Transcript Spreading practice through the ICF

Synthesizing and translating rehabilitation
evidence into practice: the experience of
the Australian aphasia rehabilitation team
Linda Worrall, Emma Thomas, Emma Power,
Alexia Rohde, Miranda Rose, Leanne Togher
and Alison Ferguson
On behalf of the Australian NHMRC Centre for Clinical
Research Excellence in Aphasia Rehabilitation
NHMRC grant #569935
Aims of this presentation
To show how you might translate evidence into practice
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Share our experience
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With aphasia rehabilitation
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Please contextualise this to your group and your area
of interest!
Aims of this presentation
1.
2.
3.
To show how the CCRE in Aphasia Rehabilitation is
synthesizing aphasia rehabilitation evidence
To describe our process of Knowledge Transfer and
Exchange (KTE) to develop the Australian Aphasia
Rehabilitation Pathway (AARP)
Describe our implementation plan and research
The NHMRC Centre for Clinical Research
Excellence (CCRE) in Aphasia Rehabilitation
Includes:
• 12 Investigators
• 7 Postdoctoral research
fellows
• 25 Research affiliates
• 200+ Clinical affiliates
The translational challenge

There is a significant time-lag for research evidence
to be integrated into clinical practice
Research
Implementation
17 years
Publication
Translation of evidence (Westfall et al., 2007, JAMA)
Translation of evidence
(Westfall et al., 2007, JAMA)
Research
Implementation
17 years
Publication
Our challenge

There is an evidence-to-practice gap in aphasia
rehabilitation
For example:
 Few
people with aphasia receive early aphasia
intervention (Godecke et al., 2011)
 Limited opportunity to access ongoing treatment post
discharge from inpatient rehabilitation (Rose et al.,
2013; Verna et al., 2009)
 Clinicians report difficulty translating evidence into real
work contexts (Rose et al., 2013)
Our Aim
To ensure effective translation of aphasia
research evidence into clinical practice
through using a Knowledge Transfer and
Exchange (KTE) approach
Terminology

Knowledge Translation (KT) is the process of
improving the uptake of knowledge, or evidence, into
practice - with the ultimate aim of improving clinical
outcomes.
Aim 1: To show how the CCRE are
synthesizing aphasia evidence
To enhance knowledge
uptake, the evidence
needs to be:
- Synthesised
- In a user-friendly
format
Knowledge
Inquiry
Knowledge
Synthesis
Products
Tools
The knowledge creation triangle of the
Knowledge-to-Action process (Graham et
al., 2006)
Are there clinical guidelines for aphasia?


Systematic review - to determine if there were
any existing quality clinical guidelines
available for stroke and aphasia.
AGREE II tool


19 multidisciplinary stroke and speech pathology
specific clinical practice
ADAPTE Collaboration tool

(Rohde et al, 2013)
Systematic Review Results
Systematic Review Results
Highest in both AGREEII and ADAPTE evaluations
The Australian Clinical Guidelines for Stroke Management (2010)
 New Zealand Clinical Guidelines for Stroke Management (2010)

Most comprehensive
The Royal College of Speech and Language Therapists (2005)
aphasia guideline

Therapy focused
Evidence-Based Review of Stroke Rehabilitation (Salter et al., 2008)
 ANCDS evidence reviews (Beeson & Robey, 2006)

Systematic review results
In patients who have language difficulties, the involvement of
speech and language therapists from the onset is important.
Alternative communication techniques may be explored, and
education of family members, particularly about the levels of
frustration experienced by people who are aphasic, must be
discussed.
Conclusions from systematic review
•
•
•
•
No high-quality aphasia clinical guidelines across the
continuum of care exist
High quality stroke clinical guidelines do contain some relevant
recommendations for aphasia rehabilitation
Stroke clinical guidelines chart best practice across the patient
journey
Best practices in aphasia rehabilitation could be incorporated
into a pathway with collated recommendations from the stroke
clinical guidelines as the basis of the “evidence” for the
pathway
Summary
Aim 1: To show how to synthesize evidence





