Do supports and barriers to routine clinical assessment for children with cerebral palsy change over time? A mixed methods study

Professor Christine Imms1

Professor of Occupational Therapy, Australian Catholic University

Aim: To investigate changes over time in allied health professional’s (AHP) perceptions of supports and barriers to implementing routine clinical assessment for children with cerebral palsy.

Method: Longitudinal mixed method approach. AHP (occupational therapists, physiotherapists and speech pathologists) employed in five disability service organisations were recruited. Participants completed the Supports and Barriers Questionnaire (SBQ; measuring organisational structures, resources, therapists, assessment tools, children and families) and participated in focus groups at baseline, 6, 12 and 24 months following introduction of routine clinical assessment procedures. Quantitative data were analysed descriptively. Baseline qualitative data were analysed inductively and a thematic framework developed. This framework was applied longitudinally using a constant comparative approach, facilitating identification of framework elements that emerged, or became less dominant, over time.

Results: 447 AHP participated (baseline n=227, 6m n=227; 12m n=224; 24m n=189). Mean SBQ ratings on all domains remained positive over time indicating that overall AHP felt supported in implementing routine clinical assessment. Five themes emerged at baseline: ‘motivated to adopt routine clinical assessment’, ‘ensuring effective ongoing communication’, ‘acquiring and utilising expertise’, ‘availability and distribution of resources’ and ‘therapist perceptions of child and families’ wishes’. Longitudinally, themes demonstrated how routine assessment practices and clinical expertise were embedded and maintained. Critical reflection on the utility and costs of routine assessment were evident over time, attributable in part to national changes in funding of disability services.

Significance of the findings to allied health: Organisational commitment, adequate resourcing and effective communication are required to implement and embed change in AHP services.

Using audit and feedback to change practice: Embedding clinical practice guidelines in acquired brain injury rehabilitation

Ms Laura Jolliffe1,2, Ms Rebecca Nicks2, A/Prof Natasha Lannin1,2, Prof Tammy Hoffmann3, Ms. Jacqui Morarty1

1La Trobe University, Melbourne, Australia

2Alfred Health, Melbourne, Australia

3Bond University, Gold Coast, Australia

 

AIM: To evaluate the effects of a sustained program of audit-feedback on therapists’ adherence to acquired brain injury (ABI) rehabilitation CPGs.

 

METHOD: Using a periodic service review method, inpatient rehabilitation care was audited fortnightly for 46 weeks (61 cases) against ABI rehabilitation CPGs (137 observable criteria), using medical record review, observation, and staff, patient and family interviews. Each fortnight, a facilitator-led multidisciplinary feedback session provided clinicians with a summary of observed adherence to CPGs, and positive behaviour feedback strategies were used to encourage clinicians to assess and adjust their performance. Three months after withdrawal of the audit-feedback, 20 randomly selected cases were audited to determine if adherence to CPGs was maintained.

 

RESULTS: Immediately following the intervention, there was a significant improvement in adherence to CPG criteria from 47% to 82% (35% improvement, 95% CI 25 to 46) (p=0.0001). Three months after intervention withdrawal adherence was lower and reduced to 73% (9% reduction, 95% CI -19 to 0.5) (p=0.002). Details of the clinical practice areas more susceptible to feedback withdrawal will be discussed.

 

SIGNIFICANCE OF FINDINGS TO ALLIED HEALTH: There are gaps between clinical practice guideline (CPG) recommendations and clinical practice provided. Studies outside of rehabilitation suggest audit and feedback is an effective behaviour-change intervention, however rehabilitation studies have demonstrated only minimal improvements. Our study demonstrates that intensive audit and feedback can improve adherence to rehabilitation CPGs. For sustainable change, audit and feedback needs to be incorporated into usual rehabilitation processes.

Development of the Translating Allied Health Knowledge (TAHK) benchmarking tool

Dr Danielle Hitch1, Associate Professor Genevieve Pepin1

1Deakin University, Geelong, Australia

 

Aim: This presentation aims to provide an overview of the formulation of a benchmarking tool from the Translating Allied Health Knowledge (TAHK) framework.

