Institutional adaptation of symptom management care pathway templates
Fig. 
Phases Required to Adapt the 14 Care Pathway Templates at Each of the 10 Institutions


For each statement, the institutional adaptation team made the decision to adopt, adapt or reject the statement regardless of whether the source CPG recommendation was strong or conditional. For statements stemming from conditional recommendations, the institutional adaptation team was encouraged to adapt it to a declarative statement or reject it rather than leave decision making to individual clinicians. Decision making of the institutional adaptation team was not constrained by this encouragement. For statements that were adopted or adapted, the institutional adaptation team framed the statements using language that would be understood by clinicians at that institution including choice of generic or brand name medications. If resources were required such as consulting services, investigations or medications, they described services, investigations or medications in language relevant to their institution. This process included choosing specific medications, in part, based upon those available according to their hospital formulary. The institutional adaptation team could also add statements not included in the care pathway template.
SSPedi measures the degree of bother as reported by the pediatric patient for each symptom. For each treatment section, the institutional adaptation team could more prescriptively direct clinicians to a specific action based upon severity of bother (for example, different actions for severely bothersome symptom compared to mild or moderately bothersome symptom). Conversely, the institutional adaptation team could allow individual clinicians to choose among a list of actions based on severity (for example, listing several actions and directing the user to make their own decision about which actions to undertake based on the degree of bothersome symptoms). Additional file 2 illustrates an example of this choice.
The initial care pathway adaptation decision-making process was accomplished over three to five videoconference calls per institution where the care pathways were revised in real time as the institutional adaptation team made decisions. The calls were recorded. On these calls, the institutional adaptation team could defer decisions using two mechanisms. For decisions that could be addressed rapidly through consulting with local personnel, decisions were made within one week of the call and the resulting statement was drafted or edited and reviewed by email. For decisions that were expected to be more contentious and at the request of the institutional adaptation team, an adaptation panel of key stakeholders could be assembled to debate and achieve consensus for any decision.
Once all 14 symptom management care pathways had been adapted, the lead institution (SickKids) evaluated each of them to ensure consistency in style and language within and across all institutions. Next, we asked the institutional adaptation team to review the draft institutional care pathways as a whole and to make changes if required.

