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Trauma is the most common cause of mortality among people between the ages of 1 and 45 years, costing Canadians 19.8 billion dollars a year (2004 data), yet half of all patients with major traumatic injuries do not receive evidence-based care, and significant regional variation in the quality of care across Canada exists. Accordingly, our goal is to lead a research project in which stakeholders themselves will adapt evidence-based trauma care knowledge tools to their own varied institutional contexts and cultures. We will do this by developing and assessing the combined impact of WikiTrauma, a free collaborative database of clinical decision support tools, and Wiki101, a training course teaching participants how to use WikiTrauma. WikiTrauma has the potential to ensure that all stakeholders (eg, patients, clinicians, and decision makers) can all contribute to, and benefit from, evidence-based clinical knowledge about trauma care that is tailored to their own needs and clinical setting.
Our main objective will be to study the combined effect of WikiTrauma and Wiki101 on the quality of care in four trauma centers in Quebec.
First, we will pilot-test the wiki with potential users to create a version ready to test in practice. A rapid, iterative prototyping process with 15 health professionals from nonparticipating centers will allow us to identify and resolve usability issues prior to finalizing the definitive version for the interrupted time series. Second, we will conduct an interrupted time series to measure the impact of our combined intervention on the quality of care in four trauma centers that will be selected—one level I, one level II, and two level III centers. Participants will be health care professionals working in the selected trauma centers. Also, five patient representatives will be recruited to participate in the creation of knowledge tools destined for their use (eg, handouts). All participants will be invited to complete the Wiki101 training and then use, and contribute to, WikiTrauma for 12 months. The primary outcome will be the change over time of a validated, composite, performance indicator score based on 15 process performance indicators found in the Quebec Trauma Registry.
This project was funded in November 2014 by the Canadian Medical Protective Association. We expect to start this trial in early 2015 and preliminary results should be available in June 2016. Two trauma centers have already agreed to participate and two more will be recruited in the next months.
We expect that this study will add important and unique evidence about the effectiveness, safety, and cost savings of using collaborative platforms to adapt knowledge implementation tools across jurisdictions.
Injuries represent a major health and economic burden for Canadians. They are the most common cause of mortality for people between the ages of 1 and 45 years [
Promoting best practices in trauma care has become an urgent and strategic investment for the health of Canadians and others [
In partnership with our team of researchers, the INESSS in Quebec is exploring how wikis could be used to improve the delivery of care to trauma patients. The INESSS oversees the quality of trauma care in the province of Quebec, Canada. It is also the accreditation body that designates different trauma center levels. This organization has expressed the need to explore wikis as a solution to improve the quality of care in trauma. To this end, we have conducted a scoping review that found that wikis could be effective in supporting the implementation of best practices in health care [
Building on these results, we held a meeting funded by the Canadian Institutes of Health Research (CIHR) in May 2014 in partnership with the INESSS, the Trauma Association of Canada, and the Royal College of Physicians and Surgeons of Canada to plan a study to evaluate WikiTrauma (see
Thus, in partnership with the INESSS and in collaboration with our other WikiTrauma partners, we propose an interrupted time series to measure the combined effect of Wiki101 and WikiTrauma on the quality of trauma care in four trauma centers in Quebec. We also propose to conduct a mixed-methods process evaluation in parallel with this trial to explore possible causal mechanisms about how our combined intervention succeeds—or fails—to lead to improved quality of trauma care.
Screenshot of WikiTrauma order set.
Screenshot of Wiki101 training program.
Ultimately, we seek to test our hypothesis that our theory-based intervention (Wiki101) in combination with the use of WikiTrauma will result in better adoption of best practices in trauma care in Canada (see the conceptual framework in
Conceptual framework underlying the proposed mechanism of action for the intervention.
Getting new evidence into health care practice is a slow and challenging process [
Various aspects of trauma care can impede best practices [
Systematic reviews indicate that computer-based reminders are effective interventions for fostering best practices in a variety of clinical areas [
According to behavior-change theories, self-efficacy—roughly defined as an individual’s belief in his/her own competence—is one of the most important cognitive determinants of behavior [
Studies have found that 70% of junior physicians (mostly residents) use Wikipedia weekly [
Our main objective will be to study the combined effect of WikiTrauma and Wiki101 on the quality of care in four trauma centers in Quebec using an interrupted time series design. Our secondary objectives will be (1) to evaluate the impact of our intervention on mortality, rate of complications, length of stay, and the Functional Independence Measure (FIM), (2) to evaluate participants' opinions about the combined intervention—Wiki101 and WikiTrauma, (3) to evaluate the quality of the different knowledge tools developed in WikiTrauma, and (4) to estimate the costs saved by sharing the different knowledge tools within WikiTrauma.
