Why Do We Need a New Clinical Practice Guideline for Moderate to Severe Traumatic Brain Injury?

OBJECTIVE: Clinical practice guidelines (CPGs) aim to improve quality and consistency of healthcare services. A Canadian group of researchers, clinicians, and policy makers developed/adapted a CPG for rehabilitation post-moderate to severe traumatic brain injury (MSTBI) to respond to end users' needs in acute care and rehabilitation settings. METHODS: The rigorous CPG development process began assessing needs and expectations of end users, then appraised existing CPGs, and, during a consensus conference, produced fundamental and priority recommendations. We also surveyed end users' perceptions of implementation gaps to determine future implementation strategies to optimize adherence to the CPG. RESULTS: The unique bilingual (French and English) CPG consists of 266 recommendations (of which 126 are new recommendations), addressing top priorities for MSTBI, rationale, process indicators, and implementations tools (eg, algorithms and benchmarks). CONCLUSION: The novel approach of consulting and working with end users to develop a CPG for MSTBI should influence knowledge uptake for clinicians wanting to provide evidence-based care.

Assessment of Users' Needs and Expectations Toward Clinical Practice Guidelines to Support the Rehabilitation of Adults With Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: Stakeholder engagement in clinical practice guideline (CPG) creation is thought to increase relevance of CPGs and facilitate their implementation. The objectives were to survey stakeholders involved in the care of adults with traumatic brain injury (TBI) regarding general perceptions of CPGs, key elements to be included, and needs and expectations about format and implementation strategy. SETTINGS: Hospitals and inpatient and outpatient rehabilitation facilities providing services to persons with TBI. PARTICIPANTS: Stakeholders identified as primary end users of the CPG: clinicians, hospital leaders, health system managers, and funders in Quebec and Ontario (Canada). DESIGN: Cross-sectional online survey conducted between May and September 2014. RESULTS: In total, 332 individuals expressed their needs and expectations. Despite positive perceptions of CPGs, only a small proportion of respondents used them. Intensity and frequency of interventions, behaviors disorders and cognitive function impairment, and social participation and community life were important subjects to cover in the CPG. Finally, respondents asked for specific recommendations including a ranking of recommendations based on level of underlying evidence. CONCLUSION: Respondents have important expectations toward a CPG. We anticipate that early and meaningful engagement of end users could facilitate CPG implementation.

A Survey of Perceived Implementation Gaps for a Clinical Practice Guideline for the Rehabilitation of Adults With Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: Appraising current practice is an important prerequisite for implementation of clinical practice guidelines (CPGs). The study objective was to determine the perceived level of implementation, priority, and feasibility of a subset of key CPG recommendations for the rehabilitation of individuals with moderate to severe traumatic brain injury (MSTBI). METHODS: Fifty-one teams at acute care and rehabilitation facilities were invited to complete an electronic survey addressing the perceived level of implementation, priority, and feasibility of 109 fundamental and priority recommendations from the CPG-MSTBI. RESULTS: Forty-four clinical teams responded across 2 Canadian provinces. Most of the recommendations were deemed as "fully" or "mostly" implemented, while relative gaps in implementation were perceived in recommendations regarding coordination with mental health and addiction providers (>75% of respondents indicated low levels of implementation), "Caregivers and Families" (26%), and "Psychosocial and Adaptation Issues" (25%). Priority levels and perceived feasibility were generally high (>60% and >86%, respectively) for recommendations with low levels of implementation. Priority recommendations for implementation were identified for both acute care and rehabilitation settings in Québec and Ontario. CONCLUSIONS: Assessment of clinician perception provides a helpful perspective for implementation. Exploring perceived implementation gaps based on users' needs and expectation should be a part of an implementation process.

Unique Features of the INESSS-ONF Rehabilitation Guidelines for Moderate to Severe Traumatic Brain Injury: Responding to Users' Needs.

OBJECTIVE: Traumatic brain injury (TBI) clinical practice guidelines are a potential solution to rapidly expanding literature. The project objective was to convene experts to develop a unique set of TBI rehabilitation recommendations incorporating users' priorities for format and implementation tools including indicators of adherence. METHODS: The Guidelines Adaptation & Development Cycle informed recommendation development. Published TBI recommendations were identified and tabulated. Experts convened to adapt or, where appropriate, develop new evidence-based recommendations. These draft recommendations were validated by systematically reviewing relevant literature. Surveys of experts and target users were triangulated with strength of evidence to identify priority topics. RESULTS: The final recommendation set included a rationale, implementation tools (algorithms/adherence indicators), key process indicators, and evidence summaries, and were divided in 2 sections: Section I: Components of the Optimal TBI Rehabilitation System (71 recommendations) and Section II: Assessment and Rehabilitation of Brain Injury Sequelae (195 recommendations). The recommendations address top priorities for the TBI rehabilitation system: (1) intensity/frequency of interventions; (2) rehabilitation models; (3) duration of interventions; and (4) continuity-of-care mechanisms. Key sequelae addressed (1) behavioral disorders; (2) cognitive dysfunction; (3) fatigue and sleep disturbances; and (4) mental health. CONCLUSION: This TBI rehabilitation guideline used a robust development process to address users' priorities.

ONF trainee awards contribute to capacity building in neurotrauma.

OBJECTIVE: Injury to the brain and spinal cord is one of the most catastrophic and costly occurrences in the Ontario health system. The objective of the present study was to evaluate the impact of past Ontario Neurotrauma Foundation (ONF) studentships and fellowships in terms of capacity building in the neurotrauma field in Ontario. METHOD: An online, cross sectional survey amongst past recipients of studentships and fellowships that terminated prior to July 2005. Explicit data were collected on various aspects of career development including current activity, awards and publications. RESULTS: Thirty-six out of 42 (86%) eligible past trainees responded; 12 (33%) were Masters students, 12 (33%) were PhD students and 12 (33%) were Post-Doctoral students. A majority of the recipients (61%) are currently involved in neurotrauma-related activities (clinical, research and teaching) in more than 20% of their time, with no substantial differences between the degree groups. Half the recipients are currently involved in neurotrauma-related research in more than 20% of their time. The awardees published 1.5 peer-review manuscripts/person-year and received multiple awards. A high majority of our recipients (86%) feel that the ONF award had a substantial impact on their career. CONCLUSIONS: A high proportion of past award recipients remain involved in neurotrauma activities, especially in research. These results may lead to a cautious conclusion of the positive impact of the ONF studentships and fellowships on neurotrauma capacity building. These results should be considered in strategic planning of funding agencies similar to ONF.