Does a 'Strong recommendation' within a clinical practice guideline change clinician behaviour? National uptake of Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) management following stroke.

Abstract

Background: The Quality in Acute Stroke Care (QASC) Trial demonstrated that protocols to manage Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) post-stroke reduce death and disability. Subsequently, in 2017, a 'Strong Recommendation' to support their use was included in the Australian Clinical Guidelines for Stroke Management. Aim(s): To compare FeSS Protocol adherence in Australian hospitals before and after recommendations included in the Australian stroke guidelines; and to assess adherence in hospitals previously participating in FeSS Intervention studies (QASC Research Program). Method(s): Cross-sectional study using Stroke Foundation Acute Service Audit data. Adherence was compared for 2015 and 2017 (pre-guideline) against 2019 and 2021 (post-guideline); and for hospitals who participated in any of the FeSS Intervention studies. Primary Outcome: a composite measure for adherence to all FeSS process variables (n=6, i.e., treatment and management for fever, hyperglycaemia, swallowing). Mixed-effects logistic regression, with a random intercept for hospital, adjusted for stroke type, age, sex, and interaction between guideline inclusion and previous participation in a FeSS intervention study. Result(s): In total,112 hospitals contributed data to at least one audit cycle for both periods (pre=7011, post=7195). An improvement in overall FeSS Protocol adherence was evident post-guideline inclusion (Pre: 35% vs Post 40%, OR:1.17, 95%CI: 1.06, 1.30). Previous participation in a FeSS intervention study was associated with higher FeSS Protocol adherence (OR:1.57, 95%CI: 1.22, 2.02). Patients with haemorrhagic stroke were less likely to receive care according to all FeSS Protocols compared with patients with ischaemic stroke (OR: 0.69, 95%CI: 0.61, 0.78). Conclusion(s): Overall, there is evidence there has been an improvement in FeSS Protocol adherence following a strong recommendation for their use in the Australian stroke guidelines. Improved adherence for hospitals who previously participated in a FeSS Intervention study suggests active efforts provide greater implementation outcomes. Further nationwide implementation of FeSS Protocols in Australian hospitals is warranted.