A pilot living clinical practice guidelines approach was feasible and acceptable to guideline panel members.

OBJECTIVES: Clinical practice guidelines (CPGs) help to translate best available evidence into clinical practice but can be challenging to keep current due to their resource intensive nature. A "living" process that is used to continually update CPGs may therefore be of value. STUDY DESIGN AND SETTING: This pilot study assesses the development of a living CPG protocol based on the CanPainSCI CPG. Two "living CPG" update searches were performed; resource costs and acceptability were assessed by a research team across Australia and Canada RESULTS: Two updates were completed over 3 years. Literature searches and data extraction were completed by trainees on 119 and 58 papers. Eight papers were included and reviewed by 14 expert panel members. Resource usage included a total 43 hours of screening by trainees at $2,356 (USD), 24 hours of expert panel review at $3,141 (USD) and 30 hours of project management at $3,241 (USD). Reviewers were generally satisfied with the process. All reviewers agreed that incorporating a living guidelines approach would be useful. CONCLUSION: This paper outlines the process of maintaining a CPG through a living guideline process and provides resource costs and acceptability data which may aid stakeholders in the development of future CPGs.

Building Long-Term Care Staff Capacity During COVID-19 Through Just-in-Time Learning: Evaluation of a Modified ECHO Model.

OBJECTIVES: The onset of the COVID-19 pandemic significantly challenged the capacity of long-term care (LTC) homes in Canada, resulting in new, pressing priorities for leaders and health care providers (HCPs) in the care and safety of LTC residents. This study aimed to determine whether Project ECHO (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education program, was effective at delivering just-in-time learning and best practices to support LTC teams and residents during the pandemic. DESIGN: Mixed methods evaluation. SETTING AND PARTICIPANTS: Interprofessional HCPs working in LTC homes or deployed to work in LTC homes primarily in Ontario, Canada, who participated in 12 weekly, 60-minute sessions. METHODS: Quantitative and qualitative surveys assessing reach, satisfaction, self-efficacy, practice change, impact on resident care, and knowledge sharing. RESULTS: Of the 252 registrants for ECHO COE-LTC: COVID-19, 160 (63.4%) attended at least 1 weekly session. Nurses and nurse practitioners represented the largest proportion of HCPs (43.8%). Overall, both confidence and comfort level working with residents who were at risk, confirmed, or suspected of having COVID-19 increased after participating in the ECHO sessions (effect sizes ≥ 0.7, Wilcoxon signed rank P < .001). Participants also reported impact on intent to change behavior, resident care, and knowledge sharing. CONCLUSIONS AND IMPLICATIONS: The results demonstrate that ECHO COE-LTC: COVID 19 effectively delivered time-sensitive information and best practices to support LTC teams and residents. It may be a critical platform during this pandemic and in future crises to deliver just-in-time learning during periods of constantly changing information.

Development of an implementation-focused network to improve healthcare delivery as informed by the experiences of the SCI knowledge mobilization network.

Context: Implementing research findings into clinical practice is challenging. This manuscript outlines the experiences and key learnings from a network that operated as a community of practice across seven Canadian Spinal Cord Injury (SCI) rehabilitation centers. These learnings are being used to inform a new implementation-focused network involving SCI rehabilitation programs based in Ontario, Canada. Methods: The SCI KMN adapted and applied implementation science principles based on the National Implementation Research Network's (NIRN) Active Implementation Frameworks in the implementation of best practices in pressure injury and pain prevention and management. Results: The SCI KMN was successful in implementing best practices in both pressure ulcer and pain prevention and management across the various participating sites. Other key objectives met were building capacity in implementation methods in site personnel so that project scaling could occur with these skills and expertise applied to numerous other initiatives. Additionally, various papers, abstracts and conference presentation as well as an implementation guide were disseminated to inform the field of implementation science. Conclusion: The key lessons learned from this experience are being used to develop a new implementation-focused network. Features felt to be especially important for the SCI KMN includes a highly representative governance structure, the use of indicators within an overall evaluation framework and the systematic application of implementation processes with shared learnings supporting each site.

