Paediatrics (RCH) - Research Publications

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    Review article: A primer for clinical researchers in the emergency department: Part XII. Sustainability of improvements in care: An introduction
    Ramsden, V ; Middleton, S ; McInnes, E ; Babl, FE ; Tavender, E (WILEY, 2022-10)
    Despite an increased focus on ways to improve implementation of evidence and de-implementation of practices with no known benefit, there is limited guidance on how to sustain these improvements. This review provides an introduction to sustainability of improvements in care and sustainability research, discussing how to support sustainability in practice and detailing a sustainability research agenda for the emergency medicine setting.
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    Sustainability of evidence-based practices in the management of infants with bronchiolitis in hospital settings - a PREDICT study protocol.
    Ramsden, V ; Babl, FE ; Dalziel, SR ; Middleton, S ; Oakley, E ; Haskell, L ; Lithgow, A ; Orsini, F ; Schembri, R ; Wallace, A ; Wilson, CL ; McInnes, E ; Wilson, PH ; Tavender, E (Springer Science and Business Media LLC, 2022-08-29)
    BACKGROUND: Understanding how and why de-implementation of low-value practices is sustained remains unclear. The Paediatric Research in Emergency Departments International CollaboraTive (PREDICT) Bronchiolitis Knowledge Translation (KT) Study was a cluster randomised controlled trial conducted in 26 Australian and New Zealand hospitals (May-November 2017). Results showed targeted, theory-informed interventions (clinical leads, stakeholder meetings, train-the-trainer workshop, targeted educational package, audit/feedback) were effective at reducing use of five low-value practices for bronchiolitis (salbutamol, glucocorticoids, antibiotics, adrenaline and chest x-ray) by 14.1% in acute care settings. The primary aim of this study is to determine the sustainability (continued receipt of benefits) of these outcomes at intervention hospitals two-years after the removal of study supports. Secondary aims are to determine sustainability at one-year after removal of study support at intervention hospitals; improvements one-and-two years at control hospitals; and explore factors that influence sustainability at intervention hospitals and contribute to improvements at control hospitals. METHODS: A mixed-methods study design. The quantitative component is a retrospective medical record audit of bronchiolitis management within 24 hours of emergency department (ED) presentations at 26 Australian (n = 20) and New Zealand (n = 6) hospitals, which participated in the PREDICT Bronchiolitis KT Study. Data for a total of 1800 infants from intervention and control sites (up to 150 per site) will be collected to determine if improvements (i.e., no use of all five low-value practices) were sustained two- years (2019) post-trial (primary outcome; composite score); and a further 1800 infants from intervention and control sites will be collected to determine sustained improvements one- year (2018) post-trial (secondary outcome). An a priori definition of sustainability will be used. The qualitative component will consist of semi-structured interviews with three to five key emergency department and paediatric inpatient medical and nursing staff per site (total n = 78-130). Factors that may have contributed to sustaining outcomes and/or interventions will be explored and mapped to an established sustainability framework. DISCUSSION: This study will improve our understanding of the sustainability of evidence-based bronchiolitis management in infants. Results will also advance implementation science research by informing future de-implementation strategies to reduce low-value practices and sustain practice change in paediatric acute care. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.
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    Review article: Developing the Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children: An adoption/adaption approach
    Tavender, E ; Ballard, DW ; Wilson, A ; Borland, ML ; Oakley, E ; Cotterell, E ; Wilson, CL ; Ring, J ; Dalziel, SR ; Babl, FE (WILEY, 2021-04)
    The Paediatric Research in Emergency Departments International Collaborative (PREDICT) released the Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children in 2021. We describe innovative and practical methods used to develop this guideline. Informed by GRADE-ADOLOPMENT and ADAPTE frameworks, we adopted or adapted recommendations from multiple high-quality guidelines or developed de novo recommendations. A Guideline Steering Committee and a multidisciplinary Guideline Working Group of 25 key stakeholder representatives formulated the guideline scope and developed 33 clinical questions. We identified four relevant high-quality source guidelines; their recommendations were mapped to clinical questions. The choice of guideline recommendation, if more than one guideline addressed a question, was based on its appropriateness, currency of the literature, access to evidence, and relevance. Updated literature searches identified 440 new studies and key new evidence identified. The decision to develop adopted, adapted or de novo recommendations was based on the supporting evidence-base and its transferability to the local setting. The guideline underwent a 12-week consultation period. The final guideline consisted of 35 evidence-informed and 17 consensus-based recommendations and 19 practice points. An algorithm to inform imaging and observation decision-making was also developed. The resulting process was an efficient and rigorous way to develop a guideline based on existing high-quality guidelines from different settings.
