Background
Methods
Ethics approval
Funding
Project team
Project framework
Terminology
Essential preliminary steps
Scope, target group and purpose
Identifying relevant guidance documents
Guidance document quality
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high quality (HQ) being 80% + of the total possible AGREE II score,
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moderate quality (MQ) being 60–79% of the total possible AGREE II score and
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poor quality (PQ) being < 60% of the total AGREE II score.
Project questions
1. Which factors might delay admission to medical facility after suffering a stroke at home? c | |
2. What is the optimal time for referral to rehab since admission to hospital? 4,3,2,1 | |
3. What is the optimal time for commencement of rehab since suffering a stroke? 4,3,2,1 | |
4. What are the factors indicating when it’s safe for rehab to commence? 4,3,2,1 | |
• EB assessment planning 4,3,2,1 | |
• Which factors should be assessed? | |
• Which outcome tools should be used? | |
5. Best practice recording method for assessment, treatment and goal setting when treating a stroke patient? 4,3,2,1,h,p | |
6. What is critical to record when assessing and treating a stroke patient? 4,3,2,1, h, s | |
7. What is the best, locally relevant communication platform for improving communication between levels of care; medical personnel; therapists; therapist/patient; therapists/family; therapist/employer? 4,3,2,1, h, s | |
8. What should be communicated with medical personnel, other rehab therapists, patient and carer/family? 4,3,2,1,h,p | |
9. What are the EB guideline on setting rehab goals and how to record these goals? 4,3,2,1, h, s | |
10. EB discharge planning: 4,3,2,1, h | |
- When should it start for a stroke patient? | |
- Who should be involved? | |
- What should it include? | |
11. Which rehab professional should first see the patient? 4,3,2,1, h | |
• What is the EB most critical first step? | |
• What are the EB criteria for referral between therapists? | |
• What is the best practice communication between therapists (devises, discharge planning and care continuation)? | |
12. According to the evidence, which therapist should communicate with the family? 4,3,2,1, h, s | |
13. What is the EB role of the physiotherapist, occupational therapist and speech therapist when assessing and treating a stroke patient? 4,3,2,1 | |
14. How does the model of care differ between the different points of entry (primary; secondary; tertiary; quaternary level)? 4,3,2,1 | |
15. What are the EB rehab interventions at each level of care? 4,3,2,1, h, s | |
16. What are the best outcome measures for SA context for all levels of care as well as urban, suburban and urban settings? 4,3,2,1, h, s | |
17. When should family education commence? 4,3,2,1, h, s | |
• Which communication channel is most appropriate? | |
• How is family incorporated into discharge planning? | |
• Who should be communicating? | |
• What should be included in the communication and in which format? | |
18. What is the EB criteria for referral to other professions such as social workers/psychologists? 4,3,2,1, h, s | |
19. Which rehab professional should take responsibility for planning and monitoring continuation of care? 4,3,2,1, h, s | |
20. What are the EB rehab criteria for discharge from rehab as an in-patient and out-patient? 4,3,2,1, h, s | |
21. What is the EB information for the best next level of care? 4,3,2,1, h, s | |
22. What are the EB interventions for longer term care h, s | |
– rehab facility | |
– Community Health Center (CHC) | |
– long term home care | |
– home or community | |
23. What are the EB ways of communicating with patient/family/other professionals? 4,3,2,1, h, s | |
24. What are the EB rehab outcome measures for longer term care? h, s | |
25. What is the EB education linked to complications of stroke (aspiration pneumonia/ secondary strokes etc.) 4,3,2,1, h, s | |
26. How should Traditional healers be incorporated into the medical system? c, h | |
27. What training should traditional healers received to appropriately refer a stroke patient? c,h | |
28. What are EB criteria for ending rehab? h, s | |
• Ongoing monitoring? | |
29. What is the evidence for the swallow test? When should it be done and by whom? 4,3,2,1 | |
30. What are the EB criteria for assistive technology? 4,3,2,1, h, s | |
– Walking Aids | |
– Slings | |
– AFO’s | |
– Wheelchairs | |
– Splints | |
– OT tools??? | |
31. What is the EB approach to re-integrating stroke patient into the community, society, leisure and work (participation)? h, s | |
32. How should rehab therapists liaise with other sectors (transport/labour/social) for facilitated participation? h, s | |
33. How should the community/general public be educated to facilitate societal participation of a person who has suffered a stroke? h, s | |
34. Therapists are not trained for inter-sectorial integration when it comes to general care/rights of a person who has suffered a stroke. What is the best practice to address this issue? h, s | |
35. “Work hardening”; aerobic capacity, effort and tolerance: 4,3,2,1, h, s | |
- When should treatment or focus on these factors start? | |
- What is the evidence based strategy to address this? | |
36. Self-efficacy – compliance to medication and self-care:4,3,2,1, h, s | |
- When should this start? | |
- Which therapist should be responsible for educating patient? | |
37. Best practice to work with mental health professionals or issues???? 4,3,2,1, h, s | |
38. Best practice to equip/educate rehab therapist to deal with bereavement and depression after stroke? 4,3,2,1, h, |
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Communication | x | x | x | x | x | x | x | x | x | x | x | x | x | x | x | x | x | x | ||||||||||||||||||||
Service delivery | x | x | x | x | x | x | x | |||||||||||||||||||||||||||||||
Organisational | x | x | x | x | x | x | x | x | x | x | x | x | x | x | x | |||||||||||||||||||||||
Clinical | x | x | x | x | x | x | x | x | x | |||||||||||||||||||||||||||||
Training requirements | x | x | x | x | x |
Excluding guidance documents
Strength of the body of evidence (SoBE)
Defining recommendations
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wording in guidance documents that was clearly labelled ‘recommendation’ (appearing in designated recommendation boxes, specific fonts or tables) and accompanied by a SoBE grading, or
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wording that appeared in the text, not necessarily labelled ‘recommendation’ but which had the intent of being a recommendation, in terms of intention words such as ‘should’, ‘could’, ‘might consider’, accompanied with an SoBE grading.
