Abstract
Background and Purpose A hospital-based pediatric outpatient center, wanting to weave evidence into practice, initiated an update of knowledge, skills, and documentation patterns with its staff physical therapists and occupational therapists who treat people with congenital muscular torticollis (CMT). This case report describes 2 cycles of implementation: (1) the facilitators and barriers to implementation and (2) selected quality improvement outcomes aligned with published clinical practice guidelines (CPGs).
Case Description The Pediatric Therapy Services of St Joseph's Regional Medical Center in New Jersey has 4 full-time, 1 part-time, and 3 per diem staff. Chart audits in 2012 revealed variations in measurement, interventions, and documentation that led to quality improvement initiatives. An iterative process, loosely following the knowledge-to-action cycle, included a series of in-service training sessions to review the basic anatomy, pathokinesiology, and treatment strategies for CMT; reading assignments of the available CPGs; journal review; documentation revisions; and training on the recommended measurements to implement 2 published CPGs and measure outcomes.
Outcomes A previous 1-page generic narrative became a 3-page CMT-specific form aligned with the American Physical Therapy Association Section on Pediatrics CMT CPG recommendations. Staff training on the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale, classification of severity, type of CMT, prognostication, measures of cervical range of motion, and developmental progression improved documentation consistency from 0% to 81.9% to 100%. Clinicians responded positively to using the longer initial evaluation form.
Discussion Successful implementation of both clinical and documentation practices were facilitated by a multifaceted approach to knowledge translation that included a culture supportive of evidence-based practice, administrative support for training and documentation redesign, commitment by clinicians to embrace changes aimed at improved care, and clinical guidelines that provide implementable recommendations.
Knowledge translation (KT) is the integration of the best available evidence with practice in the hopes of improving patient outcomes.1 It is a cyclical and iterative process that typically begins with identification of a problem or opportunity for improvement and continues with finding the knowledge and evidence to address the problem, assessment of barriers and facilitators for implementing changes, monitoring compliance with the changes, and developing methods to sustain improved care (Figure).2,3 Strategies and rates of implementation are affected by a clinic's culture, administrative support, staff readiness for change, and awareness of evidence that affects practice.4,5 Outcome measurement requires both accurate data capture to determine whether changes are meaningful and clinicians who value data-driven quality improvement.6
Knowledge-to-action cycle. Reprinted from Straus SE, Tetroe J, Graham ID, eds. Knowledge Translation in Health Care: Moving From Evidence to Practice. 2nd ed. West Sussex, United Kingdom: John Wiley & Sons Ltd; 2013, with permission of John Wiley & Sons.
Congenital muscular torticollis (CMT) commonly presents as unilateral shortening of the sternocleidomastoid (SCM) muscle, resulting in head tilting toward and rotation away from the shortened SCM muscle.7 It may be present at birth due to intrauterine crowding8 or develop shortly afterward,9 with a reported incidence ranging from 0.3% to 2%10 to 16%.11 The “back to sleep” campaign has been implicated as a source of excessive supine positioning at the expense of prone positioning,12 which may contribute to the rising number of CMT referrals. Regardless of the cause of CMT, more severe range of motion (ROM) limitations, older ages at which treatment begins, and the presence of a nodule in the SCM muscle all contribute to longer episodes of care and greater potential for surgical intervention.13–15 Ideally, infants would be referred for treatment before 3 months of age because, with earlier referrals, the resolution is faster and more complete and only conservative interventions are needed.16
St Joseph's Regional Medical Center Pediatric Therapy Department (SJRMC-PT) in Paterson, New Jersey, values evidence-based practice (EBP) and continuous quality improvement. It initially assessed its CMT services against the Cincinnati Children's Hospital Medical Center CMT clinical practice guideline (CCHMC-CPG)17 and reassessed its services against the American Physical Therapy Association Section on Pediatrics CMT clinical practice guideline (SOP-CPG).7 The purpose of this administrative case study is to describe the 2.5-year process of aligning the clinical practice at SJRMC-PT with available CPG recommendations, including development of clinician knowledge and skills, changes in documentation, and measurement of documentation compliance.
