PROTOCOLS / CLINICAL PRACTICE GUIDELINES

1. PROTOCOLS /CLINICAL PRACTICEGUIDELINES KNR 365

2. 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

3. 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”

4. WHAT ARE PROTOCOLS? • Purpose is to provide a defensible and consistent way of treating or serving client needs • Help improve quality of care

5. 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

6. 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)

7. 2 TYPES OF PROTOCOLS • Treatment or intervention (program) • Diagnostic (client) • what Connolly & Keogh-Hoss defined

8. HOW ARE THESE DIFFERENT?Formats in Stumbo & Peterson, 2009 • Treatment (intervention or program) • Based on 1 area of care • Stress management, social skills • Diagnostic (or problem based) • Specific diagnosis • TBI, depression, etc. • Related problem clusters • Confusion & disorientation

9. 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.

10. 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)

11. 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

12. Clinical Practice GuidelinesRicheson, Fitzsimmons, & Buettner in Stumbo, 2009 • Development process includes • Verifiable, systematic literature review of research in peer-reviewed journals • Must be current • Revised within last 5 years • Written in way to help practitioners digest most current research so they can apply the research to practice

13. HISTORY OF TR PROTOCOLS • 1989 NTRS Protocols in Therapeutic Recreation • Sample protocols • Efficient tool for quality treatment • Tool to market TR services & programs • No info on how to develop or use protocols

14. HISTORY OF TR PROTOCOLS • 1990-1993 ATRA Protocol Committee • Serious attempt to collect protocols from around country to develop library & database • Goal to have system where TR practitioners could go to request protocols • Only a handful of protocols were gathered • Therapists didn’t know how to write up or use protocols

15. HISTORY OF TR PROTOCOLS • 1991 Riley edited Quality Management Applications for Therapeutic Recreation • ATRA publication • Connolly & Keogh-Hoss • Knight & Johnson • Provided some direction to protocol development

16. HISTORY OF TR PROTOCOLS • 1993 ATRA Protocol Committee • Developed a 2 year strategy for moving protocols forward • 5 major diagnostic categories • Substance abuse • Aging/geriatrics • Mental health/psychiatry • Pediatrics • Rehabilitation

17. HISTORY OF TR PROTOCOLS • 1997 Kelland, Protocols for Recreation Therapy Programs (Canada) • 1997/98 Hood & Krinsky • ATRA Development Committee • Identify priority needs in alcoholism treatment • Delphi procedure • Used experts

18. 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

19. HISTORY OF TR PROTOCOLS • 1999 Personal conversation with Cyn Carruthers • Current work is on alcoholism and depression • Being tested with varying success • Legal implications • Untested protocols s/b called Clinical Practice Guidelines

20. HISTORY OF TR PROTOCOLS • 2000 Peterson & Stumbo • Provide sample formats for treatment and diagnostic protocols

21. HISTORY OF TR PROTOCOLS • 2001 Hood in Stumbo • Little consensus on usefulness of protocols • Variety of terms • Protocol • Practice Standards • Critical Pathways • Clinical Practice Guidelines

22. 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

23. 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)

24. OTHER CONCERNS • 2001 Sylvester, Voelkl, & Ellis • People may share dx, but have different beliefs, values, backgrounds, & experiences • Not consistent with multicultural approach • 1 size does not fit all

25. Other ConcernsRicheson, Fitzsimmons, & Buettner in Stumbo, 2009 • Few interventions published for TR • Research evidence from other disciplines may drive our clinical practice guidelines • 30 pages of reference for TR guideline but less than 20% TR • Raises concerns about validity

26. Clinical Practice Guidelines TodayRicheson, 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

27. Dementia Practice Guidelines for Recreational Therapy: Treatment of Disturbing Behaviors • Contains • Evidence-based practice explanation • Complexity of problem • Models & theories • Literature review • Recreation therapy and assessments • Considerations • 82 RT protocols

28. 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

29. 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

30. 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)