In 2015, the Canadian Heart and Stroke Foundation published a new pediatric stroke clinical practice guideline. An urban pediatric rehabilitation hospital that sees approximately 300 children and youth with stroke a year, aimed to select and implement appropriate recommendations to align evidence-based stroke care across inpatient, day patient and outpatient care settings.
To navigate the complexities of real-world implementation, the hospital’s knowledge translation team used the Theoretical Domains Framework (TDF) (Cane et al., 2012) and an integrated KT approach to develop and carry out an implementation strategy for one selected recommendation. The TDF is a meta-framework that combines 84 constructs and 14 domains from 33 psychological theories relevant to behaviour change. An integrated KT approach was used to optimize the relevancy and quality of implementation processes, resources and strategies to facilitate uptake. An iterative six step process was employed; (i) stakeholder engagement, (ii) recommendation selection, (iii) supporting literature review, (iv) implementation needs assessment, (v) implementation strategy development and execution (vi) process monitoring and evaluation using the Determinants of Implementation Behavior Questionnaire (DIBQ) (Michie et al., 2005).
Managing post-stroke depression was identified as the first area of need by clinicians, patients and their families. The team selected the self-report and proxy versions of the Patient Reported Outcomes Measures Information Systems (PROMIS) Pediatric Depression Screening tool to use with children between the ages of 5 – 17 across care settings at standardized points in care. To facilitate implementation, cut-off scores were generated by in-house psychologists. As appropriate, patients were referred for further investigation as identified through the tool and clinical expertise. Implementation strategies selected included; group training, case study role-play, electronic medical record modification, decision making guide, score interpretation guide, screening tool introduction scripts, clinical team check-ins, and local opinion leaders. DIBQ results showed that 90% believed that using the tool will strengthen the collaboration between professionals in the patient’s circle of care and that 80% have the knowledge, skills and confidence to deliver the tool. This highlights that clinicians feel they have the capacity and motivation to use the tool. However, for many, barriers still exist to remember to do the tool as part of their regular practice with stroke patients.
An implementation process based on the TDF and an integrated KT approach garnered frontline engagement and facilitated implementation by addressing knowledge, skill and confidence factors for screening tool use. Using a theory-informed approach in planning and evaluation highlighted tangible areas to improve upon. Findings from the DBIQ are being used to further tailor implementation efforts, such as addressing the need for greater automaticity to prompt use of the screening tool.