Case Description
St Joseph's Health Care System (SJHC) in northern New Jersey comprises 2 acute care hospitals, a visiting nurse service, and a long-term care facility. The SJHC Rehabilitation Department services 2 acute care hospitals, St Joseph's Regional Medical Center (SJRMC) and St Joseph's Wayne Hospital, under the leadership of one administrative director. St Joseph's Regional Medical Center provides hospital-based inpatient and outpatient pediatric services to people from birth to age 21 years and has a lead physical therapist and staff clinicians. Since 2008, SJRMC-PT has grown from 1.5 physical therapists and 1 occupational therapist to 3.5 physical therapists and 1.5 occupational therapists, with turnover of 1 administrative director, 2 physical therapists, and 1 occupational therapist. The clinicians are part of a multidisciplinary team of pediatric specialists, including the Regional Craniofacial Center (RCC), which evaluates patients with cranial asymmetries. The RCC averages 12 to 15 patients per weekly 3-hour session, 3 times per month.
Based on the SJRMC-PT 2013 census, 63 patients were referred for CMT: 76.19% from the RCC, 12.70% from pediatricians, 9.52% from orthopedists, and 1.59% from other specialties. The typical referral age is 6 months, with 9.52% at 0 to 3 months, 44.44% at 4 to 6 months, 33.33% at 7 to 9 months, 3.17% at 10 to 12 months, and 9.52% at >12 months. Thus, 78% of infants are referred between 4 to 9 months of age, significantly later than the SOP-CPG7 recommends.
On average, 10 to 12 children per week receive outpatient therapy for CMT. The typical episode of care lasts ≈25 visits over 6.5 months, with more frequent visits at the start. Younger infants, aged 4 to 6 months, average 23 visits; older infants, aged 7 to 9 months, average 36 visits. These findings are consistent with the literature that indicates that those children who start care at older ages require more visits to reach discharge criteria.13–15 Staff changes, the steady rate of referrals for patients with CMT, and department data that infants were being referred at older ages drove the need to assess the quality of care and alignment with current evidence.
Process
The 7 phases of the knowledge-to-action cycle (Figure) provide a natural structure for describing the 2 KT cycles conducted by SJRMC-PT. Knowledge creation is at the center and includes formation of new knowledge from research, research syntheses, and tool development to implement new knowledge. In this case study, CPGs on CMT management represent a hybrid of synthesized research and tool development, as they contain systematic literature reviews with implementable practice recommendations. Translating recommendations into practice then follows the outer circle of steps. Two review cycles are described: the first 2012–2013 cycle, when SJRMC-PT implemented the only publicly available guideline, the CCHMC-CPG,17 and the second 2013–2014 cycle, when SJRMC-PT implemented the SOP-CPG,7 available as a draft in June 2013 for public review and as a final public access publication in October 2013.
First Cycle: Step 1—Initial Problem Identification; Identify, Review, and Select Knowledge
The SJRMC-PT began its quality improvement process due to increases in the volume of pediatric referrals. Patients with CMT were specifically selected due to the number of referrals from the RCC and other physicians and awareness of evidence on CMT.
The lead physical therapist began by conducting literature searches on Google, PubMed, and PEDro (key words: torticollis, congenital muscular torticollis, physical therapy, and therapy) and consulting with his Section on Pediatrics (SOP) professional mentor and the SOP Hospital-Based Special Interest Group chairperson. Five articles were read on CMT clinical decision making,18 examination,9,19 and intervention trends.20,21 The CCHMC-CPG17 was recommended by the SOP Hospital-Based Special Interest Group chairperson.
Staff meetings were used to discuss the 17 CCHMC-CPG recommendations; by consensus, 9 were in practice, 3 would be implemented (listed in Tab. 1), and 5 would be considered later (Tab. 1; see eTab. 1 for more detail). Discrepancies between the CCHMC-CPG and SJRMC-PT practice included: use of a generic, narrative pediatric developmental evaluation rather than standardized tools; visually estimating cervical ROM; inconsistently evaluating or documenting strength of the opposite SCM or synergistic scalene and upper trapezius muscles; and inconsistently examining for hip dysplasia, gastroesophageal reflux, or the presence of a cervical mass as reasons for asymmetrical posturing.
CCHMC-CPG Recommendations, Initial Compliance, and Strategies to Achieve Compliancea
Quarterly audits are the responsibility of the lead physical therapist. Using the CCHMC-CPG recommendations, 46 outpatient charts demonstrated high variability in patient management and documentation (Tab. 2, 2012 data). In collaboration with the administrative director, 5 items were targeted for improvement for their importance to a CMT examination and because the first chart audit indicated that none were documented: midline visual focus, neck skinfold appearance, upper extremity ROM, and scalene and upper trapezius muscle palpation for tightness.
