Improving stroke clinical guideline adherence in an Australian hospital using a clinician-led implementation process

ABSTRACT

Background

Private hospitals in Australia manage 11% of acute and 48% of rehabilitation stroke admissions, yet little is known about implementation of stroke clinical guidelines in this setting. Clinical guidelines recommend that acute stroke patients be co-located in a stroke unit in a geographically defined area, rather than dispersed across the hospital.

Objective

To investigate post-intervention adherence to clinical guidelines for stroke management, and to explore staff barriers and facilitators to guideline implementation.

Methods

Observational study before-and-after local implementation of Australian stroke clinical guidelines. The primary outcome was a change in the proportion of patients who were physically co-located in an acute stroke unit. Secondary outcomes included changes in adherence to additional acute and rehabilitation guideline criteria, and staff identification of barriers and facilitators to guide implementation. Data were collected from medical record audits, health service information and staff surveys.

Results

Co-location in an acute stroke unit did not change significantly after guideline implementation (49% adherence pre-intervention and 54% post-intervention). Across acute and rehabilitation wards, 15% (11/72) of guideline criteria improved (p < .05). These related to assessments of swallowing and neglect, presence of a stroke care co-ordinator and occupational therapist, post-discharge care plan, provision of patient education and return to driving. Facilitators to guideline implementation included staff education, collaboration, and dissemination of user-friendly stroke policies.

Conclusion

Stroke clinical guideline implementation led to a favorable uptake of some criteria, yet not all. Implementation was assisted by staff education, user-friendly stroke policies and multidisciplinary team collaboration.

Trial registration

ANZCTR: registration number ACTRN12616000646448 (http://www.ANZCTR.org.au/ACTRN12616000646448.aspx).

KEYWORDS:

• Stroke
• neurological
• clinical guidelines
• health service research
• implementation science
• barriers
• facilitators

Acknowledgments

The project received support and guidance from many individuals, departments and services within Cabrini Health, including Health Information Services, Business Information Unit, Case Management Services, and Patient Administration Services. Dr Ben Clissold and Ms Bree Nation provided medical and senior management input into the evaluation, respectively. Sophie Jennings assisted with the acute medical record data collection and theming the qualitative staff survey data and Lilli Krikheli assisted with the rehabilitation medical record data collection. External support was received from Professor Sandy Middleton (ACU, Sydney), who assisted with the evaluation concept and design and Mr Kelvin Hill from the National Stroke Foundation assisted with the evaluation concept and provided the project team with the audit tool used by the National Stroke Foundation in its biannual national audit of stroke services.

Disclosure statement

The authors report no actual or perceived conflicts of interest.

Ethics approval and consent to participate

This project obtained ethics approval from the Cabrini Human Research Ethics Committee (CHREC 05-05-10-15). Staff and patients who participated in the surveys were informed that participation was voluntary and consent was implied if the individual completed the survey. Patient data extracted from the medical records did not require individual patient consent as the data were routinely collected and no individual patient data were to be presented.

Availability of data and material

The datasets generated during and/or analysed during the current study are not publicly available due to “commercial in confidence” of data from the private health service; however, some of the dataset is available from the corresponding author on reasonable request.

Author contribution

Authors NB, SF, HF, DM, SG, CB and CK contributed to the study concept and design. Authors NB, SF, SG and DM contributed to the data collection. Authors NB, HF, MEM, SF, SG, JW and DM were the major contributors to the manuscript writing. All authors read and approved the final manuscript.

Abbreviations

CGSM: Clinical Guidelines for Stroke Management; National Stroke Foundation, 2010

Additional information

Funding

This work was funded by a 2015/2016 Cabrini Foundation Research Grant ($30,000). The funding body had no part in the project concept, design, analysis or interpretation of results.