oa Physical Therapist's Adherence to a Structured Evidence Based Practice Guideline Improves Practice Behavior and Quality of Care; Result of an Exploratory Analysis in a Tertiary Level Hospital in Qatar

Background

Development of clinical guidelines in health services is generally considered important for improving and managing the care process (Grimshaw et al., 1995a, Grimshaw et al., 1995b, Grol and Grimshaw 2003, Grol et al., 2004). Clinical guidelines are systematically developed statements designed to help practitioners and patients to make decisions about appropriate health care (Field and Lohr 1992). Higher quality of care and improved cost effectiveness are important goals in guideline development, optimally resulting in improved health (Woolf et al., 1999). Moreover, the process of guideline development addresses the need to decrease variability in professional practice, and practitioners' desire to legitimize their profession in the eyes of external stakeholders (Grimshaw et al., 1995a, Grimshaw et al., 1995b, Grimshaw and Hutchinson 1995, Grol and Grimshaw 2003, Grol et al., 2004). The concept of evidence-based practice, supported by clinical guidelines, is a common aspect of health care today. No reviews have been published which specifically review the effect of strategies to increase the implementation of Physical therapy guidelines. In a study by Rebbeck et al., (2007), the effect of implementation of spinal pain guidelines was reviewed. Although 14 trials were included in the review, only three included Physical therapy interventions Currently there is no formal training or education sessions to unify the Physical therapy practice in the department, which in turn resulting in greater practice variations and results. Grater variability in professional practice directly influences the outcome of patient care. To counteract this, Physical therapy unit, Rumailah hospital, Qatar has developed Physical therapy specific clinical practice guideline called ‘PAAS Guideline’ (Physical Therapy After Acute Stroke) to enhance the effectiveness and efficiency of post acute stroke Physical therapy care. Evidence argues that guideline-adherent care results in better health outcomes, quality of care, shorter treatment period and reduced cost of care. The phase II of the PAAS guideline trail focuses on the adherence of Physical therapists on the implemented guideline through file monitoring to compare its effectiveness before and after the guideline. ‘Physical Therapy After Acute Stroke’ (PAAS) guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care ‘exclusively’ developed by the Physical therapists of Rumailah hospital. The goal of the PAAS guideline is to improve the quality, transparency, and uniformity of the physical therapy provided to patients whose main diagnosis is a stroke (cerebrovascular accident), throughout the chain of integrated care, by explicitly describing the Physical therapist's management of these patients on the basis of scientific research, adjusted where necessary on the basis of consensus among Physical therapy experts in primary, secondary and tertiary care, as well as associated professions in the field.

Objective

To find out the effectiveness of a structured clinical practice guideline in the quality of care and practice behavior of Physical therapist's practicing in stroke in the Physical therapy department of Rumailah hospital.

Alternative Hypothesis

A PAAS structured clinical practice guideline is an effective way to improve the quality of care and practice behavior of the stroke practicing Physical therapists of Rumailah hospital.

Design

The project was structured in an observational prospective cohort model implemented during the year 2015 in the Physical therapy unit, Rumailah hospital, which will include all the practicing Physical therapists of Physical therapy unit of Rumailah hospital. We have chosen Physical therapists even from other units who are seeing stroke patients at its different stages to maintain the continuum of care and coalesce the practice. We have identified the ‘Health Service Executive (HSE) model of change’ as the suitable model since it is to fit the health care organizations. HSE model of emphasizes 4 major steps: (1) Initiation of change, (2) Planning of the change, (3) implementation stage and (4) Mainstreaming comprises evaluating and learning from the change.

The change process was initiated by January 2015, around 30 Physical therapists from the concerned area were involved in the program. Staff orientation and competency to the guideline were introduced through an in-depth training programs with pre and post-tests, periodical refresher courses and information leaflets.

