Abstract T P281: Facilitating Best Practices in Rehabilitation for Persons With Stroke: Use of a Triage Tool in Toronto

Background: Best practice indicates all stroke patients (including severely affected) benefit from timely and intensive rehabilitation care. Currently in Toronto 27% of patients with stroke are discharged to inpatient rehabilitation from acute care (Canadian Institute for Health Information (CIHI) 11/12). Sixty percent of admissions to rehabilitation were patients with moderate stroke, 17% mild and 22% severe CIHI (FY12-13 Q1-3). Access to rehabilitation in Toronto is not equitable as admission criteria and rehabilitation programming are not standardized for stroke. Purpose: Develop a triage tool to support clinical decision making, equitable access to care and early referral to appropriate rehabilitation based on best practice Methods Acute and rehabilitation leaders collaboratively developed the triage tool. Provincial expert panel recommendations and existing referral frameworks were considered. The AlphaFIM® tool was used as the basis for categorizing stroke severity. Agreement was reached to support automatic acceptance of patients referred to rehab with AlphaFIM® score of 60-80. The tool was implemented Feb 1, 2013. All rehabilitation organizations agreed to standardized admission criteria and are working toward best practice for stroke inpatient rehabilitation care. Results: Baseline data (January to August 2012) for patients referred with an early AlphaFIM® of 60-80 indicated only 66% were accepted to rehab, 15% were declined and 8.5% had a decision pending. For those declined, 10% were identified as having special needs that could not be met, 29% were considered more appropriate for slow stream rehab, and 14% because of limited sitting tolerance and balance. An analysis of data following implementation will be presented. Conclusion: The triage tool creates a standard of best practice for the system. Agreement on common admission criteria and standard of practice for rehabilitation referral management for patients with AlphaFIM® 60-80 have been established between referrers and rehab providers. It is expected that transition barriers for this group should be minimal unless special needs are identified.

Download Full-text

Music Therapy Pre-internship Education and Training: Support for a Methods-Based Approach

Music Therapy Perspectives ◽

10.1093/mtp/miab026 ◽

2021 ◽

Author(s):

Susan C Gardstrom ◽

James Hiller ◽

Annie Heiderscheit ◽

Nancy L Jackson

Keyword(s):

Music Therapy ◽

Best Practice ◽

Clinical Decision Making ◽

Well Being ◽

Clinical Decision ◽

Education And Training ◽

Population Based ◽

Music Therapists ◽

Training Support ◽

And Training

Abstract As music therapists, music is our primary realm of understanding and action and our distinctive way of joining with a client to help them attain optimal health and well-being. As such, we have adopted and advocate for a music-focused, methods-based (M-B) approach to music therapy pre-internship education and training. In an M-B approach, students’ learning is centered on the 4 music therapy methods of composing, improvising, re-creating, and listening to music and how these music experiences can be designed and implemented to address the health needs of the diverse clientele whom they will eventually encounter as practicing clinicians. Learning is highly experiential, with students authentically participating in each of the methods and reflecting on these self-experiences as a basis for their own clinical decision-making. This is differentiated from a population based (P-B) approach, wherein students’ attention is directed at acquiring knowledge about the non-musical problems of specific “clinical populations” and the “best practice” music interventions that are presumed to address these problems. Herein, we discuss both approaches, identifying the limitations of a P-B perspective and outlining the benefits of an M-B curriculum and its relevance to 21st-century music therapy practice.

Download Full-text

No incentives, no innovation

Bulletin of The Royal College of Surgeons of England ◽

10.1308/147363509x379049 ◽

2009 ◽

Vol 91 (1) ◽

pp. 10-12

Author(s):

Jon Hackett

Keyword(s):

Decision Making ◽

Best Practice ◽

Clinical Decision Making ◽

Clinical Decision ◽

Bottom Up ◽

High Profile ◽

No Innovation

While the NHS has expressed a commitment to innovation with a succession of dedicated 'arms length bodies,' there are numerous high-profile cases in which advances on the ground have not received as much support as they might. In his recent Next Stage Review report, Lord Darzi has emphasised a commitment to clinical decision-making at all levels of the NHS but whether this will involve embracing best practice from the bottom up remains to be seen. For this article I spoke to two surgeons, whose sometimes controversial innovations were admired by many, about the obstacles they faced.

