Knowledge translation and implementation in spinal cord injury: a systematic review

'It depends': what 86 systematic reviews tell us about what strategies to use to support the use of research in clinical practice

BACKGROUND

The gap between research findings and clinical practice is well documented and a range of strategies have been developed to support the implementation of research into clinical practice. The objective of this study was to update and extend two previous reviews of systematic reviews of strategies designed to implement research evidence into clinical practice.

METHODS

We developed a comprehensive systematic literature search strategy based on the terms used in the previous reviews to identify studies that looked explicitly at interventions designed to turn research evidence into practice. The search was performed in June 2022 in four electronic databases: Medline, Embase, Cochrane and Epistemonikos. We searched from January 2010 up to June 2022 and applied no language restrictions. Two independent reviewers appraised the quality of included studies using a quality assessment checklist. To reduce the risk of bias, papers were excluded following discussion between all members of the team. Data were synthesised using descriptive and narrative techniques to identify themes and patterns linked to intervention strategies, targeted behaviours, study settings and study outcomes.

RESULTS

We identified 32 reviews conducted between 2010 and 2022. The reviews are mainly of multi-faceted interventions (n = 20) although there are reviews focusing on single strategies (ICT, educational, reminders, local opinion leaders, audit and feedback, social media and toolkits). The majority of reviews report strategies achieving small impacts (normally on processes of care). There is much less evidence that these strategies have shifted patient outcomes. Furthermore, a lot of nuance lies behind these headline findings, and this is increasingly commented upon in the reviews themselves.

DISCUSSION

Combined with the two previous reviews, 86 systematic reviews of strategies to increase the implementation of research into clinical practice have been identified. We need to shift the emphasis away from isolating individual and multi-faceted interventions to better understanding and building more situated, relational and organisational capability to support the use of research in clinical practice. This will involve drawing on a wider range of research perspectives (including social science) in primary studies and diversifying the types of synthesis undertaken to include approaches such as realist synthesis which facilitate exploration of the context in which strategies are employed.

Enabling knowledge translation: implementation of a web-based tool for independent walking prediction after traumatic spinal cord injury

Introduction

Several clinical prediction rules (CPRs) have been published, but few are easily accessible or convenient for clinicians to use in practice. We aimed to develop, implement, and describe the process of building a web-based CPR for predicting independent walking 1-year after a traumatic spinal cord injury (TSCI).

Methods

Using the published and validated CPR, a front-end web application called "Ambulation" was built using HyperText Markup Language (HTML), Cascading Style Sheets (CSS), and JavaScript. A survey was created using QualtricsXM Software to gather insights on the application's usability and user experience. Website activity was monitored using Google Analytics. Ambulation was developed with a core team of seven clinicians and researchers. To refine the app's content, website design, and utility, 20 professionals from different disciplines, including persons with lived experience, were consulted.

Results

After 11 revisions, Ambulation was uploaded onto a unique web domain and launched (www.ambulation.ca) as a pilot with 30 clinicians (surgeons, physiatrists, and physiotherapists). The website consists of five web pages: Home, Calculation, Team, Contact, and Privacy Policy. Responses from the user survey (n = 6) were positive and provided insight into the usability of the tool and its clinical utility (e.g., helpful in discharge planning and rehabilitation), and the overall face validity of the CPR. Since its public release on February 7, 2022, to February 28, 2023, Ambulation had 594 total users, 565 (95.1%) new users, 26 (4.4%) returning users, 363 (61.1%) engaged sessions (i.e., the number of sessions that lasted 10 seconds/longer, had one/more conversion events e.g., performing the calculation, or two/more page or screen views), and the majority of the users originating from the United States (39.9%) and Canada (38.2%).

Discussion

Ambulation is a CPR for predicting independent walking 1-year after TSCI and it can assist frontline clinicians with clinical decision-making (e.g., time to surgery or rehabilitation plan), patient education and goal setting soon after injury. This tool is an example of adapting a validated CPR for independent walking into an easily accessible and usable web-based tool for use in clinical practice. This study may help inform how other CPRs can be adopted into clinical practice.

Supporting meaningful research partnerships: an interview study applying behavior change theory to develop relevant recommendations for researchers

Research partnerships, while promising for ensuring translation of relevant and useable findings, are challenging and need support. This study aimed to apply behavior change theory to understand and support researchers' adoption of a research partnership approach and the Integrated Knowledge Translation (IKT) Guiding Principles for conducting and disseminating spinal cord injury (SCI) research in partnership. Using an IKT approach, SCI researchers across Canada and the USA completed a survey (n = 22) and were interviewed (n = 13) to discuss barriers and facilitators to deciding to partner and follow the IKT Guiding Principles. The Behaviour Change Wheel, Theoretical Domains Framework (TDF), and Mode of Delivery Ontology were used to develop the survey, interview questions, and guided analyses of interview data. COM-B and TDF factors were examined using descriptive statistics and abductive analyses of barriers and facilitators of decisions to partner and/or use the IKT Guiding Principles. TDF domains from the interview transcripts were then used to identify intervention, content, and implementation options. 142 factors (79 barriers, 63 facilitators) related to deciding to partner, and 292 factors (187 barriers, 105 facilitators) related to deciding to follow the IKT Guiding Principles were identified. Barriers to partnering or use the IKT Guiding Principles were primarily related to capability and opportunity and relevant intervention options were recommended. Interventions must support researchers in understanding how to partner and use the IKT Guiding Principles while navigating a research system, which is not always supportive of the necessary time and costs required for meaningful research partnerships.

