Implementing best evidence
in stroke rehabilitation practice:
Role of an Advanced Practice Leader
Claire Perez, MSc, pht
and Joyce Fung, PhD, PT
1st National Knowledge Translation
Conference in Rehabilitation
May 5, 2016
Advanced Practice Leader
Clinical
KT
Research
Academic
Sensori Motor Rehabilitation Research Team (2011-2016)
S. Rossignol, J. Doyon, J. Fung, S. Nadeau and C. Richards
“Stroke Team” Objectives:
1. Build a partnership between researchers,
clinicians & coordinators to promote
knowledge exchange
2. Develop and promote new treatment and
interventions
3. Track patient recovery & evaluate treatment
effectiveness using functional outcomes
4. Standardize clinical outcome measures used
in physical (PT) & occupational therapy (OT)
Ottawa Model of Research Use (OMRU)
1
Implementing a core set of outcome measures
for stroke rehabilitation (PT & OT)
4
5
2
3
Logan, J, Graham, ID. Toward a comprehensive interdisciplinary model of
health care research use. Science Communication 20/2: 227–246.1998.
Sudsawad (2007) http://www.ncddr.org/kt/products/ktintro/allinon e.html
National Collaborating Centre for Methods and Tools (2010). OMRU:
A Framework for Adopting Innovations. http://www.nccmt.ca/resources/search/65.
6
Step 1 : Set the stage
 Assessment of actual state of practice – pre project
• clinician questionnaire
• chart audit
• flowsheet treatment data
 Gap analysis
To adapt the evidence to
• identify gaps
between stroke practice and
best practice recommendations
 Present & share findings
• dessiminate info about current practice
• target audience – stroke program OT’s and PT’s
Step 1 : Set the stage
• Assessment of actual state of practice –
• clinician questionnaire
• chart audit
• flowsheet
• Present & share findings • dessiminate info about
current
To adapt
thepractice
evidence to
• target audience of OT’s and PT’s
• Gap analysis
Frequency of outcome use
• identify gaps between practice and best practice recommendations
20% - 60%
Step 1 : Set the stage
 Create awareness
• actual vs. “perceived” or “assumed” performance
ie. frequency of outcome use
 Promote reflection
& critical thinking about practice
To adapt the evidence to
 Provide rationale for use of standardized measures
 Specify resources & strategies for implementation
Theory of research utilization enhancement: A model for occupational therapy.
Craik J. and S. Rappolt. Revue Canadienne D’Ergothérapie 70(5):266-275. 2003.
Step 2 : Specify the innovation
 Use of a core set of standardized measures for stroke*
5 measures
1  new measure*
7 measures
1 new measure*
Chedoke
Montreal Cognitive Assessment
To adapt the evidence
to Shoulder Pain Scale
Chedoke Motor Recovery Scales
Bells Test
Modified Ashworth Scale
Arm & Hand Activity Inventory*
Nottingham Sensory Assesment*
(CAHAI 9)
Berg Balance Scale
Box & Blocks Test
Gait Speed
Nine Hole Peg Test
6-min walk test
*Inspired by Canadian Stroke Best
Practice Recommendations (CSBPR)
Step 3 : Assess for Barriers and Facilitators
 Barriers and facilitators
• Organization/system – time, resources, equipment
• Clinician – knowledge level, habits, beliefs
To adaptattitudes,
the evidenceskills,
to
 Consider awareness,
experience, needs
 Identify strategies to overcome /minimize barriers
Knowledge translation in physical therapy: from theory to practice.
Zidarov D. et al. Disabil Rehabil 35(18):1571-7. 2013
Knowledge exchange and translation: An essential competency in
the twenty-first century. Law M. et al. Occupational Therapy Now
10 (5):3-5. 2008
Facilitators
Barriers
Skilled, dynamic & positive group
Relevance/choice of specific measures
Full support of program coordinator
Sense of imposing vs. clinical judgement
Strong culture of incorporating best
practice
Stressful time – restructuration of hospital:
program changes, staff changes / turnover,
uncertainty …… reform of healthcare
To adapt
evidence to
Good relationship between APL
& thesystem
therapists/program
In to out-patient continuum vs. redundancy
Existing practice – use of outcomes
Time constraints/case load
Flexibility to “tailor” measures into
existing interdisciplinary evaluations Readiness to change vs. status quo
Step 3 : Assess for Barriers and Facilitators
Adaption to our local context
 Decision (research / APL) made early on that 1 outcome
measure (Chedoke Activity Inventory – gross motor &
s
walking index) would not be
implemented at JRH (too
many barriers)
Most practice changes are unlikely to be adopted universally at the same time. Some people
will be more
 New eval forms included as addendums until revision of
willing and ready
the stroke inter-disciplinary assessment
 Creation of new procedures /documentation (flowsheets)
to facilitate continuum of services from in to out patient
and avoid assessment redundancy
Step 4 : Select the Knowledge Translation Strategies
 Interactive educational meetings & workshops
• Training sessions – inservices for PT / OT
• Scoring / standardization – review / discussion groups
 Participatory work (small groups) to create flow sheet of
outcomes for in out patient “transition” phase
Over time, the innovation becomes “accepted practice” and a new operationalization of
“treatment as usual” takes its place in the community
 Support & reminders (mainly electronic) and feedback
(individual/group)
 Provide educational emails and best practice updates in
form of “Treatment Tips” – to all PT’s and OT’s
Step 5 : Monitor Adoption
Adherence
 Examples of % Frequency of outcome measure use over 3 years
Initial evaluation
PT
Discharge evaluation
OT
100
100
90
90
80
80
70
60
To adapt the70
evidence to
60
50
50
40
40
30
30
20
20
10
10
before 2014
2014 – 2015
2015 – 2016
0
0
Sensory Sensory LE SH pain
UE
Bells test
CAHAI
Box &
Blocks
9HPT
Sensory Sensory LE SH pain
UE
? transition to out-patient
vs. real adherence issue
Bells test
CAHAI
Box &
Blocks
9HPT
Step 5 : Monitor Adoption
Uptake
 Mean increase in outcome use of 20% each year (for past 2 years)
100
90
80
Year 1
Year 2
70
60
50
40
To adapt the evidence to
30
20
10
0
Sensory UE Sensory LE Chedoke
SH pain
Bells
CAHAI
B&B
9HPT
5% change indicates a real improvement in adherence*
* Clinician adherence to a standardized assessment battery across
settings and disciplines in a post-stroke rehabilitation population.
Bland M. et al. Arch Phys Med Rehabil. 94(6):1048–53. 2013
CONCLUSIONS
 Successful increase in use of outcome measures
 Yearly trend toward improved adherence
 Differences in uptake found between disciplines
To adaptlevels
the evidence
to
• PT generally higher
of adherence
• OT adherence higher at initial vs. at discharge
 Time is needed before “new” becomes “accepted practice”