Patients with disorders of consciousness (DoC) rely on their family and rehabilitation practitioners to make evidence-based clinical decisions. Practice guidelines for patients with DoC strongly recommend that rehabilitation practitioners conduct serial neurobehavioral standardized assessments. The Coma Recovery Scale-Revised (CRS-R) is widely used, yet results are difficult to interpret and communicate in clinical settings. These challenges limit the exchange of clinical information between rehabilitation practitioners and the patient’s family. Our team aimed to support rehabilitation practitioners at four post-acute care health systems in communicating CRS-R results with families.

We leveraged Rasch Measurement Theory to transform the ordinal CRS-R scale into an equal interval ruler. We engaged rehabilitation practitioners and family care partners to create the Recovery Ruler, a visual display of the CRS-R results. To support the adoption of the Recovery Ruler at these clinical sites, we collaborated with rehabilitation practitioners to tailor the Recovery Ruler. To examine adoption of the finalized Recovery Ruler, we conducted a 6-month observational study with repeated self-report surveys asking practitioners about the frequency of CRS-R administrations, frequency of Recovery Ruler use, and barriers to adoption. To identify barriers and facilitators to adopting the Recovery Ruler, we interviewed practitioners and organizational leaders at each site. 

Tailoring the Recovery Ruler: All programs suggested revisions to make the Recovery Ruler easier to understand. During the tailoring process, we identified three core functions of the Recovery Ruler: 1) communicating CRS-R data with family care partners, 2) guiding interpretation of CRS-R data, and 3) providing context for CRS-R data. 

Adoption of the Recovery Ruler: We enrolled 26 rehabilitation practitioners across the four sites. The Recovery Ruler had a 92% adoption rate, and practitioners reported utilizing the Recovery Ruler 42% of the time. The most frequently endorsed barrier (n=7, 29%) for the Recovery Ruler was, “I have problems changing my old routines.” The most frequently endorsed facilitator (n=23, 96%) was their belief about the CRS-R Recovery Ruler. Practitioners found “the Recovery Ruler [to be] a good starting point” when explaining CRS-R results to family.

Barriers and Facilitators of Adopting the Recovery Ruler: We interviewed 13 practitioners and organizational leaders to identify implementation strategies that could facilitate the sustained implementation of the Recovery Ruler. We learned that many practitioners felt that the Recovery Ruler was important when the family was in the room because it supported their conversations about the results. Many practitioners described not using the Recovery Ruler because they felt family members were not “ready” for it due to the emotional challenges of caring for a family member with DoC. 

Lessons Learned. Our rich data stemmed from conducting interviews with rehabilitation practitioners. We wanted to connect with families exposed to the Recovery Ruler because we wanted to know whether they found the Ruler easy-to-understand, but were unable to do so during the short project period. While this pilot study provides data describing the barriers and facilitators for adopting a new tool in clinical practice, we plan to map the barriers to implementation strategies that can be tested during a future multi-site implementation science study.