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Using a Decision Aid in the Emergency Room to Help Parents of Children with Head Trauma Understand Options for Diagnosing Brain Injury

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Results Summary and Professional Abstract

Results Summary
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Results Summary

What was the research about?

When a child has head trauma, parents in the emergency room (ER) need to decide, with their doctor, how to check if the child has a traumatic brain injury (TBI). A TBI occurs when an injury causes bleeding in or around the brain. One way to check for a TBI is a computed tomography (CT) scan, which takes pictures of the brain. Another way is home monitoring, where parents wait and see if their child develops TBI symptoms.

For children at low risk of TBI, doctors recommend home monitoring. For children at high risk, doctors recommend a CT scan. However, for a child at medium risk, deciding which way to check for a TBI can be hard. A CT scan shows quickly if a child has a TBI, but it exposes the child to radiation, may require a long wait in the ER, and may cost more than home monitoring. Home monitoring takes longer to see if a child has a TBI, and parents may have to come back to the ER if their child’s symptoms get worse.

The research team created a decision aid to help doctors talk with parents about whether their children should get CT scans or have home monitoring. A decision aid can help parents choose between two or more healthcare options based on what is most important to them. The team wanted to know if the decision aid helped parents learn and make decisions about care for their child.

What were the results?

Compared with parents whose doctors didn’t use the decision aid, parents whose doctors did use it

  • Knew more about ways of checking for a TBI and their children’s risks
  • Felt less conflict about the decision
  • Trusted their doctors more
  • Thought the information they discussed with doctors was clearer
  • Were happier with their decisions
  • Participated more in the decision-making process
  • Went back to the hospital for tests less often

The team found no difference between parents in the two groups in

  • How happy parents were with the information discussed in the ER
  • The number of children who got CT scans
  • The number of other visits to the hospital or ER

Only one child in the study had a TBI. The child was in the group whose doctor didn’t use the decision aid.

Who was in the study?

The study included 172 doctors of 971 children. The children went to one of seven ERs in Massachusetts, Minnesota, or Ohio. The children had head trauma, and doctors thought they had a medium risk of TBI based on symptoms. About 74 percent of children were white, 12 percent were African American, and 16 percent were other races. The children’s average age was seven.

What did the research team do?

Researchers, parents, doctors, a graphic designer, and a radiation specialist helped the research team create the decision aid. A parent whose child had been to the ER for head trauma previously was also part of the team. The decision aid was a paper handout that helped parents understand different types of brain injuries, know their child’s risk for TBI, and know the benefits and risks of home monitoring and CT scans.

The research team assigned doctors by chance to one of two groups. Doctors in the first group used the decision aid during their ER visits with the parents and children; doctors in the second group did not. Parents in both groups took a survey about themselves right before their doctor visit. After the ER visit, parents took a survey about TBI, their experiences in the ER, and deciding on a treatment plan.

The research team looked at medical records to see how many children got CT scans during the ER visit. They also looked at how many times parents took their children to the hospital or ER after the first visit and how many of the children who did not get a CT scan came back to the ER with a TBI. The team videotaped the doctor visits to see how much parents participated in the decision-making process.

What were the limits of the study?

Doctors who used the decision aid worked in the same hospitals as doctors who didn’t. Doctors in the two groups may have talked, and these conversations could have changed how doctors who didn’t have the decision aid talked to parents.

Future research could look at how best to use the decision aid in the ER, where doctor visits are often short.

How can people use the results?

Doctors and parents can use the decision aid in the ER to help decide how to check for a TBI.

Professional Abstract

Professional Abstract

Objective

To determine whether a decision aid for clinicians to use in the emergency department (ED) with parents of children with head trauma increases parents’ knowledge of their children’s risk for clinically important traumatic brain injury (ciTBI) and diagnostic options

Study Design

Design Element Description
Design Randomized controlled trial
Population 971 parents of children with head trauma at moderate risk of ciTBI
Interventions/
Comparators
  • Clinician use of decision aid in addition to standard ED care for ciTBI
  • Standard ED care for ciTBI (usual care)
Outcomes

Primary: parents’ knowledge of their children’s risk of ciTBI and available diagnostic options

Secondary: parents’ decisional conflicts, engagement in the decision-making process, trust in physicians; satisfaction with amount, clarity, and helpfulness of information discussed with clinicians; number of children who had computed tomography (CT) diagnostics, healthcare use within the seven days following ED visit, number of children who had a ciTBI
Timeframe Immediately post-ED visit for primary outcome

When children with head trauma are at moderate risk of ciTBI, it is not always clear if they need further testing or if a watch and wait approach is best. The research team conducted a randomized controlled trial to test the effectiveness of a decision aid designed to help parents of children with head trauma at moderate risk for ciTBI learn about this condition and decide between two diagnostic options: CT scan of the head or active observation at home.