Method

A subspecialty stroke form was developed as an additional form to be added with the general stroke assessment form from 1 April 2015. The subspecialty stroke form exactly reflects the PAAS guideline in its evaluation and management. It was made mandatory that the sub specialty form has to be attached with the general neurology assessment form when assessing and managing a stroke case with effect from 1 April 2015. A retrospective file monitoring was initiated to understand the practice behaviour before the PAAS guideline implementation by selecting 2 closed files of stroke patients per therapist treated from 1 January to 29 March 2015. Post guideline monitoring was started between 21 June and 30 June 2015 to cover the closed files from 1 April to 29 June 2015. The same monitoring tool was used for both the phases of monitoring. Evaluations or goals where rated as met or not met. Use of at least 80% of the basic neurological and 60% of functional measurement tools were considered as ‘MET’ in the evaluation criteria. At least 5 recommended approaches per domain from any four out of five domains during the whole treatment course as per the assessment or review was decided as ‘MET’ for the Physical therapy management part. In the pre guideline phase total number of outcome measures and total number of approaches were used to reach up the conclusion.

Result

The PASS guideline adherence analysis revealed marked difference in the Physical therapy evaluation and practice of the hemiplegic patients. Since there was no organized systems before the implementation of PAAS guideline, the evaluation and treatment part was in the ‘NOT MET’ status as pre guideline implementation phase the 80 and 60% rule in evaluation phase and 4 out of 5 domain rule in the treatment part couldn't reached. The Guideline Task Force (GTF) decided to go with the direct counting of outcome measures and treatment techniques to compare between the two phases. Comparison of stroke specific outcome measures before and after the guideline implementation revealed that the use of stroke specific outcome measures became 74% post guideline compared to 36% in the pre guideline implementation phase (Fig. 1). Comparison of use of evidence based approaches for stroke care before and after the guideline implementation has shown that 73% post guideline compared to 35% pre guideline implementation (Fig. 2) with an overall 45% gain in evidence based care post guideline implementation (Fig. 3) A paired ‘t’ test was executed to analyses the pre and post file monitoring results. The ‘t’ statistics was observed as, t = 20.003, and p = 0.001; ie, 0.001 probability of this result occurring by chance, under the null hypothesis of no difference (table 1). The null hypothesis was rejected, since p <  0.05.

Conclusion

There is strong evidence (p = 0.001) that the structured guideline improved the practice behavior and quality of care post guideline implementation. In this data set, it improved use of outcome measures and evidence based approaches after the guideline implementation directly reflects the change in practice behavior and quality of care of stroke practicing Physical therapists of Rumailah hospital.

Implication

PAAS guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care, developed by the guideline task force of Physical therapy unit, Rumailah Hospital. PAAS Guideline offers recommendations for appropriate care. An evaluation of the guideline adherence and practice variations helps to fine tune the Physical therapy care to a highest possible standard of practice. A proper assessment of the relationship between the process of Physical therapy care and outcomes with a comprehensive set of process indicators will be implemented during the year 2016. We strongly believe that by means of systematic approach and implementation we can change the culture of practice so that it can suit and align with the international quality care in evidence based manner there by uplifting the corporation and its vision of becoming an internationally recognized center of excellence in health care. We believe that this ‘small changes will make a big difference in our health care system in the coming years’.

Physical Therapy, Practice behavior, Clinical practice guideline, Adherence

References

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Grimshaw, Jeremy, Martin Eccles, and Ian Russell. “Developing clinically valid practice guidelines.” Journal of evaluation in clinical practice 1.1 (1995): 37–48.

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Grol, Richard, and Jeremy Grimshaw. “From best evidence to best practice: effective implementation of change in patients' care.” The lancet 362.9391 (2003): 1225–1230.

Rebbeck, Timothy R., et al. “A retrospective case-control study of the use of hormone-related supplements and association with breast cancer.” International journal of cancer 120.7 (2007): 1523–1528.

Woolf, Steven H., et al. “Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.” BMJ: British Medical Journal 318.7182 (1999): 527.