A Review of Implementation Concepts and Strategies Surrounding Traumatic Brain Injury Clinical Care Guidelines

Abstract

Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: (1) possible etiologies of inadequate adoption and implementation; (2) enablers to successful implementation strategies; and (3) strategies to mitigate the barriers to adoption and implementation of future research.

Introduction

Traumatic brain injury (TBI) affects millions of people worldwide each year and encompasses a spectrum of injury severity, from mild to severe. Depending on the severity, TBI manifestations range from self-limited post-concussive symptoms to significant disability and death. Implemented best practices for the management of TBI are associated with a positive impact on patient morbidity and death¹ in the hospital and pre-hospital settings.² For example, several studies report that the implementation of the Brain Trauma Foundation (BTF) severe TBI Guidelines is associated with a reduction in worse outcomes and, in two studies, a 45% decline in deaths.^2

–6 Ideally, best practices for clinical care are derived from evidence-based clinical guidelines generated from rigorous scientific studies.

For guidelines to be effective in their translation to clinical care, they require consistent adoption and implementation among larger healthcare systems as well as medical communities encompassing multi0disciplinary care providers in varied settings. Adoption is defined as the endorsed support by organizational entities while implementation is defined as a translated clinical practice at the level of the clinician-patient relationship.^7,8 Research suggests that adoption and implementation of current TBI clinical guidelines and educational resources have been limited.^1,9 Broad themes of barriers to success include recommendation awareness and acceptance, clinical agreement and competing information, and individual and systems challenges in the execution of guideline recommendations.

As part of the Brain Trauma Blueprint, TBI State of the Science, experts in the field of TBI guideline development were engaged by Cohen Veterans Bioscience to identify current and future strategies for TBI research adoption and implementation. The objectives of this consensus review are to: (1) present enablers of successful TBI guideline implementation strategies; (2) discuss possible barriers to guideline adoption and implementation; and (3) provide strategies to mitigate the barriers to adoption and implementation of future research.

Diverse stakeholders are invested in the development and dissemination of the science supporting best practices for the clinical care of TBI and include: policymakers, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health, the Department of Defense (DoD), Veterans Affairs (VA), veterans and brain-health focused research organizations, public and private funding organizations, researchers, healthcare providers, social workers, learning institutions, patient advocacy groups, as well as patients themselves. The relay of consistent messaging supporting best practices paired with well-designed implementation strategies have the potential to dramatically improve outcomes by reducing morbidity and death, improve the quality of patient care, and reduce cost to the healthcare system.³ Stakeholder agreement of defined outcomes of interest, including how they are captured, measured, and reported, drives a consistent message to support more efficient advances in the field. Stakeholders are critical to identifying and advocating for funding to support the advancement, dissemination, and implementation of a precision-medicine approach to TBI care.

State of the Science: Status of Guidelines for Managing Traumatic Brain Injury

TBI guidelines aim to advise clinical decision-making surrounding the diagnosis, management, and/or treatment of injury to improve patient outcomes. The TBI guidelines are increasingly evidence-based, rather than consensus-driven, requiring a body of quality evidence to inform guideline recommendations.¹⁰ Severe TBI evidence-based guidelines, however, are accompanied or aided by consensus clinical management algorithms that go beyond evidence to give clinicians a roadmap for integrated clinical care.¹¹

As the body of TBI-relevant scientific literature expands each year, guidelines must adapt and modify to remain relevant. Guideline modification requires that new, quality evidence based on rigorous scientific studies has sufficiently advanced the science of TBI care to result in a clinical recommendation. In the absence of a continuity of quality scientific literature advancing the field, updates to guidelines remain limited by the existing body of evidence.¹⁰

The most common ways to modify and improve on existing guideline recommendations is to update them (be it individually or as an updated edition of an entire guideline) or maintain “living” recommendations that are continually revised according to the emerging literature. For example, the American Congress of Rehabilitation Medicine's Cognitive Rehabilitation Manual utilized a regimented approach to: (1) review and (potentially) endorse clinical guidelines, (2) perform evidence reviews of commonly used treatments after TBI, and (3) release step-by-step guidelines of evidence-based recommendations for cognitive rehabilitation after TBI.¹²

Similarly, the BTF TBI guidelines are updated approximately every five years. The Ontario Neurotrauma Foundation, on the other hand, implemented a “living guideline” approach to its pediatric mild TBI guidelines, relying on a team of experts to frequently cull the literature and, thus, inform “dynamic” guidelines for Canadian clinical coordination. The DoD takes a hybrid approach in producing clinical recommendations for the management of TBI with directives on the utilization of guidelines requiring a minimum standard review for currency, but with the ability to be updated and be modified based on set criteria related to advances in the literature.