Download Full-text

Novel Neurotechnological Interventions for Pediatric Drug-Resistant Epilepsy: Physician Perspectives

Journal of Child Neurology ◽

10.1177/0883073820966935 ◽

2020 ◽

pp. 088307382096693

Author(s):

Patrick J. McDonald ◽

Viorica Hrincu ◽

Mary B. Connolly ◽

Mark J. Harrison ◽

George M. Ibrahim ◽

...

Keyword(s):

Decision Making ◽

Best Practice ◽

Clinical Decision Making ◽

Qualitative Content Analysis ◽

Scientific Evidence ◽

Clinical Decision ◽

Drug Resistant ◽

Ethical Considerations ◽

Pediatric Drug ◽

Drug Resistant Epilepsy

This qualitative study investigated factors that guide physicians’ choices for minimally invasive and neuromodulatory interventions as alternatives to conventional surgery or medical management for pediatric drug-resistant epilepsy. North American physicians were recruited to one of 4 focus groups at national conferences. Discussions were analyzed using qualitative content analysis. A pragmatic neuroethics framework was applied to interpret results. Discussions revealed 2 major thematic branches: (1) clinical decision making and (2) ethical considerations. Under clinical decision making, physicians emphasized scientific evidence and patient candidacy when assessing neurotechnologies for patients. Ongoing seizures without intervention was important for safety and neurodevelopment. Under ethical considerations, resource allocation, among other financial considerations for technology adoption, were considerable sources of pressure on decision making. Access to neurotechnology was a salient theme differentiating Canadian and American contexts. When assessing novel neurotechnological interventions for pediatric drug-resistant epilepsy, physicians balance clinical and ethical factors to guide decision making and best practice.

Download Full-text

Best practice guidelines for management of spinal disorders in skeletal dysplasia

10.21203/rs.2.23876/v1 ◽

2020 ◽

Author(s):

Klane White ◽

Michael B Bober ◽

Tae-Joon Cho ◽

Michael J Goldberg ◽

Julie Hoover-Fong ◽

...

Keyword(s):

Decision Making ◽

Practice Guidelines ◽

Skeletal Dysplasia ◽

Best Practice ◽

Clinical Decision Making ◽

Case Series ◽

Clinical Decision ◽

Spinal Disorders ◽

Best Practice Guidelines ◽

Group A

Abstract Background: Disorders of the spine present a common and difficult management concern in patients with skeletal dysplasia. Due to the rarity of these conditions however, the literature, largely consisting of small, single institution case series, is sparse in regard to well-designed studies to support clinical decision making in these situations. Methods: Using the Delphi method, an international, multi-disciplinary group of individuals, with significant experience in the care of patients with skeletal dysplasia, convened to develop multi-disciplinary, “best practice” guidelines in the care of spinal disorders in patients with skeletal dysplasia. Results: Starting with 33 statements, the group a developed a list of 31 “best practice” guidelines. Conclusions: The guidelines are presented and discussed to provide context for clinicians in their decision making in this often-challenging realm of care.

Download Full-text

Clinical frailty independently predicts early mortality after ischaemic stroke

Age and Ageing ◽

10.1093/ageing/afaa004 ◽

2020 ◽

Vol 49 (4) ◽

pp. 588-591 ◽

Cited By ~ 2

Author(s):

Nicholas R Evans ◽

Jasmine Wall ◽

Benjaman To ◽

Stephen J Wallis ◽

Roman Romero-Ortuno ◽

...