Systematic review of stroke and aphasia guidelines
Use the recommendations in the best quality stroke
guidelines
Supplement these by searching for new or other
systematic reviews
Commission systematic reviews in gap areas of
evidence
Prioritising “Top 10” best evidence
recommendations
Aim 2: To describe our process of KTE to
develop the aphasia pathway
Monitor knowledge use
Is the Aphasia Pathway being used
and how?
If not, are there modifications to
assist with re-implementation?
Select / tailor / implement
What interventions are successful in
implementing guidelines / pathways?
How can the Aphasia Pathway
implementation be tailored to
identified barriers and facilitators ?
Evaluate outcomes of use
KNOWLEDGE CREATION
Filtering CCRE research knowledge into
more synthesized, user-friendly forms.
Knowledge Inquiry
Individual CCRE research studies
(Acute + rehab + community)
Assess barriers / facilitators
What are the barriers / facilitators
in relation to the:
i. Pathway itself (content / style)
ii. Adopters (clinicians / managers)
iii. Context / setting (e.g., public
and private service contexts)?
Knowledge Synthesis
Systematic Reviews
(CCRE / others)
Tools / Products
Aphasia
Pathway
Adapt knowledge locally
Will the Aphasia Pathway be
implemented in original form?
Will clinicians adapt it to their own
contexts and how?
How have they adapted currently
available guidelines / pathways?
What factors are key in deciding to
adapt guidelines / pathways?
What is the impact of Aphasia Pathway
use compared to current practice
measured by direct and indirect
measures of:
i. Consumer health
ii. Adopter behaviour / attitudes
iii. Service / system changes.
Identify clinical problem
Do clinicians perceive a knowledge-action gap in
aphasia practice? Is this gap observed?
Sustain knowledge use
Is Aphasia Pathway use sustained?
If not, why not?
If sustained, does it get modified further?
How do clinicians integrate additional
new knowledge into the pathway?
What factors predict or contribute to
sustained usage of the Aphasia Pathway
vs. lack of sustained adoption?
Identify, review, select knowledge
Are clinicians aware of the Aphasia Pathway and
do they believe it will fill that gap?
How do they perceive guidelines / pathways?
Are they using current stroke guidelines?
What can we learn from these for our Pathway?
ACTION CYCLE
Suggested actions required for
implementation of the Aphasia
Pathway into clinical practice.
Aim of the Australian Aphasia Rehabilitation
Pathway
To improve the overall journey for
people living with aphasia by
developing a rehabilitation pathway
within a knowledge transfer framework
What is a pathway?
A pathway is a tool that promotes organised and
efficient patient care based on the best available evidence
and guidelines.
 A pathway aims to deliver the recommended care to the
right person at the right time.

Other terms:
–
–
–
–
Integrated care pathways
Clinical pathways
Patient journeys
Care maps
(Kwan et al., 2004)
How are we developing the pathway?


A community of practice (CoP) approach to Knowledge
Transfer & Exchange
CCRE Aphasia Community of Practice:
12 investigators
 24 research affiliates
 33 doctoral students
 200 clinical affiliates


Three initial face to face meetings + emailed versions
of the AARP for comment using Google documents
How are we developing the pathway?

Three initial face to face meetings

What is the current pathway for aphasia rehabilitation?


How can the new pathway help?
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Clinician descriptions + literature about patient journey
SWOT analyses
Emailed versions for comment using Google
documents
Australian Aphasia Rehabilitation Pathway
(AARP) Version1 acute
Referral
IFCI
Diagnosis of aphasia
Visitor with aphasia
Staff information
Aphasia-friendly
information
Family information
Communication
portfolio
Discharge planning
Rehabilitation ward
Home
Aged Care Facility
Participatory
environment
Overview of the Australian Aphasia
Rehabilitation Pathway (AARP) Version 3
Overview of the Australian Aphasia Rehabilitation
Pathway (AARP) – Version 4
Within each box
RECEIVING THE RIGHT REFERRALS
Recommendations &
ideal practice
Practical tips
Prehospital care &
staff education
Referral processes
Communication
screening by nonspeech pathologists
Clinician/Practitioner
perspective
Client/Patient
perspective
Resources
Summary
SWOT analysis
S
• Targeted resources linked
to evidence
• Time saving for
practitioners
• One stop shop
• Currency
• Evidence of better
outcomes when following
guidelines
• Emphasis on goal setting
• Educational – professionals
need to gain something
from them
W
• Not integrated with other
professional groups
• Will require time to
implement
• Will require maintenance /
updating
O
T
• Piloting will increase
awareness and research
• E-Health
• Integrate IP activity
• Move acute focus from
dysphagia to aphasia
• To get endorsement from
larger funding/policy
bodies – ACQHS, SPA, NSF
• To influence policy and
service provision
• Maintaining currency
• Copyright
• Responding to changing
models of care –
demoralising/burnout
• Lack of buy in from decision
makers
• Cost in making changes
Invited comments via email & Google docs
Ideal practice: Setting goals
Goal setting should be a dynamic process that is reviewed throughout the continuum of care in order
to reflect client and family context and wishes
Therapists should explain the goal setting process (and the potential benefits) to the client and their
family in an accessible way and assist in the identification of goal areas prior to formal assessment
Collaborative goal setting between the therapist, client and family should primarily focus on goal areas
identified by the client/family with consideration of results from formal and informal assessment
Systems should be established to ensure involvement of people with aphasia and their family as part
of the multidisciplinary team (i.e. MDT goal setting at the client’s bedside)
The ‘SMARTER’ framework could be used to help ensure that goal setting is truly collaborative and
client-centred
It includes resources
User-friendly web-based interface for the
Australian Aphasia Rehabilitation Pathway (AARP)
www.aphasiapathway.com.au
Summary
Aim 2: to show the process and the pathway
• We used KTE framework via a Community of Practice
• Face to face meetings and Google docs used
• The pathway has a user friendly interface
• The pathway contains evidence-based recommendations and
resources across the patient journey
Benefits of a KTE framework
• Buy in - increases the chances of uptake
• Relevance to the workplace – regular use will
improve sustainability
• Creates dialogue between researchers and
stakeholders that flows both ways – identifies
evidence gaps and priority research questions
Challenges