Many published, open access, and freely available guidelines focus on differing aspects of TBI management in varying populations (children, adults, military, and/or athletes) and settings with different severities of injury (mild through severe) and stages of recovery, as exampled in Table 1. Because of the inherent fact that they share broad topical focus, there is overlap in recommendations to some degree. No single guideline, however, encompasses all severities and populations across care settings, and variability in guideline quality exits.^13
–15

Table 1.

Examples of Common Traumatic Brain Injury Guidelines and Protocols Differing by Population and Severity of Injury

Organization	Clinical focus	Patient population	Guideline title	Link
Department of Defense	Severe TBI	Military	• Traumatic_Brain_Injury_Severe_Head_Injury_02_Mar_2017_ID30	• https://jts.amedd.army.mil/assets/docs/cpgs/Complete_Zip_of_Current_JTS_CPGs.zip
Department of Defense	Mild TBI/Concussion	Military	• Department of Defense Instruction (DoDI) 6490.11: DoD Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting • DoDI 6490.13: Comprehensive Policy on Traumatic Brain Injury-Related Neurocognitive Assessments by the Military Services	• https://www.hsdl.org/?abstract&did=722999 • https://www.hsdl.org/?abstract&did=800023
Veterans Health Administration	Mild TBI (chronic)	Military	• VHA/DoD Clinical Practice Guideline for the Management of Concussion-Mild Traumatic Brain Injury	• https://www.healthquality.va.gov/guidelines/Rehab/mtbi/mTBICPGFullCPG50821816.pdf
TBICoE	Mild TBI Repeated Concussion	Military	• Military Acute Concussion Evaluation 2 (MACE 2) • Concussion Management tool • Progressive Return to Activity Following Acute Concussion/Mild TBI Clinical Suite • Recurrent Concussion Evaluation Card	• https://health.mil/About-MHS/OASDHA/Defense-Health-Agency/Research-and-Development/Traumatic-Brain-Injury-Center-of-Excellence/Provider-Resources
Brain Injury Australia	Severe TBI	Adults	• Guidelines for the Management of Severe Traumatic Brain Injury 3^rd Edition	• https://www.braintrauma.org/uploads/11/14/Guidelines_Management_2007w_bookmarks_2.pdf
American College of Surgeons TQUIP	Severe TBI	Adults	• ACS TQIP Best Practices in the Management of Traumatic Brain Injury	• https://www.facs.org/-/media/files/quality-programs/trauma/tqip/tbi_guidelines.ashx
World Society for Emergency Surgery	Severe TBI	Adults	• WSES Consensus Conference Guidelines: Monitoring and Management of Severe Adult Traumatic Brain Injury Patients with Polytrauma in the First 24 Hours	• https://wjes.biomedcentral.com/track/pdf/10.1186/s13017-019-0270-1
CDC/ACEP	Mild TBI	Adults	• Updated Mild Traumatic Brain Injury Guidelines for Adults	• https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Clinicians_Factsheet-a.pdf
Brain Trauma Foundation	Severe TBI (acute)	Children, Adults, and Pre-hospital	• Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines • Guidelines for the Management of Severe Traumatic Brain Injury 4^th Edition • Guidelines for Prehospital Management of Traumatic Brain Injury 2^nd Edition	• https://www.braintrauma.org/uploads/10/11/guidelines_pediatric3.pdf • https://www.braintrauma.org/uploads/13/06/Guidelines_for_Management_of_Severe_TBI_4th_Edition.pdf • https://www.braintrauma.org/uploads/04/13/Prehospital_Guidelines_2nd_Edition_2.pdf
Concussion Guidelines Step 2: Subtype Classification	Mild TBI (acute and chronic)	Adults and Children	• Concussion Guidelines Step 2: Evidence for Subtype Classification	• https://academic.oup.com/neurosurgery/article/86/1/2/5552009
CDC	Mild TBI (acute and chronic)	Children	• Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children	• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006878/
Ontario Neurotrauma Foundation	Mild and Severe TBI	Adults and Children	• Clinical Practice Guideline for the Rehabilitation of Adults with Moderate to Severe TBI • Guideline for Concussion/Mild Traumatic Brain Injury & Prolonged Symptoms 3^rd Edition, For Adults Over 18 Years of Age • Living Guideline for Diagnosing and Managing Pediatric Concussion	• https://braininjuryguidelines.org/modtosevere/ • https://braininjuryguidelines.org/concussion/ • https://braininjuryguidelines.org/pediatricconcussion/
Institute of Medicine	Sports-related concussion	Children	• Diagnosis and Management of Sport-Related Concussion Best Practices	• https://www.ncaa.org/sites/default/files/SSI_ConcussionBestPractices_20170616.pdf
NCAA Sport Science Institute	Sports-related concussion	Young Adults	• Concussion Safety Protocol Template	• http://www.ncaa.org/sport-science-institute/topics/concussion-safety-protocol-template