 

Method: Benchmarking is a systematic process for measuring and comparing work processes, which has been found to be an effective approach to improving quality and effectiveness in clinical health care. The Translating Allied Health Knowledge (TAHK) framework was initially proposed in 2013, as part of a larger study on knowledge translation in occupational therapy. It developed from a comprehensive literature review of the knowledge translation literature in allied health, and was designed to highlight processes and practice characteristics rather than specific methods.

 

Results: The results from each stage of this tools development will be presented. The framework was initially piloted via consultation with a steering committee, along with a pilot mixed methods feasibility study with clinicians. Testing of the psychometric properties is currently underway, as is a qualitative study to understand the perceptions of clinicians who completed the tool.

 

Significance:

The TAHK benchmarking tool is the only measure currently available which addresses implementation processes and mechanisms across different contexts in allied health. The

comprehensive process of development described in this presentation, and the findings of evaluations to date, supports its broader adoption across allied health disciplines and services. The standardized benchmarking tool will be distributed across Victoria to build a baseline of allied health knowledge translation activities, and explore their relationship to a range of organizational contexts.

Expiratory muscle strength training improves swallowing and respiratory outcomes in people with dysphagia: A systematic review

Ms Rebecca Lamont1, Ms Marinda Brooks1, Mrs Emma  McLaughlin2, Professor Nora Shields2,1

1Northern Health, Epping, Australia

2LaTrobe University, Melbourne, Australia

 

Aim: To investigate the effects of expiratory muscle strength training on communication and swallowing outcomes in adults with acquired motor based communication and/or swallowing difficulties of any aetiology. The secondary aims were to investigate the effects on respiratory and quality of life outcomes; and to describe how expiratory muscle strength training has been applied in previous studies.

Method: A systematic review was conducted. Six databases (CINAHL, MEDLINE, EMBASE, SPEECHBYTE, AMED, PUBMED) were searched from inception until June 2016. Randomised and non-randomised controlled trials and cohort studies published in English that investigated the effects of expiratory muscle strength training were included. Trial quality was assessed using the PEDro scale. Data were analysed descriptively and effect sizes and associated 95% confidence intervals were calculated. Two researchers completed study selection, risk of bias assessment and data extraction. Disagreements were resolved by consensus.

Results: The search strategy yielded 2898 potentially relevant articles. After removal of duplicates,   inclusion and exclusion criteria were applied to the titles and abstracts of 1211 studies. Full-text copies for 62 articles were retrieved and after further review seven articles were retained for inclusion in the review. These seven articles reported data from five trials. Preliminary data suggests expiratory muscle strength training improves airway safety during swallowing in people with dysphagia and increases the strength of the expiratory muscles in all patient groups. There was little evidence to suggest changes in communication outcomes after expiratory muscle strength training.

Significance to allied health: Speech pathologists might consider using expiratory muscle strength training to improve airway safety in adults with swallowing disorders.

Merging research and advanced clinical knowledge: An illustration from paediatric hand therapy

Ms Rose Biggins1

1The Royal Children’s Hospital, Melbourne, Parkville, Australia

 

Aim: Occupational therapists within tertiary centres commonly treat medical conditions rarely seen in the community. Research for these conditions can be sparse, of poor quality and with varied recommendations. Similarly, clinical practice can be based on historical traditions, rather than from evidence. To help inform practice for camptodactyly, a congenital hand condition, this project aimed to develop a practice brief by combining a synthesis of research evidence with advanced clinical knowledge.

Method: A clinical question was developed using a PICO framework and electronic databases were searched. Validity and reliability of studies were evaluated using the Critical Appraisal Skills Program and level of evidence was assigned using NHMRC guidelines.  Findings from the literature review were analysed against current and historical clinical data and practice.

Results: A search of three electronic databases yielded six studies. All were retrospective case series (NHMRC Level IV) of mixed methodological quality. Data synthesis developed recommendations, which were analysed against historical data and practice. A practice brief was developed outlining recommended assessment procedures and options for intervention.

Significance of the findings to allied health: In all clinical settings it is important for AH clinicians to use the evidence cycle to inform best practice. However, in settings that commonly see rare conditions, expert and historical knowledge can be an invaluable source for best outcomes. A staged process enables examination of current literature, analysis of findings and synthesis of results to combine with advanced clinical knowledge to ensure expert management.