Quarterly Documentation Outcomesa
First Cycle: Steps 2 and 3—Adapt Knowledge to Local Context, Identify Barriers and Facilitators
Staff meetings were used to identify the barriers and facilitators to implementing practice changes. Barriers included a lack of specificity in some CCHMC-CPG recommendations, gaps in clinician knowledge or skills, and variations in examination methods. Facilitators included a hospital culture that valued EBP and quality improvement; department leaders supportive of evidence-based changes; and clinicians willing to lead training, read documents, learn new skills, mentor each other, and make practice changes.
First Cycle: Step 4—Select, Tailor, and Implement Interventions
Multiple approaches were used to address quality improvement and close knowledge gaps. One physical therapist and one occupational therapist provided in-service training after attending the New York Hospital for Special Surgery (HSS) 2-day CMT course. Lectures by the lead physical therapist addressed cervical ROM examination, CMT anatomy and pathokinesiology, and interventions. Practice changes included using an arthrodial protractor to measure cervical ROM; performing neck strength, skin, and vision examinations; assessing symmetrical achievement of developmental milestones; and agreement on documentation conventions. Clinicians were provided opportunities to practice procedures and compare their skills with those of the lead physical therapist for accuracy and reliability.
After the 2012 third-quarter audit, it was evident that the generic examination form did not support routine documentation of the 5 desired examination items. The narrative format produced very low levels of compliance (Tab. 2, 2012 data). Staff determined that a diagnosis-specific form that cued clinicians for the expected documentation might improve outcomes. In fall 2012, the 1-page generic form became a 2-page CMT-specific examination form, based on the CCHMC-CPG and the HSS CMT form (with permission). This diagnosis-specific form was aligned with the 27 examination bullets in the CCHMC-CPG.
First Cycle: Steps 5 and 6—Monitor Knowledge Use and Evaluate Outcomes
Monitoring of knowledge use and outcome measurement occurred in several ways. The lead physical therapist conducted chart audits and provided direct observation and mentoring of clinicians during examinations. Staff meetings were used for feedback about documentation trends, discussion of the form and documentation, and examination or treatment challenges.
The CMT examination form underwent testing and revision for approximately 1 year, beginning in the fourth quarter of 2012. After its initial use, infant history and systems screening were added to the documentation audits. Challenges included needing more time for completion and oversight omissions due to lack of familiarity with the order of items.
First Cycle: Step 7—Sustained Knowledge Use
Once the new CMT examination form was instituted, quarterly chart audits improved dramatically. Documentation of the 7 items achieved 100% by the start of 2013 (Tab. 2, 2013 data); treatment frequencies and plans of care were generally consistent with the CCHMC-CPG. Clinicians agreed that the new form made the CMT examination process more thorough, and chart audit efficiency improved because data locations were standardized across evaluations.
Second Cycle: Step 1—Identify Problem
In June 2013, the SOP posted the SOP-CPG draft for public feedback, presenting the possibility of new evidence and changes in practice recommendations, thus restarting the KT cycle. Following a detailed review, the department prepared to adopt the SOP-CPG recommendations, pending publication, because the body of evidence was stronger and the recommendations were more specific and actionable.
Staff compared the SOP-CPG recommendations with departmental practices and identified the following issues. Staff knowledge of examinations and interventions varied, especially for new hires. Training was needed on the Barlow maneuver, the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale, and use of an arthrodial protractor, the Referral Flow Diagram, the CMT Classification Grades and Decision Tree, and kinesiotape interventions. The CMT examination form underwent several revisions to align with the final SOP-CPG and to accommodate clinician suggestions for organization and layout. Of the 16 SOP-CPG recommendations (Tab. 3), 10 were either fully or partially in practice, 4 would be implemented first (Action Statements 2, 4, 8, and 11), 1 was delayed for implementation (Action Statement 1), and 1 would require re-evaluation of third-party payer conventions (Action Statement 16) (Tab. 3; see eTab. 2 for more detail).
