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.