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    Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children
    Babl, FE ; Tavender, E ; Ballard, DW ; Borland, ML ; Oakley, E ; Cotterell, E ; Halkidis, L ; Goergen, S ; Davis, GA ; Perry, D ; Anderson, V ; Barlow, KM ; Barnett, P ; Bennetts, S ; Bhamjee, R ; Cole, J ; Craven, J ; Haskell, L ; Lawton, B ; Lithgow, A ; Mullen, G ; O'Brien, S ; Paproth, M ; Wilson, CL ; Ring, J ; Wilson, A ; Leo, GSY ; Dalziel, SR (WILEY, 2021-04)
    OBJECTIVE: Children frequently present with head injuries to acute care settings. Although international paediatric clinical practice guidelines for head injuries exist, they do not address all considerations related to triage, imaging, observation versus admission, transfer, discharge and follow-up of mild to moderate head injuries relevant to the Australian and New Zealand context. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) set out to develop an evidence-based, locally applicable, practical clinical guideline for the care of children with mild to moderate head injuries presenting to acute care settings. METHODS: A multidisciplinary Guideline Working Group (GWG) developed 33 questions in three key areas - triage, imaging and discharge of children with mild to moderate head injuries presenting to acute care settings. We identified existing high-quality guidelines and from these guidelines recommendations were mapped to clinical questions. Updated literature searches were undertaken, and key new evidence identified. Recommendations were created through either adoption, adaptation or development of de novo recommendations. The guideline was revised after a period of public consultation. RESULTS: The GWG developed 71 recommendations (evidence-informed = 35, consensus-based = 17, practice points = 19), relevant to the Australian and New Zealand setting. The guideline is presented as three documents: (i) a detailed Full Guideline summarising the evidence underlying each recommendation; (ii) a Guideline Summary; and (iii) a clinical Algorithm: Imaging and Observation Decision-making for Children with Head Injuries. CONCLUSIONS: The PREDICT Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children provides high-level evidence and practical guidance for front line clinicians.
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    Process evaluation of a cluster randomised controlled trial to improve bronchiolitis management - a PREDICT mixed-methods study
    Haskell, L ; Tavender, EJ ; O'Brien, S ; Wilson, CL ; Babl, FE ; Borland, ML ; Schembri, R ; Orsini, F ; Cotterell, E ; Sheridan, N ; Oakley, E ; Dalziel, SR (BMC, 2021-11-29)
    BACKGROUND: Bronchiolitis is the most common reason for hospitalisation in infants. All international bronchiolitis guidelines recommend supportive care, yet considerable variation in practice continues with infants receiving non-evidence based therapies. We developed six targeted, theory-informed interventions; clinical leads, stakeholder meeting, train-the-trainer, education delivery, other educational materials, and audit and feedback. A cluster randomised controlled trial (cRCT) found the interventions to be effective in reducing use of five non-evidence based therapies in infants with bronchiolitis. This process evaluation paper aims to determine whether the interventions were implemented as planned (fidelity), explore end-users' perceptions of the interventions and evaluate cRCT outcome data with intervention fidelity data. METHODS: A pre-specified mixed-methods process evaluation was conducted alongside the cRCT, guided by frameworks for process evaluation of cRCTs and complex interventions. Quantitative data on the fidelity, dose and reach of interventions were collected from the 13 intervention hospitals during the study and analysed using descriptive statistics. Qualitative data identifying perception and acceptability of interventions were collected from 42 intervention hospital clinical leads on study completion and analysed using thematic analysis. RESULTS: The cRCT found targeted, theory-informed interventions improved bronchiolitis management by 14.1%. The process evaluation data found variability in how the intervention was delivered at the cluster and individual level. Total fidelity scores ranged from 55 to 98% across intervention hospitals (mean = 78%; SD = 13%). Fidelity scores were highest for use of clinical leads (mean = 98%; SD = 7%), and lowest for use of other educational materials (mean = 65%; SD = 19%) and audit and feedback (mean = 65%; SD = 20%). Clinical leads reflected positively about the interventions, with time constraints being the greatest barrier to their use. CONCLUSION: Our targeted, theory-informed interventions were delivered with moderate fidelity, and were well received by clinical leads. Despite clinical leads experiencing challenges of time constraints, the level of fidelity had a positive effect on successfully de-implementing non-evidence-based care in infants with bronchiolitis. These findings will inform widespread rollout of our bronchiolitis interventions, and guide future practice change in acute care settings. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415 .