Extracting data for project questions
Standardising SoBE
Compiling the evidence
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those which were not answered by any guidance document (absence of evidence),
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those answered by only one–two guidance documents (scant evidence) and
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those with inconsistent SoBE (inconsistent evidence).
Writing composite recommendations
Determining the OSoBE for composite recommendations
Endorsement of process and recommendations
Results
Included guidance documents
Clinical practice guideline | Acronym | Year | Source of evidence | AGREE score |
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American Heart Association/American Stroke Association (rehabilitation guideline) | AHA/ASA | 2015 | Relevant articles on adults using computerised searches of the medical literature through 2014 | 64.9% (mod) |
American Occupational Therapy Association (sourced through Guidelines Clearing House AHRQ) | AOTA | 2013 | Databases and sites searched included Medline, PsycINFO, CINAHL, AgeLine, and OTseeker, consolidated information sources(Cochrane Database of Systematic Reviews, Campbell Collaboration); reference lists from articles included in the systematic reviews were examined, and selected journals were hand searched | 72.5% (mod) |
American National Guidelines Clearing House summary (sourced through AHRQ) | AHRQ | 2013 | Commissioned by and extracted from NICE rehabilitation guidelines (2013) (based on NICE methods). A panel of independent multidisciplinary experts debated the findings and wrote recommendations | 73.2% (mod) |
Australian Council on Safety and Quality in Health Care | ACSQHC | 2015 | Australian clinical practice guidelines, standards and policies were identified from • the clinical practice guideline portal of the National Health and Medical Research Council (NHMRC) • websites of professional colleges and organisations • websites of state and territory health departments and agencies • internet search using various search engines. International clinical practice guidelines • guideline clearing houses such as the Agency for Healthcare Research and Quality (AHRQ) and Guidelines International Network (GIN) • websites of guideline developers, such as the UK’s National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guideline Network (SIGN). Other high-level evidence was identified by searching • the Cochrane Collaboration for systematic reviews and meta-analyses • medical literature databases (Medline, Embase) for systematic reviews and meta-analyses. | 27.5% (poor) |
Australian Stroke Foundation | ASF | 2017 | Update evidence search using primary and secondary literature from library databases, Cochrane Collaboration, high quality international guidelines NB search strategy similar to all previous versions of ASF guidelines | 63.0% (poor) |
Canadian stroke guidelines | CSG | 2015 | Methods based on the Practice Guideline Evaluation and Adaptation Cycle (PGEAC) [54]. Systematic literature search w for each topic area by independent contract methodologists. Updated literature searches built on previous reviews from 2012 to 2015, which overlapped the previous search time frame by 6 months to ensure high catchment of key articles within that time frame. The writing group was provided with comprehensive evidence tables that include summaries of all high-quality evidence identified through the literature searches. | 85.1% (high) |
Dept. of Defence, Veterans Association Management of Stroke Guidelines | VA/DoD | 2010 | Recommendations for the management of stroke rehabilitation were derived through a rigorous methodological approach: • Determining appropriate criteria such as effectiveness, efficacy, population benefit, or patient satisfaction • Reviewing literature to determine the strength of the evidence in relation to these criteria • Formulating the recommendations and grading the level of evidence supporting the recommendation Findings were reviewed by an expert working party and recommendations produced relevant to veterans’ needs. | 74.6% (mod) |
Malaysian stroke guideline | 2016 | A panel of committee members was appointed comprising of neurologists, a cardiologist and a radiologist from the Ministry of Health, universities and the private sectors. Authors from the first CPG were invited to contribute on new updates before being discussed by panel members. The discussion started from early 2010 before being finalised and sent for the appointed reviewers. The group members met several times throughout the development of the guideline. All retrieved literature were appraised by individual members and subsequently presented for discussion during group meetings. All statements and recommendations formulated were agreed collectively by members of the Expert Panel. Where the evidence