From 'strong recommendation' to practice: A pre-test post-test study examining adherence to stroke guidelines for fever, hyperglycaemia, and swallowing (FeSS) management post-stroke

Kelly Coughlan; Tara Purvis; Monique F Kilkenny; Dominique A Cadilhac; Oyebola Fasugba; Simeon Dale; Kelvin Hill; Megan Reyneke; Elizabeth McInnes; Benjamin McElduff; Jeremy M Grimshaw; N Wah Cheung; Christopher Levi; Catherine D'Este; Sandy Middleton

doi:10.1016/j.ijnsa.2024.100248

From 'strong recommendation' to practice: A pre-test post-test study examining adherence to stroke guidelines for fever, hyperglycaemia, and swallowing (FeSS) management post-stroke

Int J Nurs Stud Adv. 2024 Oct 23:7:100248. doi: 10.1016/j.ijnsa.2024.100248. eCollection 2024 Dec.

Authors

Kelly Coughlan^{1

2}, Tara Purvis³, Monique F Kilkenny^{3

4}, Dominique A Cadilhac^{4

5}, Oyebola Fasugba^{1

2}, Simeon Dale^{1

2}, Kelvin Hill⁵, Megan Reyneke³, Elizabeth McInnes^{1

2}, Benjamin McElduff^{1

2}, Jeremy M Grimshaw⁶, N Wah Cheung⁷, Christopher Levi⁸, Catherine D'Este^{9

10}, Sandy Middleton^{1

2}

Affiliations

¹ Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Level 5, deLacy Building, 390 Victoria Street, Darlinghurst, NSW 2010, Australia.
² School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 33 Berry Street, North Sydney, NSW 2060, Australia.
³ Sroke and Ageing Research, School of Clinical Sciences, Monash University. Monash Medical Centre, Block E, Level 5, 246 Clayton Rd, Clayton, VIC 3168, Australia.
⁴ Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC 3084, Australia.
⁵ Stroke Foundation, Level 7/461 Bourke St, Melbourne, VIC 3000, Australia.
⁶ Ottawa Health Research Institute, Ottawa Hospital - General Campus, Centre for Practice-Changing Research (CPCR); and University of Ottawa, 501 Smyth Box 511, Ottawa, ON K1H 8L6, Canada.
⁷ Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Hawkesbury Road, Westmead, NSW 2145, Australia.
⁸ John Hunter Hospital, University of Newcastle. Lookout Rd, New Lambton Heights, NSW 2305, Australia.
⁹ Sax Institute, Level 3/30C Wentworth St, Glebe, NSW 2037, Australia.
¹⁰ School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia.

Abstract

Background: The Quality in Acute Stroke Care (QASC) Trial demonstrated that assistance to implement protocols to manage Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) post-stroke reduced death and disability. In 2017, a 'Strong Recommendation' for use of FeSS Protocols was included in the Australian Clinical Guidelines for Stroke Management. We aimed to: i) compare adherence to FeSS Protocols pre- and post-guideline inclusion; ii) determine if adherence varied with prior participation in a treatment arm of a FeSS Intervention study, or receiving treatment in a stroke unit; and compare findings with our previous studies.

Methods: Pre-test post-test study using Australian acute stroke service audit data comparing 2015/2017 (pre-guideline) versus 2019/2021 (post-guideline) adherence. Primary outcome was adherence to all six FeSS indicators (composite), with mixed-effects logistic regression adjusting for age, sex, stroke type and severity (ability to walk on admission), stroke unit care, hospital prior participation in a FeSS Intervention study, and correlation of outcomes within hospital. Additional analysis examined interaction effects.

Results: Overall, 112 hospitals contributed data to ≥1 one Audit cycle for both periods (pre=7011, post=7195 cases); 42 hospitals had participated in any treatment arm of a FeSS Intervention study. Adherence to FeSS Protocols post-guideline increased (pre: composite measure 35% vs post: composite measure 40 %, aOR:1.2 95 %CI: 1.2, 1.3). Prior participation in a FeSS Intervention study (aOR:1.6, 95 %CI: 1.2, 2.0) and stroke unit care (aOR 2.3, 95 %CI: 2.0, 2.5) were independently associated with greater adherence to FeSS Protocols. There was no change in adherence over time based on prior participation in a FeSS Intervention study (p = 0.93 interaction), or stroke unit care (p = 0.07 interaction).

Conclusions: There is evidence of improved adherence to FeSS Protocols following a 'strong recommendation' for their use in the Australian stroke guidelines. Change in adherence was similar independent of hospital prior participation in a FeSS Intervention study, or stroke unit care. However, maintenance of higher pre-guideline adherence for hospitals prior participation in a FeSS Intervention study suggests that research participation can facilitate greater guideline adherence; and confirms superior care received in stroke units. Nevertheless, less than half of Australian patients are being cared for according to the FeSS Protocols, providing impetus for additional strategies to increase uptake.

Keywords: Fever; Guidelines; Hyperglycaemia; Implementation; Stroke; Sustainability; Swallow.