PROTOCOLS

1. PROTOCOLS KNR 278

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? • Help explain the black box of intervention • 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, 2004 • “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. 236)

7. PROTOCOLS DEFINED • Hood, 2001 • “Seems to refer primarily to standardized, systematic intervention descriptions designed & delivered to attain predetermined client outcomes.” (p. 191) • Medical field: “Standardized research procedure designed to determine the effectiveness of a particular intervention.” (p. 191)

8. CLINICAL GUIDELINES DEFINED • Stumbo & Peterson, 2004 • “Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” (p. 237) • Test that s/b ordered, how long stay in hospital, etc.

9. 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)

10. CLINICAL GUIDELINES DEFINED • Hood, 2001 • One common criticism is that the developed guidelines (of which there are few) do not address psycho-social factors in the development or resolution of illness.

11. Clinical Pathways/Care Maps Defined • Stumbo & Peterson, 2004 • “Multidisciplinary plans of the best clinical practice for specified groups of clients with a particular diagnosis or within a diagnostic-related group (DRG).” (p. 238) • Aid in coordination & delivery of care • Are usually agency specific • Often contain a timeline from admit to discharge

12. Clinical Pathways/Care Maps Defined • Stumbo & Peterson, 2004 • Are beginning to replace individualized care plans (which is a concern) • Hood, 2001 • Focuses on interventions by whole team vs. one professional group

13. 2 TYPES OF PROTOCOLS • Treatment or intervention (program) • Diagnostic (client) • what Connolly & Keogh-Hoss defined

14. HOW ARE THESE DIFFERENT? • 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

15. QUESTIONS • Do other professions have protocols? • Yes, but very limited • Why is TR focusing here? • Accountability • Reimbursement • Job security in hospital/clinical settings?

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. ACTIVITY

25. 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

26. HISTORY OF TR PROTOCOLS • Hood Cont. • Development challenges • Who is responsible for development? • Most other professions from professional organizations, but TR has 2 organizations. • Both have protocols • Both protocols look different • How can TR practice guidelines reflect all TR approaches and models?

27. 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

28. HISTORY OF TR PROTOCOLS • Hood cont. • Not designed to provide a step-by-step outline, but developed to help make decisions about appropriate interventions

29. HOOD’S QUESTION • “What are the relative merits of having guidelines which require the use of substantial clinical judgment and expertise, and protocols that provide a step-by-step, sequential outline of ‘if-then’ statements to guide service delivery?” (p. 206)

30. HISTORY OF TR PROTOCOLS • Hood Cont. • Implementation challenge • How can practitioners be encouraged to use guidelines? • Complex & difficult to review • Need to be studied & remembered • Concrete suggestions not present in most guidelines • Research shows mixed results • How know if practitioners are using?

31. HISTORY OF TR PROTOCOLS • Hood Cont. • What is best way to handle conflicting guidelines? • How balance desire for individualized care with standardized services descriptions?

32. 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)

33. HOOD’S CONCERNS • How resolve conflict between moving toward standard practice and desire to provide individualized services? • Every situation cannot be covered • Each patient is unique • Many conditions are too complex for a single set of recommendations • Social work is skeptical about guidelines (p. 209)

34. 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

35. PROTOCOLS TODAY • Stumbo & Peterson, 2004 • Efficacy of Prescribed Therapeutic Recreation Protocols on Falls and Injuries in Nursing Home Residents with Dementia • Buettner, 2001 • Dementia Practice Guideline for Recreational Therapy: Treatment of Disturbing Behaviors • Buettner & Fitzsimmons, 2003

36. Dementia Practice Guideline for Recreational Therapy: Treatment of Disturbing Behaviors • Decrease agitation without increased medication or side effects • Cost • $94 ATRA member • $179 Non member

37. Dementia Practice Guideline for Recreational Therapy: Treatment of Disturbing Behaviors • Contains • Evidence-based practice • Defining behaviors • Models & theories • Literature review • Assessment instruments • Outcomes • 82 RT protocols

38. Dementia Practice Guideline for Recreational Therapy: Treatment of Disturbing BehaviorsEvidence-Based Competency Training • Cost • $190-210 ATRA Member (get copy of book) • $335-355 Non member (get copy of book & 1 yr membership in ATRA) • Regional workshops

39. Dementia Practice Guideline for Recreational Therapy: Treatment of Disturbing BehaviorsEvidence-Based Competency Training • Format • 6-50 minute training segments with test for each • Knowledge & understanding of dementia • Appropriate selection of intervention • Assessment & identification of disturbing behavior to target • Case study

40. Dementia Practice Guideline for Recreational Therapy: Treatment of Disturbing BehaviorsEvidence-Based Competency Training • Certificate of Training in Dementia Practices • Valid 3 years • On ATRA’s Dementia Practice Directory (website) • 1st graduating class in 2003 • 45 RTs & 2 RNs

41. What’s next for Protocols? • 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)

42. Protocols and Standardization • What are Stumbo &Peterson’s thoughts on the need for standardization? • What are your thoughts on the need of standardization for TR?