The choice of which guideline to adopt is directly related to its thematic applicability and relevance to the patient population and setting in question, as well as its timeliness and quality of recommendations. For example, the Ontario Neurotrauma Foundation's mild TBI guidelines is used to direct clinical care of pediatric patients in Canada's coordinated health system, and the BTF severe TBI guidelines are mandated in all United States (US) trauma centers verified by the American College of Surgeons Committee on Trauma.^16,17 Further exemplified in the military health system, the DoD instructions and Traumatic Brain Injury Center of Excellence (TBICoE) clinical recommendations provide mild TBI evaluation and management guidance from the point of injury,¹⁸ while the Veterans Health Administration/Department of Defense (VHA/DoD) Clinical Practice Guideline for the Management of Concussion-Mild Traumatic Brain Injury specifically excludes the immediate injury period (0–7 days).

Barriers to Adoption and Implementation

The availability of widely published, evidence-based TBI guidelines does not guarantee their adoption and implementation. A survey of severe TBI management across more than 250 US trauma centers shortly after the first TBI guidelines were published reported that approximately one-third followed guideline recommendations to routinely perform intracranial pressure monitoring.¹⁹ Similarly, the adoption/adherence of mild and severe TBI guidelines is inconsistent among many clinicians.^1,9,20

Several previously reported frameworks to advance implementation science of healthcare research in general exist,^21
–23 exemplified by the Consolidated Framework for Implementation Research (CFIR),²⁴ which is composed of five major domains: intervention characteristics (evidence strength and quality), outer setting (patient needs and resources), inner setting (culture and engagement), characteristics of the individuals involved, and implementation process. The following specifically addresses barriers relevant to TBI guideline adoption and implementation at both the system-wide and individual clinician level, including geographical considerations, in line with domains reflected in the CFIR.

Barriers to system-wide adoption and implementation of TBI guidelines include: (1) limitations to time and resources dependent upon hospital capabilities and trauma designations; (2) variations in patients' point of healthcare entry; (3) multi-disciplinary coordination of efforts; (4) limitations to coordination of care in transitioning care settings and in return to work/school; and (5) mandates requiring universal utilization. For instance, the delivery of care within a given healthcare system appears to depend on the point of entry of the individual patient into the system (i.e., primary care, specialty care, emergency department).²⁵ Even among high-volume trauma centers in the United States, many patients with mild TBI do not complete medical follow-up after hospital discharge.²⁶

Organizational factors such as reimbursement, provider caseload, and time constraints can affect adherence to guidelines.²⁷ Studies have shown that patients receiving treatment in a Level I Trauma Center or being in a country with higher economic status were more likely to receive care consistent with BTF guideline recommendations.^28
–30 Similarly, a study found that trauma center designation and TBI patient volumes impacted adherence to guideline recommendations for pediatric intracranial pressure monitoring.³¹ These findings highlight the need for increased education and coordination of TBI management spanning a variety of settings such as critical care units and emergency departments, but also in family clinics and outpatient settings.

Barriers to guideline implementation by individual clinicians include: (1) concern for strength of evidence supporting guidelines and guideline quality; (2) concern for complexity of recommendation implementation; (3) limited time and resources for clinical implementation; and (4) concern for clarity and detail of clinical applicability of recommendations.^9,32,33 For example, although guidelines advise intracranial pressure monitoring for severe pediatric TBI, there is inconsistent practice in the emergency department setting. One study found that 29% of children with severe TBI presenting to one of five academically affiliated pediatric trauma centers received intracranial pressure monitoring early in the emergency department, with wide variations in the frequency and setting of monitor placement.³¹ Although guidelines exist, they lack definitive parameters that may lead to inconsistent practice among clinicians in the emergency settings.^31,34