Principles to guide spinal cord injury research partnerships: a Delphi consensus study

PURPOSE

To establish consensus regarding principles that should be used to guide spinal cord injury (SCI) research partnerships between researchers and research users.

MATERIALS AND METHODS

A three-round Delphi consensus exercise was carried out with researchers and/or research users involved in one or more SCI research partnerships. Participants considered a list of 125 partnership principles. In rounds 1 and 2, participants rated their agreement that a principle should guide SCI research partnerships on an 11-point Likert scale. After each round, principles that received a mean score of ≥8.0 or 70% of participants rated the principle ≥8.0 were retained. In round 3, participants categorized principles as essential, desirable, irrelevant, or unsure.

RESULTS

At least 20 individuals participated in each round. In round 1, 103 principles met consensus criteria and eight principles were added. In round 2, 93 principles met the criteria. In round 3, 29 principles were categorized as essential and eight as desirable. Recommended principles focused on the interpersonal, relational, and logistical aspects of partnerships. Principles that did not reach consensus related to social justice and actionable impact.

CONCLUSIONS

Findings provide insight into 37 principles that could be used to combat tokenism and inform future guidance to meaningfully engage partners in SCI research.Implications for RehabilitationConsensus-based research partnership principles (i.e., norms or beliefs) were identified and could be prioritized to help support spinal cord injury (SCI) researchers and research users combat tokenism and meaningfully engage research users as partners in the co-creation of knowledge.The resulting list of recommended research partnership principles was used to inform the development of guidance to support quality partnerships between SCI researchers and research users within and outside the rehabilitation context (www.IKTprinciples.com).Guidance supporting meaningful research partnerships may accelerate the time between discovery and use of research in practice.

Implementation strategies for knowledge products in primary healthcare: a systematic review of systematic reviews (Preprint)

Background

The underuse or overuse of knowledge products leads to waste in health care, and primary care is no exception.

Objective

This study aimed to characterize which knowledge products are frequently implemented, the implementation strategies used in primary care, and the implementation outcomes that are measured.

Methods

We performed a systematic review (SR) of SRs using the Cochrane systematic approach to include eligible SRs. The inclusion criteria were any primary care contexts, health care professionals and patients, any Effective Practice and Organization of Care implementation strategies of specified knowledge products, any comparators, and any implementation outcomes based on the Proctor framework. We searched the MEDLINE, EMBASE, CINAHL, Ovid PsycINFO, Web of Science, and Cochrane Library databases from their inception to October 2019 without any restrictions. We searched the references of the included SRs. Pairs of reviewers independently performed selection, data extraction, and methodological quality assessment by using A Measurement Tool to Assess Systematic Reviews 2. Data extraction was informed by the Effective Practice and Organization of Care taxonomy for implementation strategies and the Proctor framework for implementation outcomes. We performed a descriptive analysis and summarized the results by using a narrative synthesis.

Results

Of the 11,101 records identified, 81 (0.73%) SRs were included. Of these 81, a total of 47 (58%) SRs involved health care professionals alone. Moreover, 15 SRs had a high or moderate methodological quality. Most of them addressed 1 type of knowledge product (56/81, 69%), common clinical practice guidelines (26/56, 46%) or management, and behavioral or pharmacological health interventions (24/56, 43%). Mixed strategies were used for implementation (67/81, 83%), predominantly education-based (meetings in 60/81, 74%; materials distribution in 59/81, 73%; and academic detailing in 45/81, 56%), reminder (53/81, 36%), and audit and feedback (40/81, 49%) strategies. Education meetings (P=.13) and academic detailing (P=.11) seemed to be used more when the population was composed of health care professionals alone. Improvements in the adoption of knowledge products were the most commonly measured outcome (72/81, 89%). The evidence level was reported in 12% (10/81) of SRs on 62 outcomes (including 48 improvements in adoption), of which 16 (26%) outcomes were of moderate or high level.

Conclusions

Clinical practice guidelines and management and behavioral or pharmacological health interventions are the most commonly implemented knowledge products and are implemented through the mixed use of educational, reminder, and audit and feedback strategies. There is a need for a strong methodology for the SR of randomized controlled trials to explore their effectiveness and the entire cascade of implementation outcomes.

