From knowledge generation to synthesis to translation

PREDICT, the Paediatric Research in Emergency Departments International Collaborative, is an Australian and New Zealand network of EDs with a mission to generate new knowledge and improve emergency care for children and adolescents through rigorous research. However, generation of new knowledge is only half the battle to improve care. To address this, PREDICT has gradually moved over time from knowledge generation via cohort studies and multicentre randomised controlled trials to knowledge synthesis and knowledge translation (Fig. 1). Taking a broader perspective, knowledge translation includes adaption of knowledge to local context via guidelines, an understanding of current practice and the factors influencing practice variation, the development and evaluation of tailored implementation strategies and research on ways to sustain knowledge use. The evidence for what works in emergency medicine to improve the uptake of research knowledge into everyday clinical practice, however, is limited. There is an urgent need to improve implementation research in emergency medicine, particularly in our unique practice setting, and PREDICT has set a goal to advance the field by exploring whether successful implementation is influenced by the type of condition (high vs low volume), the type of ED, the direction of improvement (adopting new practices vs ceasing practices of low value) and the complexity of behavioural change needed. We also want to identify organisational and other predictors of research uptake and factors that influence the sustainability of effective interventions. As part of this programme, the PREDICT Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children has recently been released. The guideline builds on several multicentre PREDICT projects and 30 related PREDICT publications to understand the optimal clinical decision rule for head CT imaging in our setting, the management of head injury in children with underlying medical conditions and variation in current practice. We were particularly keen to understand practice outside tertiary paediatric hospitals, where the majority of children in Australia and New Zealand with head injuries present and where the widest variation in head CT rates had been reported in other counties. Data from a study of 31 Australian and New Zealand EDs show that head CT imaging rates are lower, at approximately 10%, than those reported in North America, with similar rates regardless of type of ED (tertiary, suburban, regional or rural) when adjusted for head injury severity. However, importantly, CT rates and length of stay showed a fivefold variation across types of EDs and patients with head injuries and more complex underlying problems, such as children with ventricular shunts, presented to all types of EDs, not just to tertiary hospitals. Why not simply implement an established high-quality clinical decision rule? In our setting, the Pediatric Emergency Care Applied Research Network (PECARN) clinical decision rule for CT imaging is the most effective and accurate tool to stratify children for the risk of clinically important traumatic brain injuries and forms the core of the imaging recommendations of our guideline. Although the PECARN clinical decision rule has been successfully implemented in several countries with a safe decrease in CT rates, our CT rates are lower than those seen in North America, and its primary purpose (and high sensitivity) is to identify which children presenting with head injuries can be safely discharged from the ED without a CT scan. Thus, the PECARN clinical decision rule needed to be embedded into a guideline incorporating observation as a management strategy clinicians in Australia and New Zealand are successfully using as an additional tool to risk stratify patients. Furthermore, the decision to obtain a CT scan or not is only one part of the management of children presenting with head injuries; there is also a need for guidance in pre-hospital triage, discharge advice and follow up. Why not use existing high-quality international guidelines? There was no guideline that addresses the management of paediatric head injuries in the Australian and New Zealand setting. For those guidelines from other countries we selected, no single guideline addressed all the questions and conditions ED clinicians had identified as important, and there was a need to update the evidence used. To be efficient and not ‘reinvent the wheel’, we drew on the evidence and recommendations from these guidelines using existing adaption frameworks, in particular GRADE-ADOLOPMENT, which provided the scientific underpinning for adopting, adapting or creating new recommendations. Still, over half of the recommendations were created de novo as no suitable existing recommendations could be found. Simply creating new guidelines, even high-quality ones, is not enough to improve practice. For implementation, key questions are the ‘dose’ (i.e. intensity) and type of implementation strategy needed for a particular condition in a particular setting. We are striving to develop evidence for what works in our ED setting. One of the major research priorities for the network has been bronchiolitis; following years of primary research and guideline development within PREDICT, we have now assessed the effectiveness of tailored implementation strategies to improve care through a cluster