Keyword(s):

Ischaemic Stroke ◽

Clinical Decision Making ◽

Clinical Care ◽

Multivariable Analysis ◽

Clinical Decision ◽

Ordinal Scale ◽

Stroke Severity ◽

Clinical Frailty Scale ◽

Point Increase ◽

Stroke Thrombolysis

Abstract Background Clinical frailty is an important syndrome for clinical care and research, independently predicting mortality and rates of institutionalisation in a range of medical conditions. However, there has been little research into the role of frailty in stroke. Objective This study investigates the effect of frailty on 28-day mortality following ischaemic stroke and outcomes following stroke thrombolysis. Methods Frailty was measured using the Clinical Frailty Scale (CFS) for all ischaemic stroke admissions aged ≥75 years. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). 28-day mortality and clinical outcomes were collected retrospectively. Analysis included both dichotomised measures of frailty (non-frail: CFS 1–4, frail: 5–8) and CFS as a continuous ordinal scale. Results In 433 individuals with ischaemic stroke, 28-day mortality was higher in frail versus non-frail individuals (39 (16.7%) versus 10 (5%), P < 0.01). On multivariable analysis, a one-point increase in CFS was independently associated with 28-day mortality (OR 1.03 (1.01–1.05)). In 63 thrombolysed individuals, median NIHSS reduced significantly in non-frail individuals (12.5 (interquartile range (IQR) 9.25) to 5 (IQR 10.5), P < 0.01) but not in frail individuals (15 (IQR 11.5) to 16 (IQR 16.5), P = 0.23). On multivariable analysis, a one-point increase in CFS was independently associated with a one-point reduction in post-thrombolysis NIHSS improvement (coefficient 1.07, P = 0.03). Conclusion Clinical frailty is independently associated with 28-day mortality after ischaemic stroke and appears independently associated with attenuated improvement in NIHSS following stroke thrombolysis. Further research is needed to elucidate the underlying mechanisms and how frailty may be utilised in clinical decision-making.

Download Full-text

Clinical utility of CLIA-grade AR-V7 testing in patients (pts) with metastatic castration-resistant prostate cancer (mCRPC).

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.6_suppl.183 ◽

2017 ◽

Vol 35 (6_suppl) ◽

pp. 183-183 ◽

Cited By ~ 1

Author(s):

Mark Christopher Markowski ◽

John Silberstein ◽

James R. Eshleman ◽

Jun Luo ◽

Emmanuel S. Antonarakis

Keyword(s):

Clinical Trial ◽

Clinical Practice ◽

Targeted Therapies ◽

Clinical Decision Making ◽

Clinical Decision ◽

Castration Resistant Prostate Cancer ◽

Castration Resistant ◽

Line Therapy ◽

Improved Outcomes ◽

Practice Methods

183 Background: The AR-V7 splice variant may confer resistance to AR-targeted therapies but not taxane chemotherapies. Since August 2015, a clinical-grade assay to detect AR-V7 mRNA expression in circulating tumors cells (CTC) has been available through a CLIA-certified lab at Johns Hopkins. In the first 12 months after launch, 195 AR-V7 tests were ordered for clinical purposes. We contacted the ordering providers of the first 100 tests using a questionnaire-based survey to determine how (and if) the results of AR-V7 testing were used in clinical practice. Methods: We identified 100 consecutive mCRPC pts who underwent AR-V7 testing in our CLIA lab. Ordering providers received a questionnaire for each test ordered, asking how (and if) the results of the assay affected their clinical decision-making, and whether a PSA50 response was obtained on next-line therapy after AR-V7 testing was performed. Results: 80 of 100 questionnaires were completed by 26 providers from 17 sites across 14 states. AR-V7 assay results were reported either as CTC negative (21/80: 26%), CTC+ AR-V7 negative (26/80: 33%), or CTC+ AR-V7 positive (33/80: 41%). Prevalence of AR-V7 detection increased with prior exposure to AR targeted drugs (Abi/Enza-naive 29%, post-Abi or Enza 39%, post-Abi and Enza 62%). Overall, management was impacted by AR-V7 testing in 54% of cases (43/80), and even more so with AR-V7+ results (see Table). AR-V7+ pts were commonly switched from AR targeted therapies to a taxane (10/19: 53%) or were offered a clinical trial (8/19: 42%). Pts who had a change in management based on AR-V7 testing were more likely to achieve a PSA50 response on next-line therapy than those not changing treatment (18/36: 50% vs 10/30: 33%). Conclusions: Providers used AR-V7 testing to influence clinical practice more often than not. AR-V7+ pts were most often treated with taxane-based therapy or offered a clinical trial, which may have improved outcomes. Clinical qualification of AR-V7 is ongoing. [Table: see text]

Download Full-text

Graphical representations of patient tolerability data: Recommendations from the National Cancer Institute (NCI) Cancer Moonshot Standardization Working Group.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e18612 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e18612-e18612

Author(s):

Gillian Gresham ◽

Gina L. Mazza ◽

Blake Langlais ◽

Bellinda King-Kallimanis ◽

Lauren J. Rogak ◽

...

