New guidelines for traumatic brain injury—built with input from rehabilitation professionals

Clinical practice guidelines play a critical role in promoting quality care for patients with traumatic brain injury (TBI). A new set of guidelines for rehabilitation of patients with moderate to severe TBI—incorporating insights from the rehabilitation professionals responsible for providing care from initial assessment through long-term follow-up—is introduced in the September issue of the The Journal of Head Trauma Rehabilitation (JHTR), official journal of the Brain Injury Association of America.

"The novel approach of consulting and working with end users to develop a clinical practice guideline for moderate to severe TBI should influence knowledge uptake for clinicians wanting to provide evidence-based care," according to an introductory article by Bonnie Swaine, Ph.D., of Université de Montréal and the Center for Interdisciplinary Rehabilitation Research (CRIR) and colleagues.

Unique Focus on Responding to Needs of Professionals Caring for TBI

The guidelines were developed by a collaborative effort of researchers, clinicians, and policymakers from Ontario and Quebec. The complete, bilingual (English and French) guidelines can be accessed at http://braininjuryguidelines.org. The guidelines were sponsored by the Québec Institut national d'excellence en santé et en services sociaux (INESSS) and the Ontario Neurotrauma Foundation (ONF).

Several sets of guidelines for TBI have been developed in recent years—so why develop a new clinical practice guideline now? "Because clinicians told us that they need specific features and tools," Dr. Swaine and coauthors write. Updated guidelines are also needed to reflect the trend toward community-based rehabilitation, as well as the context of the Canadian healthcare system.

From the outset, the guideline development process assessed the needs and expectations of "end users": the clinicians and managers providing rehabilitation care for patients with moderate to severe TBI. A study by Marie-Eve Lamontagne, Ph.D., of Université Laval, Québec City, and colleagues found that rehabilitation professionals expressed positive perceptions of clinical practice guidelines—however, only a small proportion of respondents used them in everyday practice. The professionals identified several key topics to be covered in guidelines, including the intensity and frequency of rehabilitation services, managing behavioral disorders and cognitive function impairment, and social participation and community life.

A separate survey asked professionals their views on how well guideline recommendations were implemented into the care of patients with TBI. While a high percentage of recommendations were considered "fully or mostly implemented," several gaps in implementation were recognized, both in acute care and rehabilitation settings.

An article by Dr. Mark Bayley, MD, of University of Toronto and colleagues highlights the unique features of the INESSS/ONF guideline development process that address user's needs, including providing prioritization of recommendations for implementation, implementation tools, indicators to measure uptake, system implications and background rationale and evidence supporting the recommendation. The final clinical practice guideline includes 71 recommendations related to the components of the optimal TBI rehabilitation system, including the intensity/frequency of interventions, rehabilitation mechanisms, duration of interventions, and mechanisms for promoting continuity of care; and 195 recommendations pertaining to assessment and rehabilitation of the sequelae of brain injury, including behavioral disorders, cognitive dysfunction, fatigue and sleep disturbance, and mental health.

The vision behind the guidelines encompasses the whole "knowledge to action cycle," including measures to define and support implementation of the recommendations across Ontario and Québec. Drs. Swaine, Bayley, and Lamontagne and colleagues conclude: "Only time will tell whether our attention to user needs and expectations will positively influence the uptake of knowledge using the clinical practice guideline and, ultimately, patient outcomes following moderate to severe TBI. "