title: Implementing evidence-based recommended practices for the management of patients with mild traumatic brain injuries in Australian emergency care departments: study protocol for a cluster randomised controlled trial.
abstract: BACKGROUND
  Mild head injuries commonly present to emergency departments. The challenges facing clinicians in emergency departments include identifying which patients have traumatic brain injury, and which patients can safely be sent home. Traumatic brain injuries may exist with subtle symptoms or signs, but can still lead to adverse outcomes. Despite the existence of several high quality clinical practice guidelines, internationally and in Australia, research shows inconsistent implementation of these recommendations. The aim of this trial is to test the effectiveness of a targeted, theory- and evidence-informed implementation intervention to increase the uptake of three key clinical recommendations regarding the emergency department management of adult patients (18 years of age or older) who present following mild head injuries (concussion), compared with passive dissemination of these recommendations. The primary objective is to establish whether the intervention is effective in increasing the percentage of patients for which appropriate post-traumatic amnesia screening is performed.
  
  
  METHODS
  The design of this study is a cluster randomised trial. We aim to include 34 Australian 24-hour emergency departments, which will be randomised to an intervention or control group. Control group departments will receive a copy of the most recent Australian evidence-based clinical practice guideline on the acute management of patients with mild head injuries. The intervention group will receive an implementation intervention based on an analysis of influencing factors, which include local stakeholder meetings, identification of nursing and medical opinion leaders in each site, a train-the-trainer day and standardised education and interactive workshops delivered by the opinion leaders during a 3 month period of time. Clinical practice outcomes will be collected retrospectively from medical records by independent chart auditors over the 2 month period following intervention delivery (patient level outcomes). In consenting hospitals, eligible patients will be recruited for a follow-up telephone interview conducted by trained researchers. A cost-effectiveness analysis and process evaluation using mixed-methods will be conducted. Sample size calculations are based on including 30 patients on average per department. Outcome assessors will be blinded to group allocation.
  
  
  BACKGROUND
  Australian New Zealand Clinical Trials Registry ACTRN12612001286831 (date registered 12 December 2012).
authors.affiliation: Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia. marije.bosch@monash.edu.
authors.forename: Marije
authors.initials: M
authors.lastname: Bosch
authors.forename: Joanne E
authors.initials: JE
authors.lastname: McKenzie
authors.forename: Duncan
authors.initials: D
authors.lastname: Mortimer
authors.forename: Emma J
authors.initials: EJ
authors.lastname: Tavender
authors.forename: Jill J
authors.initials: JJ
authors.lastname: Francis
authors.forename: Sue E
authors.initials: SE
authors.lastname: Brennan
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Knott
authors.forename: Jennie L
authors.initials: JL
authors.lastname: Ponsford
authors.forename: Andrew
authors.initials: A
authors.lastname: Pearce
authors.forename: Denise A
authors.initials: DA
authors.lastname: O'Connor
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Grimshaw
authors.forename: Jeffrey V
authors.initials: JV
authors.lastname: Rosenfeld
authors.forename: Russell L
authors.initials: RL
authors.lastname: Gruen
authors.forename: Sally E
authors.initials: SE
authors.lastname: Green
mesh_terms: D001315:Australia; D001930:Brain Injuries / Q000150:complications / Q000175:diagnosis / Q000191:economics / Q000628:therapy*; D002985:Clinical Protocols; D003362:Cost-Benefit Analysis; D004502:Education, Medical, Continuing; D004632:Emergency Medical Services / Q000191:economics / Q000592:standards; D019317:Evidence-Based Medicine / Q000191:economics / Q000193:education / Q000592:standards; D019983:Guideline Adherence; D017721:Hospital Costs; D006801:Humans; D015601:Injury Severity Score; D007318:Inservice Training; D010348:Patient Care Team; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D012107:Research Design; D018401:Sample Size; D013997:Time Factors; D016896:Treatment Outcome