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, and 2Children’s Emergency Department, Starship Children’s

Health Service, Auckland, New Zealand

Aim: Traumatic brain injury (TBI) in childhood can impose a significant threat to life and longer-term disability. This study investigated the extentto which the documentation of key indicators of healthcare quality in the emergency department (ED) setting was consistent with clinicalguidelines for the management of children with mild TBI (MTBI).Methods: The clinical records of a random sample of 60 children (stratified by ethnicity and age group), who were seen and discharged froma large metropolitan paediatric hospital ED following a head injury, were systematically reviewed to examine the processes of care and follow-up.Results: Based on the documentation in clinical records, processes designed to identify and manage potentially life-threatening acutecomplications (e.g. computed tomography scanning to identify intracranial haemorrhage) were consistent with best practice standards.However gaps existed between current and best practice for some aspects of care that could minimise risks of longer-term disability from MTBI.For example, relevant clinical criteria were well documented, but this information did not appear to be applied systematically to identify and tofollow up children with definite or possible MTBI.Conclusion: The apparent absence of a systematic approach to the diagnosis and follow-up of MTBI in children presenting to ED suggests amissed opportunity to minimise the risk of disability following these injuries. Greater attention to an integrated care pathway that improves theidentification, documentation, and follow-up of children with MTBI presenting to ED is required.

Key words: child; closed head injury; quality of health care; traumatic brain injury.

Introduction

There is substantial New Zealand and international evidencepointing to the large public health burden associated with trau-matic brain injury (TBI).1–6 While 90% of all TBI among chil-dren is estimated to be at the mild end of the severity spectrum,2

there are significant gaps in knowledge about the clinical man-agement and outcomes of children with mild TBI (MTBI).1

The level of unmet healthcare need among these children andtheir families is suspected to be high in New Zealand andelsewhere.1,2,4,7

It is widely acknowledged that assessing for and identifyingMTBI is an important component of delivering quality health-care for patients presenting with an acquired head injury.8–15

Accurate estimations of the burden and impact of these injuriesare required to plan and fund appropriate prevention effortsand community-based services for people with MTBI.8,15,16

From a clinical perspective, accurate diagnosis of MTBI assists

Correspondence: Dr Bridget Kool, Section of Epidemiology and Biostatis-tics, School of Population Health, The University of Auckland, Private Bag92019, Auckland 1142, New Zealand. Fax: +64 9 373 503; email:[email protected]

Accepted for publication 29 November 2010.

What is already known on this topic

1 The majority of all traumatic brain injury (TBI) among children isat the mild end of the severity spectrum.

2 There is a growing body of evidence pointing to longer-termadverse outcomes following mild TBI (MTBI).

3 In the acute care setting, accurate diagnosis and appropriatemanagement of MTBI are important components of high-qualityhealthcare for children presenting following an acquired headinjury.

What this paper adds

1 In this study, the investigation of head-injured children to ruleout acute complications was consistent with best practice stan-dards.

2 A significant proportion of children with mild traumatic braininjury (MTBI) were not specifically identified or provided withadvice regarding follow-up after discharge from the emergencydepartment.

3 Quality improvement efforts in the emergency departmentsetting should focus on ensuring the appropriate documenta-tion, identification and follow-up of children with MTBI.

doi:10.1111/j.1440-1754.2011.02068.x

Journal of Paediatrics and Child Health 48 (2012) 170–176© 2011 The Authors

Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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appropriate management and the targeting of information,advice and referrals for follow-up.8,15 Children with multipleTBIs are likely to have particular requirements with regard toneuropsychological needs and prevention advice.1,2,17 Accuratedocumentation of clinical details and diagnosis of a TBI is animportant prerequisite for the delivery of appropriate care byother health professionals (e.g. primary care practitioners orrehabilitation specialists) who may be required to provide ser-vices beyond the acute care setting.8

Despite these imperatives, concerns have been raised withinNew Zealand that children with MTBI are ‘slipping through thecracks’ in the current health service, and it has been recom-mended that this subject warrants further, targeted researchefforts.1,18 Hospital emergency departments (EDs) are an impor-tant yet often overlooked point of clinical contact where defi-ciencies in quality of healthcare could be addressed.19

The clinical audit model provides a systematic approach toinvestigating issues related to quality of healthcare and whetherbest practice is being translated into everyday clinicalpractice.20–23 In such evaluations, observed or recorded practicesare typically compared with standards of care representingevidence-based best practice.

