protocols / clinical practice guidelines knr 365
TRANSCRIPT
WHAT ARE PROTOCOLS?
Provide link between addressing client needs & evaluating the effects of service delivery
Document the purposeful procedures used to deliver intervention to clients
Provide a basis for evaluating the efficacy of those procedures
WHAT ARE PROTOCOLS?
Major factor in being able to standardize care & produce predictable client outcomes
When researched and validated, may provide a common basis of TR treatment procedures used across the country
“Common practice”
WHAT ARE PROTOCOLS?
Purpose is to provide a defensible and consistent way of treating or serving client needs
Help improve quality of care
PROTOCOLS DEFINED
Connolly & Keogh-Hoss, 1991 Given a specific diagnostic need or
problem, a particular protocol may be developed and tested and used with consistency to lead to a predetermined outcome that is defined as alleviating or remediating the diagnostic related need or problem
PROTOCOLS DEFINED
Stumbo & Peterson, 2009 “Documents that describe the ‘best
practice’ of specific interventions as applied to a specific group of clients or client needs that have been standardized and result from recent research evidence, literature reviews, or professional consensus.” (p. 231)
2 TYPES OF PROTOCOLS
Treatment or intervention (program) Diagnostic (client)
what Connolly & Keogh-Hoss defined
HOW ARE THESE DIFFERENT?Formats in Stumbo & Peterson, 2009 Treatment (intervention or program)
Based on 1 area of careStress management, social skills
Diagnostic (or problem based)Specific diagnosisTBI, depression, etc.Related problem clustersConfusion & disorientation
CLINICAL GUIDELINES DEFINED
Stumbo & Peterson, 2009 “Systematically developed statements to
assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” (p. 231)
Test that s/b ordered, how long stay in hospital, etc.
CLINICAL GUIDELINES DEFINED
Hood, 2001 Term most widely used & accepted in
health-care “Distillation of the best collective thinking
from the literature, from practicing clinicians, from academics on how to treat a particular medical situation.” (p. 193)
Clinical Practice GuidelinesRicheson, Fitzsimmons, & Buettner in Stumbo, 2009
Evidence-based Guidelines Manual of systematic statements developed
to assist practitioners on selecting appropriate healthcare for specific situations.
Summarize & evaluate strength of evidence related to a healthcare problem
Make practice recommendations
Clinical Practice GuidelinesRicheson, Fitzsimmons, & Buettner in Stumbo, 2009
Development process includesVerifiable, systematic literature review of
research in peer-reviewed journalsMust be currentRevised within last 5 years
Written in way to help practitioners digest most current research so they can apply the research to practice
HISTORY OF TR PROTOCOLS
1989NTRS Protocols in Therapeutic RecreationSample protocolsEfficient tool for quality treatmentTool to market TR services & programsNo info on how to develop or use protocols
HISTORY OF TR PROTOCOLS
1990-1993 ATRA Protocol CommitteeSerious attempt to collect protocols from
around country to develop library & databaseGoal to have system where TR practitioners
could go to request protocolsOnly a handful of protocols were gatheredTherapists didn’t know how to write up or use
protocols
HISTORY OF TR PROTOCOLS
1991Riley edited Quality Management Applications for Therapeutic RecreationATRA publicationConnolly & Keogh-HossKnight & JohnsonProvided some direction to protocol
development
HISTORY OF TR PROTOCOLS
1993ATRA Protocol CommitteeDeveloped a 2 year strategy for moving protocols
forward5 major diagnostic categories
Substance abuse Aging/geriatrics Mental health/psychiatry Pediatrics Rehabilitation
HISTORY OF TR PROTOCOLS
1997Kelland, Protocols for Recreation Therapy Programs (Canada)
1997/98 Hood & KrinskyATRA Development Committee Identify priority needs in alcoholism treatmentDelphi procedureUsed experts
HISTORY OF TR PROTOCOLS
Hood & Krinksy cont.Findings
Fairly wide range of opinions from a select panel of experts on needs s/b viewed as priority for TR intervention
Underestimate impact of philosophical differences
HISTORY OF TR PROTOCOLS
1999Personal conversation with Cyn CarruthersCurrent work is on alcoholism and depressionBeing tested with varying successLegal implicationsUntested protocols s/b called Clinical Practice
Guidelines
HISTORY OF TR PROTOCOLS
2000Peterson & StumboProvide sample formats for treatment and
diagnostic protocols
HISTORY OF TR PROTOCOLS
2001 Hood in StumboLittle consensus on usefulness of protocolsVariety of terms
Protocol Practice Standards Critical Pathways Clinical Practice Guidelines
HISTORY OF TR PROTOCOLS
Hood Cont. What process of development should be followed?
Extensive literature review, panel of experts Efficacy research In TR little evidence of efficacy of services provided
What kind of information is required for practice guidelines?
Debate about level of detail & what s/b included How make accessible & useable to practioners
HOOD’S CONCERNS
The kinds of problems addressed in TR tend to be more psychosocial and not as amenable to standardization as biomedical needs. (p. 194)
May be hard to design step-by-step procedures to address psychosocial issues or secondary effects of disability (p. 204)
OTHER CONCERNS
2001 Sylvester, Voelkl, & EllisPeople may share dx, but have different
beliefs, values, backgrounds, & experiencesNot consistent with multicultural approach
1 size does not fit all
Other Concerns Richeson, Fitzsimmons, & Buettner in Stumbo, 2009
Few interventions published for TR
Research evidence from other disciplines may drive our clinical practice guidelines30 pages of reference for TR guideline but
less than 20% TR Raises concerns about validity
Clinical Practice Guidelines Today Richeson, Fitzsimmons, & Buettner in Stumbo, 2009
Dementia Practice Guidelines for Recreational Therapy: Treatment of Disturbing Behaviors
Buettner & Fitzsimmons, 2003
Wheelchair Biking for the Treatment of Depression
Fitzsimmons, 2001
Only 2 in National Guideline Clearinghouse
Dementia Practice Guidelines for Recreational Therapy: Treatment of Disturbing Behaviors
ContainsEvidence-based practice explanationComplexity of problemModels & theoriesLiterature reviewRecreation therapy and assessmentsConsiderations82 RT protocols
Dementia Practice Guidelines for Recreational Therapy: Treatment of Disturbing Behaviors Each protocol
Ratings R = shows protocol effective for this behavior RU = research is underway to examine the effect
of the protocol E = expert opinion feels this protocol is effective Blank = no research or expert opinion
Dementia stage appropriate for protocol
Clinical Practice Guidelines Today Efficacy of Prescribed Therapeutic Recreation
Protocols on Falls and Injuries in Nursing Home Residents with Dementia
Buettner, 2001
Being developed according to Stumbo & Peterson, 2009
Effect of animal-assisted therapy on distress in oncology patients being treated for pain
Therapeutic recreation and the treatment of obesity Therapeutic recreation and pain management
What’s next?
Stumbo & Peterson, 2004“Protocols are among the most powerful and
the most needed tools in the therapeutic recreation profession. Only in the last decade or so have therapeutic recreation specialists become active in developing protocols for intervention purposes: a significant amount of work remains to be done in this area.” (p. 246)