SOP-CPG Action Statements, Initial Compliance, and Strategies to Achieve Compliancea
Second Cycle: Steps 2 and 3—Adapt Knowledge to Local Context, Identify Barriers and Facilitators
The department addressed knowledge by identifying the recommended measures to implement and scheduled in-service training on them. Barriers included clinician confidence and efficiency with the Barlow maneuver, the FLACC pain scale, the Referral Flow Diagram, the CMT Classification Grades and Decision Tree, and the revised CMT examination form, which required more time to complete. Facilitators included agreement with the CMT CPG recommendations, the desire to align practice, clinicians' willingness to learn and be mentored, and prior success with improving documentation consistency as evidenced by the 2012–2013 audits.
Second Cycle: Step 4—Select, Tailor, and Implement Interventions
Multiple strategies were again used to translate the SOP-CPG7 recommendations into practice. By the time the SOP-CPG recommendations were published, the department had completed reviews of CMT anatomy and pathokinesiology and had in-service training and supervised practice sessions on the Barlow maneuver, the FLACC pain scale, the arthrodial protractor, the Referral Flow Diagram,7 the CMT Classification Grades and Decision Tree,7 and kinesiotaping methods. These efforts addressed gaps in staff knowledge and their reported confidence in performing the procedures. The SJRMC-PT New Clinician Orientation Checklist was revised to include a CMT knowledge assessment, CMT anatomy and pathokinesiology in-service training sessions, and a SOP-CPG orientation, all provided by the lead physical therapist.
After the SOP-CPG was published in October 2013, the CMT examination form was revised to its current 3 pages (eAppendix 1), and a CMT progress note form was created (eAppendix 2). They were trialed for 1 year to allow for additional changes.
Documentation audits for 2014 changed from the original 5 items, which had reached 100% compliance, to 4 new items plus continuation of infant history and screenings, as specified in the SOP-CPG. These 6 items reflected critical aspects of the CMT diagnostic process and included: CMT type, determination of severity using the SOP-CPG classifications, objective cervical ROM measures at each session, use of a standardized test rather than a narrative description of development, a complete infant history, and conducting the formal screening process to rule out other causes of asymmetrical neck postures (Tab. 2, 2014 data). Clinicians received individual feedback about documentation compliance from the lead physical therapist, and where needed, corrections or clarifications were made to ensure documentation completeness or accurate interpretation of measures into severity grades and prognostic summaries. Peer mentoring was common among the clinicians for guidance with a patient's management or assistance with examination processes. This was an informal process whereby one clinician examined an infant and then requested another, more experienced, clinician to repeat selected measures for comparison. Thus, clinicians with less experience could check their skills and accuracy with tests that were newer to them; most often, the lead physical therapist served as the experienced comparator.
Second Cycle: Steps 5 and 6—Monitor Knowledge Use and Evaluate Outcomes
Quarterly chart audits were conducted in 2014 on the 6 items for both initial examinations and subsequent appointments (Tab. 2, 2014 data). Less formally, the lead physical therapist looked for the accurate choice of CMT severity grades based on the documented ROM measures and infant history, accurate interpretation of the measures for prognostication, and notation of “red flags” from the screening process for referral generation. Data were not formally collected on these reviews; however, documentation inconsistencies were discussed individually as forms of mentorship and skill development. The chart reviews provided insight into whether the clinicians were integrating their knowledge and skills in cervical measurement and history taking to correctly determine a severity classification as per the SOP-CPG and to link that classification to expected episodes of care.
Second Cycle: Step 7—Sustained Knowledge Use
Three quarterly audits were conducted in 2014 that support the sustainability of practice changes. To ensure consistent documentation going forward, the final templates for the CMT examination and progress note forms were submitted to the hospital's Forms Committee in May 2014 and approved in February 2015.
Outcomes
The sixth step in the knowledge-to-action cycle is evaluating outcomes, which was done with several measures. The number of recommendations that were in practice, the number that could be implemented, and the number that could not be implemented were counted for each of the 2 published CPGs (Tabs. 1 and 3). Development of clinician knowledge and skills was measured by the number of clinicians who needed to learn special tests and their resulting consistency with an experienced clinician and through a brief survey. Documentation compliance was measured by the accurate documentation of the targeted examinations.
Alignment With CPG Recommendations
In the first audit of 29 charts in 2012 (Tab. 1), 27 CCHMC-CPG items from 16 recommendations were used as criteria for data collection. Results were clustered according to the 4 categories outlined in the CCHMC-CPG. Overall, 4 recommendations were fully in practice, 3 recommendations needed to be implemented, and the remaining recommendations were partially compliant, as follows: examination (40% compliant on examination content), treatment recommendations (57.14% and 80% compliant on visit components), frequency and treatment progressions (58.62% compliant), and discharge (86.36% compliant) (Tab. 1). In that audit, midline visual focus, neck skinfolds, upper and lower extremity ROM, scalene muscle tightness, and upper trapezius muscle tightness were absent from all charts and became the criteria for the 2012–2013 audits.