Another central issue to TBI guideline adoption and implementation by individual clinicians surrounds the need for clarity and consistency in the definition of mild, moderate, and severe TBI.³⁵

Geographical and socioeconomic factors, as well as disparities in care, present barriers to guideline adoption and implementation. Guidelines generated from other regions of the world may be less applicable and/or feasible to another healthcare system. The majority of TBI deaths occur in low and middle-income countries, yet guidelines are often developed based on resources that are more widely available in high-income countries.^13,36 Indeed, most studies that advise the pre-hospital and severe TBI guidelines for children and adults were conducted in the US and Europe.^1,37

A 2016 study found that the guideline adherence rate is particularly low for pre-hospital care (∼26%, compared with 85% in the emergency department setting).³⁸ Importantly, longer transport time was associated with worse discharge outcomes, consistent with findings from a pediatric TBI study in the US that showed that non-value–added time has negative impacts on outcomes.³⁹ These observations highlight the need to improve adherence to guidelines, especially in rural, pre-hospital, and other austere settings, and to find ways to reduce delays, interruptions, waiting times, and transfer times for TBI care.

Enabler Strategies to Improve Guideline Adoption and Implementation

Because coordination of care across disciplines, settings, and systems is critical to best outcomes, TBI guidelines must focus on translatable, evidence-based content designed for dissemination in a variety of settings and target populations.⁴⁰ There is a paucity of evidence-based strategies specific to TBI. While evidence-based strategies to improve guideline adoption relevant to other disease processes are limited in scope and impact, and the generalizability to TBI is unclear, we review key concepts. The following describes previously employed strategies to improve existing TBI guideline adoption and implementation by healthcare systems and clinicians including knowledge transfer models incorporating dissemination strategies, clinical tools, and clinical constructs.⁴¹

Dissemination strategies

Commonly used dissemination strategies for TBI guidelines include media (print and radio) report, television report, website content, social media messaging, didactic courses, and digital applications including video gaming. Media is a powerful dissemination strategy that has facilitated general knowledge transfer regarding sports-related concussion, especially following news stories on high profile athletes and professional sports teams, as well as the release of Hollywood movies on the topic.⁴² This has improved TBI awareness in general, making “concussion” a common household term.

In addition to traditional printed knowledge transfer strategies such as newspapers and other periodicals, emerging knowledge-transfer strategies involve the interactive use of social media, mobile device apps, website content, and video games.⁴³ Social media platforms may be cost-effective and potentially powerful tools for educating clinicians, athletics personnel such as coaches, and the community about the prevention, diagnosis, and management of TBI.^44,45 The HEADS UP educational initiative by the CDC⁴⁶ utilizes many of these aforementioned dissemination strategies. This program, first initiated in 2003, provides education and awareness on the long-term consequences of concussion and other types of TBI. These materials aim to support coaches, parents, and school professionals to help improve prevention, recognition, and response to concussion. During development, the CDC tailored these resources to appeal to target audiences, leveraged a variety of formats (e.g., videos, fact sheets, mobile apps, and social media content), and worked with partner organizations for dissemination. Importantly, the structure of the HEADS UP campaign has remained flexible to adjust for different growth opportunities.

Similarly, the Ontario Neurotrauma Foundation utilizes a web-based platform to disseminate information to patients and clinicians. Smaller organizational efforts to expand TBI guideline dissemination include the non-profit organization TeachAids' Crash Course—a virtual reality video game aimed to educate users about concussion. The DoD primarily disseminates moderate and severe TBI guidelines through the Joint Trauma System (JTS)⁴⁷ and mild TBI information through TBICoE and designated TBI service leaders from Air Force, Army, Marine Corps, and Navy representation on the TBI Advisory Committee (TAC) providing web-based programs, videos, and directives for clinicians, Service members, Veterans, and their caregivers.

Guideline dissemination strategies that have been studied in relationship to other disease states and research support that focusing on (1) the education of clinicians and/or patients and (2) print material were the most commonly employed strategies for translating guidelines to practice.⁴⁸ Multi-faceted strategies using interactive education were successful in a 2008 systematic review of other disease states. Notably, this work reported that the use of didactic education and passive dissemination strategies were ineffective, although this review did not examine TBI research implementation.