Hospital food service interventions and their effect on nutritional outcomes of cancer patients

Ms Elizabeth Doyle1, Ms Natalie Simmance1, Ms Helen Wilding2, Ms Judi Porter3,4

1Nutrition Department, St. Vincent’s Hospital, Fitzroy, Australia,

2Carl de Gruchy Library, St Vincent’s Hospital, Fitzroy, Australia,

3Allied Health Research Office, Eastern Health, Box Hill, Australia,

4Department of Food, Nutrition and Dietetics, Monash University, Notting Hill, Australia

 

Aim:  Foodservice interventions are an integral part of nutrition care for patients with cancer.  This systematic review aimed to determine the effect of foodservice interventions across a range of nutritional outcomes and satisfaction of hospitalised and ambulatory adult patients with cancer.

Method:  The review protocol was registered with PROSPERO (CRD42016045772).  Six databases were searched with a defined search strategy focusing on the intervention and population; no date or language restrictions were applied.  Inclusion criteria were applied to the title and abstract, then review of full text papers.  Outcome data were combined narratively and, where possible, by meta-analysis using RevMan.  Methodological quality was evaluated using the Cochrane risk of bias tool.

Results:  Twelve studies testing the effect of foodservice interventions in cancer patients were included in this review.  Meta-analyses of energy and protein intake of four randomised control trials of oral nutrition support interventions were undertaken.  These trials demonstrated significantly greater energy (mean difference 1.54MJ/day; 95% CI 0.85-2.23MJ/day) and protein (mean difference 18.98g/day; 95% CI 11.58-26.39g/day) intake.  Positive effects on anthropometric and other nutritional outcomes were identified through the narrative synthesis of other included studies.

Significance of the findings to allied health: Our review identified that foodservice interventions can improve clinical outcomes of cancer patients, both in inpatient and ambulatory settings. Effective foodservice interventions for cancer patients remain under-researched, demonstrated by the few foodservice studies published as full text papers.  There is a clear opportunity for dietitians and foodservice staff to extend foodservice knowledge through trialling interventions in this clinical group.

Neuromuscular rehabilitation improves strength and reduces functional impairment following moderate-severe wrist injury

Ms Hayley  O’sullivan1

1Royal Melbourne Hospital , Carlton North , Australia

 
Background:

Studies on wrist rehabilitation indicate the importance of incorporating proprioception, strength and endurance. Failure to address these aspects can reduce the effectiveness of rehabilitation and impact on patient outcomes. Whilst clinical research indicates the benefits of neuromuscular rehabilitation programs, there is little evidence of how to design and implement these programs.

This study outlines an 8-week neuromuscular program to enhance functional outcomes for patients following a moderate-severe wrist injury.

 

Problem:

There is evidence to suggest that neuromuscular rehabilitation can enhance patient outcomes following moderate-severe wrist injuries. However, there is a lack of information on either the structure and effectiveness of such program

 

Method:

  • Patients who met the inclusion criteria were recruited  to the study
  • Patients attended one 45 minute wrist rehab group on a weekly basis for 8 weeks.
  • Individualised programs were developed according to the patient’s presentation and progress
  • 6-7 exercises were completed each session and upgraded as progress was achieved
  • Pre and post measures were taken:

o             Jamar push off test

o             Grip/ lateral pinch strength

o             Active range of motion

o             Visual analogue scale

o             Patient rated wrist evaluation

 

Results:

Twenty patients were recruited to the study over a 12 month period. Preliminary results indicate improvement in all outcomes measured including PRWE.

 

Significant findings for Allied Health:

Patients with moderate-severe wrist injuries benefit from an 8 week neuromuscular rehabilitation program. Further research comparing effectiveness of a neuromuscular approach to conventional treatment would further develop the evidence.

Clinical assessment and management of patients presenting to the emergency departments of a metropolitan health service with vertigo, dizziness or imbalance

Ms Melanie Lloyd1, Ms Alexandra Mackintosh1, Ms  Catherine Grant1, Dr Clarice Tang2

1Western Health, St Albans, Australia

2La Trobe University, Bundoora, Australia 

Aim: To determine the proportion of patients: 1) presenting with symptoms of dizziness, vertigo or imbalance, who were assessed and managed in accordance with published clinical practice guidelines for BPPV, 2) with a positive diagnostic test for BPPV, and 3) who were discharged without a clear cause for symptoms identified.

