apartado 5 bis (nuevo)

4.0 Phase 1 Outcome 4.0 Phase 1 Outcome

Phase 1 entailed:

ƒ Distribution of an on-line survey to all speech pathologists working for ADHC, which aimed to answer the question “How do speech

pathologists working within ADHC currently use the principles of evidence-based practice to facilitate client outcomes”?

The positive outcomes of using evidence-based practice at ADHC identified by speech pathologists included improving the quality of client outcomes and allowing more informed decisions to be made with families regarding intervention goals for clients. Many speech pathologists believed that EBP can fit into a trans-disciplinary model of service delivery by allowing therapists to share evidence outcomes that support collaborative service delivery models with other professionals. Recent speech pathology

graduates were more knowledgeable about EBP due to its inclusion in many university curriculums. New speech pathologists were also aware of how to access journal articles and search online databases more effectively. This has lead to a divide of knowledge between speech pathologists. Speech pathologists believed that EBP should be encouraged within ADHC and that referring to evidence in intervention plans represented good practice. Most speech pathologists were aware of EBP databases (such as speechBITE™) and were aware of the ADHC Online Library, which gives electronic access to research and clinical journals.

The main concern regarding use of EBP in ADHC was the lack of formal training in EBP most speech pathologists received as part of their professional development. Most speech pathologists cited a Community Support Team (CST) conference attended in 2009 as the extent of EBP training they had received in ADHC. As well, EBP was seen as a time- consuming process that can take away from direct client hours. The time needed to gather information and summarize the literature was reported to be particularly onerous for those clinicians who were not familiar with using EBP. Another reason why speech pathologists reported EBP to be less useful was the belief that there was a paucity of literature relating to disability populations compared to other client populations.

Most speech pathologists agreed that EBP can be successfully implemented in ADHC. However, for this to occur, a range of strategies were suggested by participants. The first recommendation was the need for further training in how to incorporate EBP into clinical practice for speech pathologists in ADHC. Electronic resources such as the ADHC Online Library and

speechBITE™ also need to be promoted to speech pathologists and,

specifically, how these can be used to facilitate the uptake of EBP at ADHC. It was suggested that senior speech pathologists lead this process by sharing strategies to make EBP more easily accessible to their team members.

Managers need to be made aware of the importance and benefits for speech pathologists (and other clinicians) to set aside time to search for current evidence, and for systems which support the accurate recording of time spent on clients applying the principles of EBP. Additionally, it was suggested that policy leaders consider increasing the accessibility of the ADHC Online Library by expanding its journal subscription and by decreasing the time lag as a result of accessing articles through document-delivery rather than directly.

4.1 Phase 2 Outcome

Phase 2 entailed:

ƒ Development of EBP resources and EBP workshops for ADHC speech pathologists.

Phase 2 of the project involved increasing the volume of journal articles reviewed relating to disability populations on the speechBITE™ database and the development of an EBP workshop for senior speech pathologists, which would form the basis for training other speech pathologists within ADHC. Project manager Michael Brunac was responsible for collecting articles for the database. Six databases were used in the gathering of journal articles at The University of Sydney. The Ovid platform was used to access the

electronic databases of Medline, PsychINFO and Education Resources Information Centre (ERIC). The Cambridge Scientific Abstracts (CSA) platform was used to access the electronic database Linguistics and

Language Behaviour Abstracts (LLBA) while the Cumulative Index to Nursing and Allied Health Literature (CINAHL) platform was used to access the Elton B Stephens Company (EBSCOhost) database.

In general, papers accepted onto speechBITE™ must fulfil the following four criteria for inclusion:

1. The paper is published as a full-length paper (not an abstract) in a peer-reviewed scientific journal;

2. The population treated are representative of those whom the intervention may be applied to in the course of speech pathology practice. The population treated will have, or be at risk of, a communication disorder and/or dysphagia;

3. The treatment is currently part of speech pathology practice or could become part of speech pathology practice. The intervention need not be carried out by speech pathologists; and

4. The trial includes an evaluation of at least one intervention and includes empirical data regarding treatment efficacy (i.e., editorials, non-systematic reviews or case descriptions are not eligible for

With reference to criteria 2, only articles that represented populations of clients with intellectual disabilities met the criterion for this project. This is representative of the client population that is serviced by speech

pathologists in ADHC.

Once articles are considered to have met selection criteria, there was still the possibility of rejection due to incomplete research design, duplicate articles found within the database, and articles written in foreign

languages.