Systematic overviews of partnership principles and strategies identified from health research about spinal cord injury and related health conditions: A scoping review

STUDY DESIGN

Scoping review.

OBJECTIVE

To identify and provide systematic overviews of partnership principles and strategies identified from health research about spinal cord injury (SCI) and related health conditions.

METHODS

Four health electronic databases (Medline, Embase, CINAHL, PsycINFO) were searched from inception to March 2019. We included articles that described, reflected, and/or evaluated one or more collaborative research activities in health research about SCI, stroke, multiple sclerosis, Parkinson's disease, amputation, cerebral palsy, spina bifida, amyotrophic lateral sclerosis, acquired brain injury, or wheelchair-users. Partnership principles (i.e. norms or values) and strategies (i.e. observable actions) were extracted and analyzed using directed qualitative content analysis.

RESULTS

We included 39 articles about SCI (n = 13), stroke (n = 15), multiple sclerosis (n = 5), amputation (n = 2), cerebral palsy (n = 2), Parkinson's disease (n = 1), and wheelchair users (n = 1). We extracted 110 principles and synthesized them into 13 overarching principles. Principles related to building and maintaining relationships between researchers and research users were most frequently reported. We identified 32 strategies that could be applied at various phases of the research process and 26 strategies that were specific to a research phase (planning, conduct, or dissemination).

CONCLUSION

We provided systematic overviews of principles and strategies for research partnerships. These could be used by researchers and research users who want to work in partnership to plan, conduct and/or disseminate their SCI research. The findings informed the development of the new SCI Integrated Knowledge Translation Guiding Principles (www.iktprinciples.com) and will support the implementation of these Principles within the SCI research system.

Lessons learned and functional outcomes following multifaceted team training in a cognitive strategy-based approach to stroke rehabilitation

AIM

To estimate the impact of a multifaceted knowledge translation intervention on patient rehabilitation outcomes in an inpatient stroke setting.

METHODS

Interprofessional stroke rehabilitation teams were trained in Cognitive Orientation to daily Occupational Performance as part of the larger knowledge translation study. This study describes a two group (historical control vs. post knowledge translation intervention) nonrandomized study. Patient participants with stroke and cognitive impairment were recruited from five rehabilitation hospitals and completed an assessment battery upon admission to and discharge from rehabilitation and at three follow-up times. Data were analyzed using a two-way ANOVA.

RESULTS

Seventeen historical controls and eight postintervention participants were recruited. The effect for time was significant (P ≤ 0.05) for the majority of outcomes, but there were no significant group × time effects. Small effect sizes for the group × time interaction were noted on several indicators.

CONCLUSION

Few studies report on patient outcomes following a knowledge translation intervention. Small effect sizes were detected on several patient outcomes, despite study limitations. Lessons learned for future patient-level studies within knowledge translation interventions include the importance of monitoring therapist adherence to implementation protocols and ensuring research designs consider the impact on patient recruitment and retention.

Exploring perspectives and adherence to guidelines for adult spinal trauma in low and middle-income healthcare economies: A survey on barriers and possible solutions (part I)

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Most spinal trauma occurs in low- and middle-income countries (LMICs), but some elements may limit the application of current guidelines.

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In LMICs, a respectable proportion of physicians treating spinal trauma is not aware of any guidelines on this topic.

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Most physicians managing spinal trauma in LMICs believe that following the guidelines may positively affect patient outcomes.

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Most believed they have the capability to apply, the guidelines, but variation according to income and geographical region exists.

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The perceived limitations and their relevance to guideline adherence vary across different income and geographic areas worldwide.

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Resource-targeted guidelines for spinal trauma are considered a valuable option to overcome the limitations of real-life application of the current guidelines.

Effective factors on establishment of knowledge translation in the health system policy-making: A protocol for systematic review

Despite the importance and position of evidence-based policymaking in the proper management of the health system, studies show that the lack or improper and untimely use of evidence are still one of the main challenges of health systems. Knowledge translation as a solution to this challenge is a process that includes a period of time that starts of decision to choose the research topic and continue to publish of research results, in which the interaction of the researchers and stakeholders is the key factor and the main axis of the process. Since the recognition and promotion of knowledge translation processes resulting from research in health system policy-making will lead to the improvement of the health system, this review protocol was designed to identify factors affecting knowledge translation implementation, including barriers and facilitators of this process. Identifying these factors can be used as a guide for health system decision-makers and research managers in planning to select appropriate policies for deployment of the knowledge translation process to increase the use of research results in the health system.