Method: This is a retrospective study conducted across three acute hospitals within a metropolitan health service. All adults (age ≥18) who presented to the ED with symptoms of vertigo, dizziness or imbalance were included. Upon identification, comprehensive review of the patient’s medical history was conducted to identify the clinical assessment and management received during the presentation.

Results: A total of 96 patients were included in this study. More than half (55%) of participants’ symptoms were potentially attributable to a vestibular cause, of which 4% had a positive diagnostic test for BPPV.  For these patients, CT scans were the most common assessment tool (37%) while gold standard clinical tests were rarely used. Patients were often prescribed with vestibular suppressants (61%) in contradiction to published clinical guidelines, and were infrequently (6%) treated with the recommended canalith-repositioning technique.

Significance of findings to allied health: Patients with symptoms of dizziness, vertigo or imbalance present frequently to the ED. Current clinical management of these patients often contradicts published clinical guidelines, and it is likely that BPPV is under-diagnosed. Physiotherapy services should investigate novel ways to address the translation gap in evidence-based management of BPPV.

 

Removing barriers to evidence translation: Facilitating clinician and patient uptake of evidence-based stroke rehabilitation

Dr Leah Wiseman1

1Albury Wodonga Health, Albury, Australia, 2Charles Sturt University , Albury, Australia

Aim: The project will develop and trial an online resource that addresses clinician cited barriers to implementing the National Stroke Clinical Guidelines and works more collaboratively with patients and their caregivers enabling a long-term, self management approach to rehabilitation after stroke.  This project has focused specifically on cognitive and upper limb interventions as recommended by the National Stroke Clinical Guidelines.

Method: Data collection methods included a series of focus groups involving patients, caregivers and clinicians, eliciting responses regarding barriers and enablers to implementing a self management approach and understanding of cognitive and upper limb interventions within the National Stroke Guidelines. The online resource will be a combination of written information, links with existing on-line resources and instructional videos and will be trialled with over 200 patients who have had a stroke, recruited from two regional health services. Outcome measures include goal achievement, self-reported performance and satisfaction, the Stroke Self-efficacy Questionnaire and the Stroke Impact Scale. Secondary outcome measures will evaluate upper-limb and/or cognitive changes following the program. The extent to which clinician cited barriers have been addressed by this resource will be measured via a staff audit.

Results: At the time of presentation, the study will be in the initial stages. Findings from the focus groups and the preliminary evaluation of the resource trial will be presented.

Significance of the findings to allied health: Overall the uptake and application of the National Stroke Foundation’s Clinical Guidelines is a critical success factor in improving the health outcomes of stroke patients. The resource developed aims to overcome many clinician cited barriers and support staff in implementing evidence based practice. The resource adopts a self-management approach which aims to enable patients and caregivers to implement an effective upper limb or cognitive rehabilitation program at home.

A novel tool for engaging eye care clinicians in patient education about the ocular health risks of tobacco smoking

Dr Laura Downie1, Associate Professor Peter Keller1

1Department of Optometry and Vision Sciences, The University Of Melbourne, Parkville, Australia

Aim: Smoking is a key modifiable risk factor for sight-threatening eye disease. The main aim was to develop a tool, based upon the best-available evidence, to enable eye care clinicians to accurately quantify three key aspects of patient smoking behaviour: risk of smoking-related eye disease, level of nicotine dependence and motivation to quit smoking. We also sought to evaluate public perceptions regarding the role of optometrists in providing patient education about smoking behaviours, and assess the utility of the tool in a primary eye care setting.

Method: A 10-item ‘quantitative clinical smoking behaviour’ tool was developed, based upon a systematic literature review. A convenience sample of adults (n=220), attending the University of Melbourne eye care clinic, was recruited to assess the usability of the tool and complete a survey assessing their perception of the role of optometrists in providing care in this domain.

Results: The tool was easily implemented in an optometry practice, with 99% of participants providing independent and fully-complete responses. Most respondents expected their optometrist to ask them about their smoking status (60%) and were comfortable discussing their smoking behaviours (69%).

Significance of the findings to allied health: It is critical that eye care clinicians assess and advise patients about the ocular risks of smoking and benefits of smoking cessation. Broader implementation of this tool into eye care practices will likely translate into enhanced care delivery in this important practice area.