Pradip P. Chaudhari

Background: Pediatric neurocritical care (PNCC) has emerged as a distinct field, and many hospitals have moved to establishing dedicated PNCC programs. How practice change is implemented within these programs is not well understood. This study had two objectives. First, we sought to understand the barriers and facilitators of practice change in PNCC from the perspectives of the multiprofessional clinicians who deliver it. Second, we sought to characterize how well the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation determinant framework captures them. Methods: We conducted semi-structured interviews with a purposive sample of clinicians involved in PNCC at three U.S. academic medical centers. The interview guide was developed using i-PARIHS to organize barriers and facilitators of practice change across the innovation, recipients, context, and facilitation constructs. We applied framework analysis, combining deductive i-PARIHS, study-specific, and inductively derived categories. Two coders independently indexed the transcripts and reconciled them to consensus, with first-author adjudication. Preliminary site-level findings were validated with participants. Results: We interviewed 33 clinicians: 24 physicians, 7 nurses, and 2 advanced practice providers. Most determinants of practice change mapped to existing i-PARIHS constructs, but three were not adequately captured by the framework as currently specified. The most consequential was an interprofessional authority gradient that determined whose preferences prevailed when intensive care, neurology, and neurosurgery disagreed. The other two were clinician autonomy, which served as the lens through which the acceptability of a change was judged, and the affective state clinicians bring to practice change. Receptivity depended more on recipients’ values, prior experience, and capacity to absorb change into a demanding workflow. Facilitation was variable, frequently under-resourced, and dependent on credibility across professional groups. We translated these findings into three propositions linked to implementation strategies and outcomes. Conclusions: Participants attributed practice change in PNCC more to the recipients of change, the multiprofessional context, and the availability of facilitation than to the strength of evidence for a given practice. i-PARIHS captured most barriers and facilitators well but may be adapted in this setting. Credible, resourced, authority-sensitive facilitation may improve the prospects for sustained practice change as institutions develop PNCC programs. Contributions to the literature: Determinant frameworks are widely used but rarely revised once published; this study supports three i-PARIHS framework modifications potentially applicable to the general pediatric ICU and PNCC programs regarding clinician autonomy, the affective state clinicians bring to change, and the interprofessional authority gradient. We identify authority-sensitive facilitation as an important driver of sustained practice change amongst multispecialty teams. We offer three i-PARIHS elaborations with linked implementation outcomes and implications for selecting implementation strategies for teams with shared authority across professions.

Background: Evidence-based clinical prediction rules (CPRs) improve care delivery to children in the emergency department (ED); however, clinician-level factors may impact rule implementation. We aimed to investigate the association between clinician characteristics and their risk tolerances with CT scan ordering in children with blunt head trauma at very low risk for clinically important traumatic brain injuries (ciTBI). Methods: As part of a prospective multicentre study of children with minor head trauma (Glasgow Coma Scale scores ≥14), we collected data from ED clinicians on clinician demographics, clinical experience, self-reported risk tolerance and perceptions/self-reported use of CPRs. Children enrolled were considered very low risk for ciTBI if they were negative for the Pediatric Emergency Care Applied Research Network (PECARN) TBI CPRs. Survey results were linked to the children they enrolled in the analytic database. We performed multivariable logistic regression to identify clinician-level factors associated with CT ordering in children at very low risk of ciTBI. Results: Of 481 clinicians, 421 (88%, 95% CI 84% to 90%) completed the survey. Among the 8957 children at very low risk for ciTBI, 654 (7.3%, 95% CI 6.8% to 7.9%) underwent CT scanning. In multivariable modelling, clinician-reported characteristics associated with ordering CTs in very low risk children included years of experience (adjusted OR (aOR) 1.02, 95% CI 1.00 to 1.03), caring for <50% children in one’s practice (aOR 1.55, 95% CI 1.13 to 2.12) and avoidance of uncertain outcomes (aOR 1.31, 95% CI 1.02 to 1.69). Conclusions: Despite awareness of the PECARN TBI CPRs, some clinicians ordered CTs for children at very low risk for ciTBI. More years of practice, lower clinician risk tolerance and lower proportion of children in one’s clinical practice were associated with higher CT use. Increasing involvement of providers with greater paediatric expertise in imaging decisions and addressing clinician perceptions and decision-making biases may further safely lower CT use in children with minor head trauma.

An increasing number of systematic reviews and meta-analyses examine health outcomes from traumatic brain injury (TBI). This umbrella review examines the association of TBI with comorbid health outcomes and evaluates the methodological rigor of existing literature. This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; Registration No. CRD42024581341). EMBASE, PubMed, MEDLINE, and the Cochrane Library were searched from database inception to November 26, 2025. Two reviewers screened abstracts and full texts using predefined criteria. Meta-analyses of observational studies were included if they assessed health outcomes following TBI and reported effect sizes were convertible to pooled equivalent odds ratios (eOR). PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-Analyses) guidelines were utilized for study formatting. We applied AMSTAR2 (A Measurement Tool to Assess Systematic Reviews 2) criteria to assess the quality of included studies. Health outcomes described in each meta-analysis were reanalyzed and presented through eOR using a random-effects model. 41 meta-analyses were included, covering 671 original studies and 53 comorbid health outcomes, in a cohort comprising 83 million participants across 40 countries. Our findings suggest that traumatic brain injury, acquired at any age, may be associated with impairments across neurological, somnological, cognitive, mental health, and behavioral domains. Despite these associations, 78% of the included studies were themselves classified as having “critically low” methodological quality by AMSTAR2 criteria, which limited the ability to provide causal conclusions. These findings may help inform care guidelines following TBI. Improved research frameworks are important to better understand the lasting effects of TBI.