Development and implementation of a clinical practice guideline for the rehabilitation of adults with moderate to severe traumatic brain injury in Quebec and Ontario

Abstract

There has been a growing interest in the development of Clinical Practice Guidelines (CPGs) to bridge the gap between research and clinical practice in order to improve health care. CPGs are promising tools for aligning services and assisting health care professionals in making clinical decisions based on the best available evidence. Our study aims to structure and facilitate the adaptation and implementation of a CPG intended for clinicians and administrators providing rehabilitation services to adults having sustained a moderate to severe traumatic brain injury (MS-TBI) in Québec and Ontario (Canada).

Full text

CONSENSUS PROCESS AMONGST EXPERTS
OBJECTIVE: To prepare and hold a two-day consensus meeng
with experts (clinicians and researchers), key stakeholders,
consumer representaves and professional associaons
covering all domains and perspecves relang to TBI, in order
to determine, on the basis of the evidence synthesis matrix
provided in advance, the:
• Exisng recommendaons to retain
• Exisng recommendaons to retain but needing some
adaptaon
• New recommendaons to be formulated (based on
exisng evidence or expert consensus)
• Key recommendaons to priorize, and their potenal
indicators
ADAPTATION OF THE RECOMMENDATIONS AND
PRODUCTION OF THE GUIDELINES
OBJECTIVE: To nalize the formulaon, priorize and
associate, where possible, process and result indicators to the
recommendaons developed during the consensus meeng
using a web-based interacve plaorm (Alfresco)
IMPLEMENTATION OF THE CPG IN CLINICAL
SETTINGS
OBJECTIVE: To pilot and guide, in collaboraon with key
stakeholders, a systemac mobilizaon and implementaon
process throughout acute care and rehabilitaon facilies in
Québec and Ontario
DEVELOPMENT AND IMPLEMENTATION OF A CLINICAL PRACTICE GUIDELINE FOR THE
REHABILITATION OF ADULTS WITH MODERATE TO SEVERE TRAUMATIC BRAIN INJURY IN
QUÉBEC AND ONTARIO
Catherine Truchon, Ph.D., M.Sc.Adm.,1 Corinne Kagan, B.A., BPS Cert.,2 Bonnie Swaine, Ph.D.,3,4 Marie‑Eve Lamontagne, Ph.D.,5,6 Mark Bayley,
M.D., FRCPC,7,8 Shawn Marshall, M.D., M.Sc., FRCPC,9,10 Mario De Bellefeuille, PT,1 A.‑S. Allaire, M.Sc.,5 Ailene Kua, M.Sc.7
1 Instut naonal d’excellence en santé et en services sociaux (INESSS), Québec 2 Ontario Neurotrauma Foundaon (ONF), Ontario 3 Centre for Interdisciplinary Research in Rehabilitaon of Greater
Montreal (CRIR), Centre de réadaptaon Lucie-Bruneau, Québec 4 Université de Montréal, Québec 5 Centre for Interdisciplinary Research in Rehabilitaon and Social Integraon (CIRRIS), Québec 6 Université
Laval, Québec 7 University Health Network—Toronto Rehabilitaon Instute (UHN—TRI), Ontario 8 University of Toronto, Ontario 9 Oawa Hospital Research Instute (OHRI), Ontario 10 University of
Oawa, Ontario
INESSS AND ONF PARTNERING TO SUPPORT CLINICAL PRACTICE
The Instut naonal d’excellence en santé et en services sociaux (INESSS), in
Québec, Canada, and the Ontario Neurotrauma Foundaon (ONF), in Ontario,
Canada, are partnering to jointly produce and support the implementaon of a
clinical pracce guideline (CPG) for the rehabilitaon of adults having sustained a
moderate to severe traumac brain injury (MSTBI).
This guide, which should be available in 2015, will provide recommendaons,
adapted to the Canadian context, for front-line clinicians, program coordinators
and managers working in rehabilitaon sengs, and also for those providing early
rehabilitaon within acute care facilies.
ADAPTED CONTENT AND SCOPE
The projected guidelines will:
• Apply to 
• Cover —physical, sensory, cognive, behavioural,
medical and nursing components
• Address  commonly encountered aer TBI, such as severe
behaviour disorders as well as mental health and addicon issues
• Be based on the  and other guidance available in
the literature
• Use expert consensus where evidence-based data is limited, notably for issues of

• Focus on the including subacute early
rehabilitaon, intensive funconal rehabilitaon and rehabilitaon toward social
integraon
• Formulate recommendaons from an  rather than a
profession-specic perspecve
• Provide  to support the
implementaon and sustaining process
• Feature  aimed at clinicians (e.g., forms and rang scales, algorithms)
along with some informaon material (e.g., brochures) for paents and their family
and friends
• Be available in both English and French

PERSPECTIVES AND EXPERTISE
• The project is structured and planned to ensure a close and connuous collaboraon
with all stakeholders concerned by the development and ulizaon of the CPG in
Québec and Ontario.
• All stages of the producon and implementaon of the CPG is overseen by the ONF
and INESSS with the support of a governing commiee, while the development of the
CPG content is under the responsibility of a scienc commiee of researchers and
clinicians from the two provinces.
PROjECT ORGANIzATIONAL STRUCTURE
SCIENTIFIC COMMITTEE
Mandate: Development of the CPG based on evidence and
clinical experse – literature appraisal – expert consensus
process – adaptaon of CPG – external review process
Scienc co-directors: Dr. Mark Bayley and Dr. Bonnie Swaine
CORE WORKING GROUP
Clinical and research experse from Ontario and Québec,
along with representaon from the ONF and INESSS
ADVISORY WORKING GROUP
Clinical and program experts from Ontario and Québec