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    Development of targeted, theory-informed interventions to improve bronchiolitis management
    Haskell, L ; Tavender, EJ ; Wilson, CL ; O'Brien, S ; Babl, FE ; Borland, ML ; Cotterell, E ; Sheridan, N ; Oakley, E ; Dalziel, SR (BMC, 2021-08-03)
    BACKGROUND: Despite international guidelines providing evidence-based recommendations on appropriate management of infants with bronchiolitis, wide variation in practice occurs. This results in infants receiving care of no benefit, with associated cost and is potentially harmful. Theoretical frameworks are increasingly used to develop interventions, utilising behaviour change techniques specifically chosen to target factors contributing to practice variation, with de-implementation often viewed as harder than implementing. This paper describes the stepped process using the Theoretical Domains Framework (TDF) to develop targeted, theory-informed interventions which subsequently successfully improved management of infants with bronchiolitis by de-implementing ineffective therapies. Explicit description of the process and rationale used in developing de-implementation interventions is critical to dissemination of these practices into real world clinical practice. METHODS: A stepped approach was used: (1) Identify evidence-based recommendations and practice variation as targets for change, (2) Identify factors influencing practice change (barriers and enablers) to be addressed, and (3) Identification and development of interventions (behaviour change techniques and methods of delivery) addressing influencing factors, considering evidence of effectiveness, feasibility, local relevance and acceptability. The mode of delivery for the intervention components was informed by evidence from implementation science systematic reviews, and setting specific feasibility and practicality. RESULTS: Five robust evidence-based management recommendations, targeting the main variation in bronchiolitis management were identified: namely, no use of chest x-ray, salbutamol, glucocorticoids, antibiotics, and adrenaline. Interventions developed to target recommendations addressed seven TDF domains (identified following qualitative clinician interviews (n = 20)) with 23 behaviour change techniques chosen to address these domains. Final interventions included: (1) Local stakeholder meetings, (2) Identification of medical and nursing clinical leads, (3) Train-the-trainer workshop for all clinical leads, (4) Local educational materials for delivery by clinical leads, (5) Provision of tools and materials targeting influencing factors, and prompting recommended behaviours, and (6) Audit and feedback. CONCLUSION: A stepped approach based on theory, evidence and issues of feasibility, local relevance and acceptability, was successfully used to develop interventions to improve management of infants with bronchiolitis. The rationale and content of interventions has been explicitly described allowing others to de-implement unnecessary bronchiolitis management, thereby improving care.
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    Clinically important sport-related traumatic brain injuries in children
    Eapen, N ; Davis, GA ; Borland, ML ; Phillips, N ; Oakley, E ; Hearps, S ; Kochar, A ; Dalton, S ; Cheek, J ; Furyk, J ; Lyttle, MD ; Bressan, S ; Crowe, L ; Dalziel, S ; Tavender, E ; Babl, FE (WILEY, 2019-10)
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    Review article: A primer for clinical researchers in the emergency department: Part VIII. Implementation science: An introduction
    Tavender, E ; Babl, FE ; Middleton, S (WILEY, 2019-06)
    New research findings may not lead to change in practice, or a change at the front line may be delayed by years. A number of terms have been used to describe efforts and strategies to speed a change in evidence-based practice, such as: implementation science, knowledge translation, research translation and others. In contrast to traditional clinical research, implementation science generally aims to understand and change health professional behaviour to promote evidence uptake as opposed to attempting to change patient behaviour. There are now theoretical frameworks and evolving evidence providing guidance how to change clinician behaviour and, specifically, emerging evidence on how to achieve this in the emergency setting. This review will provide an introduction to implementation science and illustrate how to target evidence practice gaps using ED examples.
