Improving the care of people with traumatic brain injury through the Neurotrauma Evidence Translation (NET) program: protocol for a program of research
Improving the care of people with traumatic brain injury through the Neurotrauma Evidence Translation (NET) program: protocol for a program of research
Sally E Green 0
Joanne E McKenzie 0
Denise A O'Connor 0
Emma J Tavender
Jeffrey V Rosenfeld
Russell L Gruen
0 School of Public Health and Preventive Medicine, Monash University , Melbourne , Australia
The Neurotrauma Evidence Translation (NET) program was funded in 2009 to increase the uptake of research evidence in the clinical care of patients who have sustained traumatic brain injury. This paper reports the rationale and plan for this five-year knowledge translation research program. The overarching aims of the program are threefold: to improve outcomes for people with traumatic brain injury; to create a network of neurotrauma clinicians and researchers with expertise in knowledge translation and evidence-based practice; and to contribute knowledge to the field of knowledge translation research. The program comprises a series of interlinked projects spanning varying clinical environments and disciplines relevant to neurotrauma, anchored within four themes representing core knowledge translation activities: reviewing research evidence; understanding practice; developing and testing interventions for practice change; and building capacity for knowledge translation in neurotrauma. The program uses a range of different methods and study designs, including: an evidence fellowship program; conduct of and training in systematic reviews; mixed method study designs to describe and understand factors that influence current practices (e.g., semi-structured interviews and surveys); theory-based methods to develop targeted interventions aiming to change practice; a cluster randomised trial to test the effectiveness of a targeted theoryinformed intervention; stakeholder involvement activities; and knowledge translation events such as consensus conferences.
Knowledge translation research; Study protocol; Neurotrauma; Traumatic brain injury
Traumatic Brain Injury (TBI) is an important global
health problem. It is defined as injuries caused by
external mechanical force to the head, e.g., in motor vehicle
accidents, falls, sporting accidents, violent assaults, or
blast injuries . Incident estimates range from 108 to
332 hospitalised new cases per 100,000 population per
year . There are limited data on the incidence of TBI
in low- and middle-income countries; however,
epidemiological research from India, with an estimated
population size of 1.2 billion, indicates nearly 2 million
people sustain TBI each year .
TBI can result in long term or lifelong physical,
cognitive, behavioural, and emotional consequences. As a result
of these consequences, TBI is one of the most disabling
injuries  and the leading cause of death and disability in
children and adults from ages 1 to 44 . The US Centre
for Disease Control and Prevention estimates at least 3.17
million Americans, approximately 1.1% of the US
population, are living with long-term disability as a result of TBI
. Even mild TBI (mTBI), which accounts for 80% to
90% of all TBIs, can cause long-term cognitive problems
that may affect a persons ability to perform daily activities
and to return to work . Given the incidence and severity
of the condition, TBI poses a significant financial burden
to society . The lifetime cost per case of severe TBI is
estimated at $396,331 USD, with disability and lost
productivity costs outweighing medical and rehabilitation costs
by a factor of 4 to 1 ($330,827 / $65,504) .
Worldwide, much research is conducted relevant to TBI
and with the potential to improve outcomes for people with
TBI . However, translation of knowledge from research
into practice takes considerable time and effort [11,12].
Concerted action is needed to facilitate this process,
involving individuals, teams, organisations, and systems [13,14].
Knowledge translation (KT) is a way to close
evidencepractice gaps, and has been defined as a dynamic and
iterative process that includes the synthesis, dissemination,
exchange and ethically sound application of knowledge to
improve health, provide more effective health services and
products and strengthen the healthcare system .
The care of people with TBI includes many disciplines
because patients often have a long journey of care through
pre-hospital, hospital, rehabilitation, and community
settings . At the same time, these are relatively discrete
professional communities, which provide opportunities for
researchers and research users to collaboratively shape
research  and so ensure the research conducted is
relevant to the TBI community and stakeholders.
In November 2009, the Neurotrauma Evidence
Translation (NET) program (www.netprogram.org.au)
commenced, funded by the Victorian Governments Transport
Accident Commission and Department of Innovation
Industry and Regional Development, Australia. This
fiveyear program provides opportunity to develop and sustain
a coordinated collaborative approach to KT for TBI in
Australia. The overall aims of the program are: to improve
outcomes for people with TBI; to create a network of
neurotrauma clinicians and researchers with expertise in KT
and evidence-based practice; and to contribute knowledge
to the field of KT research. The program includes a range
of integrated activities in the knowledge-to-action-cycle
; captured in the following themes: reviewing
research evidence; understanding practice; developing and
testing interventions for practice change, and building
capacity for KT in neurotrauma (see Figure 1).
