PROTOCOLS / CLINICAL PRACTICE GUIDELINES 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 care Stress management, social skills Diagnostic (or problem based) Specific diagnosis TBI, depression, etc. Related problem clusters Confusion & 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 Guidelines Richeson, 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 Guidelines Richeson, 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

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

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

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

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

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

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

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

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

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

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

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, & Ellis People may share dx, but have different beliefs, values, backgrounds, & experiences Not 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 guidelines 30 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 Contains Evidence-based practice explanation Complexity of problem Models & theories Literature review Recreation therapy and assessments Considerations 82 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)