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M. Alt Murphy1,2, A. Björkdahl1,2, G. Forsberg-Wärleby1,2, C.U. Persson1,2
1Sahlgrenska University Hospital, Department of Occupational Therapy and Physiotherapy, Gothenburg, Sweden, 2University of Gothenburg, Institute of Neuroscience and Physiology, Clinical Neuroscience, Gothenburg, Sweden
Background: Current national clinical guidelines recommend the use of standardized outcome measures, but often do not specify what measures should be used, at what frequency and in what settings. Considerable efforts have recently been made in the field of stroke rehabilitation to develop evidence based agreed recommendations for upper extremity assessment. There is, however, an evidence-practice gap regarding implementation into day-to-day clinical practice.
Purpose: This work targeted an evidence-practice gap and aimed to develop, evaluate implementation of and adherence to evidence-based clinical practice guidelines for occupational therapists and physiotherapists in assessment of upper extremity (UE) during acute and subacute stroke rehabilitation.
Methods: Implementation process was initiated 2014 at Sahlgrenska University Hospital and involved 4 sites (3 stroke units and one rehabilitation unit) with approximately 23 physiotherapists (PT) and 22 occupational therapists (OT) working with stroke rehabilitation. The work included five stages: mapping the current clinical practice, identifying evidence base, development of guidelines, implementation and evaluation. Systematic theoretical framework was used to guide and facilitate the implementation.
Results: Upper extremity assessment routines were vaguely defined between PT and OT and the assessments performed by PT relied predominantly on clinical observation. UE assessment was not prioritized when time was limited. High level of evidence was found for several outcome measures and the time-points for assessments. The final guideline was published 2019 and defined the primary standardized instruments: SAFE, ARAT-2, Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Box & Block Test, 9 Hole Peg Test and grip strength, as well as time-points for assessments. Evaluation showed that more than 80% of clinicians were content with the guidelines and the implementation work. Adherence to newly introduced scales (SAFE, ARAT-2, FMA-UE) varied between 60-90%, whereas the comprehensive scales were more difficult to implement compared to short. High work rotation and need to prioritise other assessments during the first week of stroke hindered the adherence.
Conclusion(s): The robustness of evidence, adequate facilitation and receptive context including the support from official leaders facilitated the implementation. To allow the process to take time was important in order to achieve informed consensus and acceptance on the content. Clinicians valued the clear structure of the guidelines and found it useful for prognosis and treatment planning.
Implications: The guideline enables a more structured, knowledge-based and equal assessment and thereby supports the clinical decision-making and patient involvement. This work can be used as guidance in other stroke rehabilitation organisations, both nationally and internationally, when implementing evidence-based assessment into clinical praxis.
Funding, acknowledgements: This work has been partly supported by the Department of Occupational Therapy and Physiotherapy at Sahlgrenska University Hospital.
Keywords: clinical practice guidelines, implementation science, stroke
Topic: Neurology: stroke
Did this work require ethics approval? No
Institution: N/A
Committee: N/A
Reason: This work was part of clinical development of evidence practice guidelines and implementation and evaluation of the results .
All authors, affiliations and abstracts have been published as submitted.