RE-AIMing conferences: a reach, effectiveness, and maintenance evaluation of the Rick Hansen Institute's Praxis 2016

This article reported on the reach, effectiveness, and maintenance dimensions of a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) analysis to evaluate Praxis 2016, a conference aimed to develop solutions to overcome challenges to translating research into practice in the spinal cord injury (SCI) community. Reach indicators were collected from the Praxis 2016 organizing committee. For effectiveness and maintenance, attendees (n = 106) completed a questionnaire pre-, post-, and 9-month post-Praxis 2016 assessing (a) capability (e.g., knowledge), (b) motivation, (c) opportunities, and (d) the groups they currently, need to, and/or plan to work with to develop solutions to overcome the challenges of translating SCI research into practice. They also reported their satisfaction with Praxis 2016. Qualitative interviews with attendees and organizers post-Praxis 2016 were conducted. Praxis 2016 reached 28% of their intended audience. For effectiveness, attendees' knowledge significantly increased (t(59)= 3.83, p < .001), they reported a greater need to work with members within the SCI community from pre- to post-Praxis 2016, and were generally satisfied with Praxis 2016. Regarding maintenance, more attendees reported needing to work with researchers, clinicians and SCI community organizations at 9-month post-Praxis 2016. The interviewees reported increased knowledge and capacity to network with the SCI community, but highlighted concerns for the long-term impact of Praxis 2016. Praxis 2016 was an effective approach to create short-term change in knowledge, and to expand knowledge translation networks. Further efforts could build on Praxis 2016 to foster long-term success in overcoming the challenges in translating SCI research into practice.

Integrated Knowledge Translation Guiding Principles for Conducting and Disseminating Spinal Cord Injury Research in Partnership

OBJECTIVE

To address a gap between spinal cord injury (SCI) research and practice by rigorously and systematically co-developing integrated knowledge translation (IKT) guiding principles for conducting and disseminating SCI research in partnership with research users.

DESIGN

The process was guided by the internationally accepted The Appraisal of Guidelines for REsearch & Evaluation (AGREE) II Instrument for evaluating the development of clinical practice guidelines.

SETTING

North American SCI research system (ie, SCI researchers, research users, funders).

PARTICIPANTS

The multidisciplinary expert panel (n=17) and end users (n=35) included individuals from a North American partnership of SCI researchers, research users, and funders who have expertise in research partnerships.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Clarity, usefulness, and appropriateness of the principles.

RESULTS

Data regarding 125 principles of partnered research were systematically collected from 4 sources (review of reviews, scoping review, interviews, Delphi consensus exercise). A multidisciplinary expert panel held a 2-day meeting to establish consensus, select guiding principles, and draft the guidance. The panel reached 100% consensus on the principles and guidance document. The final document includes a preamble, 8 guiding principles, and a glossary. Survey data showed that the principles and guidance document were perceived by potential end users as clear, useful, and appropriate.

CONCLUSIONS

The IKT Guiding Principles represent the first rigorously co-developed, consensus-based guidance to support meaningful SCI research partnerships. The principles are a foundational tool with the potential to improve the relevance and impact of SCI research, mitigate tokenism, and advance the science of IKT.

Implementation of pain best practices as part of the spinal cord injury knowledge mobilization network

Context/objective: The spinal cord injury (SCI) knowledge mobilization network (KMN) is a community of practice formed in 2011 as part of a national best practice implementation (BPI) effort to improve SCI care. This study objective was to determine whether completion and documentation of pain practices could be improved in a neurorehabilitation setting using the KMN implementation approach. Design: Single site, pre-post intervention study. Setting: Neurorehabilitation hospital. Participants: Twenty sequential consenting inpatients with SCI, with retrospective comparative analysis of 50 sequential SCI admissions pre-KMN. Interventions: A local Site Implementation Team (SIT) was formed to develop an implementation plan, including acceptable timeframes for completion and documentation of four specific pain best practices: (1) pain assessment on admission, (2) development of an Inter-Professional Pain Treatment Plan (IPTP), (3) pain monitoring throughout admission, and (4) a pain discharge plan. Outcomes: Provider adherences to pain best practices were the primary outcomes. The secondary outcome was patient satisfaction. Results: Provider adherence for most outcomes exceeded 70% completion within acceptable timeframes, with improvements found for all outcomes as compared to the retrospective cohort. Notably, pain education as part of the IPTP improved from 12% completion to 74%, documenting pain onset from 4.5% to 80% and pain discharge plan from 40% to 74%. Overall, participants were satisfied with their pain management. Conclusions: Pain best practices were more consistently documented after the KMN implementation. Pain practices in all four areas have now been expanded to all inpatient diagnoses using the same forms and framework created in the implementation process.

Understanding the clinical management of obstructive sleep apnoea in tetraplegia: a qualitative study using the theoretical domains framework

BACKGROUND

Clinical practice guidelines recommend further testing for people with tetraplegia and signs and symptoms of obstructive sleep apnoea (OSA), followed by treatment with positive airway pressure therapy. Little is known about how clinicians manage OSA in tetraplegia. The theoretical domains framework (TDF) is commonly used to identify determinants of clinical behaviours. This study aimed to describe OSA management practices in tetraplegia, and to explore factors influencing clinical practice.

