protocols / clinical practice guidelines knr 365

PROTOCOLS /CLINICAL PRACTICEGUIDELINES

KNR 365

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


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


1991Riley edited Quality Management Applications for Therapeutic RecreationATRA publicationConnolly & Keogh-HossKnight & JohnsonProvided some direction to protocol

development


1993ATRA Protocol CommitteeDeveloped a 2 year strategy for moving protocols

forward5 major diagnostic categories

Substance abuse Aging/geriatrics Mental health/psychiatry Pediatrics Rehabilitation


1997Kelland, Protocols for Recreation Therapy Programs (Canada)

1997/98 Hood & KrinskyATRA Development Committee Identify priority needs in alcoholism treatmentDelphi procedureUsed experts


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


1999Personal conversation with Cyn CarruthersCurrent work is on alcoholism and depressionBeing tested with varying successLegal implicationsUntested protocols s/b called Clinical Practice

Guidelines


2000Peterson & StumboProvide sample formats for treatment and

diagnostic protocols


2001 Hood in StumboLittle consensus on usefulness of protocolsVariety of terms

Protocol Practice Standards Critical Pathways Clinical Practice Guidelines


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)