A systematic review of the content and quality of clinical practice guidelines for management of the neurogenic bladder following spinal cord injury.

INTRODUCTION: Neurogenic bladder following acute spinal cord injury (SCI) increases urinary tract infection (UTI) risk and affects quality of life and health system costs. OBJECTIVES: This study aimed to identify, describe and evaluate quality of clinical practice guidelines (CPGs) for managing neurogenic bladder following SCI. METHODS: A comprehensive search covered six electronic databases (PubMed, Web of Science, Health Systems Evidence, Cochrane, CINAHL, Epistomonikos) and 12 CPG portals. Inclusion criteria were English language CPG; includes recommendations for managing neurogenic bladder in adults; all phases of care; published 2011 onwards in peer-reviewed journal/CPG portal. For eligible CPGs, key characteristics including years covered by CPG searching and number of neurogenic bladder recommendations were extracted. Quality appraisal used the AGREE II instrument. Appraiser agreement was assessed using the intraclass correlation coefficient. RESULTS: Searching yielded 4028 citations and eight relevant CPGs. Collectively the CPGs contained 304 recommendations. Over half (160) pertained to assessment, surgery or education. Most surgery recommendations were from older CPGs; more recent CPGs emphasised conservative therapy. Methodological quality across CPGs was good in the domains of 'clarity of presentation' (84% mean domain score), 'scope and purpose' (72%) and 'editorial independence' (68%). There were shortcomings in the domains of 'rigor of development' (52%) 'stakeholder involvement' (42%) and 'applicability' (33%). CONCLUSION: CPGs for the management of neurogenic bladder following SCI are generally robust in stating their scope and clearly presenting recommendations. Only three CPGs attained domain scores over 70% pertaining to methodological rigor. Future CPGs should also focus on providing implementation / audit resources and incorporating patient perspectives.

Implementation of Pressure Injury Prevention Best Practices Across 6 Canadian Rehabilitation Sites: Results From the Spinal Cord Injury Knowledge Mobilization Network.

OBJECTIVE: To use the theoretical frameworks of implementation science to implement pressure injury (PI) prevention best practices in spinal cord injury (SCI) rehabilitation. DESIGN: Quality improvement. SETTING: Six Canadian SCI rehabilitation centers. PARTICIPANTS: Inpatients (N=2371) admitted from 2011 to 2015. INTERVENTIONS: The SCI Knowledge Mobilization Network (SCI KMN) selected and implemented 2 PI prevention best practices at 6 Canadian SCI rehabilitation centers: (1) completing a comprehensive PI risk assessment comprised of a structured risk assessment instrument followed by an individualized, interprofessional risk factor determination and prevention plan; and (2) providing structured and individualized PI prevention patient education. Active Implementation Frameworks provided a systematic approach to best practice implementation. MAIN OUTCOME MEASURES: Implementation indicators (completion rates) and patient outcomes (PI incidence, patient education survey). RESULTS: After implementation, risk assessment completion rates improved from 46% to 94% (P<.05). Between initial (2012-2013) and full (2014-2015) implementation stages, completion rates improved for both interprofessional risk factor determination (67% to 96%) and prevention plans (67% to 94%). Documentation of patient education also increased to 86% (vs. 71% preimplementation). At rehabilitation admission 22% of patients had PIs, with 14% of individuals developing new PIs during rehabilitation. The overall PI prevalence was 30%. Considering only PIs of stage 2 or greater, prevalence was 21% and incidence 7%. There were no statistically significant differences in PI incidence between pre- and postimplementation. Patient education surveys indicated that PI education improved patients' knowledge of prevention strategies. CONCLUSIONS: Active Implementation Frameworks supported successful implementation of PI prevention best practices across the 6 participating SCI KMN sites. Achieving a reduction in PI incidence will require additional measures, and there is an ongoing need to strengthen the evidence base underpinning PI prevention guidelines.