Keyword(s):

Working Group ◽

Best Practice ◽

Clinical Decision Making ◽

Clinical Decision ◽

Section 508 ◽

Graphical Displays ◽

Patient Reported ◽

Tolerability Data ◽

Survey Results ◽

Data Incorporate

e18612 Background: Effective communication of treatment tolerability data is essential for clinical decision making and improved patient outcomes, yet standardized approaches to the analysis and visualization of tolerability data in cancer clinical trials are currently limited. To address this need, the Standardization Working Group (SWG) was established within the NCI Cancer Moonshot Tolerability Consortium. This abstract describes the SWG’s initiative to develop a publicly accessible online toolkit with a comprehensive set of guidelines, references, and resources for graphical displays of tolerability data. Methods: A multidisciplinary group of PRO researchers including biostatisticians, clinicians, epidemiologists, and representatives from the NCI and FDA convened monthly to discuss toolkit development and content. Considerations for standardization of graphical displays of tolerability data included (1) types of graphical displays, (2) incorporation of missing data, (3) labeling and color schemes, and (4) software to produce graphical displays. For consistency, considerations of tolerability relied on the Patient-Reported Outcomes version of the CTCAE (PRO-CTCAE), which includes 124 items assessing the frequency, severity, interference, and/or presence of 78 symptomatic adverse events. Graphical displays were generated using simulated PRO-CTCAE data and summarized by composite score (range 0-3).Color schemes that were Section 508 compliant and color blindness accessible were created. Surveys were distributed to 68 consortium members to assess preferences and interpretability of the graphical displays. Results: The SWG created graphical displays for PRO-CTCAE data, including bar charts, butterfly plots, and Sankey diagrams and compiled SAS macros and R functions to do so. Graphical displays made available in the toolkit maximize the use of PRO-CTCAE data, incorporate missingness, support between-arm comparisons, and present data longitudinally over treatment cycles or study timepoints. Survey results for labeling and color schemes were summarized and informed a list of short labels for PRO-CTCAE items (e.g., “radiation burns” for “skin burns from radiation”) and standardized color schemes for use in graphical displays. Survey results were also summarized to provide insight into PRO researchers’ ability to accurately interpret the graphical displays. Conclusions: Standardizinggraphical displays is important for improving the communication and interpretation of tolerability data. The type of graphical display used depends on the purpose of the analysis and should be tailored to the intended audience, including patients. This toolkit will provide a comprehensive resource with best practice recommendations.

Download Full-text

Administration of the Canadian Occupational Performance Measure: Effect on practice

Canadian Journal of Occupational Therapy ◽

10.2182/cjot.2012.79.2.7 ◽

2012 ◽

Vol 79 (2) ◽

pp. 120-128 ◽

Cited By ~ 18

Author(s):

Heather L. Colquhoun ◽

Lori J. Letts ◽

Mary C. Law ◽

Joy C. MacDermid ◽

Cheryl A. Missiuna

Keyword(s):

Occupational Therapy ◽

Clinical Decision Making ◽

Clinical Decision ◽

Performance Measure ◽

Occupational Performance ◽

Chart Audit ◽

Canadian Occupational Performance Measure ◽

Before And After ◽

Practice Methods ◽

Client Progress

Background. The Canadian Occupational Performance Measure (COPM) is recommended as a systematic approach to identify issues and determine client progress in occupational therapy, yet little empirical evidence is available that supports this practice. Purpose. To determine if COPM administration was associated with changes in eight dimensions of occupational therapy practice. Methods. Twenty-four occupational therapists on eight geriatric rehabilitation sites completed a before-and-after study with a repeated baseline. The eight practice dimensions were assessed after three months of usual care (no COPM use) and after three months of intervention (COPM use) using chart stimulated recall (CSR) interviews and chart audit. Findings. Mean practice scores for CSR interviews indicated a statistically significant practice improvement (p < .0001) across the eight dimensions, including knowledge of client perspective, clinical decision making, clinician ability to articulate outcomes, and documentation. Chart audit indicated that COPM use resulted in identifying more occupation-focused issues. Implications. COPM administration could improve occupational therapy practice.

