Towards Enhanced Prehospital Triage for Patients with Traumatic Brain Injury

Abstract

Background: Traumatic brain injury (TBI) is a serious condition that requires rapid and accurate prehospital triage to ensure patients receive timely and appropriate care. Prehospital triage for TBI is an essential process that can significantly impact patient outcomes. This PhD research aimed to enhance prehospital triage for patients with suspected TBI by identifying gaps in current practices and exploring future opportunities to enhance its accuracy and effectiveness.

Methods: A multi-phase approach was adopted, consisting of a systematic review, a mixed- methods study, a feasibility study, and an additional qualitative study. The systematic review evaluated the accuracy of existing prehospital triage tools in identifying TBI. The mixed- methods study was conducted using a convergent design that integrated data from a survey of UK ambulance services with qualitative data from semi-structured interviews. The survey mapped current practices, while the interviews explored the challenges of triaging, future opportunities, and the barriers and facilitators to implementing new diagnostic tools. The feasibility of a large-scale study to assess the implementation of the Canadian CT Head Rule (CCHR) in the prehospital field was also examined. After pre-defined feasibility criteria were not met, an additional qualitative study was conducted to identify the barriers and facilitators to paramedic research participation.

Results: The systematic review revealed that existing prehospital triage tools for TBI have variable and generally suboptimal diagnostic accuracy, with sensitivity ranging from 19.8% to 87.9% and specificity from 41.4% to 94.4%. Concerns were particularly identified regarding the under-triaging of older patients. The mixed-methods study highlighted significant challenges faced by paramedics in triaging TBI, especially in non-obvious cases and among older populations. It also identified considerable variation in the use of triage criteria and indicated that existing major trauma triage tools do not adequately address the specific needs of TBI. Key areas for improvement included enhanced education, specific triage criteria for TBI, and the use of new diagnostic tools. The feasibility study faced significant challenges, particularly with regard to recruitment rate. As a result, the study concluded that a large-scale study is not feasible in its current form. These challenges highlight the need to explore factors influencing paramedic engagement with research. Additional qualitative interviews identified several barriers to paramedic research engagement, including time constraints due to demanding work schedules, burnout from high-intensity work, and mixed attitudes toward clinical studies. The interviews also suggested strategies to enhance engagement, such as offering incentives, improving communication, and providing organisational support.

Conclusion: This PhD research mapped national care pathways for prehospital TBI triage, identifying key gaps and challenges in current practices. It highlighted the suboptimal diagnostic accuracy of existing triage tools and identified important areas for improvement, such as the need for TBI-specific triage criteria and improved paramedic training. Additionally, the feasibility study revealed significant challenges in paramedic research engagement, emphasising the need for innovative recruitment strategies to support definitive future studies. These findings lay a foundation for advancing prehospital TBI care and guiding future research to optimise patient outcomes.