METHODS

Semi-structured interviews were conducted with 20 specialist doctors managing people with tetraplegia from spinal units in Europe, UK, Canada, USA, Australia and New Zealand. Interviews were audiotaped for verbatim transcription. OSA management was divided into screening, diagnosis and treatment components for inpatient and outpatient services, allowing common practices to be categorised. Data were thematically coded to the 12 constructs of the TDF. Common beliefs were identified and comparisons were made between participants reporting different practices.

RESULTS

Routine screening for OSA signs and symptoms was reported by 10 (50%) doctors in inpatient settings and eight (40%) in outpatient clinics. Doctors commonly referred to sleep specialists for OSA diagnosis (9/20 in inpatients; 16/20 in outpatients), and treatment (12/20, 17/20). Three doctors reported their three spinal units were managing non-complicated OSA internally, without referral to sleep specialists. Ten belief statements representing six domains of the TDF were generated about screening. Lack of time and support staff (Environmental context and resources) and no prompts to screen for OSA (Memory, attention and decision processes) were commonly identified barriers to routine screening. Ten belief statements representing six TDF domains were generated for diagnosis and treatment behaviours. Common barriers to independent management practices were lack of skills (Skills), low confidence (Beliefs about capabilities), and the belief that OSA management was outside their scope of practice (Social/Professional role and identity). The three units independently managing OSA were well resourced with multidisciplinary involvement (Environmental context and resources), had 'clinical champions' to lead the program (Social influences).

CONCLUSION

Clinical management of OSA in tetraplegia is highly varied. Several influences on OSA management within spinal units have been identified, facilitating the development of future interventions aiming to improve clinical practice.

RE-AIMing conferences: evaluating the adoption, implementation and maintenance of the Rick Hansen Institute's Praxis 2016

BACKGROUND

In April 2016, the Rick Hansen Institute (RHI) hosted an innovative, 2-day conference called Praxis 2016. RHI aimed to bring together a diverse group of stakeholders to develop solutions for overcoming the challenges of translating spinal cord injury (SCI) research into practice. To understand the impact of Praxis, RHI funded an independent team to evaluate Praxis at the individual and setting level using the RE-AIM framework. Individual-level findings are published elsewhere. The aim of this evaluation is to report on the impact of Praxis at the setting level in terms of its adoption, implementation and maintenance.

METHODS

Data sources included interviews with attendees (n = 13) and organisers (n = 9), a fidelity assessment conducted at the conference, and observation notes provided by the evaluation team.

RESULTS

Main findings indicated that the Praxis model was adopted by organisers and attendees, implemented by RHI as intended, and has the potential for long-term maintenance. Lessons learned highlighted the importance of including SCI community members throughout the entire process from development to post-conference activities as well as in the research process, the value of facilitation and fostering interactive problem solving, and the need to identify leadership and funds to foster long-term efforts.

CONCLUSIONS

Developing and implementing a solutions-focused conference that brings together a diverse group of SCI stakeholders was challenging and rewarding for attendees and organisers. Other domains could learn from, adopt and build on the Praxis 2016 approach to address research-to-practice gaps.

An inclusive, online Delphi process for setting targets for best practice implementation for spinal cord injury

RATIONALE, AIMS, AND OBJECTIVES

The Spinal Cord Injury Knowledge Mobilization Network is a pan-Canadian community of practice composed of seven rehabilitation hospitals. The goal of this network is to utilize implementation science processes to facilitate the adoption of best practice in spinal cord injury (SCI) rehabilitation. In addition to selecting specific practices for implementation, a key aspect of effective implementation is the engagement of stakeholders in decision-making processes. To achieve this, the network utilized a Delphi process to reach consensus on two pressure ulcer prevention and management practices to be implemented in SCI inpatient rehabilitation. A diverse, multidisciplinary panel of clinicians, researchers, sponsoring agency representatives, and persons with SCI participated in this process.

METHOD

An online Delphi process was conducted in order to prioritize pressure ulcer prevention and management best practice recommendations and performance indicators for implementation. The process was conducted in six stages: (1) steering committee selection; (2) identification and selection of evidence; (3) participant selection and recruitment; (4) survey development; (5) identification of voting criteria; and (6) five rounds of voting.

RESULTS

The Delphi process resulted in the selection of two best practices: (1) comprehensive risk assessment and (2) education for pressure ulcer prevention and management in persons with SCI.

CONCLUSIONS

In this Delphi process, a large expert panel achieved consensus on best practice recommendations and associated performance indicators for implementation. This process was undertaken as a first step towards optimization of service delivery and outcomes for persons with SCI across Canada.