Three subsequent 2012 audits (Tab. 2) demonstrated inconsistent documentation of the 5 items, despite reminders, training, and chart reviews of individual clinicians. This outcome spurred the draft of the first CMT examination form. Implementation of the CMT examination form resulted in 100% compliance (Tab. 2, 2013 data).
New audit criteria were introduced in 2014 based on the SOP-CPG recommendations (Tab. 3). Quantitative data were not collected on the level of compliance with every recommendation, as was done with the CCHMC-CPG, but rather each recommendation was determined to be “fully in practice,” “partially in practice,” or “needing implementation,” and 6 specific documentation items were targeted for quantitative audits. The 2014 audit results on the 6 items ranged from 81.9% to 100% (Tab. 2) and suggest reasonably high compliance. Second-quarter outcomes were 100%; however, third-quarter outcomes indicated a slight drop for 4 items, ranging from 89% to 95%. The lower scores are due to errors of omission for the CMT type, cervical ROM and developmental progression, or miscalculation of the severity grade.
Through clinician consensus, it was determined that SJRMC-PT began with 10 of the 16 SOP-CPG recommendations either partially or fully in practice and was fully compliant with 13 recommendations by early 2015 (Tab. 3). The first 2 recommendations deal with early identification and referrals for which administrative and educational activities have begun but for which there are not yet any data. The last recommendation, to provide a follow-up examination 3 to 12 months after service discharge, is currently limited by third-party payer conventions and pediatrician awareness of the reasons for follow-up.
Development of Clinician Knowledge and Skills
The multifaceted approach of education, training, documentation changes, and feedback facilitated a smooth assimilation of evidence into SJRMC-PT practice. Of the 6 clinicians, 6 needed training to perform the Barlow maneuver, 4 needed training on the FLACC pain scale, 6 needed training on the Referral Flow Diagram, and 6 needed training on the CMT Classification Grades and Decision Tree. All clinicians are now confident in test administration and documentation of results; selection of the correct severity classification is at 88.9%, due to miscalculations or infants who were challenging to measure.
Formal feedback was derived from an internal clinician survey administered in November 2014, which asked the clinicians to rate the usefulness of the in-service training sessions, the usefulness of reviewing the SOP-CPG, the degree to which the SOP-CPG changed their practice, and whether the SOP-CPG has helped them treat patients with other diagnoses. All items were rated as very useful, with mode scores of 4/5 or 5/5. Feedback comments were shared that the anatomy, pathokinesiology, and intervention in-service training sessions helped with understanding how to manage CMT and its effects on the physical and overall development of a baby; that review of the SOP-CPG improved the precision of intervention and the severity grading system helped with prognosis; that awareness of potential CMT with other clients is increased; and that knowledge of other causes of CMT and the importance of home exercise were reinforced.
Informally, clinicians reported that the demonstrations and mentored therapy sessions using the FLACC pain scale, the arthrodial protractor, and the Barlow maneuver helped to improve their confidence with the procedures. They reported that the SOP-CPG recommendations are realistic and helpful for guiding patient examinations, making prognoses, and organizing treatment plans. Reading the SOP-CPG improved the overall awareness of what to address, with what and for how long, and when to refer a patient back to the physician or to recommend a specialist. Clinicians also found the CMT examination form very helpful because it reminds them what to examine and document.
Documentation Changes and Compliance
The SJRMC-PT documentation is still paper-based, although there are plans to move toward an electronic health record. The original evaluation form had formatted headings for narrative recordings of infant history, CMT measures, developmental progression, goals, and a plan of care. A structured 2-page form accounted for the 27 CCHMC-CPG examination items, and compliance with the 7 targets reached a consistent 100%. Publication of the SOP-CPG required a revision of the 2-page form. The revised 3-page version resulted in high compliance but with room for improvement. The longer examination form was initially overwhelming for given examination time limits; although that has resolved with repeated use, there are still occasional omissions that account for audit results of less than 100%.
The format of the CMT progress note also aided in more consistent documentation of critical measures recommended by the SOP-CPG. Its single-page format with 2 visits documented on one side is efficient and focuses on measurement rather than narrative descriptions.
