Ways to improve guideline adherence in the emergency department: an interview study on the management of traumatic brain injuries.

PURPOSE: The aim was to explore factors affecting guideline adherence among doctors in the emergency department and to explore the general perception about local guidelines for traumatic brain injuries. METHODS: Thirty semi-structured interviews were conducted with doctors with experience working in the emergency department regarding different aspects of guideline use, with emphasis on the management of traumatic brain injuries. Twenty-eight interviews were included for analysis. The interviews were recorded, transcribed, and analysed iteratively. Emergent codes were identified and organised into themes and subthemes. RESULTS: Eight themes were identified. Barriers were centred on low availability of local guidelines and guideline document design. Facilitating factors included a concise document, appropriate visual aids, high accessibility, and encouragement by management and senior peers. The local guidelines on traumatic brain injuries were regarded as distinct, but it was occasionally difficult to determine when they were applicable. Mandatory admission of patients on anticoagulants was sometimes perceived as excessive. Biomarker S100b was believed to sometimes lead to delayed care. CONCLUSION: The participants believed that guideline adherence would increase by facilitating guideline availability, by providing concise, easy-to-understand, and well-illustrated guidelines available in printed form, as well as establishing a culture that promotes guideline use. The local guidelines for traumatic brain injuries were appreciated, but could be improved.

Comparison of the predictive value of two international guidelines for safe discharge of patients with mild traumatic brain injuries and associated intracranial pathology.

PURPOSE: To determine and compare the sensitivity, specificity, and proportion of patients eligible for discharge by the Brain Injury Guidelines and the Mild TBI Risk Score in patients with mild traumatic brain injury and concomitant intracranial injury. METHODS: Retrospective review of the medical records of adult patients with traumatic intracranial injuries and an initial Glasgow Coma Scale score of 14-15, who sought care at Helsingborg Hospital between 2014/01/01 and 2019/12/31. Both guidelines were theoretically applied. The sensitivity, specificity, and percentage of the cohort that theoretically could have been discharged by either guideline were calculated. The outcome was defined as death, in-hospital intervention, admission to the intensive care unit, requiring emergency intubation due to intracranial injury, decreased consciousness, or seizure within 30 days of presentation. RESULTS: Of the 538 patients included, 8 (1.5%) and 10 (1.9%) were eligible for discharge according to the Brain Injury Guidelines and the Mild TBI Risk Score, respectively. Both guidelines had a sensitivity of 100%. The Brain Injury Guidelines had a specificity of 2.3% and the Mild TBI Risk Score had a specificity of 2.9%. CONCLUSION: There was no difference between the two guidelines in sensitivity, specificity, or proportion of the cohort eligible for discharge. Specificity and proportion of cohort eligible for discharge were lower than each guideline's original study. At present, neither guideline can be recommended for implementation in the current or similar settings.