In consultation with two human factors specialists (HW, ST) and using the versions of WikiTrauma and Wiki101 developed at the planning meeting, we will further refine WikiTrauma and Wiki101 by employing user-centered design methods focused on our users' needs [
This study will be an interrupted time series with a parallel, theory-based process evaluation alongside the trial (see
Diagram representing the interrupted times series design.
Participants from trauma centers assigned to the experimental group will receive a password to access and complete the Wiki101 course and to use WikiTrauma. They will receive three reminders at 2-week intervals to complete Wiki101. Before and after each Wiki101 course, participants will be administered a validated questionnaire to measure changes in opinion and beliefs about using WikiTrauma. Questionnaires will also be repeated after the prospective 12-month period. After each course, participants will also receive a 2-week reminder about skills taught during the course.
Participants in the control group will receive an email promoting access to the regular INESSS webpage and will also receive three reminders at 2-week intervals to access the website. They will not have access to view or edit WikiTrauma.
For the purpose of this trial, to monitor its use, and ensure its quality, access to WikiTrauma will be protected by password.
Since the wiki content can be constantly changed by the participants, the quality of information and the strength of evidence will be assessed weekly by a medical expert (JL) and monthly by the steering committee using a standardized evaluation form. This committee will edit any serious deviations from recognized standards of care and will flag controversial topics to stimulate discussion within the wiki community.
All professionals and decision makers working in the four participating trauma centers will be eligible to participate. With the help of the local leaders on the trauma committee, we will recruit as many clinicians (eg, physicians, nurses, respiratory therapists, and pharmacists) and decision makers (eg, heads of Emergency Department, Surgery Department, and Critical Care Department) as possible. All participating trauma committees will also be asked to designate five patient representatives to take part in the construction of various tools designed for their use (eg, decision aids and patient handouts). In each center, we will present the project to the local representatives of each trauma committee. We will provide a hands-on Wiki101 session to all the members of the local trauma committee and the five patient representatives, who will then become the local leaders able to teach their colleagues how to access the wiki and contribute to its content. An online version of Wiki101 will be available to all clinicians and patient representatives for future consultation.
Although blinding of the participants and randomization are not feasible in this small trial, we will mobilize all efforts to minimize any other sources of bias. All data collectors (medical archivists) will be blinded to the allocation group. Throughout our study, we will prevent contamination by protecting Wiki101 and WikiTrauma by password and note any potential competing intervention. We will also identify any professional working in more than one participating trauma center to consider the impact of this potential source of bias. Wiki101 will be a standardized online training program. We will encourage all participants to complete all 12 months of the study. To minimize a potential Hawthorne effect, our control group will receive an invitation to consult the INESSS website at the beginning of the study. Moreover, our proposed study design of an interrupted time series provides the advantage of controlling for secular trends in the data.
We will select four trauma centers—one level I, one level II, and two level III trauma centers. The two level III centers will be identified by the authors based on their willingness to participate and collaborate with the other trauma centers for the 12-month project. At the individual level, study participants must be decision makers (eg, trauma program coordinators) or health care professionals (eg, emergency physicians, critical care physicians, trauma surgeons, nurses, respiratory therapists, physiotherapists, or pharmacists). Patient representatives will be selected without any restrictions or limitations with regard to their qualifications. These patient representatives could also be caregivers to existing trauma patients. Health care professional students and trainees (eg, residents, medical students, and nursing students) will have the same access to WikiTrauma and Wiki101 as fully certified professionals.
At the cluster level, a trauma center will not be eligible to participate if more than 50% of the members of the local trauma committee refuse to participate. Reasons for exclusion or refusal to participate will be documented. Pediatric trauma centers will be excluded.
Wiki101 will take 3 hours to complete for each participant and they will have access to use Wiki101 and WikiTrauma for 12 months.
Aside from our pre- and post-Wiki101 questionnaire and the 2-week reminder after completing Wiki101, we will only administer a final questionnaire after the 12-month treatment period.
