Improving communicative access and patient experience in acute stroke care: An implementation journey.

INTRODUCTION: Patient experience for people with aphasia/families in acute care is frequently reported as negative, with communication barriers contributing to adverse events and significant long-term physical and psychosocial sequelae. Although the effectiveness of providing supported communication training and resources for health care providers in the stroke system is well documented, there is less evidence of implementation strategies for sustainable system change. This paper describes an implementation process targeting two specific areas: 1) improving Stroke Team communication with patients with aphasia, and 2) helping the Stroke Team provide support to families. The project aimed for practical sustainable solutions with potential contribution toward the development of an implementation practice model adaptable for other acute stroke contexts. METHODS: The project was designed to create a communicatively accessible acute care hospital unit for people with aphasia. The process involved a collaboration between a Stroke Team covering two units/wards led by nurse managers (19 participants), and a community-based Aphasia Team with expertise in Supported Conversation for Adults with Aphasia (SCA™) - an evidence-based method to reduce language barriers and increase communicative access for people with aphasia. Development was loosely guided by the integrated knowledge translation (iKT) model, and information regarding the implementation process was gathered in developmental fashion over several years. OUTCOMES: Examples of outcomes related to the two target areas include provision of accessible information about aphasia to patients as well as development of two new products - a short virtual SCA™ eLearning module relevant to acute care, and a pamphlet for families on how to keep conversation alive. Potential strategies for sustaining a focus on aphasia and communicative access emerged as part of the implementation process. CONCLUSIONS: This implementation journey allowed for a deeper understanding of the competing demands of the acute care context and highlighted the need for further work on sustainability of communicative access interventions for stroke patients with aphasia and their families.

Optimizing our evidence map for cognitive-communication interventions: How it can guide us to better outcomes for adults living with acquired brain injury.

BACKGROUND: Speech and language therapists (SLTs) share a collective goal of ensuring that adults with cognitive-communication disorders (CCD) due to acquired brain injuries (ABI) attain their highest possible level of participation and satisfaction in family, community, social, work and academic communications through evidence-based interventions. While there is a considerable evidence base to support SLT cognitive-communication interventions, there are also numerous barriers to its implementation. AIMS: The first aim is to describe the development of a comprehensive knowledge translation tool that synthesizes evidence-based practice recommendations for SLT cognitive-communication interventions across the care continuum. The second aim is to critically analyse the barriers to implementation of these interventions and to explore how this knowledge translation tool might assist in overcoming these challenges. METHODS & PROCEDURES: We developed a map of 148 clinical practice recommendations extracted from 129 reviews and guidelines called the Cognitive-Communication Evidence Application for SLTs (CCEAS-Map). The process of developing the CCEAS-Map included: (1) examination of implementation science frameworks to inform knowledge tool creation; (2) search and synthesis of the evidence provided in reviews and guidelines that met specific criteria; (3) development of a framework to critically analyse and categorize the barriers and facilitators affecting the implementation of these clinical recommendations; (4) consultation with potential end users of the CCEAS-Map, including 16 expert SLTs and eight persons with lived experience (PWLE), regarding the tool's construction, barriers and facilitators to implementation, and the potential of the CCEAS-Map to address evidence-practice gaps; and (5) refining the CCEAS-Map based on expert input. MAIN CONTRIBUTION: To our knowledge this is the first synthesis of all available clinical recommendations for SLT cognitive-communication interventions for ABI, across all severities of injury, stages along the continuum of care, and areas of CCD practice. The paper presents a novel approach to analysing knowledge-practice gaps: drawing on implementation science tools, analysing barriers and facilitators, and collaborating with end users in designing a knowledge translation tool. CONCLUSIONS & IMPLICATIONS: The CCEAS-Map provides a comprehensive synthesis of the available evidence in a format that can facilitate clinical application of the evidence, provide education for all stakeholders, serve as a basis for CCD pathway development, support researcher-clinician collaboration and encourage advocacy at the system level. As a knowledge translation tool, the CCEAS-Map can promote the availability of SLT services and has the potential to ultimately improve the lives of those with CCD. WHAT THIS PAPER ADDS: What is already known on this subject A great deal is known about cognitive-communication deficits incurred after ABI, including their impact on daily functioning, optimal methods for sensitive and ecologically valid assessment, and the efficacy of various speech-language therapy interventions along the care continuum. However, considerable constraints remain that interfere with the application of this evidence to daily SLT practice. A need was identified to develop a knowledge translation tool to help close these evidence-practice gaps. What this paper adds to existing knowledge This study describes the development of the CCEAS-Map, a critical synthesis of 129 reviews and guidelines, leading to 148 evidence-based clinical recommendations, which can be used to guide SLT cognitive-communication practice and education, as well as clinical pathway development, and advocacy for systemic changes and other healthcare policy improvements. What are the potential or actual clinical implications of this work? The CCEAS-Map is a clinical knowledge translation tool designed to guide cognitive-communication interventions by linking practice recommendations directly to the current evidence. This paper also offers insights into barriers to SLT intervention across the care continuum and strategies for improving implementation of cognitive-communication best practices, to improve the lives of those living with ABI related disabilities.

Development and evaluation of the Basic Outcome Measure Protocol for Aphasia (BOMPA).

PURPOSE: The Basic Outcome Measure Protocol for Aphasia (BOMPA) is a practical tool that allows for a quick self-report on quality of life from the perspective of the person with aphasia, as well as a clinical evaluation of aphasia severity and the ability to participate in conversation. The primary aim of this paper is to describe development of BOMPA and report on results of an inter-rater reliability study involving speech-language pathology raters. METHOD: The inter-rater reliability study utilised a fully crossed design and included independent ratings of 12 videos by 20 speech-language pathologists. RESULT: Results indicate moderate to strong inter-rater reliability among participant speech-language pathology raters (0.65-0.96), as well as when comparing these participant ratings with an expert rater's gold standard (0.59-0.86). CONCLUSION: BOMPA may be a useful outcome measurement tool for time-pressed clinicians in clinical settings.

Assumptions about Decision-Making Capacity and Aphasia: Ethical Implications and Impact.

This article explores the issue of aphasia and decision-making within the context of clinical ethics and patient rights. The cases described illustrate the danger of making assumptions about the inherent competence of people with aphasia and the life-altering consequences if no attempt is made to "accommodate" or support communication when competence may be masked by aphasia. Speech-language pathologists have a moral obligation and a key role to play in providing communication support that may serve to reveal a person's intact capacity to make specific decisions, as well as in supporting the steps involved in the decision-making process. This role also extends to providing guidance, education, and training for others involved in evaluating the decision-making capacity of people with aphasia. Communication support strategies useful at each stage of the decision-making process are detailed.