Searches were conducted by specified categories of the disability client population. In total, five individual searches were conducted from March 2010 to February 2011. The client populations were separated into the following categories: Autism, Cerebral Palsy, Intellectual Disability,

Congenital Disorders, and Dysphagia/Feeding. Table 2 illustrates the number of papers assessed by category, and the ratio of papers accepted/rejected.

SUBJECT PAPERS ACCEPTED REJECTED

Autism 141 90 51 Cerebral Palsy 60 42 18 Intellectual Disability 67 36 31 Congenital Disorders 101 41 60 Dysphagia/Feeding 31 11 20 Total 400 220 180

Table 2: Journal articles found during search selection process. An average of 47% of papers that met selection criteria were ultimately rejected for the reasons noted above.

At the time of this report, there were over 600 papers relating to disability populations listed on the speechBITE™ database. This ADHC funded project has contributed 220 papers to the total, comprising approximately one-third of the available papers on disability on speechBITE™. Most research articles that appear on speechBITE™ are independently rated according to their methodological quality using a scale of 1 to 10.

Approximately 25% of the papers contributed by this study used group designs which were rated for their methodological quality using the Physiotherapy Evidence Database (PEDro™) scale. This scale assesses the internal validity of a trial and whether it contains sufficient statistical information to make it interpretable. The first item relates to external validity, and is not counted in the final methodological quality rating score, which is out of 10. The remaining items address: biases prior to the

treatment phase including random allocation, concealed allocation and groups being statistically similar at baseline; performance biases during treatment including blinding of participants, therapists and assessors; and biases at data analysis, including drop out rates, and intention to treat analysis and statistical reporting. The PEDro™ scale has acceptable inter- rater reliability (Maher et al, 2003) and has been extensively used to rate

research reports published on PEDro™ (Maher et al, 2003). The rating scale is also used to rate papers on OTseeker™, a web based database of evidence for occupational therapists. Also, approximately 47% of papers contributed used single case experimental designs which were rated for methodological quality using the Single Case Experimental Design (SCED) scale. The scale consists of 11 items which address potential sources of bias in these types of studies. Even though randomized control trials are considered a higher level of research evidence, the increasing number of studies reporting only on data collected from one participant made the need for a methodologically sound way of conducting research and reporting results obvious. This is particularly the case for research areas dealing with rare conditions. The SCED scale presents a methodological framework in which scientifically rigorous research can be conducted and outcome interpreted (Tate et al, 2008).

4.2 Phase 3 Outcome

Phase 3 entailed:

ƒ Evaluation of the uptake of EBP clinical reasoning by ADHC speech pathologists following the workshops through an on-line case based survey.

The results from the EBP quiz contained in the follow-up survey indicated that while knowledge of EBP principles in clinical practice was adequate, an understanding of research design would be enhanced by further training. Providing the tools which would enable speech pathologists to judge the worth and appreciation of various studies and relevance to their own clinical settings would promote productive use of time allocated to EBP work. The more knowledgeable clinicians are about research design, the better

equipped they will be if they decide to design their own research studies in the future.

Many of the grade 1 and 2 participants pointed out that support from grade 3 and grade 4 senior speech pathologists and management would be a key factor in sustaining the growth of EBP in ADHC. It was suggested that this support be manifested in continued training in EBP, the allocation of time to search electronic databases whilst managing busy caseloads, and utilizing methods of sharing EBP resources with all clinicians across ADHC. This sentiment was shared by many speech pathologists who wished to see EBP be promoted across all disciplines in ADHC and a centralized network of EBP resources relating to disability be created. Some speech pathologists also desired more Critically Appraised Papers and Topics (CAPs and CATs), which provide treatment-summaries for different client populations, to be

created. It was also suggested that provision be made for clinicians who work in rural regions to access EBP resources that may be otherwise hard to find.

The case-study activity distributed along with the follow-up survey was designed to test speech pathologists’ use of EBP in an applied setting. Although utilizing external evidence was strongly encouraged, many speech pathologists did not refer to research in core vocabulary to justify their chosen intervention. Speech pathologists were strongly encouraged to cite specific research in their responses. However, many responses indicated that they were nonetheless implicitly aware of which intervention was supported by evidence.

It is anticipated that further training could consolidate knowledge of current evidence in speech pathology and encourage references to evidence in documentation. This knowledge can lead to increased awareness of current best-practices in speech pathology.