Adverse events associated with the delivery of telerehabilitation: A scoping review protocol.

OBJECTIVE: This scoping review aims to map the existing research on adverse events during the delivery of telerehabilitation. INTRODUCTION: Telerehabilitation, a subset of telemedicine, has gained traction during the COVID-19 pandemic as a means to deliver rehabilitation services remotely. However, there exists a research gap as there has yet to be any scoping review, systematic review, or meta-analysis published to identify and summarize the current primary research on adverse events related to telerehabilitation as a whole. It is important to understand how adverse events, such as falls during physiotherapy or aspiration pneumonia during speech language pathology sessions, are associated with telerehabilitation delivery. This will help to identify key limitations for optimizing telerehabilitation delivery by allowing for the development of key risk-mitigation measures and quality indicators. It can also help improve the uptake of telerehabilitation among clinicians and patients. This review aims to fill this research gap by conducting a search of published literature on adverse events in telerehabilitation. Anticipated key findings of this scoping review include identifying the characteristics and frequencies of adverse events during telerehabilitation, the patient populations and types of telerehabilitation associated with the most adverse events, and the quality of reporting of adverse events. METHODS: The review follows the Joanna Briggs Institute (JBI) methodological framework and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The review protocol has been registered and published on Open Science Framework. A comprehensive search strategy was implemented across multiple databases (MEDLINE ALL, EMBASE, APA PsycINFO, CENTRAL, and CINAHL). All stages (screening, extraction, and synthesis) will be conducted in duplicate and independently, with data extraction following the TIDieR framework, along with authors, year of publication (before or after COVID), population and sample size, and specific mode/s of telerehabilitation delivery. For synthesis, data will be summarized quantitatively using numerical counts and qualitatively via content analysis. The data will be grouped by intervention type and by type of adverse event. INCLUSION CRITERIA: This scoping review will include qualitative and quantitative studies published between 2013 and 2023, written in English, and conducted in any geographic area. All modes of telerehabilitation delivery (asynchronous, synchronous, or hybrid) will be included. Systematic reviews, meta-analyses, commentaries, protocols, opinion pieces, conference abstracts, and case series with fewer than five participants will be excluded.

Clinicians' Experiences of Implementing a Telerehabilitation Toolkit During the COVID-19 Pandemic: Qualitative Descriptive Study.

BACKGROUND: Although the COVID-19 pandemic resulted in a rapid implementation and scale-up of telehealth for patients in need of rehabilitation, an overall slower scaling up to telerehabilitation has been documented. OBJECTIVE: The purpose of this study was to understand experiences of implementing telerehabilitation during the COVID-19 pandemic as well as using the Toronto Rehab Telerehab Toolkit from the perspective of rehabilitation professionals across Canada and internationally. METHODS: The study adopted a qualitative descriptive approach that consisted of telephone- or videoconference-supported interviews and focus groups. Participants included rehabilitation providers as well as health care leaders who had used the Toronto Rehab Telerehab Toolkit. Each participant took part in a semi-structured interview or focus group, lasting approximately 30-40 minutes. Thematic analysis was used to understand the barriers and enablers of providing telerehabilitation and implementing the Toronto Rehab Telerehab Toolkit. Three members of the research team independently analyzed a set of the same transcripts and met after each set to discuss their analysis. RESULTS: A total of 22 participants participated, and 7 interviews and 4 focus groups were included. The data of participants were collected from both Canadian (Alberta, New Brunswick, and Ontario) and international sites (Australia, Greece, and South Korea). A total of 11 sites were represented, 5 of which focused on neurological rehabilitation. Participants included health care providers (ie, physicians, occupational therapists, physical therapists, speech language pathologists, and social workers), managers and system leaders, as well as research and education professionals. Overall, 4 themes were identified including (1) implementation considerations for telerehabilitation, encompassing 2 subthemes of "infrastructure, equipment, and space" and "leadership and organizational support"; (2) innovations developed as a result of telerehabilitation; (3) the toolkit as a catalyst for implementing telerehabilitation; and (4) recommendations for improving the toolkit. CONCLUSIONS: Findings from this qualitative study confirm some of the previously identified experiences with implementing telerehabilitation, but from the perspective of Canadian and international rehabilitation providers and leaders. These findings include the importance of adequate infrastructure, equipment, and space; the key role of organizational or leadership support in adopting telerehabilitation; and availing resources to implement it. Importantly, participants in our study described the toolkit as an important resource to broker networking opportunities and highlighted the need to pivot to telerehabilitation, especially early in the pandemic. Findings from this study will be used to improve the next iteration of the toolkit (Toolkit 2.0) to promote safe, accessible, and effective telerehabilitation to those patients in need in the future.

