Title: Developing an intervention to support paramedics in safely assessing and managing children with minor head injury.
Funder: Health Education England

Abstract: Background:The NHS is under substantial pressure due to rising demand. A leading priority is to reduce the number of patients who are unnecessarily conveyed to an Emergency Department (ED) by ambulance. Children are frequent users of the ambulance service and ED, and head injury is common in children. However very few children with head injury who are conveyed to the ED need specialist treatment, and the vast majority could be managed safely at scene. Several decision tools exist to support clinical decision-making when a child presents to the ED with a minor head injury (MHI), yet there is no pre-hospital decision tool designed for use by paramedics to reduce unnecessary conveyance to hospital. None of the existing hospital-based tools can be implemented directly in pre-hospital care, because they are designed to advise clinicians of the need for a computed tomography (CT) scan, rather than ED conveyance. This gap is recognised in existing national guidance, and a pre-hospital tool to support effective decision-making by paramedics is required urgently. Aim and Objectives:To develop a clinical decision support tool for the assessment and management of children with MHI for use by paramedics in pre-hospital care, to safely reduce unnecessary conveyance to the ED. Determine which hospital-based clinical decision tools are most relevant to the pre-hospital setting, and identify the elements of these tools that can be adapted for pre-hospital use. Identify the factors that influence paramedics when deciding whether to convey a child with MHI to the ED. Adapt existing hospital-based clinical decision tools to create a new pre-hospital decision tool that will support paramedics in assessing and managing children with MHI. Evaluate the acceptability and usability of the new clinical decision tool by paramedics.Methods:This project consists of four work packages (WPs) addressing these four objectives. WP1 is a systematic review and mapping exercise to determine which hospital-based clinical decision tools are most relevant to pre-hospital care, and identify the elements of these tools that can be adapted for use by paramedics. WP2 uses qualitative interviews with paramedics to explore the factors that influence their conveyance decisions for children with MHI. WP3 is a Delphi study with key stakeholders aiming to adapt existing hospital-based decision tools to create a new tool that will support paramedics in assessing and managing children with MHI. WP4 is a simulation study with focus groups to understand the acceptability and usability of the new support tool. Impact and dissemination:The main dissemination strategy will be publication in peer reviewed journals and presentations at conferences. The findings will be disseminated to ambulance services, and to patients and the public through a website, press articles and social media. Short term impact will be the development and evaluation of an intervention ready to test in a subsequent evaluation of safety, then feasibility study. Long term impact will be a reduction in unnecessary ED attendances and hospital admissions, with reduced costs and improved patient and parent experience, whilst delivering safe and effective clinical care.

Lay abstract: Background:Pressure on NHS hospitals has increased due to rising patient numbers. Recent initiatives have tried to find ways that people can get the care they need at home, without having to go to a hospital. Head injury in children is a common reason for a 999 ambulance call and hospital attendance, but 90% of head injuries in children are minor and do not need hospital treatment. There are already several decision support tools that clinicians use in hospitals to help them decide if a child needs further treatment or tests, such as a head scan, or whether they can go home safely. However, there is no decision tool outside hospitals to help paramedics decide whether to take a child with head injury to the Emergency Department. Paramedics regularly use decision support tools in pre-hospital care for other problems, to help them to safely manage patients in the community, rather than take them to the hospital. For example, paramedics have used a decision support tool to help them decide whether to take older people who have fallen to the hospital. This tool has been proven to safely reduce hospital admissions. A tool to support decision-making by paramedics when attending to children with minor head injury is required urgently. Aim:To develop a decision support tool for use by paramedics to help with the management of children with minor head injury. This will support paramedics to reduce the number of children that are taken to hospital unnecessarily, and allow more children to stay at home safely. Method:This research is made up of four work packages (WPs): WP1: We will search for all available research evidence to find out which hospital-based clinical decision tools are most relevant to the out-of-hospital setting. We will also find out which parts of these tools are most useful for paramedics. WP2: Paramedics will be interviewed to find out what things influence them to take a child with a minor head injury to hospital. We will also ask paramedics what things are important to include in a decision support tool. WP3: We will work with paramedics, parents, experts, general practitioners and hospital staff, to decide and agree on what the new decision support tool will include. This will create the first version of the new decision support tool for paramedics to use with children who have a minor head injury. For example, the tool may look like a mobile phone 'App', or a flow chart. WP4: Groups of paramedics will use the decision tool in simulated scenarios, using actors as patients. They will then feedback on the tool, and how it can be improved. Patient and Public Involvement:A Young Persons Advisory Group supports this project, and thinks it is a good idea. A newly-formed Parents Advisory Group has also reviewed this project, and fully support the research plan. They have agreed to help complete the research and share the results as widely as possible. Distribution of findings and impact:The results of this research will be published in medical journals and presented at conferences. They will also be given to ambulance services, and to patients and the public through a website, press articles and social media. This research will produce a new tool that is ready to be tested in more detail, to see if it helps paramedics to manage children with head injury safely in practice. In the longer term, the new tool may help to reduce pressure on the ED and provide a better patient and parent experience, whilst ensuring safe and effective care.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: INJURIES AND ACCIDENTS