Clinicians – Researchers – Program and facility managers –
Consumer representaves – Other stakeholders
Ad hoc
commiee on
implementaon
Project
coordinators
(Québec and
Ontario)
Research
assistants
GOVERNING COMMITTEE
Mandate: Overall guidance and decision making regarding
context, process, requirements and consideraons for CPG
development – linkage to key stakeholders – needs survey –
implementaon – overarching project supervision
Co-leads: C. Truchon and C. Kagan
Instut naonal
d’excellence
en santé et en
services sociaux
(INESSS)
Ontario
Neurotrauma
Foundaon
(ONF)
STEP BY STEP PROCESS


CHALLENGING OPPORTUNITIES AND PERSPECTIVES

• A bi-provincial, bilingual partnership, promong links and exchanges between clinicians and managers in Ontario and Québec, facilitang the sharing of knowledge, tools and pracces
• A ght alignment with clinicians and administrators from the onset of the project, increasing the complexity of the process but also the potenal of successful uptake of the CPG
• An innovave consultaon phase to explore and validate end-users’ needs and expectaons, helping to guide the development of the CPG as well as the implementaon process
• A systemac implementaon process across a large number of acute care and rehabilitaon facilies in two provinces
• A specic emphasis on progress and results indicators to accompany pracce recommendaons, which will enable support and monitoring of uptake across the networks
Review and

CPGs
May – Nov. 2013



Nov. 2013 – jan. 2014
12


evidence
Mar. – Nov. 2014
3


Oct. – Nov. 2014
4



guidelines
Nov. 2014 – May 2015
5


6Further input from panel
experts
External review
Guidelines release
1
2
3
4
5
6
Renement
Agreement
• 10 acute care
facilies
• 11 in-paent
rehab facilies
• TBD outpaent
rehab facilies
• 8 acute care
facilies
• 9 in-paent
rehab facilies
• 7 outpaent
rehab facilies
REVIEW AND EVALUATION OF EXISTING CPGS
OBjECTIVE: To idenfy all exisng clinical guidelines or related
tools in the literature pertaining to the rehabilitaon of adults
having sustained a moderate or severe traumac brain injury
For more details: See poster 829
CLINICAL PRACTICE GUIDELINES SELECTED
FOR qUALITY EVALUATION
  
1Brain injury rehabilitaon in adults 2013 Scosh Intercollegiate
Guidelines Network (SIGN)
2
Community integraon in moderate to severe TBI
Depression in moderate to severe TBI
Aging in moderate to severe TBI
Substance abuse in moderate to severe TBI
2011 Accident Compensaon
Corporaon (ACC)
3A guideline for vocaonal evaluaon following traumac brain
injury: a systemac and evidence-based approach 2011 Stergiou-Kita, M.
4Occupaonal therapy pracce guidelines for adults with
traumac brain injury 2009 American Occupaonal
Therapy Associaon (AOTA)
5
ABIKUS (Acquired Brain Injury Knowledge Uptake Strategy)
evidence-based recommendaons for rehabilitaon of
moderate to severe acquired brain injury
2007
ABIKUS Guidelines
Development Group (Bayley
et al.)
6Guidelines for the pharmacologic treatment of
neurobehavioural sequelae of traumac brain injury 2006 Warden et al.
7Traumac brain injury: diagnosis, acute management and
rehabilitaon 2006 New Zealand Guidelines
Group (NZGG)
VALIDATION OF THE END-USERS’ NEEDS AND
EXPECTATIONS
OBjECTIVE: To conduct a formal (FluidSurvey) consultaon
of the targeted end-users of the CPG concerning their needs
and expectaons with regard to the scope, content and
implementaon of the CPG
 Targeted end‑users
All clinicians, physicians, clinical coordinators and
managers of TBI programs in acute care sengs and
rehabilitaon facilies in Québec and Ontario
 
1. Prole of respondents
2. Knowledge/percepon of CPGs
3. Content and format of CPG
4. Implementaon process

RESPONDENT PROFILE N %
Hospital (early rehabilitaon) 105 22
Rehabilitaon instuon with an in-paent unit 247 51
Rehabilitaon instuon without an in-paent unit 99 21
Other 31 6
Total 482 100
SYNTHESIS OF ALL EXISTING DOCUMENTATION
AND EVIDENCE
OBJECTIVE: To develop a comprehensive matrix integrang, by
domains pertaining to TBI, all available informaon (exisng
recommendaons, other supporng evidence, end-users’
needs and expectaons) in order to support the panel of experts
in the process of adapng or formulang recommendaons
EVIDENCE SYNTHESIS MATRIX
THEME 

Level of
evidence Source
Other

evidence
Level of
evidence Source
Other factors to
consider


Motor
and
sensory
decits
Recommendaon 1 ASIGN,
2013 Evidence 1 1b ERABI,
2013
Recommendaon 2 BNZGG,
2006 Evidence 2 3 Author,
year
Recommendaon 3 CSource,
year None
Mental
health
None Evidence 1 4 Author,
year
None Evidence 2 1a ERABI,
2013
Other
Québec
Ontario
SPECIAL THANKS to our partners in this project, the Associaon des établissements de réadaptaon en décience physique du Québec (AERDPQ), the Associaon québécoise d’établissements de santé et de
services sociaux (AQESSS), the Québec Ministère de la Santé et des Services sociaux (MSSS), the Ontario Rehabilitave Care Alliance (RCA) and the Ontario Ministry of Health and Long-Term Care (MHLTC).