1. PROTOCOLS / CLINICAL PRACTICE GUIDELINES
KNR 365

2. WHAT ARE PROTOCOLS?
Provide link between addressing client needs & evaluating the effects of service delivery
Document the purposeful procedures used to deliver intervention to clients
Provide a basis for evaluating the efficacy of those procedures

3. WHAT ARE PROTOCOLS?
Major factor in being able to standardize care & produce predictable client outcomes
When researched and validated, may provide a common basis of TR treatment procedures used across the country
“Common practice”

4. WHAT ARE PROTOCOLS?
Purpose is to provide a defensible and consistent way of treating or serving client needs
Help improve quality of care

5. PROTOCOLS DEFINED Connolly & Keogh-Hoss, 1991
Given a specific diagnostic need or problem, a particular protocol may be developed and tested and used with consistency to lead to a predetermined outcome that is defined as alleviating or remediating the diagnostic related need or problem

6. PROTOCOLS DEFINED Stumbo & Peterson, 2009
“Documents that describe the ‘best practice’ of specific interventions as applied to a specific group of clients or client needs that have been standardized and result from recent research evidence, literature reviews, or professional consensus.” (p. 231)

7. 2 TYPES OF PROTOCOLS Treatment or intervention (program)
Diagnostic (client)
what Connolly & Keogh-Hoss defined

8. HOW ARE THESE DIFFERENT? Formats in Stumbo & Peterson, 2009
Treatment (intervention or program)
Based on 1 area of care
Stress management, social skills
Diagnostic (or problem based)
Specific diagnosis
TBI, depression, etc.
Related problem clusters
Confusion & disorientation

9. CLINICAL GUIDELINES DEFINED
Stumbo & Peterson, 2009
“Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” (p. 231)
Test that s/b ordered, how long stay in hospital, etc.

10. CLINICAL GUIDELINES DEFINED
Hood, 2001
Term most widely used & accepted in health-care
“Distillation of the best collective thinking from the literature, from practicing clinicians, from academics on how to treat a particular medical situation.” (p. 193)

11. Clinical Practice Guidelines Richeson, Fitzsimmons, & Buettner in Stumbo, 2009
Evidence-based Guidelines
Manual of systematic statements developed to assist practitioners on selecting appropriate healthcare for specific situations.
Summarize & evaluate strength of evidence related to a healthcare problem
Make practice recommendations

12. Clinical Practice Guidelines Richeson, Fitzsimmons, & Buettner in Stumbo, 2009
Development process includes
Verifiable, systematic literature review of research in peer-reviewed journals
Must be current
Revised within last 5 years
Written in way to help practitioners digest most current research so they can apply the research to practice

13. HISTORY OF TR PROTOCOLS
1989 NTRS Protocols in Therapeutic Recreation
Sample protocols
Efficient tool for quality treatment
Tool to market TR services & programs
No info on how to develop or use protocols

14. HISTORY OF TR PROTOCOLS
ATRA Protocol Committee
Serious attempt to collect protocols from around country to develop library & database
Goal to have system where TR practitioners could go to request protocols
Only a handful of protocols were gathered
Therapists didn’t know how to write up or use protocols

15. HISTORY OF TR PROTOCOLS
1991 Riley edited Quality Management Applications for Therapeutic Recreation
ATRA publication
Connolly & Keogh-Hoss
Knight & Johnson
Provided some direction to protocol development

16. HISTORY OF TR PROTOCOLS
1993 ATRA Protocol Committee
Developed a 2 year strategy for moving protocols forward
5 major diagnostic categories
Substance abuse
Aging/geriatrics
Mental health/psychiatry
Pediatrics
Rehabilitation

17. HISTORY OF TR PROTOCOLS
1997 Kelland, Protocols for Recreation Therapy Programs (Canada)
1997/98 Hood & Krinsky
ATRA Development Committee
Identify priority needs in alcoholism treatment
Delphi procedure
Used experts

18. HISTORY OF TR PROTOCOLS
Hood & Krinksy cont.
Findings
Fairly wide range of opinions from a select panel of experts on needs s/b viewed as priority for TR intervention
Underestimate impact of philosophical differences

19. HISTORY OF TR PROTOCOLS
1999 Personal conversation with Cyn Carruthers
Current work is on alcoholism and depression
Being tested with varying success
Legal implications
Untested protocols s/b called Clinical Practice Guidelines

20. HISTORY OF TR PROTOCOLS
2000 Peterson & Stumbo
Provide sample formats for treatment and diagnostic protocols

21. HISTORY OF TR PROTOCOLS
2001 Hood in Stumbo
Little consensus on usefulness of protocols
Variety of terms
Protocol
Practice Standards
Critical Pathways
Clinical Practice Guidelines

22. HISTORY OF TR PROTOCOLS
Hood Cont.
What process of development should be followed?
Extensive literature review, panel of experts
Efficacy research
In TR little evidence of efficacy of services provided
What kind of information is required for practice guidelines?
Debate about level of detail & what s/b included
How make accessible & useable to practioners

23. HOOD’S CONCERNS
The kinds of problems addressed in TR tend to be more psychosocial and not as amenable to standardization as biomedical needs. (p. 194)
May be hard to design step-by-step procedures to address psychosocial issues or secondary effects of disability (p. 204)

24. OTHER CONCERNS 2001 Sylvester, Voelkl, & Ellis
People may share dx, but have different beliefs, values, backgrounds, & experiences
Not consistent with multicultural approach
1 size does not fit all

25. Other Concerns Richeson, Fitzsimmons, & Buettner in Stumbo, 2009
Few interventions published for TR
Research evidence from other disciplines may drive our clinical practice guidelines
30 pages of reference for TR guideline but less than 20% TR
Raises concerns about validity

26. Clinical Practice Guidelines Today Richeson, Fitzsimmons, & Buettner in Stumbo, 2009
Dementia Practice Guidelines for Recreational Therapy: Treatment of Disturbing Behaviors
Buettner & Fitzsimmons, 2003
Wheelchair Biking for the Treatment of Depression
Fitzsimmons, 2001
Only 2 in National Guideline Clearinghouse

27. Dementia Practice Guidelines for Recreational Therapy: Treatment of Disturbing Behaviors
Contains
Evidence-based practice explanation
Complexity of problem
Models & theories
Literature review
Recreation therapy and assessments
Considerations
82 RT protocols

28. Dementia Practice Guidelines for Recreational Therapy: Treatment of Disturbing Behaviors
Each protocol
Ratings
R = shows protocol effective for this behavior
RU = research is underway to examine the effect of the protocol
E = expert opinion feels this protocol is effective
Blank = no research or expert opinion
Dementia stage appropriate for protocol

29. Clinical Practice Guidelines Today
Efficacy of Prescribed Therapeutic Recreation Protocols on Falls and Injuries in Nursing Home Residents with Dementia
Buettner, 2001
Being developed according to Stumbo & Peterson, 2009
Effect of animal-assisted therapy on distress in oncology patients being treated for pain
Therapeutic recreation and the treatment of obesity
Therapeutic recreation and pain management

30. What’s next? Stumbo & Peterson, 2004
“Protocols are among the most powerful and the most needed tools in the therapeutic recreation profession. Only in the last decade or so have therapeutic recreation specialists become active in developing protocols for intervention purposes: a significant amount of work remains to be done in this area.” (p. 246)