Fever, Hyperglycaemia (Sugar), Swallow (FeSS) Protocols use in Australian hospitals : analysis of national stroke data and clinician perspectives of critical factors that influence their use

Background/aims: The landmark Quality in Acute Stroke Care (QASC) Trial published in 2011 demonstrated that supported implementation of protocols to manage Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) reduced death and disability post-stroke. Subsequently, in 2017, a ‘Strong Recommendation’ to support their use was included in the Australian Clinical Guidelines for Stroke Management. FeSS Intervention studies have been conducted (four locally and two internationally) as part of a fifteen-year implementation program to translate these protocols into everyday clinical practice. Despite this, many Australian patients do not receive this recommended care. In a national audit of acute stroke services in Australian hospitals (2021), prompt treatment for fever was reported for only 50% of patients and 25% of patients with hyperglycaemia and 40% of patients received oral intake before having their swallowing ability screened or assessed.

The overarching focus of this thesis is to evaluate and explore diffusion of the FeSS Protocols for stroke in Australian hospitals. Specifically, this program of work aims to evaluate ‘passive’ dissemination techniques (i.e. the strong recommendation in national clinical guidelines using data from the biennial national acute stroke service audits), and the sustainment of ‘active’ implementation strategies (such as those used by hospitals in FeSS Intervention studies and as reported by clinicians)

Methods: National stroke audit data and front-line clinician perspectives have been used to assess adherence and factors that influence sustainment of implementation strategies for the FeSS Protocols. The thesis is comprised of three studies: i) A systematic-narrative hybrid review of behaviour change interventions designed to improve clinician adherence to any stroke clinical practice guideline; ii) A quantitative pre-test/post-test study to evaluate adherence to the FeSS Protocols for stroke in Australian hospitals after the inclusion in the guidelines using national stroke audit data and iii) a qualitative descriptive process evaluation to investigate factors perceived by clinicians to influence sustained adherence to the FeSS Protocols.

Results: Study One yielded seven systematic reviews and ten randomised controlled trials. Most studies reported an improvement in care processes but not patient outcomes. The wide variation in outcome measures and interventions, quality and study duration contributed to uncertainty in the evidence. The inclusion of mixed study designs in systematic reviews is likely to have influenced this uncertainty. However, in the absence of stronger evidence their important contribution to the overall body of evidence should not be discounted.

Study Two reported a modest but significant improvement in FeSS Protocol adherence post-guideline inclusion (Pre: 35% vs Post 40%, OR:1.2, 95%CI: 1.2, 1.3). Higher FeSS Protocol adherence was independently associated with hospitals’ previous participation in a FeSS Intervention study and patients receiving care in a stroke unit. These findings highlight that research participation can facilitate greater guideline adherence; and confirms the superior care received in stroke units.

Study Three consisted of interviews with Stroke Co-ordinators from hospitals stratified by adherence to the FeSS Protocols (high, low and variable). Two major themes (and sub-themes) were mapped to factors from the Sustainability of Innovation Framework. Stroke Coordinator as sustainability champions and boundary spanners; and Hospital executive and middle management respect of stroke specialty themes mapped to workforce, organisational, innovation-specific and political factors from the Framework. The importance of organisational support, designated stroke care areas, and recognition of stroke specialist nursing skills in fostering a culture of evidence-based practice were identified as key factors that influence sustained adherence to the FeSS Protocols. Additionally, the unique skillset of Stroke Coordinators to drive engagement and sustain evidence-based practice across services and disciplines was identified.

Conclusions: A ‘strong recommendation’ in the 2017 Clinical Guidelines for Stroke Management for all acute stroke services to implement FeSS Protocols came several years after the seminal QASC Trial results were published in 2011. The substantial timeline used to evaluate the ‘natural history’ of the diffusion of the protocols into acute stroke care services provides new insights into longer-term adherence to this clinical practice guideline which may have wider applicability for other stroke clinical practice guidelines.

Collectively, the findings substantiate existing evidence on passive dissemination and highlight the value of specialised stroke unit care. The contribution of new knowledge relates to the importance of supporting hospitals to implement clinical practice guidelines, the long-term outcomes of both passive and active implementation strategies and evidence on the pivotal role of Stroke Co-ordinators as sustainability champions and boundary spanners.

The study of the diffusion of FeSS Protocols into acute stroke care services, offers new insights into the broader field of stroke care and implementation science by highlighting the influence of clinician behaviour on the integration and sustained use of evidence-based practices in clinical care.

© Kelly Coughlan, 2025.