An ecological perspective on implementing environmental control units for veterans with spinal cord injuries and disorders

Purpose: Guided by an ecological perspective, the purpose of this study was to identify multilevel factors that influenced the implementation of environmental control units (ECUs) in Veterans Health Administration (VHA) Spinal Cord Injury/Disorders (SCI/D) Centres.Materials and methods: Mixed methods including an online survey and qualitative interviews of VHA healthcare employees.Results: VHA healthcare employees participated in the online survey (n = 153, 21% participation rate) and semi-structured interview (n = 28; 54% participation rate). About 58.2% of survey respondents indicated that patients admitted to a VHA SCI/D Centre received ECU training. Interview participants reported that patients might benefit from educational materials on using ECUs. About 53.7% of survey respondents indicated that they did not receive ECU training. Interview participants emphasized that more healthcare employees needed to be trained to distribute ECU-related tasks including patient training and troubleshooting problems. The most common challenge was the coordination involved in moving patients out of rooms that were being outfitted with an ECU.Conclusions: Application of an ecological framework highlighted a range of factors at multiple levels that dynamically influence ECU implementation while accounting for the SCI/D care context. Integrating this technology with the care experiences of patients, the workflow of healthcare employees, and the structure of the organization may improve the implementation of ECUs.IMPLICATIONS FOR REHABILITATIONAn environmental control unit (ECU) is an assistive technology device that provides persons with a physical disability (e.g., spinal cord injuries and disorders) increased independence in a home, hospital, or rehabilitation facility setting.An ECU allows a person to access and control appliances like their hospital bed, lights, television, doors, nurse call button, telephone, and computer, thus, decreasing workload on attendants and family members while increasing independence for the user.Application of an ecological framework in this study highlighted a range of factors at multiple levels that dynamically influence ECU implementation while accounting for the SCI/D care context.Integrating this technology with the care experiences of patients, the workflow of healthcare employees, and the structure of the organization may improve the implementation of ECUs in an inpatient setting.

Nature of the Non-traumatic Spinal Cord Injury Literature: A Systematic Review

Background: Non-traumatic SCI (NTSCI) etiologies represent a markedly heterogeneous cluster of conditions defined within the consensus NTSCI taxonomy. This meta-analysis assembles evidence about the occurrence of NTSCI and its clinical outcomes with respect to 6 research domains. Purpose: To investigate the quality and quantity of clinical NTSCI evidence published in the peer reviewed literature with reference to prognosis, diagnosis, intervention, process of care, methodology, and qualitative approaches. Methods: PubMed and MEDLINE OVID MeSH heading searches were conducted for 5 common-language NTSCI descriptors. Filters were English language and Entrez date (1997-2016). Filters also controlled for case reports, editorials or errata, and invited reviews. NTSCI etiologies incorrectly classified, animal studies, and multidimensional mapping studies were excluded. Full texts were retrieved and ranked for evidence quality according to PRISMA statement guidelines, or PEDro criteria. Data were extracted and simple descriptive statistics applied. Results: The search terms non traumatic and non-traumatic SCI retrieved 282 articles, with 39 duplicates. After exclusion of 117 articles: Level 1V (60); NTSCI incorrectly evaluated (14); publication bias (2); non-English language (1); and animal experiments (1), 126 titles/abstracts were screened and ranked against criteria. Of the 8 papers allocated for full-text review, a subset of 3 articles was ranked level 1A (1) or level 11A (2); mean PEDro score 5.75±0.5. Reasons for full-text exclusions (5) were NTSCI incorrectly classified (1) and statistical limitations (4). Of the 6 domains, prognostics had adequate data yield (86) for evidence synthesis (4.8% ranked level 1A, or 11A). Notable evidence gaps were identified in qualitative (1), methodological (2), and diagnostic (8) domains. Conclusion: Therapeutic approaches require an evidence-based understanding of the distinct contexts in which NTSCI occurs, especially in less resourced settings. Our findings underscore the need for qualitative and quantitative research on the occurrence of NTSCI in all contexts.

Facilitators and Barriers to International Collaboration in Spinal Cord Injury: Results from a Survey of Clinicians and Researchers

International collaboration in spinal cord injury (SCI) research is necessary to overcome the challenges often encountered by clinicians and researchers, including participant recruitment, high cost, and the need for specialized expertise. However, international collaboration poses its own obstacles. The objective of this study was to conduct an international online survey to assess barriers and facilitators to international SCI clinical research, potential initiatives to facilitate future collaborations, and the use of SCI-specific data sets and standards. Results were analyzed using descriptive statistics. Of 364 total respondents, 213 completed the survey, with the majority of these participants based in North America (38%), Asia (22%), Europe (18%), and Oceania (16%). Over half had more than 10 years of experience in SCI research or clinical practice (57%) and 60% had previous experience with international collaborations. Funding was identified as a top barrier (82%), a facilitator (93%), and a proposed future initiative (97%). Communication and technology were also identified as strong facilitators and proposed future initiatives. The International Standards for Neurological Classification of SCI were used by 69% of participants, the International Standards to document remaining Autonomic Function after SCI by 13% of participants, and the International SCI Data Sets by 45% of participants. As the need for international collaborations in SCI research increases, it is important to identify how clinicians and researchers can be supported by SCI consumer and professional organizations, funders, and networks. Furthermore, unique solutions to overcome modifiable barriers and creation of new facilitators are also needed.