In defence of falling: the onomastics and ethics of "therapeutic" falls in rehabilitation.

Aim: Despite efforts towards a more just culture, rehabilitation providers still experience shame and trauma when their patients fall. This paper proposes a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls in rehab are not seen as something to be avoided at all costs, but rather as part of the recovery journey for some patients.Methods: Patients who understand and are willing to take on the risks of falling are more likely to collaborate with their care team to practice higher-risk activities, such as walking to the bathroom independently at night, as part of their recovery. If a fall takes place in this context, we argue that it should be considered a "therapeutic" fall.Results: This paper details some of the clinical and ethical approaches to supporting a care environment where values-and potential conflicts-about the benefits and challenges of risk-taking are recognized. An expanded concept of a therapeutic fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Conclusion: The goal of this work is to offer rehabilitation patients greater opportunities to make autonomous decisions about their mobility, and lay the groundwork for a more successful transition home.IMPLICATIONS FOR REHABILITATIONDespite best efforts, patients are often less active than they or their rehabilitation team might wish them to be.An expanded concept of a "therapeutic" fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Rehabilitation is the right environment to support shared decision-making about risk that better prepares patients and families for the often challenging transition back to community living.This works represents a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls are not something to be avoided at all costs, but can instead be part of the journey to recovery.

Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study.

OBJECTIVE: Best practice guidelines recommend that aerobic exercise (AEx) be implemented as early as possible poststroke, yet the prescription of AEx remains limited in stroke rehabilitation settings. This study used theoretical frameworks to obtain an in-depth understanding of barriers and enablers to AEx implementation in the stroke rehabilitation setting. METHODS: A qualitative, descriptive study was conducted. Participants were recruited from 4 stroke rehabilitation settings in Ontario, Canada, that have participated in an implementation study to provide structured AEx programming as part of standard care. Six clinician focus groups (with 19 physical therapists and 5 rehabilitation assistants) and one-to-one interviews with 7 managers and 1 physician were conducted to explore barriers and enablers to AEx implementation. The Theoretical Domains Framework and Consolidated Framework for Implementation Research informed content analysis for clinician and manager perspectives, respectively. RESULTS: Barriers specific to resource constraints and health care system pressures, combined with patient goals, led to interventions to improve function being prioritized over AEx. Successful implementation was enabled through an interprofessional approach and team engagement in the planning and implementation process. Health care providers described concerns about patient safety, but confidence and capability for implementing AEx were enabled by education, skill development, use of exercise tests, and consultation with individuals with content expertise. Participants described the development of supportive processes that enabled AEx implementation within team workflows and shared resources. CONCLUSION: Strategies to support implementation of AEx in stroke rehabilitation should incorporate knowledge and skills, the provision of clinical decision-making tools, access to expert consultation, the roles and social influence of the interprofessional team and formal and informal leaders, and supportive processes adapted to the local context. IMPACT: Results from this study will inform the development of a clinical implementation toolkit to support clinical uptake of AEx in the stroke rehabilitation setting.

Excelling in the role of advocate: a qualitative study exploring advocacy as an essential physiotherapy competency.

PURPOSE: To explore the perspectives of leading advocates regarding the attributes required for excelling in the advocate role as described within the Essential Competency Profile for Physiotherapists in Canada (2009). METHODS: We used a descriptive qualitative design involving in-depth, semi-structured interviews conducted with leading Canadian advocates within the physiotherapy profession. Transcribed interviews were coded and analyzed using thematic analysis. RESULTS: The 17 participants identified eight attributes necessary for excelling in the role of advocate: collaboration, communication, scholarly practice, management, professionalism, passion, perseverance, and humility. The first five attributes correspond to roles within the Essential Competency Profile for Physiotherapists in Canada. Participants identified the attributes of collaboration, communication, and scholarly practice as the most important for successful advocacy. Participants also noted that the eight identified attributes must be used together and tailored to meet the needs of the advocacy setting. CONCLUSIONS: Identifying these eight attributes is an important first step in understanding how competence in the advocate role can be developed among physiotherapy students and practitioners. Most importantly, this study contributes to the knowledge base that helps physiotherapists to excel in advocating for their clients and the profession.

