The Implementation Process of Two Evidence-Based Protocols: A Spatial Neglect Network Initiative

Abstract

IntroductionSpatial neglect, a neurocognitive disorder of lateralized spatial attention, is prevalent among stroke survivors especially in inpatient rehabilitation facilities (IRFs). The ultimate goal of the project was to improve spatial neglect care in inpatient rehabilitation and trained as many OTs as possible using both tools in their regular practices as the means to achieve our overall objective. Therefore, we conducted a project aimed at implementing two evidence-based protocols, one for assessment (KF-NAP®) and the other for treatment (KF-PAT®), and share the implementation process, which included barriers and facilitators identified during and after the process, and implementation outcomes.MethodsSixteen IRFs were involved. The Knowledge-To-Action Cycle was used to describe the process of knowledge inquiry (training), translating knowledge (implementation) and evaluating the use of knowledge in clinical practice (outcomes). Barriers and strategies were reported using the Consolidated Framework for Implementation Research and identified through a survey, after the study concluded.ResultsThirty-two therapists at the participating sites were trained to some level of the KF-NAP and KF-PAT. Throughout the project and also once after it finished, different barriers were identified by researchers and clinicians, who then determined together actions to eliminate or minimize the barriers. For example, multiple sites reported: “not having time to train other staff at their hospital due to high patient volume and other responsibilities.”DiscussionThe project shared our implementation process which demonstrated the importance of using implementation methods and incorporating a researcher-clinician partnership, not only for knowledge generation but also knowledge translation. Frequent communications and exchanging information with stakeholders at different levels, may be determinant to the success of each implementation phase. Further research is needed.

Impacts of Prism Adaptation Treatment on Spatial Neglect and Rehabilitation Outcome: Dosage Matters

“…While the present analysis was focused on PAT dosage, more analyses have been planned to answer questions based on the clinical records gathered through the multi-site implementation project 29 such as whether patients with left-sided neglect and right-sided neglect differed in their outcomes associated with PAT, whether receiving PAT earlier or later during inpatient rehabilitation care predicted outcomes, and whether FIM Gains and changes in measures of the CARE Tool were comparable. However, some questions cannot be answered from this dataset.…”

“…While number of PAT sessions and SN improvement were correlated, we investigated whether this linear relation stopped at a certain number of sessions. Because therapists reported difficulties providing 10 once-daily sessions to every patient (due to LOS and other factors), 29 the following post hoc analysis may provide insight into whether fewer than the suggested dosage of 10 sessions could be enough for similar SN improvement. Visual examination of CBS Change by number of PAT sessions (Figure 1) indicated a more prominent linear relationship between session attendance and gains in patients attending 8 or fewer sessions.…”

“…In addition, whether or why patients received no or any number of PAT sessions were not entirely at random but determined by various factors, which is discussed in depth in a separate article. 29 Other than PAT, we had no information about types or total hours of therapies, or treatment activities within a therapy in which patients participated during their LOS. The noisy dataset may explain that in the present study, the multiple linear regression models predicting CBS Change accounted for less than 50% variance and less than 30% variance regarding FIM Gains.…”

“…In the overarching implementation project, 29 therapists were encouraged to assess all neurological patients under their care, with the understanding that SN can occur after different types of brain injury, using the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP®). 30,31 Therapists were encouraged to deliver PAT following the Kessler Foundation Prism Adaptation Treatment (KF-PAT®) protocol 13,22 when SN was detected.…”

“…To gain insight of the relationship between PAT dosage and outcomes, the present study examined data gathered through regular clinical practice (i.e., clinical records) in 16 rehabilitation hospitals that participated in a large-scale implementation project for improving SN care of patients with brain injury (for details about the overarching project, see Hreha et al) 29 It is important to note that clinical records can provide practice-based evidence, which differs from evidence generated from prospective RCTs and has inherent limitations such as no blinding (i.e., the same therapists or colleagues on the same therapy team assessing and treating the same patients), no randomization or allocation concealment procedures assigning patients to control conditions, and a great heterogeneity of the sample. Nonetheless, as demonstrated in the matched, controlled study described above, 18 data based on clinical records can help answer certain questions and generate new research questions.…”