Abstract
The PhD project aimed to explore the current evidence base on pathways of care following mild and moderate traumatic brain injury (TBI) internationally as well as in the Canterbury region in New Zealand. The thesis includes a scoping review, a retrospective cohort study and a mixed method study.
A scoping review was conducted to explore current clinical assessment and care for patients following a mild or moderate TBI. Searches in four databases-Medline, EMBASE, ISI Web of Science, and PsycINFO-were identified eligible studies between 2001-2023. After screening by two independent reviewers, 41 manuscripts were included. There was marked variability in how TBI was defined and classified, as well as variability in assessment and treatment protocols.
In a retrospective cohort study, the medical records of adult patients admitted with head trauma from Christchurch Hospital Emergency Department (ED) in 2021 were reviewed. There were 553 mild or moderate TBI cases, representing a rate of 103.4 per 100,000 adult population. Predictors of a documented TBI diagnosis included isolated head injury, a request for Head Computed Tomography (CT) and a place of injury. Seventy-seven patients (14%) were referred to a concussion service. Older age and non-isolated head injury were linked with decreased referral, while female and ED documentation of TBI resulted in increased referral.
In 2023, a new tool called Wayfind-TBI was introduced to improve the consistency of assessment and clinical pathways for people presenting to the ED with mild TBI. The tool includes assessments to determine the need for a CT scan, symptom burden and post-traumatic amnesia and recommendations where a referral to a concussion service may be required. A concurrent mixed-methods study included semi-structured interviews with ten clinicians and a clinical audit study of 53 medical records to evaluate implementation of the tool and to identify facilitators and barriers for referral to concussion services.
More than half of patients did not receive a symptom and post-traumatic amnesia assessment as recommended by clinical guidelines. Forty percent of patients did not go for a head CT when indicated, and 40% went for CT without indications. Fifteen percent had no documented indication for referral. Space limitations, insufficient access to devices, single-user access, manual data transfer, inability to save data and lack of integration into hospital records disrupted screening, workflow and uptake of the tool within the ED.
The diversity in definitions, classifications, ED observation practice, admission, discharge, and follow-up plans for TBI patients identified in the international scoping review and current practice within the Canterbury ED underlines the need for a standardized pathway of care. Whilst the Wayfind-TBI tool was found to be useful by many of the clinicians interviewed, some infrastructural modifications and support would facilitate uptake and improve completion of the tool.