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    Review article: A primer for clinical researchers in the emergency department: Part IX. How to conduct a systematic review in the field of emergency medicine
    Long, E ; Craig, S ; Babl, FE ; Tavender, E ; Lunny, C (WILEY, 2019-08)
    In this series we address important topics for emergency clinicians who either participate in research as part of their work, or use the knowledge generated by research studies. Emergency clinicians are routinely in the position of applying new evidence in clinical practice. With an ever-increasing volume of evidence generated, this can be problematic when studies are conducted in different settings, and include different patient groups, different interventions and different outcomes. This is made even more difficult when the results of primary research studies do not agree. Systematic reviews are becoming increasingly valuable as they appraise and synthesise research findings using a clear methodology, and summarise the results of primary studies. As such, systematic reviews help translate research findings into clinical practice. This paper provides a practical starting point for understanding the steps involved in conducting a systematic review in emergency medicine and will help readers appraise the findings of systematic reviews.
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    Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis A Randomized Clinical Trial
    Haskell, L ; Tavender, EJ ; Wilson, CL ; O'Brien, S ; Babl, FE ; Borland, ML ; Cotterell, E ; Schembri, R ; Orsini, F ; Sheridan, N ; Johnson, DW ; Oakley, E ; Dalziel, SR (AMER MEDICAL ASSOC, 2021-08)
    IMPORTANCE: In developed countries, bronchiolitis is the most common reason for infants to be admitted to the hospital, and all international bronchiolitis guidelines recommend supportive care; however, significant variation in practice continues with infants receiving non-evidence-based therapies. Deimplementation research aims to reduce the use of low-value care, and advancing science in this area is critical to delivering evidence-based care. OBJECTIVE: To determine the effectiveness of targeted interventions vs passive dissemination of an evidence-based bronchiolitis guideline in improving treatment of infants with bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS: This international, multicenter cluster randomized clinical trial included 26 hospitals (clusters) in Australia and New Zealand providing tertiary or secondary pediatric care (13 randomized to intervention, 13 to control) during the 2017 bronchiolitis season. Data were collected on 8003 infants for the 3 bronchiolitis seasons (2014-2016) before the implementation period and 3727 infants for the implementation period (2017 bronchiolitis season, May 1-November 30). Data were analyzed from November 16, 2018, to December 9, 2020. INTERVENTIONS: Interventions were developed using theories of behavior change to target key factors that influence bronchiolitis management. These interventions included site-based clinical leads, stakeholder meetings, a train-the-trainer workshop, targeted educational delivery, other educational and promotional materials, and audit and feedback. MAIN OUTCOMES AND MEASURES: The primary outcome was compliance during the first 24 hours of care with no use of chest radiography, albuterol, glucocorticoids, antibiotics, and epinephrine, measured retrospectively from medical records of randomly selected infants with bronchiolitis who presented to the hospital. There were no patient-level exclusions. RESULTS: A total of 26 hospitals were randomized without dropouts. Analysis was by intention to treat. Baseline data collected on 8003 infants for 3 bronchiolitis seasons (2014-2016) before the implementation period were similar between intervention and control hospitals. Implementation period data were collected on 3727 infants, including 2328 boys (62%) and 1399 girls (38%), with a mean (SD) age of 6.0 (3.2) months. A total of 459 (12%) were Māori (New Zealand), and 295 (8%) were Aboriginal/Torres Strait Islander (Australia). Compliance with recommendations was 85.1% (95% CI, 82.6%-89.7%) in intervention hospitals vs 73.0% (95% CI, 65.3%-78.8%) in control hospitals (adjusted risk difference, 14.1%; 95% CI, 6.5%-21.7%; P < .001). CONCLUSIONS AND RELEVANCE: Targeted interventions led to improved treatment of infants with bronchiolitis. This study has important implications for bronchiolitis management and the development of effective interventions to deimplement low-value care. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415.