Sociotechnical Perspective on Implementing Clinical Video Telehealth for Veterans with Spinal Cord Injuries and Disorders

BACKGROUND

Real-time videoconferencing technology such as clinical video telehealth (CVT) offers a means to reach patient populations who face limited access to healthcare. The Veterans Health Administration has invested in CVT to improve care access for U.S. military veterans with spinal cord injuries and disorders (SCI/D); however, no studies have assessed the factors that influence implementation of this technology in clinical practice for individuals with SCI/D.

INTRODUCTION

Guided by a sociotechnical perspective, the purpose of this study was to identify factors that influence implementation of CVT for veterans with SCI/D.

MATERIALS AND METHODS

We conducted semistructured telephone interviews with 40 healthcare providers who use CVT to deliver services to veterans with SCI/D.

RESULTS

Factors related to workflow and communication were widely reported as implementation barriers. Coordinating logistics for CVT appointments was challenging, and effective communication between CVT team members across facilities was considered crucial. Providers also cited factors related to technical infrastructure, people, and organizational features, including the need for appropriate equipment, space, personnel, and support for using CVT equipment.

DISCUSSION

The implementation of CVT in the care of veterans with SCI/D was influenced by an interrelated set of social and technical factors. Key among them were social factors related to people, workflow, and communication, given that CVT supports healthcare teams interacting remotely in real time.

CONCLUSIONS

CVT implementation requires teams working together to negotiate a complex, distributed process across multiple sites. Such complexity places a premium on teamwork and communication among healthcare teams before, during, and after a CVT encounter.

Systematic Review of Knowledge Translation Strategies to Promote Research Uptake in Child Health Settings

Strategies to assist evidence-based decision-making for healthcare professionals are crucial to ensure high quality patient care and outcomes. The goal of this systematic review was to identify and synthesize the evidence on knowledge translation interventions aimed at putting explicit research evidence into child health practice.

METHODS

A comprehensive search of thirteen electronic databases was conducted, restricted by date (1985-2011) and language (English). Articles were included if: 1) studies were randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) target population was child health professionals; 3) interventions implemented research in child health practice; and 4) outcomes were measured at the professional/process, patient, or economic level. Two reviewers independently extracted data and assessed methodological quality. Study data were aggregated and analyzed using evidence tables.

RESULTS

Twenty-one studies (13 RCT, 2 CCT, 6 CBA) were included. The studies employed single (n=9) and multiple interventions (n=12). The methodological quality of the included studies was largely moderate (n=8) or weak (n=11). Of the studies with moderate to strong methodological quality ratings, three demonstrated consistent, positive effect(s) on the primary outcome(s); effective knowledge translation interventions were two single, non-educational interventions and one multiple, educational intervention.

CONCLUSIONS

This multidisciplinary systematic review in child health setting identified effective knowledge translation strategies assessed by the most rigorous research designs. Given the overall poor quality of the research literature, specific recommendations were made to improve knowledge translation efforts in child health.

Development of theory-based knowledge translation interventions to facilitate the implementation of evidence-based guidelines on the early management of adults with traumatic spinal cord injury

RATIONALE

Optimal, early management following a spinal cord injury (SCI) can limit individuals' disabilities and costs related to their care. Several knowledge syntheses were recently published to guide health care professionals with regard to early interventions in SCI patients. However, no knowledge translation (KT) intervention, selected according to a behaviour change theory, has been proposed to facilitate the use of SCI guidelines in an acute care setting.

OBJECTIVES

To develop theory-informed KT interventions to promote the application of evidence-based recommendations on the acute care management of SCI patients.

METHODS

The first four phases of the knowledge-to-action model were used to establish the study design. Knowledge selection was based on the Grading of Recommendations Assessment, Development and Evaluation system. Knowledge adaptation to the local context was sourced from the ADAPTE process. The theoretical domains framework oriented the selection and development of the interventions based on an assessment of barriers and enablers to knowledge application.

RESULTS

Twenty-nine recommendations were chosen and operationalized in measurable clinical indicators. Barriers related to knowledge, skills, perceived capacities, beliefs about consequences, social influences, and the environmental context and resources theoretical domains were identified. The mapping of behaviour change techniques associated with those barriers led to the development of an online educational curriculum, interdisciplinary clinical pathways as well as policies and procedures.