The primary outcome measure will be the change over time in a validated, composite performance indicator score based on 15 process performance indicators found in the Quebec Trauma Registry [
We will measure quarterly composite performance scores from the Quebec Trauma Registry for all 57 adult trauma centers. Data in the Quebec Trauma Registry is routinely collected in all Quebec trauma centers every 3 months. The composite performance score is calculated as the average of 15 other indicators routinely collected in the Quebec Trauma Registry [
Since participants can change wiki content, the quality of information and the strength of evidence will be assessed weekly by an INESSS medical expert, and monthly by the scientific committee using a standardized evaluation form. This committee will edit any serious deviations from recognized standards of care and will flag controversial topics to stimulate discussion within the wiki community. The quality of different KT tools will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology for grading quality of evidence and strength of recommendations [
As a rule of thumb for an interrupted time series, 10 measurement points before and 10 measurements after an intervention provides 80% power to detect a change in level of 5 standard deviations (of the predata) only if the autocorrelation is greater than .4 (ie, extent to which data collected close together in time are correlated with each other) [
Segmented regression will be used to measure, statistically, the changes in level and slope in the postintervention period compared to the preintervention period [
We plan to enlist two researchers experienced in qualitative content analysis who will review participants' written questionnaire answers to identify the barriers in using our intervention. They will also try to understand how our combined intervention succeeded—or failed—to lead to improved quality of trauma care. When consensus between the two reviewers is not possible, a third reviewer will be consulted.
This project is planned to last 18 months. We have planned 3 months to implement the trial, including ethics approval in the four designated trauma centers and for delivering Wiki101 to the four local trauma committees. We will analyze all retrospective data obtained from the Quebec Trauma Registry in the first 3 months of our study and every 3 months thereafter for a total of 12 months. The last 3 months will be used to prepare our datasets, conduct our various analyses, and write our final report.
We will apply for ethical approval to conduct this trial in all four participating trauma centers. All participants will be asked to consent before accessing the wiki for the first time and before any questionnaire administration. Local trauma committees will be consulted and we will obtain approval and support from each trauma center's chief executive officer. Patient participants will also be asked to complete a consent form before participating in any phase of this trial.
A legal disclaimer will also be posted on the wiki site asking participants to always use their clinical judgement first. Clinical judgement should never be replaced by any information found in a protocol based in WikiTrauma. In addition, clinicians should only use the wiki pages that have been approved by their local trauma committee.
All personal information on study participants will remain anonymous and we will not publish the names of any of the participating trauma centers. All sensitive information will be kept in a locked filing cabinet at the principal investigator’s (PI) research center or in a password-protected computer at the research center.
This project was funded in November 2014 by the Canadian Medical Protective Association. We expect to start this trial in early 2015 and preliminary results should be available in June 2016. Two trauma centers have already agreed to participate and two more will be recruited in the next months.
We expect that this study will yield important and unique evidence about the effectiveness, safety, and cost savings of using collaborative platforms to adapt knowledge-implementation tools across jurisdictions. A recent scoping review had not identified any prospective studies analyzing the impact of a wiki intervention on the quality of care in any field of health care [
Centre hospitalier affilié universitaire
Centre hospitalier universitaire
Canadian Institutes of Health Research
continuing professional development
Centre de santé et services sociaux
computerized tomography
Functional Independence Measure
Grading of Recommendations, Assessment, Development and Evaluation
Institut national d'excellence en santé et services sociaux
knowledge translation
principal investigator
The authors would like to thank the following agencies for funding this project: the Canadian Medical Protective Association, Fonds de recherche du Québec—Santé (Career Scientist Award, 24856 and Establishment of young researchers—Junior 1 grant, 24856), the Canadian Institutes of Health Research (Planning Grant, RN201023 - 309271), and the CSSS Alphonse-Desjardins—Centre hospitalier affilié universitaire (CHAU) de Lévis. The authors would also like to thank the members of the Canadian Critical Care Trials Group for supporting the development of this protocol and Dr Shane English for having peer-reviewed our manuscript. The authors would also like to thank Louisa Blair and Sandra Owens for editing the manuscript. In addition, the authors would like to thank Marie Robert from the Fondation NeuroTrauma Marie-Robert, François Belleau, Jacob Orlowitz, Patrice Di Marcantonio, Mathieu Vézina, Marcel Rheault, Sylvain Croteau, Jean-Luc Morin, Saileth Ramirez, Yves Daigle, Susie Gagnon, Claudine Blanchet, Amina Belcaïd, Charles Lacroix, Jean-Michel Garro, Amélie Bujold, Rémi Blanchette, Jean-Daniel Boutin, Dr Richard Boisvert, Dr Nelson Piché and Dr Stéphane Panic for participating in the development of this project.
Christian Chabot works for Telus Health. Telus Health offers many different health information technology solutions, including electronic medical records. Telus has not had any role in influencing the content of this protocol. None of the other authors have received any honorariums for the conduct of this trial from Telus. Richard Grenier works for Thales Canada as Director of Research and Technology. Thales has provided in-kind financial support for the development of the wiki, but has not had any role in influencing the content of this protocol. None of the other authors have received any honorariums for the conduct of this trial from Thales.