Objectif: Étudier les points de vue des principaux défenseurs au sujet des qualités requises pour exceller dans le rôle de défenseur décrit dans le Profil des compétences essentielles des physiothérapeutes au Canada (2009). Méthodes: Nous avons utilisé un contexte qualitatif descriptif comportant des entrevues semi-structurées détaillées réalisées auprès de défenseurs canadiens de premier plan de la profession. Nous avons codé les entrevues transcrites et les avons analysées en appliquant une analyse thématique. Résultats: Les 17 participants ont défini huit qualités nécessaires pour exceller dans le rôle de défenseur: collaboration, communication, pratique savante, gestion, professionnalisme, passion, persévérance et humilité. Les cinq premières qualités correspondent aux rôles décrits dans le Profil des compétences essentielles des physiothérapeutes au Canada. Les participants ont considéré la collaboration, la communication et la pratique savante comme les qualités les plus importantes pour réussir comme défenseur. Ils ont aussi signalé que les huit qualités définies doivent servir ensemble et être personnalisées de façon à répondre aux besoins du contexte de défense. Conclusion: La détermination de ces huit qualités constitue une première étape importante pour comprendre comment les étudiants en physiothérapie et les praticiens peuvent devenir défenseurs compétents. Le plus important: cette étude contribue à la base de savoir qui aide les physiothérapeutes à exceller dans la défense de leurs clients et de la profession.

Using SBAR to communicate falls risk and management in inter-professional rehabilitation teams.

This study implemented and evaluated the adapted Situation-Background-Assessment-Recommendation (SBAR) tool for use on two inter-professional rehabilitation teams for the specific priority issue of falls prevention and management. SBAR has been widely studied in the literature, but rarely in the context of rehabilitation and beyond nurse-physician communication. In phase one, the adapted SBAR tool was implemented on two teams with a high falls incidence over a six-month period. In phase two, process and outcome evaluations were conducted in a pre-post design comparing the impact of the intervention with changes in the rest of the hospital, including the perceptions of safety culture (as measured by the Hospital Survey on Patient Safety Culture); effective team processes, using the Team Orientation Scale; and safety reporting, including falls incidence, severity and near misses. This study suggests that the adapted SBAR tool was widely and effectively used by inter-professional rehabilitation teams as part of a broader program of safety activities. Near-miss and severity of falls incidence trended downward but were inconclusive, likely due to a short time frame as well as the nature of rehabilitation, which pushes patients to the limit of their abilities. While SBAR was used in the context of falls prevention and management, it was also utilized it in a variety of other clinical and non-clinical situations such as transitions in care, as a debriefing tool and for conflict resolution. Staff found the tool useful in helping to communicate relevant and succinct information, and to "close the loop" by providing recommendations and accountabilities for action. Suggestions are provided to other organizations considering adopting the SBAR tool within their clinical settings, including the use of an implementation tool kit and video simulation for enhanced uptake.

Implementation of a safety framework in a rehabilitation hospital.

This patient safety initiative was implemented at the Toronto Rehabilitation Institute, a fully affiliated hospital of the University of Toronto that operates in-patient and outpatient facilities on five sites. A working group was created to engage the leaders and employees in defining and implementing our "ideal" safety culture. A subset of this group became the Research Team, mandated to do the "discovery work" with external groups and internal stakeholders to provide valuable input for designing the safety culture model. This involved identifying the key components required to support a safety culture, testing this model with findings from the academic literature and best in class organizations and identifying the who, what, when, where and how of each key component. Future activities will focus on the integration of safety into existing programs, initiatives and policies, seeking feedback from staff, patients and families, and evaluating the effectiveness of our intervention and the extent of the culture change.

Effectiveness of an Adapted SBAR Communication Tool for a Rehabilitation Setting.

Effective communication and teamwork have been identified in the literature as key enablers of patient safety. The SBAR (Situation-Background-Assessment-Recommendation) process has proven to be an effective communication tool in acute care settings to structure high-urgency communications, particularly between physicians and nurses; however, little is known of its effectiveness in other settings. This study evaluated the effectiveness of an adapted SBAR tool for both urgent and non-urgent situations within a rehabilitation setting. In phase 1 of this study, clinical staff, patient and family input was gathered in a focus-group format to help guide, validate and refine adaptations to the SBAR tool. In phase 2, the adapted SBAR was implemented in one interprofessional team; clinical and support staff participated in educational workshops with experiential learning to enhance their proficiency in using the SBAR process. Key champions reinforced its use within the team. In phase 3, evaluation of the effectiveness of the adapted SBAR tool focused on three main areas: staff perceptions of team communication and patient safety culture (as measured by the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture), patient satisfaction (as determined using the Client Perspectives on Rehabilitation Services questionnaire) and safety reporting (including incident and near-miss reporting). Findings from this study suggest that staff found the use of the adapted SBAR tool helpful in both individual and team communications, which ultimately affected perceived changes in the safety culture of the study team. There was a positive but not significant impact on patient satisfaction, likely due to a ceiling effect. Improvements were also seen in safety reporting of incidents and near misses across the organization and within the study team.