CONCLUSIONS

This research project allowed us developing KT interventions according to a thorough behavioural change methodology. Exposure to the generated interventions will support health care professionals in providing the best care to SCI patients.

The fragility of statistically significant findings from randomized trials in spine surgery: a systematic survey

BACKGROUND CONTEXT

Randomized controlled trials (RCTs) are the most trustworthy source for evaluating treatment effects, but RCTs of spine surgery interventions often produce discordant results. The Fragility Index is a novel metric to inform about the robustness of statistically significant results.

PURPOSE

The aim was to determine the robustness of statistically significant results from RCTs of spine surgery interventions.

STUDY DESIGN/SETTING

This was a systematic survey.

PATIENT SAMPLE

The sample included RCTs of spine surgery interventions.

OUTCOME MEASURES

The Fragility Index is the minimum number of patients in a trial whose status would have to change from a nonevent to an event to change a statistically significant result to a nonsignificant result. Events refer to the occurrence of any dichotomous outcome, such as successful fusion, incident fracture, adjacent segment degeneration, or achievement of a certain functional score. A small Fragility Index indicates that the statistical significance of a result hinges on only a few events, and a large Fragility Index increases one's confidence in the observed treatment effects.

METHODS

We systematically reviewed a database for evidence-based orthopedics and identified all the RCTs that reported at least one positive outcome (ie, p<.05). Two reviewers independently assessed eligibility and extracted data. We used the Fisher exact test to compute Fragility Index values and multivariable linear regression to evaluate potential associated factors.

RESULTS

We identified 40 eligible RCTs with a median sample size of 132 patients (interquartile range [IQR] 79-208) and a median total number of outcome events for the chosen outcome of 31 (IQR 13-63). The median Fragility Index was two (IQR 1-3), which means that adding two events to one of the trial's treatment arms eliminated its statistical significance. The Fragility Index was less than or equal to three events in 75% of the trials, and was less than or equal to the number of patients lost to follow-up in 65% of the trials. Fragility Index values correlated positively with total sample size (r=0.35; p<.05). When adjusted for losses to follow-up and risk of bias, increasing Fragility Index values were associated only with increasingly significant reported p values (p<.01).

CONCLUSIONS

Statistically significant results in spine surgery RCTs are frequently fragile. The addition of only a small number of outcome events can completely eliminate significance. Surgeons, researchers, and other evidence users should exercise caution when interpreting the findings from RCTs with low Fragility Index values and applying these results to patient care.

Evaluating implementation of methicillin-resistant Staphylococcus aureus (MRSA) prevention guidelines in spinal cord injury centers using the PARIHS framework: a mixed methods study

BACKGROUND

To prevent methicillin-resistant Staphylococcus aureus (MRSA) in Spinal Cord Injury and Disorder (SCI/D) Centers, the "Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers" were released in July 2008 in the Veterans Affairs (VA) Health Care System. The purpose of this study was to use the Promoting Action on Research Implementation in Health Systems (PARiHS) framework to evaluate the experiences of implementation of SCI/D MRSA prevention guidelines in VA SCI/D Centers approximately 2-3 years after the guidelines were released.

METHODS

Mixed methods were used across two phases in this study. The first phase included an anonymous, web-based cross-sectional survey administered to providers at all 24 VA SCI/D Centers. The second phase included semi-structured telephone interviews with providers at 9 SCI/D Centers. The PARiHS framework was used as the foundation of both the survey questions and semi-structured interview guide.

RESULTS

The survey was completed by 295 SCI/D providers (43.8 % response rate) from 22 of the 24 SCI/D Centers (91.7 % participation rate). Respondents included nurses (57.3 %), therapists (24.4 %), physicians (11.1 %), physician assistants (3.4 %), and other health care professionals (3.8 %). Approximately 36 % of the SCI/D providers surveyed had not seen, did not remember seeing, or had never heard of the MRSA SCI/D guidelines, whereas 42.3 % of providers reported that the MRSA SCI/D guidelines were fully implemented in their SCI/D Center. Data revealed numerous barriers and facilitators to guideline implementation. Facilitators included enhanced leadership support and provider education, focused guideline dissemination to reach SCI/D providers, and strong perceived evidence supporting the guidelines. Barriers included lack of awareness of the guidelines among physical therapists and physician assistants and challenges in cohorting/isolating MRSA-positive patients and following contact precautions.

CONCLUSIONS

Successful implementation of MRSA infection prevention guidelines in SCI/D settings requires (1) guideline dissemination that reaches the full range of SCI/D providers working in inpatient, outpatient, and other care settings, (2) provider education that is frequent and systematic, (3) strong leadership support, and (4) that barriers unique to the recommendations are addressed. These findings may be used to inform selection of implementation strategies and optimize infection prevention beyond MRSA as well as in other specialty care populations.