Adapting two American Decision Aids for Mild Traumatic Brain Injury to the Canadian Context Using the Nominal Group Technique

Patient. 2020 Dec;13(6):729-743. doi: 10.1007/s40271-020-00459-y. Epub 2020 Oct 20.


Background: Decision aids are patient-focused tools that have the potential to reduce the overuse of head computed tomography (CT) scans.

Objective: The objective of this study was to create a consensus among Canadian mild traumatic brain injury and emergency medicine experts on modifications required to adapt two American decision aids about head CT use for adult and paediatric mild traumatic brain injury to the Canadian context.

Methods: We invited 21 Canadian stakeholders and the two authors of the American decision aids to a Nominal Group Technique consensus meeting to generate suggestions for adapting the decision aids. This method encourages idea generation and sharing between team members. Each idea was discussed and then prioritised using a voting system. We collected data using videotaping, writing material and online collaborative writing tools. The modifications proposed were analysed using a qualitative thematic content analysis.

Results: Twenty-one participants took part in the meeting, including researchers and clinician researchers (n = 9; 43%), patient partners (n = 3; 14%) and decision makers (n = 2; 10%). A total of 84 ideas were generated. Participants highlighted the need to clarify the purpose of the decision aids, the nature of the problem being addressed and the target population. The tools require sociocultural adaptations, better identification of their target population, better description of head CT utility, advantages and related risks, modification of the visual and written representation of the risk of brain injury and head CT use, and locally adapted, patient follow-up plans.

Conclusions: This study based on a Nominal Group Technique identified several adaptations for two American decision aids about head CT use for mild traumatic brain injury to support their use in Canada's different healthcare, social, cultural and legal context. These adaptations concerned the target users of the decision aids, the information presented, and how the benefits and risks were communicated in the decision aids. Future steps include prototyping the two adapted decision aids, conducting formative evaluations with actual emergency department patients and clinicians, and measuring the impact of the adapted tools on CT scan use.

Plain Language Summary

A mild traumatic brain injury (also called concussion) can happen when the brain moves around in the skull after an impact to the head. A concussion is not a brain bleed and you cannot see a concussion. Concussions do not show up on a computed tomography (CT) scan. Brain bleeds do. Computed tomography scans are specialised X-ray machines that can detect serious brain injuries. Unfortunately, CT scan use also exposes patients to radiation and a future increased risk of cancer.Shared decision making involves health professionals and patients making decisions together based on the best available evidence, health professionals’ experience, and patients’ values and preferences. Shared decision making improves appropriate diagnostic test use.Two decision aids created in the USA are available to facilitate shared decision making regarding the use of head CT scans for patients with concussion. These decision aids are not fully adapted for use in Canada because the healthcare, social and legal context is different. Our study brought together patients and experts in the field of concussion and shared decision making to analyse these decision aids and propose adaptations that would increase their acceptance in Canadian emergency departments. We used a technique called the Nominal Group Technique to create a consensus about the most important changes to make to both original decision aids. The main adaptations needed for the Canadian context concerned avoiding information about cost and removing any information that does not change clinical management. This project will help us adapt two decision aids for clinical use in Canada and support appropriate CT scan use for patients with concussion.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Brain Concussion*
  • Canada
  • Child
  • Decision Support Techniques
  • Emergency Service, Hospital
  • Humans
  • Tomography, X-Ray Computed
  • United States

Associated data

  • figshare/10.6084/m9.figshare.12943274