Clinical tools

Commonly used clinical tools include clinical care algorithms, protocols, pathways, calculators, and diagnostic tests. The recent BTF Pediatric Severe TBI Guideline⁴⁹ included care algorithms in response to research calling for guideline recommendation translation to advanced clinical care pathways.¹⁰ In the context of sport-related concussion, several research conferences have worked toward a consensus on the management of patient symptoms.⁴⁵ These efforts have led to development and deployment of the Sport Concussion Assessment Tool (SCAT), a brief multi-dimensional screener of post-concussive symptoms, cognitive function, balance, and other abilities affected by concussion. More recently, in 2017, a modified SCAT5 (5th edition) was introduced and has become a standard in sports concussion assessment, adopted by many sporting organizations such as the National Football League.

The Concussion in Sport Group Consensus Statements⁵⁰ also outline a step-wise protocol for graded exertion and return to play after sport-related concussion. Follow-up work has focused on adapting and implementing these guidelines for specific sports, ages, and levels of participation.⁵¹ Military-specific clinical tools are developed through TBICoE in coordination with the TAC providing a refresh to the Military Acute Concussion Evaluation 2nd version in 2018 and the Progressive Return to Activity Clinical Recommendation expected in early 2021.

Clinical and organizational constructs

Large-scale efforts to implement guideline recommendations have resulted in new clinical and organizational constructs. For example, studies report that the US experienced a rise in specialty concussion clinics⁵² with a major shift in concussion management over the past 20 years.⁵³ Current-day concussed athletes are withheld from play more than 10 days longer than in the past, which resulted in a 41% reduction in the rate of same-season repeat concussion.⁵³

On a healthcare systems scale, the Ontario Neurotrauma Foundation utilizes a united healthcare system to translate research into clinical practice. The Pediatric Guideline Adherence and Outcomes (PEGASUS) program was designed to improve implementation and effectiveness of guidelines.⁵⁴ This program leverages knowledge from multiple stakeholders, including surgeons, emergency department physicians, anesthesiologists, nurses, pharmacists, nutritionists, and social workers, and utilizes implementation science frameworks, a multi-level approach, and tailored clinical pathways. In a pilot study at a Level 1 trauma center, PEGASUS showed high fidelity and improved adherence to guidelines.⁵⁴ The results of this study emphasize the importance of bedside nursing in successful implementation.

As stated previously, and with relevance to organizational constructs supporting guideline adoption, BTF Severe TBI Guidelines recommendations are mandated in all US trauma centers verified by the American College of Surgeons Committee on Trauma (ACS-COT).¹⁶ Most states use the ACS-COT recommendations to monitor trauma center adherence to best practice. Compliance with ACS-COT criteria has been associated with low undertriage rates and improved overall mortality rates for acutely injured patients.⁵⁵ This enforcement of evidence-based guidelines by a certifying body is a model for ensuring adherence to guidelines recommendations.

Other efforts include the CDC developing the National Concussion Surveillance System,⁵⁶ which may assist in supporting and indirectly monitoring guideline implementation. In response to a lack of standardization of mild TBI care in the DoD, the DHA has prioritized an initiative “Improving Treatment Outcomes for Patients with Acute Concussion,” providing policy mandating the utilization of common mild TBI tools and clinical recommendations, providing education to support implementation, and measuring patient reported and clinical outcomes to best inform ongoing refinement of the process.

The National Academies of Science, Medicine and Engineering (NASEM) has recently commissioned a committee on Accelerating Progress in Traumatic Brain Injury Research and Care. Based on current state and opportunities for advancement, this NASEM committee is charged with identifying major barriers and knowledge gaps that are impeding progress in the field, highlighting opportunities for collaborative action (both intergovernmental and public-private) that could accelerate progress in TBI research and care, and provide a road map for advancing both research and clinical care that would guide the field over the next decade.⁵⁷

Finally, TBICoE has conducted active surveillance of DoD TBI numbers and severity since 2000, and JTS utilizes a data collection tool through the DoD Trauma Registry generating actionable medical information leading to advancements in TBI care.⁵⁸

Call to Action: Framework Strategies for Guideline Implementation

While the previously discussed enabler strategies represent a host of important initiatives, understanding their impact on guideline adoption and implementation is key to support specific frameworks for future projects. Guideline work groups/committees may utilize validated guideline appraisal instruments, such as the Appraisal of Guidelines, Research, and Evaluation (AGREE) Instrument⁵⁹ or the Agency for Healthcare Research and Quality's National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) Instrument⁶⁰ to inform key factors in guideline development and process reporting.