An inclusive, online Delphi process for setting targets for best practice implementation for spinal cord injury.

RATIONALE, AIMS, AND OBJECTIVES: The Spinal Cord Injury Knowledge Mobilization Network is a pan-Canadian community of practice composed of seven rehabilitation hospitals. The goal of this network is to utilize implementation science processes to facilitate the adoption of best practice in spinal cord injury (SCI) rehabilitation. In addition to selecting specific practices for implementation, a key aspect of effective implementation is the engagement of stakeholders in decision-making processes. To achieve this, the network utilized a Delphi process to reach consensus on two pressure ulcer prevention and management practices to be implemented in SCI inpatient rehabilitation. A diverse, multidisciplinary panel of clinicians, researchers, sponsoring agency representatives, and persons with SCI participated in this process. METHOD: An online Delphi process was conducted in order to prioritize pressure ulcer prevention and management best practice recommendations and performance indicators for implementation. The process was conducted in six stages: (1) steering committee selection; (2) identification and selection of evidence; (3) participant selection and recruitment; (4) survey development; (5) identification of voting criteria; and (6) five rounds of voting. RESULTS: The Delphi process resulted in the selection of two best practices: (1) comprehensive risk assessment and (2) education for pressure ulcer prevention and management in persons with SCI. CONCLUSIONS: In this Delphi process, a large expert panel achieved consensus on best practice recommendations and associated performance indicators for implementation. This process was undertaken as a first step towards optimization of service delivery and outcomes for persons with SCI across Canada.

Advancing research and clinical care in the management of neuropathic pain after spinal cord injury: Key findings from a Canadian summit.

Background: Optimal management of neuropathic pain (NP) is essential to enhancing health-related quality of life for individuals living with spinal cord injury (SCI). A key strategic priority for the Ontario Neurotrauma Foundation (ONF) and Rick Hansen Institute (RHI) is optimizing NP management after SCI. Aims: A National Canadian Summit, sponsored by ONF and RHI, was held to develop a strategic plan to improve NP management after SCI. Methods: In a one-day meeting held in Toronto, Ontario, a multidisciplinary panel of 18 Canadian stakeholders utilized a consensus workshop methodology to (1) describe the current state of the field, (2) create a long-term vision, and (3) identify steps for moving into action. Results: A review of the current state of the field identified strengths including rigourously developed evidence syntheses and practice landscape documentation. Identified gaps included limited evidence on NP hindering recommendation development in evidence syntheses, absence of a national strategy, care silos with limited cross-continuum connections, limited consumer involvement, and limited practice standard implementation. The panel identified key themes for a long-term vision to improve the management of SCI NP in Canada, including establishing an integrated collaborative network; standardized care and outcome evaluation; education; advocacy; and directing resources to innovative solutions. The panel identified the next step as prioritization of areas that will have the greatest impact in a 5-year time frame. Conclusion: A strategic plan outlining a long-term vision to improve management of NP after SCI in Canada was developed and will inform future activities of the sponsors.

