A supported primary health pathway for mild traumatic brain injury quality improvement report

Overview of quality improvement methodology

The Plan, Do, Study, Act (PDSA) as a stand-alone quality improvement method was utilised to test the feasibility and evaluate the implementation of the supported health pathway on health system access after mTBI. To address the identified issues within the current health pathway for mTBI, the supported primary care pathway for mTBI included a range of components outlined in Box 1. Further details of the BIST can be seen in Supplementary Information 1.

A collaborative approach between the Accident Compensation Corporation (ACC), Primary health organisations (PHOs: ProCare, Pegasus, Well South and Nelson Bays), Manage my Health (secure health portal provider) and academics was undertaken. The digital health pathway was developed, tested and refined by Manage my Health in collaboration with the project team. ACC and academic team members contributed to the development of the education and training resources. PHOs were responsible for recruiting practices and clinicians, reviewing all referrals, providing peer support, relaying feedback from clinicians to the project team and administrative help eg application of funding reimbursement codes.

Once a practice had signed up, GPs, nurse practitioners and nurses from that practice could register to be part of the quality improvement project. Participating clinicians had to complete at least one online training module to be given access to the digital supported health care pathway tool for mTBI. Participating practitioners were asked to use the tool to guide their assessment of children (aged ≥8 years) and adults who presented with a suspected mTBI (including concussion). mTBI was defined as being an injury to the brain resulting from an external force resulting in disruption of brain function and alteration in mental state (such as feeling dazed and confused or loss of consciousness).¹⁶ While the pathway could be used for all patients with a suspected mTBI to support clinical assessment and diagnosis, eligibility for follow-up was based on a clinical diagnosis of mTBI or concussion. Delivery of the supported health pathway is outlined in Fig. 1.

Fig. 1.

Overview of the ACC supported primary health care pathway improvement strategy for mTBI.

On completion of the pathway assessment, if there was a high symptom burden and/or presence of another risk factor (eg previous prolonged recovery), the digital pathway generated a recommendation for the clinician to consider a referral to a concussion service. If no risk factors were present, the tool generated a recommendation to arrange primary care follow-up in 7–10 days to determine how they were recovering. Indicators of high-risk patients who may need a CT scan generated a recommendation for the clinician to consider a referral to an emergency department (ED). Referrals to concussion services could still be made at follow-up if the person was not recovering as expected. Clinicians were informed that the tool was only a guide and that triaging decisions ultimately remained their responsibility. An open text box was made available in the pathway tool to enable clinicians to outline their reasons if their action taken was different to the tool recommendation to aid identification of potential tool modifications.

Quantitative data was collected continuously over the course of the project, alongside feedback received from clinicians via the PHOs. This enabled a continuous and responsive test and learn approach. In line with the PDSA method, two PHOs were initially identified and recruited by ACC (ProCare and Pegasus) to ensure inclusion of clinicians working across the north and south islands of NZ. Initial learnings from the first PDSA cycle revealed that it was difficult to initially enrol practices due to high demands placed on primary care at the time. However, once enrolled there was positive feedback from clinicians on usability and utility of the tool. Refinements made to the tool following clinician feedback included the need for flexibility in the timing of appointments (eg on some occasions a 30-min second consultation was needed to complete the initial assessment, particularly in cases of multiple injuries or complex presentations). The wording of the ED referral recommendation was reframed to reflect cases where an ED referral was not appropriate eg person presents several months post-injury. Further clarification for practices on claiming for funding of the appointments was also provided.

Following these changes, the project was extended to include other PHOs servicing other areas of the country, including rural and high tourist areas (WellSouth and Nelson Bays PHOs). By the end of the second PDSA cycle, 10 PHOs were involved, encompassing 56.8% of the NZ population. The PHO areas were broadly representative of the national context as shown in Supplementary material S2, based on age, sex, ethnicity and deprivation extracted from the Ministry of Health.

Following the second PDSA cycle, further refinements were identified including the need to separate out triggers for the ED and concussion service. It became evident that in a few cases, early referral to a concussion service was being recommended unnecessarily eg patients presenting with a history of mental health but who had low acute symptom burden. On review of these cases, it became evident that this was a result of each risk factor being weighted equally. To improve the specificity of referrals, weightings were assigned to individual risk factors following a conjoint analysis process. Concerns were raised about the inability to provide appropriate follow-up appointments after the initial assessment due to service demand constraints. User feedback also favoured access to the pathway tool with as few ‘clicks’ as possible, such as access through a desktop or toolbar icon.

Evaluation of the quality improvement project

To evaluate the impact of the supported health pathway, routinely collected data were extracted from ACC databases. Prior to commencing the quality improvement project, ACC data revealed that 36% of patients received a follow-up appointment by any health professional.¹⁰ The mean time to concussion services was also found to be 55 days (s.d. = 65.4).¹⁴ It was determined that a successful pilot should see an increase in the relative proportion of clients receiving a follow-up appointment by any health professional and that there should be a decrease in mean time to concussion services for those who need it. Sociodemographic data on age, sex, ethnicity, injury code(s), time from injury to primary care appointment, number and type of follow-up received and referrals made were extracted from the ACC database. Frequencies and proportions were used to describe the sample and the impact of the supported primary care pathway on the proportion of patients receiving at least one follow-up appointment by type. For those requiring a concussion service, the mean time from injury to first appointment within the concussion service was recorded in days.

Risks and benefits of the proposed system change

The potential benefits of operationalising international best practice guidelines for mTBI was considered to outweigh the potential risks for patients. Any possible risks to patient care were mitigated by empowering clinicians to use the tool as part of a comprehensive assessment and to override the recommendation. All completed Brain Injury Screening Tool (BIST) assessments were checked by an experienced medical practitioner at the PHO who contacted the clinician if necessary. Subsequent use of the BIST at follow-up appointments also ensured that any deterioration in symptoms was detected and that any patients not recovering as expected would result in a recommendation for the clinician to consider a referral to a concussion service at that time. Data was collated into an excel spreadsheet and all identifying details were removed by a member of ACC staff before being shared for analysis to protect privacy. De-identified data were stored on secure, password protected Auckland University of Technology (AUT) and ACC servers.

Ethics and consent to participate

As a quality improvement project using deidentified patient data, patient consent and ethics approval was not required.

Impact on follow-up rates

The number of patients who received at least one follow-up appointment (by any health professional) increased from 36.0% pre-implementation to 56.8% post-implementation. There were 28 patients (12.7%) who were followed up both in primary care and a concussion service.

Impact on referral and time to access concussion services

Sixty-three patients (28.6%) received a referral to a concussion service compared to 10% pre-implementation. The mean time from accident to concussion service reduced from 55.0 days (s.d. 65.4) pre-implementation to 36.8 days (s.d. 29.5) post-implementation. There were three people who were identified as experiencing significant delays between their claim lodgement date and access to a concussion service post-implementation. On reviewing these cases, it was identified that there had been a claim lodgement date within 2 days of injury (either an ED presentation or primary care consultation not involved in the project), however, the person had not presented for their primary care appointment within the quality improvement project until 77–126 days post-injury. All three of these cases had received a concussion service within 1 month of their primary care appointment.