Improving outcomes and reducing disparities through integrated primary care-specialty care implementation of the CDC Pediatric Mild TBI Guideline

轻度创伤性脑损伤（mTBI）是儿童期常见的损伤，可能会产生实质性影响 在学校和体育环境中的作用。早期识别，然后是最新的mTBI护理， 经证实，可改善预后，降低持续性脑震荡后症状（PPCS）的发生率。 目前mTBI护理的最佳证据已汇集在CDC的儿科mTBI指南中， 准备通过严格的、有计划的实施转化为临床护理。心灵震荡 费城儿童医院（CHOP）的项目显示出积极的跟踪记录， 通过实施电子临床决策支持（eCDS）影响mTBI儿童的护理 嵌入在网络范围的电子健康记录中。本项目的目标是在这一经验的基础上， 改善患有mTBI的儿童的结果，并通过翻译这些结果来减少这些结果的差异。 目前的标准护理。第一个目标将是针对理解的具体根源， 通过检查Minds Matter脑震荡，目前8000多名儿童的儿科mTBI结局差异 登记处，在CHOP医疗保健网络中对mTBI儿童进行的普查。此外，我们将评估 通过我们与BrainSTEPS的合作，学校的成果，一个由脑损伤管理的计划 宾夕法尼亚州协会。在第二个目标中，通过我们与CHOP的持续成功合作， 初级保健网络，我们将利用经验证的临床预测评分实施指南告知的eCDS (5P风险评分）和有针对性的mTBI体格检查（前庭检查）在选定的城市和 郊区初级保健的做法，在一个阶梯楔形试验。这项工作将量化的直接影响， 关于改善儿科mTBI结局的指南，包括识别PPCS高危儿童， 需要转诊到专门护理，并通过包括不同的做法，干预措施的有效性， 减少差距。作为试验设计的一部分，城市和郊区的初级保健实践也将参与 在使用智能手机应用程序来执行移动的健康（mHealth）干预的新颖实现中 对症状进行生态瞬时评估，以确定那些处于中度风险类别的人将受益 早期的转介。第三个目标将调查和解决障碍，以获得专业的mTBI护理， 进入医疗保健系统的替代点，即城市学校和青年俱乐部体育组织 通过进行定性半结构化访谈，并根据以下内容为这些人员提供mTBI教育 的指导方针。我们将实施创新的远程健康运动训练咨询服务， 它对临床结果的影响和减少差异。该项目完成后，除了产生 关于儿科mTBI结局和差异的新知识，也将产生eCDS的可交付成果， 指南的临床实施，包括新的mHealth和远程医疗方法，以改善 这将有助于减少mTBI的结果和差距，广泛影响儿童的生活。

Mild traumatic brain injury (mTBI) is a common injury in childhood with the potential to have a substantial impact on function in the school and sports setting. Early recognition, followed by up-to-date mTBI care, has been demonstrated to improve outcomes, reducing the incidence of persistent post-concussive symptoms (PPCS). The current best evidence for mTBI care has been brought together in the CDC’s Pediatric mTBI Guideline, poised to be translated into clinical care via rigorous, planned implementation. The Minds Matter Concussion Program at the Children’s Hospital of Philadelphia (CHOP) has demonstrated a track record of positively impacting the care of children with mTBI via the implementation of electronic clinical decision support (eCDS) embedded in the network-wide electronic health record. The goal of this project is to build on that experience to improve the outcomes of children with mTBI and reduce the disparities in those outcomes by translating the current Guideline into standard care. The first aim will be directed at understanding the specific roots of the current disparities in pediatric mTBI outcomes for over 8000 children by examining the Minds Matter Concussion Registry, a census of children seen for mTBI across the CHOP healthcare network. In addition, we will evaluate school outcomes through our partnership with BrainSTEPS, a program administered by the Brain Injury Association of Pennsylvania. In the second aim, through our ongoing successful partnership with the CHOP Primary Care Network, we will implement Guideline-informed eCDS utilizing a validated clinical prediction score (5P risk score) and targeted mTBI physical examination (visio-vestibular examination) in selected urban and suburban primary care practices in a stepped-wedge trial. This effort will quantify the direct impact of the Guideline on improving pediatric mTBI outcomes, including the identification of children at high risk of PPCS in need of referral for specialized care, and by including diverse practices, the effectiveness of the intervention in reducing disparities. As part of the trial design, an urban and suburban primary care practice will also participate in the novel implementation of a mobile health (mHealth) intervention using a smartphone application to perform ecological momentary assessment of symptoms to identify those in the moderate risk category who would benefit from earlier referral. The third aim will investigate and address barriers to accessing specialized mTBI care from alternative points of entry into the healthcare system, namely urban schools and youth club sports organizations by conducting qualitative semi-structured interviews and providing mTBI education to those personnel based on the Guideline. We will implement an innovative telehealth athletic training consultation service line and examine its impact on clinical outcomes and reducing disparities. This project, when completed, in addition to generating new knowledge about outcomes and disparities in pediatric mTBI, will also produce the deliverables of eCDS for clinical implementation of the Guideline, including novel mHealth and telehealth approaches to improving outcomes and reducing disparities in mTBI, impacting the lives of children broadly.