This paper provides the rationale and an overview of
the content of the NET program of KT research,
including a brief description of the themes and the projects
within each theme, their objectives, design, progress to
date, and anticipated outcomes. Detailed methods and
results of individual projects will be reported separately.
At the time of writing of this manuscript, several
components had already commenced.
summarised and then made available in formats that are
useful and relevant to the local setting . Theme one
activities are focused on reviewing the research evidence
in TBI, generating knowledge products (e.g., systematic
reviews and their derivates, such as consensus
statements, and quality indicators), and building capacity to
conduct research synthesis. The theme builds on the
work of the Global Evidence Mapping Initiative (www.
evidencemap.org) , which identified priority research
questions relevant to TBI via key stakeholder
involvement and produced evidence maps to illustrate the
breadth and depth of available research addressing these
questions. These evidence maps can be used to identify
areas in need of synthesis (where evidence exists to
guide practice) and evidence gaps where primary
research needs to be undertaken.
Theme one of the NET program has two main
components: an Evidence Fellowship Program, and the
development of locally relevant best practice recommendations.
NET evidence fellowship program
Knowledge of current research evidence combined with
clinical experience and patient preference is pivotal to
evidence-based practice. To support evidence-based
practice, clinicians need skills to search for, acquire,
appraise, and interpret research findings. Barriers to
evidence-based practice for clinicians have been
welldocumented, and include a lack of time, insufficient
resources, and limited skills in accessing and applying
research . Fellowships offer clinicians protected time
and provide access to resources and technical support
that might otherwise be difficult to obtain [24,25].
The objectives of the NET Evidence Fellowship
Program are to:
1. build skills and capacity for evidence-based practice
within the neurotrauma community through
mentoring clinicians to undertake systematic
2. encourage fellows to become future leaders and
3. produce systematic reviews in priority neurotrauma
topics to inform clinical practice.
To inform the design of the NET Evidence Fellowship
Program, a systematic search was conducted in
MEDLINE and EMBASE from 1996 to August 2011 to
identify literature that described and evaluated
evidencebased practice skill-development programs. Relevant
papers were reviewed regarding their program concept,
results, and experiences. The program was designed to
incorporate the main findings from the systematic
review and includes: recruitment of clinicians by targeting
specific networks or recommendations by referral; access
1. Improvement of outcomes for people with TBI
2. Create a network of neurotrauma clinicians and researchers with expertise in KT and evidence-based practice
3. Contribute knowledge to the field of KT research
Figure 1 Overview of NET program themes, high-level methods and overall program aims.
to training workshops (e.g., Cochrane Collaboration
author training); one-on-one mentoring and training by an
experienced systematic reviewer and trainer with skills
in searching, critical appraisal, interpretation of results
and evidence-based decision making; and the provision
of peer and administrative support.
Over the lifetime of the program, eight systematic
reviews will be conducted predominantly on the
effectiveness of interventions for the management of TBI. Five
fellows have been recruited thus far and two protocols
have been published [26,27].
Developing locally relevant best practice
When evidence has been synthesised, and a reliable body
of evidence exists, then efforts need to focus on
converting the evidence into formats that are useful to
endusers . The second project of theme one focuses on
developing best practice recommendations that are
actionable, locally applicable, and consistent with best
available research-based evidence. In our context,
evidence synthesis needs to be suitable to underpin
quality indicators and to define and measure best practice.
Local adaptation of the evidence is essential , as
potential dissimilarities in populations, interventions, or
outcomes used in research [28,29], or organisational and
cultural differences (e.g., beliefs and values) between the
research settings of the original studies and the site of
implementation [30,31] may influence the relevance and
feasibility of implementing a particular body of
evidence into a local setting.
Our process therefore encompasses the following
steps: identifying current, high quality clinical practice
guidelines (CPGs) and extracting recommendations;
selecting strong recommendations in key clinical
management areas; updating evidence and creating evidence
overviews; discussing evidence and producing agreed
evidence statements; discussing the relevance of the
evidence with local stakeholders; and developing locally
applicable actionable best practice recommendations,
suitable for use as the basis of quality indicators. The
process is reported in full elsewhere .
This project aims to develop recommendations in
three areas of practice, relevant to TBI, in acute and
rehabilitation phases of care. To date, the process has been
completed for the management of mTBI in Australian
emergency department (ED) settings [32,33].