Download Full-text

Unravelling the ‘Tangled Web’: Chemotherapy for Tuberculosis in Britain, 1940–70The William Bynum Prize Essay

Medical History ◽

10.1017/mdh.2015.19 ◽

2015 ◽

Vol 59 (2) ◽

pp. 156-176 ◽

Cited By ~ 4

Author(s):

Clare Leeming-Latham

Keyword(s):

Clinical Trials ◽

Best Practice ◽

Research Council ◽

Clinical Decision Making ◽

Medical Research Council ◽

Bed Rest ◽

Clinical Decision ◽

Success Story ◽

Post War ◽

The Relationship

AbstractThe introduction and assimilation of chemotherapy to treat pulmonary tuberculosis (TB) during the mid-twentieth century appears at first sight to be a success story dominated by the use of streptomycin in a series of randomised clinical trials run under the auspices of the Medical Research Council (MRC). However, what this standard rhetoric overlooks is the complexity of TB chemotherapy, and the relationship between this and two other ways of treating the disease, bed rest and thoracic surgery. During the late 1940s and 1950s, these three treatment strands overlapped one another, and determining best practice from a plethora of prescribing choices was a difficult task. This article focuses on the clinical decision-making underpinning the evolution of successful treatment for TB using drugs alone. Fears over the risk of streptomycin-resistant organisms entering the community meant that, initially, the clinical application of streptomycin was limited. Combining it with other drugs lessened this risk, but even so the potential of chemotherapy as a curative option for TB was not immediately apparent. The MRC ran a series of clinical trials in the post-war period but not all of their recommendations were adopted by clinicians in the field. Rather, a range of different determinants, including the timing of trials, the time taken for results to emerge, and whether these results ‘fitted’ with individual experience all influenced the translation of trial results into clinical practice.

Download Full-text

Incidence and impact of incivility in paramedicine: a qualitative study

Emergency Medicine Journal ◽

10.1136/emermed-2020-209961 ◽

2021 ◽

pp. emermed-2020-209961

Author(s):

Nicola Jane Credland ◽

Clare Whitfield

Keyword(s):

Decision Making ◽

General Public ◽

Best Practice ◽

Clinical Decision Making ◽

Cumulative Effect ◽

Well Being ◽

Clinical Decision ◽

Interpersonal Aggression ◽

Professional Groups ◽

Semistructured Interviews

BackgroundIncivility or rudeness is a form of interpersonal aggression. Studies suggest that up to 90% of healthcare staff encounter incivility at work with it being considered ‘part of the job’.MethodsQualitative, in-depth, semistructured interviews (n=14) undertaken between June and December 2019. Purposive sampling was used to identify front-line paramedics working for one NHS Ambulance Trust. Interviews lasted between 16 and 45 min, were audiorecorded, verbatim transcribed and analysed using thematic analysis.ResultsFour themes were identified: paramedics reported a lack of respect displayed both verbally and non-verbally from other professional groups. The general public and interdisciplinary colleagues alike have unrealistic expectations of the role of a paramedic. In order to deal with incivility paramedics often reported taking the path of least resistance which impacts on ways of working and shapes subsequent clinical decision-making, potentially threatening best practice. Finally paramedics report using coping strategies to support well-being at work. They report that a single episode of incivility is easier to deal with but subsequent episodes compound the first.ConclusionsThis study highlights the effect incivility can have on operational paramedics. Incivility from the general public and other health professionals alike can have a cumulative effect impacting on well-being and clinical decision-making.

Download Full-text