Clinicians, researchers, parents, a graphic designer, and a radiation physicist helped create the decision aid and select study outcomes. A parent advocate served as co-investigator and member of the research steering committee. The decision aid was a paper handout that helped parents understand different types of brain injuries, their child’s risk for ciTBI, and the advantages and disadvantages of the two diagnostic options in light of their own preferences.

The study included 172 clinicians serving 971 parents of children with head trauma who were at moderate risk for ciTBI and who visited one of seven EDs in Massachusetts, Minnesota, or Ohio. The research team randomly assigned the clinicians to one of two groups: an intervention group, in which clinicians used the decision aid with parents, and a control group that did not use the decision aid. About 74% of children were white, 12% were African American, and 16% were other races. The children’s average age was seven.

Parents in both groups took a survey before the clinician visit about their demographics and other personal characteristics. Immediately after the visit, parents took a survey about their knowledge of their children’s risk of ciTBI and available diagnostic options, decisional conflicts they experienced, trust in their clinicians, and satisfaction with the information discussed during the visit.

The research team collected additional information seven days after the ED visit via phone follow-up and hospital billing records. Data collected included numbers of children who had CT scans, additional visits to the hospital or ED, and children who did not get a CT scan who returned to the ED with ciTBI. The research team also reviewed video recordings of the clinician-and-parent visits to assess parents’ engagement in the decision-making process.

Results

Compared with parents in the control group, parents in the intervention group had statistically significantly (p <0.05)

  • Greater knowledge of their children’s risks of ciTBI and of diagnostic options
  • Less decisional conflict
  • Greater trust in their physicians
  • Better ratings of information clarity
  • Greater satisfaction with their diagnostic choices
  • More engagement in the decision-making process
  • Lower healthcare use for imaging and blood tests within seven days of the ED visit

The team found no statistically significant difference between intervention and control groups in

  • Satisfaction with the amount or helpfulness of the information they discussed with clinicians
  • Number of CT scans performed
  • Number of additional visits to the hospital or ED

One child in the control group and none in the intervention group had a ciTBI.

Limitations

Clinicians in the intervention group may have discussed the decision aid with clinicians in the control group who worked in the same hospital, introducing bias.

Conclusions and Relevance

This study demonstrated that the decision aid can help facilitate shared decision-making for parents of children who have experienced head trauma and are at moderate risk of ciTBI, regarding their children’s treatment.

Future Research Needs

Future research could investigate how best to embed routine use of the decision aid in emergency care, in particular addressing the short time available during ED visits.

Final Research Report

View this project's final research report.

Journal Articles

Article Highlight: Head CT scans may detect evidence of brain injury in children after minor head trauma, but they also expose children to radiation. In a JAMA Network Open article, this study reported that a decision aid used in emergency departments helped parents make better-informed decisions about whether their children would receive CT scans. Parents who used the aid had a better understanding of the symptoms of concussion, their child’s relative risk of brain injury, and the pros and cons of head CT scans.

Results of This Project

JAMA Network Open

Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma A Cluster Randomized Trial

Related Articles

Trials

Effectiveness of the head CT choice decision aid in parents of children with minor head trauma: study protocol for a multicenter randomized trial

More on this Project  

Videos

Helping Parents Understand Head Trauma Care Options in the ER
PCORI-funded researcher Erik Hess talks about his project that tested the use of a decision aid to help emergency department doctors and parents of children with head trauma discuss care options, including whether or not to obtain a head CT scan.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also confirms that the research has followed PCORI’s Methodology Standards. During peer review, experts who were not members of the research team read a draft report of the research. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. Reviewers do not have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve how the research team analyzed its results or reported its conclusions. Learn more about PCORI’s peer-review process here.

In response to peer review, Hess made changes including

  • Adding results on the trust-in-physician scale to the abstract
  • Noting clearly in the abstract that the decision aid used in the study safely improved care with less utilization of hospital resources
  • Clarifying the clinical relevance of avoiding unnecessary CT scans and the need to engage parents in decisions regarding cranial CT scanning for children who have experienced a head injury

Conflict of Interest Disclosures

View the COI disclosure form.

Project Details

Principal Investigator
Erik Hess, MD, MS
Project Status
Completed; PCORI Public and Professional Abstracts, and Final Research Report Posted
Project Title
Shared Decision Making in Parents of Children with Head Trauma: Head CT Choice
Board Approval Date
May 2013
Project End Date
December 2017
Organization
Mayo Clinic
Year Awarded
2013
State
Minnesota
Year Completed
2018
Project Type
Research Project
Health Conditions  
Trauma/Injuries
Head Injury
Intervention Strategies
Other Health Services Interventions
Shared Decision Making
Training and Education Interventions
Populations
Racial/Ethnic Minorities
Low Health Literacy/Numeracy
Rural
Children -- 18 and under
Urban
Funding Announcement
Assessment of Prevention, Diagnosis, and Treatment Options
Project Budget
$1,824,598
DOI - Digital Object Identifier
10.25302/11.2018.CE.12114435
Study Registration Information
HSRP20143213
NCT02063087
Page Last Updated: 
February 20, 2020