Theme two: understanding practice
Once evidence-based best practice has been agreed,
current practice needs to be determined so as to identify
gaps between evidence and practice and establish areas
most in need of change . In addition, current KT
literature underlines the importance of researching and
targeting the factors or determinants that may influence
current practice and practice change prior to any efforts
to change practice. These determinants may affect
individual care providers, teams, organisations, or the wider
healthcare system [35,36]. Interventions targeting
prospectively identified determinants of change are more
likely to improve professional practice than no
intervention or dissemination of guidelines only . A wide
range of methods exist for the identification of these
factors [37,38], including the use of theories of behavioural
change [39,40]. The second theme focuses on
understanding current practice and the factors that influence
practice change within two clinical areasmanagement
of mTBI in EDs and management of skeletal muscle
spasticity following TBI in rehabilitation and community
Management of mTBI in ED settings
TBI is a frequent cause of presentation to EDs, and 70%
to 90% of these are classified as mild [41,42]. The
National Institutes of Health, USA, has declared that mTBI
is a major public health problem and that effort to
reduce disability after a mTBI should be a national
research priority . As the ED is the main, and often
only, point of medical contact for these patients, ED care
may have significant impact on the outcomes for these
patients. Despite the existence of a variety of
evidencebased CPGs on the management of mTBI, studies have
shown considerable practice variation in a number of
key clinical areas .
To explore current practice in the ED management of
mTBI we triangulated data derived from the following
methods: a literature search identifying previous studies
on mTBI management in Australian EDs; an audit of
management of mTBI in two Victorian EDs; and
qualitative interviews with ED staff and directors in a
purposeful sample of Victorian EDs to explore reported
management. Our descriptions of current practices were
compared with agreed local best practice, as determined
in theme one [32,33], so as to estimate the presence and
extent of any knowledge-practice gaps.
Interviews with ED staff and directors also explored
the individual, team, organisational, and system factors
that may influence management and implementation of
the agreed local best practice recommendations. We
interviewed 42 participants (staff and directors) across
13 EDs until data saturation was reached . Sites were
selected to reflect both rural and metropolitan EDs. The
design of the interview questions and analysis were
guided by a theoretical framework . Detailed
methods and the findings of the interviews will inform the
design of a targeted intervention (theme three) and will
be reported in full in subsequent publications.
Managing skeletal muscle spasticity following TBI in
rehabilitation and community settings
Skeletal muscle spasticity is a major physical complication
resulting from TBI. There is limited epidemiological data
regarding the prevalence of spasticity following TBI,
however it has been reported to affect more than one in ten
patients with severe TBI . Spasticity and its
management have been identified as a priority topic by people
with TBI and the multidisciplinary teams managing their
care . Interventions for managing skeletal muscle
spasticity include pharmacological treatment (e.g., baclofen,
botulinum toxin A) and non-pharmacological
interventions (e.g., casting, stretching). Currently, little is known
about the nature of current management of spasticity
following TBI in rehabilitation or community settings.
We plan to explore current practice in the
management of spasticity through conduct of a survey of
Australian medical and allied health practitioners who
manage spasticity following TBI. A random sample of
practitioners working in rehabilitation and community
care settings will be invited to complete a survey
eliciting information about their assessment and treatment of
spasticity following TBI. Our estimates of current
practice will be compared with systematic review evidence
supporting the use of interventions for managing
skeletal muscle spasticity following TBI, as determined in
theme one , so enabling us to estimate the size of
the knowledge-practice gap. In-depth interviews with a
purposeful sample of medical and allied health
practitioners will then be conducted to explore the factors
influencing current practice and the determinants of
practice change (i.e., the factors that influence the actual
Theme three: developing and testing interventions for
Once the factors influencing practice and practice change
have been identified, the next steps are to develop a KT
intervention aiming to address these factors, and to test its
effectiveness . We aim to use a theory-informed
approach to intervention development . The use of theory
can offer a generalisable framework for considering
effectiveness across different clinical conditions and settings .
Given the wide variety of factors that may influence practice
change, designing interventions using multiple theoretical
perspectives minimises the chance of overlooking
important factors  and is more likely to promote
understanding about how and why change occurs. Research in this
theme will build on work we have completed on the
development of complex implementation interventions in other
settings [52,54,55] and be informed by themes one and two.
Theme three aims to improve outcomes for patients with
mTBI presenting to the ED through implementation of the
locally relevant best practice recommendations developed
in theme one. More specifically, the objectives are:
1. to systematically develop a targeted,
theoryinformed, and evidence-based implementation
intervention to increase uptake of evidence
informing the ED management of mTBI into
2. to test in a cluster randomised trial (CRT) the
effectiveness of this intervention in changing
practice compared with passive dissemination of the
3. to conduct a process evaluation alongside the CRT
to understand the pathway of change.
