Appl Clin Inform 2022; 13(02): 456-467
DOI: 10.1055/s-0042-1745829
Research Article

Usability and Acceptability of Clinical Decision Support Based on the KIIDS-TBI Tool for Children with Mild Traumatic Brain Injuries and Intracranial Injuries

Jacob K. Greenberg
1   Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States
Ayodamola Otun
1   Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States
Pyi Theim Kyaw
2   McKelvey School of Engineering, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States
Christopher R. Carpenter
3   Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States
Ross C. Brownson
4   Brown School of Social Work, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States
Nathan Kuppermann
5   Department of Emergency Medicine, University of California Davis, Davis, California, United States
David D Limbrick Jr.
1   Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States
Randi E. Foraker*
6   Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States
Po-Yin Yen*
6   Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States
› Author Affiliations
Funding This study was supported by the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (1F32HS027075-01A1), and Thrasher Research Fund (#15024).


Background The Kids Intracranial Injury Decision Support tool for Traumatic Brain Injury (KIIDS-TBI) tool is a validated risk prediction model for managing children with mild traumatic brain injuries (mTBI) and intracranial injuries. Electronic clinical decision support (CDS) may facilitate the clinical implementation of this evidence-based guidance.

Objective Our objective was to evaluate the acceptability and usability of an electronic CDS tool for managing children with mTBI and intracranial injuries.

Methods Emergency medicine and neurosurgery physicians (10 each) from 10 hospitals in the United States were recruited to participate in usability testing of a novel CDS prototype in a simulated electronic health record environment. Testing included a think-aloud protocol, an acceptability and usability survey, and a semi-structured interview. The prototype was updated twice during testing to reflect user feedback. Usability problems recorded in the videos were categorized using content analysis. Interview transcripts were analyzed using thematic analysis.

Results Among the 20 participants, most worked at teaching hospitals (80%), freestanding children's hospitals (95%), and level-1 trauma centers (75%). During the two prototype updates, problems with clarity of terminology and navigating through the CDS interface were identified and corrected. Corresponding to these changes, the number of usability problems decreased from 35 in phase 1 to 8 in phase 3 and the number of mistakes made decreased from 18 (phase 1) to 2 (phase 3). Through the survey, participants found the tool easy to use (90%), useful for determining a patient's level of care (95%), and likely to improve resource use (90%) and patient safety (79%). Interview themes related to the CDS's ability to support evidence-based decision-making and improve clinical workflow proposed implementation strategies and potential pitfalls.

Conclusion After iterative evaluation and refinement, the KIIDS-TBI CDS tool was found to be highly usable and useful for aiding the management of children with mTBI and intracranial injuries.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed and approved by the authors' institutional review board. The authors' institutional review board reviewed and approved the study procedures with a waiver of documentation of consent (IRB #201902091). Therefore, participants were provided with a consent document, a verbal study description, and an opportunity to ask questions before verbally agreeing to proceed with the study.

* P.Y. and R.E.F. shared equal responsibility for study supervision.

Supplementary Material

Publication History

Received: 14 August 2021

Accepted: 18 February 2022

Article published online:
27 April 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

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