The aim of this study was to determine the extent to which themanagement of children discharged home following an EDassessment for a head injury aligned with current TBI guidelines.

Methods

The audit comprised a retrospective review of clinical records ofpatients aged <15 years who were discharged from a large met-ropolitan paediatric hospital ED (with approximately 32 000attendances per year) following an assessment for a head injurybetween 1st January 2007 and 31st December 2007. The eligiblestudy population comprised patients whose International Clas-sification of Diseases (ICD)-10 coded discharge summaries indi-cated a primary or secondary diagnosis of a head injury (S099)or head injury with concussion (S0600). It was necessary toinclude diagnosis code S099 rather than code S0600 only, asmedical staff use either one of these codes when assigningdischarge diagnoses in cases of TBI. If a child was seen morethan once during 2007 with the same discharge code, only thefirst assessment was included in the sampling frame as the auditfocused on the management of acute injury events rather thanre-presentations following an initial injury assessment.All injuries meeting these criteria were included, regardless ofwhether the cause of injury was deemed to be intentional,unintentional or of uncertain intent. Sociodemographic charac-teristics for sample selection (including ethnicity) were based onthe ED administrative database.

Using a stratified purposeful sampling strategy, 15 patientswere selected from each of the major ethnic groups in NewZealand: New Zealand European, Maori, Pacific and Asian.Five children from each age group (0–4 years, 5–9 years and10–14 years) were selected using computer-generated randomnumbers. The aim of the sampling strategy was to select a rangeof cases, covering the major ethnic groups and age rangeincluded in the study population in order to gain insightsregarding the quality of healthcare delivered to children withMTBI. However, this study was not designed to select a repre-

sentative sample with sufficient statistical power to makeempirical generalisations to the population of injured children.We also excluded those children whose ethnicity was coded as‘other’ – a highly heterogeneous group comprising 8.3% ofinjury assessments at this hospital ED.

A comprehensive data collection proforma was developed forthe study. The lead author inspected the electronic records ofthe 60 selected patients and abstracted information relating todemographic characteristics, injury details, clinical assessmentand investigations performed, criteria for discharge, advicegiven and follow-up provisions.

The specific standards of practice examined included the col-lection of appropriate data for determining the diagnosis of TBIand deciding whether a computed tomography (CT) scan wasindicated, the application of criteria for safe discharge, the pro-vision of appropriate information and advice about TBI, and thedescription of current follow-up practices. For the purposes ofthis study, two guidelines served as resources for establishingbest practice standards. They were the New Zealand guidelineTraumatic Brain Injury: Diagnosis, Acute Management and Rehabili-tation1 and the in-house hospital guideline Management of Paedi-atric Head Injury.24

The criteria implicit in the World Health Organisation (WHO)TBI Task Force operational definition (Table 1) was used toascertain the likelihood of a TBI for each case. It is acknowl-edged, however, that distinguishing individuals who have sus-tained a brain injury from among those who have sustained ahead injury is problematic for many reasons including theabsence of a ‘gold standard’ diagnostic test.1

Descriptive analyses of the data were undertaken usingMicrosoft Office Excel. Ethics approval for the study was grantedby the Northern Regional Ethics Committee and AucklandDistrict Health Board.