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The Community of Practice is a new way of working – not
fast
Synthesis of evidence is hard
Making evidence into useable and meaningful tools is
challenging
Some practice areas have very little research published
Levels of evidence are not always high
The creation of a pathway does not mean that it will be
implemented - whole new area of research into what works
Ongoing
• More systematic reviews are needed in specific topic areas
– currently in progress
• Further consensus on the evidence will use the RAND/UCLA
Appropriateness Method (RAM) – Nov 1
• The perspectives of consumers and expert clinicians for
each topic will be collected through the Community of
Practice
• Launch date November 2013
• Aphasia friendly site and pathway
• Research and planning for implementation
Aim 3 – Describe our research and planning
for implementation
a) What are the barriers to implementation?
b) What evidence-based strategies are needed to
overcome these barriers?
c) What are the highest priorities for
implementation?
d) Did the AARP change Australian speech
pathology practice for aphasia rehabilitation?
See Rose et al (in press) IJSLP for pre- pathway survey results
a) Identify barriers to implementation (Power et al., 2013)
3 themes with 10 subthemes
Demand vs.
ability to change
(4)
Making
implementation
explicit
(3)
SP motivation to
implement
guidelines
(3)
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Overcoming barriers - recommendations
(Power et al., 2013)



Implementation requires planned, explicit and locally
adapted intervention
Funding affects feasibility - addressed through team
collaboration within and across networks
Speech pathologists are highly motivated to use
evidence
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b) What strategies are needed to
overcome these barriers? (Power et al., 2013)

Printed educational materials

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Educational meetings


(e.g., dyadic conferences / workshops – passive or more
active)
Educational outreach


(e.g., dissemination of clinical practice guidelines, publications)
(e.g., a knowledge expert who meets clinicians locally)
Local opinion leaders

(e.g., educationally and professional influential clinicians)
(Grimshaw, et al., 2012, Cochrane Effective Practice & Organization of Care group (EPOC))
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
Audit / feedback


Computerized reminders


(e.g., paper or computer based reminders for a point of care)
Tailored interventions


(e.g., objective summary & feedback of clinical performance)
(e.g., planned strategies based on actual analysis of barriers)
Multifaceted interventions

(e.g., interventions with two or more components)
(Grimshaw, et al., 2012, Cochrane Effective Practice & Organization of Care group (EPOC))
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KTE evidence

Passive methods mostly ineffective in behaviour change

Overall mixed results, modest effects: +ve results for:

Audit & feedback, academic outreach, interactive education sessions, reminder
alerts, tailored interventions, consider using 2 or more strategies
(Baker, 2010; Grimshaw et al., 2001; Wensing et al., 2010)
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Summary
Aim 3 – how to implement evidence?

Publishing the AARP online will not be effective alone
Speech pathologists need implementation plans to be
explicit

Speech pathologists will resource it by working
together

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Conclusion

This is the work we all need to do

Synthesize the evidence

Translate the evidence

Implement the evidence
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To keep in touch and for further
information
www.aphasiapathway.com.au
www.ccreaphasia.org.au
[email protected]