Contexte: La gestion optimale de la douleur neuropathique est essentielle à l'amélioration de la qualité de vie liée à la santé des personnes vivant avec une lésion de la moelle épinière. L'une des priorités stratégiques de la Fondation ontarienne de neurotraumatologie et de l'Institut Rick Hansen est l'optimisation de la prise en charge de la douleur neuropathique après une lésion de la moelle épinière.Buts: Un sommet national canadien parrainé par la Fondation ontarienne de neurotraumatologie et l'Institut Rick Hansen a été tenu afin d'élaborer un plan stratégique pour l'amélioration de la gestion de la douleur neuropathique après une lésion de la moelle épinière.Méthodes: Dans le cadre d'une rencontre d'une journée tenue à Toronto, Ontario, un panel multidisciplinaire composé de 18 parties prenantes canadiennes a eu recours à la méthodologie de l'atelier consensuel pour (1) décrire la situation actuelle dans le domaine, (2) définir une vision à long terme et (3) déterminer les étapes à suivre pour passer à l'action.Résultats: Une revue de la situation actuelle dans le domaine a permis d'en répertorier les forces, parmi lesquelles on compte des synthèses de données probantes élaborées avec rigueur et la documentation des pratiques. Les lacunes suivantes ont été répertoriées: des données probantes limitées en ce qui concerne la formulation de recommandations pour empêcher la douleur neuropathique dans les synthèses de données probantes; l'absence de stratégie nationale; un mode de prestation des soins en silos, où les liens entre les continuums sont limités; une participation du consommateur limitée et une mise en œuvre limitée des normes de pratique. Le panel a répertorié les grands thèmes pour élaborer une vision à long terme afin d'améliorer la prise en charge de la douleur neuropathique occasionnée par une lésion de la moelle épinière au Canada, parmi lesquels on compte: l'établissement d'un réseau de collaboration intégré; la normalisation des soins et l'évaluation des résultats; l'éducation; le plaidoyer; et l'attribution de ressources aux solutions novatrices. Le panel a déterminé que la prochaine étape consisterait à prioriser les domaines qui auront le plus de répercussions au cours des cinq prochaines années.Conclusion: Un plan stratégique définissant une vision à long terme pour améliorer la prise en charge de la douleur neuropathique après une lésion de la moelle épinière a été élaboré. Ce plan servira de base aux prochaines activités des promoteurs.

Antidepressants Are Effective in Decreasing Neuropathic Pain After SCI: A Meta-Analysis.

OBJECTIVE: To systematically review and assess the effectiveness and safety of antidepressants for neuropathic pain among individuals with spinal cord injury (SCI). METHODS: A systematic search was conducted using multiple databases for relevant articles published from 1980 to April 2014. Randomized controlled trials (RCTs) involving antidepressant treatment of neuropathic pain with ≥ 3 individuals and ≥ 50% of study population with SCI were included. Two independent reviewers selected studies based on inclusion criteria and then extracted data. Pooled analysis using Cohen's d to calculate standardized mean difference, standard error, and 95% confidence interval for primary (pain) and other secondary outcomes was conducted. RESULTS: Four RCTs met inclusion criteria. Of these, 2 studies assessed amitriptyline, 1 trazadone, and 1 duloxetine among individuals with neuropathic SCI pain. A small effect was seen in the effectiveness of antidepressants in decreasing pain among individuals with SCI (standardized mean difference = 0.34 ± 0.15; 95% CI, 0.05-0.62; P = .02). A number needed to treat of 3.4 for 30% or more pain relief was found by pooling 2 studies. Of these, significantly higher risk of experiencing constipation (risk ratio [RR] = 1.74; 95% CI, 1.09-2.78; P = .02) and dry mouth (RR = 1.39; 95% CI, 1.04-1.85; P = .02) was found amongst individuals receiving antidepressant treatment compared to those in the control group. CONCLUSIONS: The current meta-analysis demonstrates that antidepressants are effective in reducing neuropathic SCI pain. However, this should be interpreted with caution due to the limited number of studies. Further evaluation of long-term therapeutic options may be required.

Moving beyond the stigma: systematic review of video games and their potential to combat obesity.

Increasing epidemic proportions of overweight children in the United States presents formidable challenges for education and healthcare. Given the popularity and pervasiveness of video gaming culture in North American children, the perfect opportunity arises to investigate the potential of video games to promote healthful behaviour. Our objective was to systematically review the literature for possible benefits of active and educational video games targeting diet and physical activity in children. A review of English-language journal articles from 1998 to 2011 using EMBASE and PubMed was conducted. Thirty-four studies concerned with children, video games, physical, and/or nutritional outcomes were included. Results of these studies that showed some benefit (increased physical activity and nutritional knowledge as a result of gaming) demonstrate the possibility of video games to combat childhood obesity-looking beyond the stigma attached to gaming.