Results

The main demographic and injury characteristics of the childrenincluded in the study are outlined in Table 2. Documentation of

Table 1 Definition of MTBI7

WHO TBI task force operational definition of MTBI

One or more of the following:

• Confusion or disorientation

• LOC </= 30 min

• PTA <24 h

• Transient neurological abnormalities such as focal signs, seizure, and

intracranial lesion

And:

• GCS 13–15

• Manifestations of TBI are not due to drugs, alcohol, or medications,

are not caused by other injuries or treatment for other injuries, and

are not caused by other problems (e.g. psychological trauma,

language barrier, or coexisting medical conditions) or penetrating

craniocerebral injury.

WHO, World Health Organisation; MTBI, mild traumatic brain injury; LOC, loss

of consciousness; PTA, post-traumatic amnesia; GCS, Glasgow Coma Scale.

S Sharpe et al. Mild traumatic brain injury

Journal of Paediatrics and Child Health 48 (2012) 170–176© 2011 The AuthorsJournal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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most data elements required for making decisions aboutwhether a CT scan is indicated was performed to a high standardconsistent with best practice among children aged <5 years,5–9 years, and 10–14 years (Figs 1–3, respectively).

However, documentation deficiencies were evident withregard to criteria that could identify children with a TBI. Recordsof children aged 0–4 years had predictably low levels of docu-mentation of criteria that are difficult to assess in preschool-agedchildren, such as confusion/disorientation, post-traumaticamnesia (PTA) and headache. Records of older children also hadlow levels of documentation of PTA. Most importantly, it wasnot clear that the information documented was applied to dis-tinguish children with and without a TBI. While 30 of the 60cases fulfilled the WHO criteria for definite or possible TBI basedon information extracted from their clinical records, half werecoded as S099 (unspecified injury of head) and half as S0600(head injury, concussion).

Regarding practices for safe discharge, all patients in the studyhad a Glasgow Coma Scale (GCS) score of 15 prior to discharge,with intracranial abnormality ruled out in those who had a CTscan performed (n = 9). The majority of records reviewed (48 of60) did not specifically document that support structures (suchas access to phone and transport, appropriate supervision of thechild after discharge) were adequate for safe discharge.

The administration of appropriate information and adviceabout TBI is an important best practice criterion for childrenwith MTBI. Current practice compared favourably with thestandard, assisted by the availability and provision of hospitalhead injury advice sheets. However, it was not clear from therecords if cultural support and language needs were considered,with the exception of one case where the use of an interpreterwas documented. Similarly, only four records documented theconsideration of injury prevention issues. While the possi-bility of an intentional injury is important to consider in thecontext of head injuries in young children, only eight of the 20records of patients aged less than 5 years documented that thispossibility was considered.

Consistent with best practice, all patients seen in the ED hada discharge summary letter emailed to their general practitioner(GP). Specific referral to a GP was documented in 14 of 60 cases,including two of the nine children who had CT scans. However,the head injury advice sheet provided to the majority ofpatients/families included the general guidance to seek medicalattention if the child developed signs of complications (listed onthe sheet).

Ten of the 14 GP referrals were among the patients thatfulfilled the criteria for definite or possible MTBI in this audit(Table 2). Specific follow-up plans were not documented in thenotes of the remaining 20 patients with definite or possibleMTBI.

Discussion

In this study of children with MTBI assessed at a busy ED in atertiary paediatric hospital, clinical documentation of manage-ment was consistent with best practice standards for manyaspects of the care. This was particularly apparent with regard tothe criteria employed to determine the need for CT scanning.However, the documented information in clinical records

Table 2 Demographic and injury characteristics documented in a clini-

cal audit of 60 cases of head injured children

Variable Patient

records (n)

Patients with definite or

possible MTBI* (n)

Age

0–4 years 20 6

5–10 years 20 12

11–14 years 20 12

Sex

Male 37 (62%) 21

Ethnicity†

NZ European 14 8

Maori 13 4

Pacific Peoples 14 6

Asian 16 9

Not recorded 3 3

Length of stay (h : min)

