Severe traumatic brain injury (sTBI) is a leading cause of death and disability. Previous work by our group and others demonstrates that guideline based care improves outcomes for children with sTBI. Despite evidence from multiple reports that guideline based care improves outcomes, the current limited implementation and compromised fidelity of sTBI guidelines, particularly in pediatric patients, results in large variability in care and outcomes. sTBI guideline implementation is highly complex, requiring multi-level team-based, time-sensitive responses to patients with rapidly changing clinical conditions and life-altering outcomes. Many experts therefore call for technology based implementation strategies, which are particularly relevant to the Intensive Care Unit (ICU) environment as they can mitigate information overload and facilitate effective organization of workflow. We propose to develop a technology based bedside decision support tool (implementation strategy), called the ?Bedside Guideline Engine? (BGE), that facilitates efficient integration and real-time provision of guideline based care for sTBI in pediatric patients. The BGE will comprise: (1) a clinical care pathway reflecting sTBI guidelines developed by the Brain Trauma Foundation (BTF) for hospital management of children with sTBI; and (2) a bedside PC displaying the pathway along with patient physiologic data and provider input (CNS Monitor). The CNS Monitor allows for graphic display of the patient's clinical course and response to therapy. It also links patient data to the guideline based pathway, thereby reducing need to search for guideline information normally printed or stored in a digital archive or the Electronic Health Record. These two components of the BGE facilitate more timely, patient-appropriate, consistent and sustained application of pediatric sTBI guideline based care. We propose two specific aims in this developmental work:
Aim 1 (Year 1): Develop and assess the acceptability of a technology-driven implementation strategy (BGE) that addresses the ICU environment and culture and facilitates the uptake of evidence-based guidelines for management of sTBI in pediatric patients. We will capture ICU environment contingencies using interviews, ethnographic observation, and group model building. With technology partners we will develop a computer-readable, BTF guideline-congruent clinical pathway designed to fit the ICU workflow. The pathway will be deployed in a PC at the bedside and directly linked to high resolution patient data from the CNS Monitor, constituting the BGE. The BGE will be designed to automatically recommend a course of action based on patient context and guideline content. It will also provide bedside logging capabilities for auditing (i.e. fidelity to the BTF guidelines and timeliness of therapy). We will use standardized acceptance questionnaires, qualitative input from providers, and evaluation of adoption potential measures for initial adaptation of the BGE. The goal is to optimize design and functionality of the BGE prior to deploying it in an ICU simulation environment and in real world ICU practice.
Aim 2 (Years 1-2): To adapt the BGE to the ICU environment using patient simulation and evaluate the feasibility of incorporating the adapted BGE into real world practice in the ICU. Feasibility testing will yield real world practice identification of site-specific barriers and facilitators to scalable and sustained use of the BGE. The BGE's bedside functionality will be introduced to lead clinicians from three participating ICU's using patient simulation at the Saigh Pediatric Simulation Center, St. Louis. We will reapply standardized acceptance questionnaires and will also capture qualitative input from users using a think-aloud cognitive interviewing strategy to obtain in-vivo thoughts and reactions in the simulation environment. The resulting environmental, ergonomic, and medical workflow information will assist final configuration of the BGE prior to roll out for bedside feasibility testing in real world ICU practice. The BGE will then be deployed to the bedside at the participating ICU's. We will test the BGE's functionality to capture guideline uptake, timeliness of therapy, and team workflow in the participating Intensive Care Units (ICUs). We will also evaluate the BGE's practicality, integration, and expansion. Information will be obtained through semi-structured interviews of clinicians and hospital administrators. !
Severe traumatic brain injury (TBI) is a leading cause of death and disability in children. Evidence based care improves outcomes but has not been effectively applied in real world practice. This proposal will support the development and evaluation of an innovative implementation strategy (a technology based guideline engine) to facilitate timely delivery of evidence based care for children with severe TBI.
