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Qualitative study of emergency clinicians to inform a national guideline on the management of children with mild-to-moderate head injuries
  1. Emma J Tavender1,2,
  2. Catherine L Wilson1,
  3. Stuart Dalziel3,4,
  4. Ed Oakley1,2,5,
  5. Meredith Borland6,7,
  6. Dustin W Ballard8,
  7. Elizabeth Cotterell9,10,
  8. Natalie Phillips11,12,
  9. Franz E Babl1,2,5
  1. 1 Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
  2. 2 Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
  3. 3 Emergency Department, Starship Children's Hospital, Auckland, New Zealand
  4. 4 Departments of Surgery and Paediatrics, University of Auckland, Auckland, New Zealand
  5. 5 Emergency Department, The Royal Children’s Hospital, Melbourne, Victoria, Australia
  6. 6 Emergency Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
  7. 7 Paediatrics and Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
  8. 8 CREST Network & Division of Research, Kaiser Permanente, Oakland, California, USA
  9. 9 Armidale Rural Referral Hospital, Armidale, New South Wales, Australia
  10. 10 School of Rural Medicine, Tablelands Clinical School, University of New England, Armidale, New South Wales, Australia
  11. 11 Emergency Department, Queensland Children’s Hospital, Brisbane, Queensland, Australia
  12. 12 Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
  1. Correspondence to Professor Franz E Babl, Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, VIC 3052, Australia; franz.babl{at}


Background Head injury is a common reason children present to EDs. Guideline development to improve care for paediatric head injuries should target the information needs of ED clinicians and factors influencing its uptake.

Methods We conducted semi-structured qualitative interviews (November 2017–November 2018) with a stratified purposive sample of ED clinicians from across Australia and New Zealand. We identified clinician information needs, used the Theoretical Domains Framework (TDF) to explore factors influencing the use of head CT and clinical decision rules/guidelines in CT decision-making, and explored ways to improve guideline uptake. Two researchers coded the interview transcripts using thematic content analysis.

Results A total of 43 clinicians (28 doctors, 15 nurses), from 19 hospitals (5 tertiary, 8 suburban, 6 regional/rural) were interviewed. Clinicians sought guidance for scenarios including ED management of infants, children with underlying medical issues, delayed or representations and potential non-accidental injuries. Improvements to the quality and content of discharge communication and parental discussion materials were suggested. Known risks of radiation from head CTs has led to a culture of observation over use of CT in Australasia (TDF domain: beliefs about consequences). Formal and informal policies have resulted in senior clinicians making most head CT decisions in children (TDF domain: behavioural regulation). Senior clinicians consider their gestalt to be more accurate and outperform existing guidance (TDF domain: beliefs about capabilities), although they perceive guidelines as useful for training and supporting junior staff. Summaries, flow charts, publication in ED-specific journals and scripted training materials were suggestions to improve uptake.

Conclusion Information needs of ED clinicians, factors influencing use of head CT in children with head injuries and the role of guidelines were identified. These findings informed the scope and implementation strategies for an Australasian guideline for mild-to-moderate head injuries in children.

  • emergency departments
  • guideline
  • pediatric emergency medicine
  • head

Data availability statement

No data are available. Not applicable.

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Data availability statement

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  • Handling editor Shammi L Ramlakhan

  • Contributors EJT, CLW and FEB conceptualised the study. All authors participated in the design of the study. EJT and CLW carried out the interviews. EJT and CLW analysed and interpreted data. EJT led the writing and editing of this manuscript. All authors revised the manuscript for important intellectual content and gave final approval of the version to be published. FEB is responsible for the overall content as guarantor.

  • Funding This study was funded by the Angior Family Foundation; the Emergency Medicine Foundation (EMPJ-375R27-2017-PHILLIPS) Queensland; the National Health and Medical Research Council Centre of Research Excellence grant in Paediatric Emergency Medicine (GNT1171228), Australia and by the Victorian Government’s Operational Infrastructure Support Programme.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.