Average 3:19

Range 0:23–12:33

Mechanism of injury

Falls 40 17

Struck by or striking against

an object

13 7

Motor vehicle-related injury 3 3

Bicycle injury not involving

a motor vehicle

3 2

Not known 1 1

GCS on presentation to ED

GCS 15 58 29

GCS 14 1 1

GCS not recorded 1 0

Documentation of past

history of head injury

Positive past history of

head injury

3 2

Negative past history of

head injury

3 0

No information 54 28

CT performed during the ED

assessment

9 9

Formal follow-up plan

documented in notes

14 10

*The likelihood of MTBI was ascertained by using the WHO MTBI defini-

tion outlined in Table 1. †The actual numbers of patients in the ethnicity

groups differed from those in the sampling frame due to discrepancies

between the ethnicities listed in the ED information system (from which

the population was determined) and the clinical records. In three cases

patients were placed in a different ethnicity group to the one from which

they were sampled. Three further patients did not have ethnicity

recorded anywhere in the electronic record.

MTBI, mild traumatic brain injury; NZ, New Zealand; GCS, Glasgow Coma

Scale; CT, computed tomography; ED, emergency department; WHO,

World Health Oraganisation.

Mild traumatic brain injury S Sharpe et al.



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revealed gaps in the explicit identification of children with defi-nite or possible MTBI and consistent approaches to post-discharge follow-up that could mitigate the risks of longer-termdisability.

Several limitations must be considered when interpreting thestudy findings. The study sample was not intended to be repre-sentative or large enough to obtain generalisable population-based estimates. Rather, we obtained a sample representing abroad cross-section of the major age and ethnic groups assessedat a large urban paediatric hospital ED. The recruitment strategyfocused on patients with a principal discharge diagnosis of ahead injury. It is possible that mild head injuries, even TBIs, maybe missed in children whose main diagnosis was consideredanother injury.

It is also acknowledged that a lack of documentation in clini-cal records does not necessarily imply some standards of carewere not met. For example, criteria for safe discharge, preven-tion advice and consideration of cultural and language needsmay be addressed but poorly documented, an issue that cannotbe resolved in a retrospective review.

Our findings regarding inconsistent documentation andcoding of the diagnosis of MTBI are similar to research under-taken elsewhere. A study investigating the accuracy of diagnosisof MTBI among 197 adults seen in the EDs of two hospitals inSeattle compared prospectively identified ED patients withMTBI with the ICD-9 diagnostic codes assigned in their clinical

records (reviewed retrospectively).8 In the prospective part ofthe study, patients were required to have GCS scores of 13 orhigher at or prior to ED evaluation, and were diagnosed withMTBI based on criteria outlined by the Centers for DiseaseControl and Prevention (CDC),25 which are consistent with theWHO definition.7 Of the cases identified in the ED as meetingthe CDC criteria for MTBI, 56% did not have a documenteddiagnosis in the medical record indicative of MTBI. The authorsacknowledged that this may be an underestimate as the pres-ence of study personnel in the ED may have led to more diag-noses of TBI than usual. While most records had informationregarding loss of consciousness, 60% of medical records had nodocumentation about amnesia and 70% of medical records con-tained no information about confusion/disorientation

Pressures relating to time and many other factors imposingstresses on ED staff can compromise the quality of documenta-tion in terms of both content and legibility. While inadequatedocumentation is not uncommon with respect to head injurypatients seen in EDs,8,19,26,27 one study found that introducing acustomised proforma improved the quality of documentation.27

Many factors could also explain the apparent low probabilityof identifying patients with TBI in the ED setting. The diagnosisof MTBI can be difficult to make due to the absence of a ‘goldstandard’ test, variable criteria employed, limitations of theGCS score for assessing severity and the difficulties assessingsome diagnostic criteria (e.g. PTA) in young children.1,15 The

Fig. 1 Documentation of Data Elements Relevant to MTBI: 0–4 years (n = 20). *Indicates data elements that are useful in the assessment of an adult patient,

but which are difficult or impossible to assess in young children. †Nine patients had been discharged by 2 h. With a denominator of 11, the percentage of

patient records documenting this data element was 91% (i.e. 10 of the 11 patients).