was insufficient the recommendations were derived by consensus of the Panel. The draft was then sent to local external reviewers for comments. The level of recommendation and the grading of evidence used in this guideline was adapted from the U.S./Canadian Preventive Services Task Force and the Guidelines for Clinical Practice Guideline, Ministry Of Health Malaysia 2003. The principles and layout follows the methodology stated in the Guidelines for Clinical Practice Guidelines booklet published by the Medical Development division of the Ministry of Health Malaysia. A standard methodology based on a systematic review of current evidence was used to look at the literature. These guidelines have been presented to the Chairman of the Health Technology Assessment and Clinical Practice Guidelines Council of the Ministry of Health Malaysia for review and approval. | 81.9% (high) | |
New Zealand Guidelines Group | NZGG | 2010 | Builds on the ASF search 2009. Systematic identification of relevant studies was conducted between May and August 2009, EMBASE, Medline and Cochrane databases were used. CINAHL and Psychinfo databases were searched where relevant. The PEDro database was used to check PT studies. A second updated search of the literature up to 19 February 2010 using Medline and EMBASE databases was conducted. Updated Cochrane reviews were also searched and included. Economic studies were included where available | 73.6% (mod) |
National Institute for Health and Clinical Excellence | NICE | 2013 | De novo literature reviews were undertaken including evidence from economic studies, consensus was sought on the evidence findings for each question | 75.4% (high) |
NSW Agency for Clinical Innovation | NSW ACI | 2016 | 2015 National Acute Stroke Services, Framework by the National Stroke Foundation; 2015 Acute Stroke Clinical Care Standard and Indicator Specification by ACSQHC; 2010 Clinical Guidelines for Stroke Management NSF; 2015 Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment by the American Heart Association/American Stroke Association; NSW ACI Stroke Reperfusion Program Evaluation Report; 2015; Bureau of Health Information, The Insight Series, 30-day mortality following hospitalisation, five clinical conditions. July 2009–2012 (7); Middleton S et al. ‘Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial’ Lancet 378(9804): 1699–706.(20) | 65.6% (mod) |
Royal College of Physicians | RCP | 2012 | Systematic searching of computerised databases Medline, AMED, CINAHL, Psychinfo and Embase. The Cochrane Collaboration database, SIGN and NICE; Health Technology Appraisal (HTA) reports; members of the working party brought their own expertise and information from their organisations and professional bodies. For topics newly added since 2008 searches included the time period from 1966 onwards; for the remainder of the topics searches were performed from 2007 until February 2012. | 90.2% (high) |
South Australian Dept. of Health Stroke Network | SA Dept. of Health SN | 2017 | Expert input | 79.0% (mod) |
Scottish Intercollegiate Guidelines Network (dysphasia, rehabilitation) | SIGN | 2010, 2010 | De novo and updating searches as per all SIGN activities (comprehensive systematic reviewing, critical appraisal, independent data extraction) | 81.5% (mod) |
South African Stroke Society | SASS | 2010 | Consensus based on AHA/ASA guidelines | 51.8% (poor) |
Questions and composite recommendations
Methodological quality
Standardising SoBE gradings
NICE/ AHRQ[1] (consensus wording from evidence strength) | VA/ DoD | RCP (consensus on evidence strength), Sth Aust; NSW ACI | AHA/ASA, Canada[2], Sth Africa[3] | NZGG[4], Malaysia, SIGN | ASF | SA-cSRG standard approach |
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Evidence synthesis and consensus words | Hierarchy and quality | Evidence synthesis and consensus words | Hierarchy and quality | Hierarchy and quality | Evidence strength words | |
High confidence (positive) | A | Strong = should | A | A | Strong | ☺☺☺ |
Moderate confidence | B | Moderate = could | B | B | Strong | ☺☺ |
Low confidence | C | weak = apply with caution | C | C | Weak | ☺ |
D | D | Weak | ☺ | |||
Insufficient | ||||||
Opinion | Practice point | Practice point | ☺ or ☹ | |||
Moderate confidence (negative) | Moderate not | ☹☹ | ||||
High confidence (negative) | Should not | A | Strong (against) | ☹☹☹ |
Composite recommendations
Discussion
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standardise differently reported SoBE gradings,
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synthesis intent and wording from multiple recommendations that reported the evidence for one question in different ways and
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determine an OSoBE grading for a composite recommendation which summarised recommendations from multiple guidance documents, for one question.