Quarterly audits consistently improved from 0% to between 80% and 100% with structured forms that prompt for the expected documentation. Clinicians are open to feedback based on the chart audits, both collectively and individually, which is attributed to the collegial culture within SJRMC-PT and consensus on achieving 100% compliance.
Discussion
Provision of the best pediatric rehabilitation services has long been a goal for SJRMC-PT, but prior service changes were based on ideas culled from primary research articles and continuing education courses. This case report presents SJRMC-PT's first systematic implementation of evidence-based guidelines. Factors that contributed to a smooth implementation included free access to diagnosis-specific guidelines, clearly written and implementable recommendations, and a department culture that values putting evidence into practice. The identified barriers of knowledge and skill gaps and of varying skill levels and methods for documenting measures were addressed through small-group in-service training sessions and discussions, chart audits, clinician feedback, direct supervision of patient care, and skills practice; all are active learning strategies supportive of KT.3
Quality performance goals for this process initially focused on accurate measures and complete documentation. The documentation changes have been well received by clinicians despite the increased length of the examination form. Clinicians have come to appreciate conducting a more thorough, evidence-based examination and the usefulness of standardizing the objective measures collected on all patients; they are looking forward to using that data to demonstrate improved patient outcomes. Department goals will now shift toward patient outcomes, such as lowering the average age of referral or episode of care, or exploring which patient variables and severity classifications affect the episodes of care.
The multifaceted approach used during this process is consistent with evidence on factors that facilitate successful KT. Underlying all of the initiatives was a culture with administrative support, willingness of stakeholders to change their practice, and facilitators with the knowledge base and skills to provide supportive education and monitoring and feedback.22 The SJRMC-PT clinicians are very comfortable requesting assistance with infants with more complicated conditions than their experience has necessarily prepared them for, and this open culture of seeking assistance was foundational to making practice changes.
Implementing evidence to change practice can be a challenging process, but both health care processes and outcomes can improve.23 One challenge is that not all published evidence can readily be applied to patient conditions or practice settings; this application is easier if CPG recommendations are clear and actionable.24 The 80-page, double-spaced SOP-CPG draft was daunting to tackle, but reviewing manageable chunks, EBP methods, and discussing each recommendation separately facilitated clinician comfort with the contents, appreciation of the evidence, and realizations of how much they aligned with practice. Having the SOP-CPG be freely available for distribution,25 with robust synthesized evidence aligned with patient needs,25 opportunities for knowledge acquisition and active practice of skills,26,27 individual feedback on skills and documentation,6,25 decision aids25 in the form of the SOP-CPG decision tree and the examination and progress forms, aligning changes with specific CPG recommendations,23 and having the lead physical therapist as a local champion or knowledge broker6,28,29 all contributed to the successful implementation of the CPG recommendations.
Future challenges include sustaining documentation compliance while introducing patient outcomes, staying current with CMT while introducing high-quality evidence for other diagnoses, and identifying more efficient orientation and educational processes. Future performance measures will focus on documenting clinical rationales to support the episodes of care, determining whether specialist consultations occur appropriately, and reducing the average age of CMT referrals and parent-reported infant health outcomes. The 3-page SJRMC-PT examination template represents only one department's preferences; studies are needed to determine whether the form improves CMT management and documentation in other pediatric settings.
In conclusion, this case report describes a successful multifaceted KT process to implement pediatric clinical practice guidelines for CMT in order to standardize examination and documentation procedures. The combination of a supportive departmental culture that values EBP, use of knowledge brokers for training and feedback on outcome measures, clinicians willing to learn and act as peer mentors, opportunities for active practice of knowledge and skills, and diagnosis-specific documentation and decision aids enabled this department to successfully cycle through 2 iterations of KT to implement CPGs. The benefits derived include more thorough initial examinations for the infants and standardized documentation that will support future departmental studies of patient-related outcomes.
Footnotes
Both authors provided concept/idea/project design, writing, and data analysis. Dr Gutierrez provided data collection, facilities/equipment, and institutional liaisons. Dr Kaplan provided consultation (including review of manuscript before submission).
The authors thank the members of the Rehabilitation Department, St Joseph's Regional Medical Center, who were instrumental in the translation of the CMT guidelines into practice and provided feedback about the process and the manuscript.
- Received January 9, 2015.
- Accepted September 9, 2015.
- © 2016 American Physical Therapy Association
References
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