Large organizations such as the CDC, Ontario Neurotrauma Foundation, and World Health Organization utilize epidemiologic data to inform associations with guideline initiatives and patient outcomes over time. The DoD has conducted several studies focused on the value of observational and interventional trials performed within the clinical milieu where the evaluated practices and programs would ultimately be implemented.^61

–65 These studies evaluate the effectiveness of TBI tools and guidelines in real world clinical settings, the results of which may identify best practice for compliance, implementation, and adoption of principles designed to improve clinical capabilities and patient outcomes.

Ideally, prior to designing future research aimed at informing best practices, strategies for implementation should be addressed. Large scale effort to coordinate research and implementation is exampled by efforts currently under way to support the Deputy Secretary of Defense's Comprehensive Strategy and Action Plan for Warfighter Brain Health memo, which called for a unified DoD plan to address warfighter brain health and TBI in the areas of research, surveillance, prevention, diagnosis, treatment, outreach, and education.

Several studies have examined improving clinical guideline use with proposed frameworks to address future work. For example, a 2011 review suggested that future guidelines address “implement-ability” content that included several domains (adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation).⁴⁰ Along these lines, and with specific relevance to TBI research, pre-specified frameworks for guideline implementation should incorporate aspects of these domains (see Table 1). On a larger scale, funding agencies should take an active role in supporting the implementation of best practices by requiring proposals to include an implementation plan and/or a focus on measuring dissemination and implementation.

Conclusions

Numerous TBI guidelines exist aiming to inform best patient care with significant measured impacts on patient morbidity, death, and other clinical outcomes. Despite this, their universal adoption and implementation by healthcare systems and individual clinicians in the US remain limited and will continue to remain limited in the absence of well-designed frameworks, as exampled, for implementation. For clinical relevance, we summarize our findings with five takeaways and four recommendations that include specific action items (Table 2).

Table 2.

Actionable Research Recommendations for Implementation Science in Traumatic Brain Injury

Recommendation	Action
Identify implementation limitations of existing and future guidelines as well as scientific studies and develop mitigating strategies	• Introduce strategies and tools that identify the limitations of scientific study implementation. • Discuss potential implementation barriers and suggest strategies to address them within future guidelines.
Support the development of evidence-based consensus-driven “living” guidelines that adapt with pre-clinical and clinical discoveries	• Collaborate with implementation scientists during the development of clinical trials and guidelines. • Adapt guidelines to address severity and chronicity of injury, as well as varied demographics.
Plan and conduct scientific studies that provide strategies and tools supportive of study outcome adoption and implementation across domains of care	• Encourage studies dedicated to implementation science relevant to TBI and/or incorporate implementation planning relevant to TBI. • Identify potential implementation barriers and suggest strategies to address them within future reports. • Include a variety of user-friendly materials to support study implementation. • Develop improvement strategies for next iterations and updates.
Develop and integrate an implementation action plan by leveraging state, local, and community action	• Develop a centrally managed patient research registry and provide a framework for facilitating scientific access and funding support. • Develop effective partnerships across government and non-government agencies to reduce silos and ensure a coordinated approach to research and information dissemination. • Develop funding efforts geared toward studies utilizing implementation science to translate study outcomes. • Propose legislative changes that remove administrative barriers delaying success in research.

TBI, traumatic brain injury.

Major takeaways

▪ Numerous evidence-based TBI guidelines exist addressing various severities of injury and stages of recovery in specific populations and settings.

▪ Existing TBI guidelines have been variably adopted and implemented by healthcare systems and clinicians.

▪ Limited adoption or implementation of TBI guidelines is likely multi-factorial—because of a wide range of individual, patient, clinician, and healthcare systems-based issues, as well as geographical issues.

▪ TBI guideline recommendations require frequent re-assessment and update as quality evidence emerges.

▪ There is a need for more effective paradigms/frameworks to support and measure the effectiveness of TBI guideline implementation.

Footnotes

Acknowledgments

The views expressed in this manuscript are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.DVBICinfo@mail.mil. UNCLASSIFIED

Author Contributions

All authors had full access to this manuscript and take responsibility for the integrity and accuracy of the content.

Funding Information

This work would not have been possible without the financial support provided by Cohen Veterans Bioscience through grant COH-0003 from Steven A. Cohen. Cohen Veterans Bioscience conceptualized and funded the Brain Trauma Blueprint. Additional information can be found at www.braintraumablueprint.org.

Author Disclosure Statement

No competing financial interests exist.

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