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commonly used terms, such as minor head injury and concus-sion, add to the confusion. Inadequate awareness of disablinglonger-term consequences of MTBI among both health profes-sionals and the public15,19 is also likely to be important.

A key priority of ED management of head injury is the detec-tion of significant acute complications.1,24 Consequently, clinicaldecision-making in this setting is largely focussed on determin-ing which patients require CT scans. Once moderate to severebrain injury is ruled out and a child is deemed fit for discharge,identifying and enabling the management of MTBI followingdischarge may be overlooked.8 This is compounded by a lackof agreement regarding the indications for follow-up afterMTBI.1,19,28,29

The methodological issues that plague research about MTBIoutcomes (including the lack of an agreed definition for MTBI)have contributed to controversy about the probability ofongoing adverse effects.30 However, there is a growing body ofevidence pointing to adverse outcomes following MTBI,31–40 par-ticularly in studies with a follow-up duration greater than5 years.30

Until further evidence is available regarding more refinedcriteria for follow-up, it seems prudent for EDs to take a pre-cautionary approach when managing children with MTBI. For asignificant proportion of children with MTBI, an episode of carein the ED for their acute injury is the only time they havecontact with a healthcare provider regarding this injury, makingthe appropriate identification and management of these chil-

dren in this setting particularly salient.15 A systematic approachto identifying children with MTBI (in all settings) is also impor-tant for robust epidemiological studies of the occurrence, out-comes and inequalities related to MTBI.8,16

While this study was not designed to identify ethnic-specificdifferences in access, quality of care or outcomes, a recent inter-national report on indigenous children’s health, which includeddata on Maori children, suggests that such disparities are likelyto exist.41 A New Zealand qualitative study examining expecta-tions, preferences and experiences of Maori consumers of healthand disability services identified some dissatisfaction with thehealthcare they and the Maori community in general received.42

US data indicates rates of hospital admission and ED visits forhead injuries are highest among children in lower socioeco-nomic groups.43 Several studies have described ethnic disparitiesin TBI care processes.44,45 Priorities for future research shouldinclude exploring inequities (e.g. by ethnicity, socio-economicstatus and area of residence) in the quality of TBI care as well asinvestigating interventions with the potential to reduce dispari-ties in quality of care and hence reduce disparities in TBIoutcomes.

One approach to improving the diagnosis and managementof MTBI is the use of computerised decision support systems(CDSS). By matching characteristics of individual patients tosoftware algorithms, these information systems generatepatient-specific recommendations that assist clinical decision-making. CDSSs have been shown to have benefits in terms of

Fig. 2 Documentation of Data Elements Relevant to MTBI: 5–9 years (n = 20). *Two patients had been discharged by 2 h. With a denominator of 18 (rather

than 20), the percentage of patient records documenting this data element was 67%.




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increased adherence to guidelines and enhanced surveillanceand monitoring.46,47 CDSSs can facilitate knowledge transfer andretention while not being completely reliant on knowledgeretention. This is of relevance to children assessed for MTBI as alarge number are assessed by doctors in various stages of train-ing or with limited paediatric experience. Decision rules arecurrently utilised in the acute management of TBI, particularlyin deciding ‘when to CT’.48 This presents an ideal opportunity toextend currently adopted CDSS to incorporate elements thatwould improve the diagnosis and ongoing management ofMTBI.

Acknowledgements

This study was partially funded by a performance based researchfund grant allocated by the School of Population Health, Uni-versity of Auckland, New Zealand. Sarah Sharpe receivedfunding from the New Zealand Population Health CharitableTrust, which provides the Public Health Medicine Training Pro-gramme in New Zealand.

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