A systematic process to map intervention components
to identified determinants of practice change will be
used in developing the targeted theory-informed
We will conduct a CRT to test whether the
intervention is effective in improving the uptake of key
evidencebased recommendations in the management of mTBI.
Hospital EDs will form the clusters. A randomised
design is the preferred design to evaluate the effectiveness
of an intervention because it minimises bias in
estimating intervention effects [57,58]. In this study, clusters
(hospital EDs) have been chosen because the
intervention is targeted at the team of ED staff, and EDs
represent patient populations in geographical areas,
precluding the use of an individually randomised design
[59,60]. Intervention sites will receive the targeted,
theory-informed intervention, while control sites will
receive passive dissemination of the recommendations. A
process evaluation will be completed to measure factors
along the causal pathway of change and understand why
change has or has not taken place . Detailed
methods of the CRT will be published as a study protocol.
Theme four: building capacity for KT in neurotrauma
The overarching and supporting theme of the NET
program is to build sustained capacity and infrastructure for
KT in TBI , thereby improving patient outcomes as
well as contributing to the science of KT research. To
stimulate widespread and sustained uptake of research
results into clinical practice beyond those forming the
NET program, we aim to contribute to building a
culture of research-informed decision making.
Building capacity and developing infrastructure requires
investment in resources and structures, such as innovative
training, skill development and support for practitioners,
and sustained commitment from clinical leaders. Cross
sector relationships and partnerships are needed between
researchers, clinicians, policy makers, and healthcare
consumers to build forums for exchange. To inform this, we
need evaluation of what works to implement research into
practice; for whom, why, and at what cost. Theme four
will harness activities and networks from themes one to
three to establish resources and systems, develop a
workforce with KT skills, and foster a sustainable neurotrauma
KT structure and culture. Specific functions under theme
four include the coordination and hosting of three KT
conferences over the course of the program, stakeholder
dialogue events, and brokerage of relationships across
disciplines and sectors through advisory structures and
The NET program has a program-wide
multidisciplinary steering committee, which provides strategic
direction to the program, offers practical support towards
achieving the overarching aims of the program, and
fosters links between the NET program and its identified
stakeholder groupsthe neurotrauma clinical
community, consumers, policy makers, and funders. A number
of networks and collaborations have been formed
spanning Australia, Canada, USA, and UK, and these teams
are exploring new neurotrauma KT initiatives that build
upon the activities in the NET program.
The NET program is a coordinated approach to KT in
TBI in Australia. The program comprises a series of
interlinked projects spanning varying clinical
environments and disciplines, anchored within four themes
representing core KT activities: reviewing research
evidence; understanding practice; developing and testing
interventions for practice change, and building capacity
for KT in neurotrauma. The program aims to contribute
to improving care for patients with TBI in Australia, and
to contribute to the science of KT research.
CPG: Clinical Practice Guideline; CRT: Cluster Randomised Trial;
ED: Emergency Department; (m)TBI: (mild) Traumatic Brain Injury;
NET: Neurotrauma Evidence Translation; KT: Knowledge Translation.
Sally Green and Russell Gruen conceived of the program and wrote the
original grant proposal. Joanne McKenzie and Denise OConnor contributed
to sections of the original grant proposal. Marije Bosch wrote the first draft
of the manuscript and prepared the revised versions. All other authors
critically reviewed and contributed to draft revisions, and read and approved
the final version of the manuscript.
This protocol is based on the grant titled Improving evidence-based care
and the outcomes of patients with traumatic brain injury and spinal cord
injury through a program to facilitate knowledge transfer and exchange.
This study was funded by the Victorian Transport Accident Commission,
Australia. We thank Ms Kate Phillips and the wider investigator team: Dr Mark
Bayley; Dr Heather Buchan; Professor Peter Cameron; Professor Jamie Cooper;
Dr David Cooksley; Professor Niki Ellis; Associate Professor Mark Fitzgerald;
Professor Jill Francis; Professor Jeremy Grimshaw; Dr Sophie Hill; Ms Sue
Huckson; Dr Tony Joseph; Dr Fary Khan; Dr Jonathan Knott; Professor John
Lavis; Associate Professor Shawn Marshall; Professor Susan Michie; Associate
Professor Peter Morley; Dr Andrew Pearce; Professor Jennie Ponsford; Mr Nick
Rushworth; Dr Elisabeth (Lisa) Sherry.
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