Adherence of allied health clinicians to the Stroke Foundation clinical guidelines for management of stroke (2010): a retrospective clinical record audit of both acute and rehabilitation services.

In 2012, stroke affected over 420 000 people within Australia and the number of stroke survivors is anticipated to increase. Many stroke survivors live with a disability which affects their ability to carry out activities of daily living. In Australia stroke survivors are cared for by both publicly and privately funded hospitals. Available to both systems are the Stroke Foundation Clinical Guidelines for the Management of Stroke Survivors (SF 2010a). The Stroke Foundation carries out biannual national audits in Australia, one focusing on acute services and the other on rehabilitation services, to determine hospitals’ quality of care in accordance with the recommendations of the Stroke Foundation clinical guidelines. Participation of privately funded hospitals in both these national audits has been consistently low. Therefore, there is less understanding of how privately funded hospitals manage stroke survivors compared with publicly funded hospitals.

Stroke survivors admitted to hospitals often journey through both acute and rehabilitation services. A stroke audit that follows the journey of stroke survivors by auditing both acute and rehabilitation services concurrently is required to gain a better understanding of how the clinical guidelines are applied across each service individually and across the combined services.

When developing a stroke audit tool for either local or national use, clinicians tend to have limited input into the selection of audit criteria and tool development. As the overarching framework underpinning this research program, knowledge translation involves clinicians and researchers partnering to develop ready to use research. Therefore, in this research program allied health clinicians (physiotherapists, occupational therapists, social workers, speech pathologists, and dietitians) were invited to assist in the development of a stroke audit tool in a single privately funded hospital and to test its reliability. Establishing the reliability of the stroke audit tool adds to its robustness. The stroke audit tool was used to assess the adherence of allied health clinicians from a privately funded hospital to the selective Stroke Foundation clinical guidelines. The audit included stroke survivors with consecutive admissions to both acute and rehabilitation services.

This research comprised two studies. Study 1 developed a stroke audit tool with allied health clinicians selecting the most relevant clinical guidelines from the Stroke Foundation Clinical Guidelines for Stroke Management (SF 2010a). Both inter and intra-rater reliability of the tool were tested with allied health clinicians who were able to agree on eight Stroke Foundation clinical guidelines with 70% agreement. An additional two Stroke Foundation clinical guidelines with 50% agreement and a further two Stroke Foundation clinical guidelines were added to ensure the stroke audit tool was relevant to all disciplines. Interrater reliability for the stroke audit tool was tested across ten clinical records by five (one from each discipline) allied health clinicians or raters. Inter-rater reliability was high with substantial consistency demonstrated across both services. Intra-rater reliability demonstrated substantial to moderate consistency.

Study 2 comprised a 12-month retrospective clinical record audit of stroke survivors with consecutive admission to both acute and rehabilitation services. The stroke audit tool assessed the percentage adherence of allied health clinicians against the selected Stroke Foundation’s clinical guidelines included in the audit tool. Adherence was defined as stroke survivor care delivered in accordance with the Stroke Foundation clinical guidelines 2010. A minimal adherence level was set at 60% with an aspirational level set at 80%. Secondary analysis compared adherence across acute and rehabilitation services. Also, a subgroup analysis was undertaken investigating the influence of age, gender and length of stay to allied health clinician’s adherence of Stroke Foundation clinical guidelines. Allied health clinicians met the 60% adherence rate, for nine (out of 12) Stroke Foundation clinical guidelines, including three that were above 80% adherence rate (aspirational level). There was a significant difference across acute and rehabilitation services for eight of the 12 Stroke Foundation clinical guidelines. Age, gender and length of stay did not influence adherence rates of the allied health clinicians across acute and rehabilitation stroke services.

Allied health clinicians from a privately funded hospital developed a reliable stroke audit tool. The stroke audit tool highlighted areas of adherence as well as service gaps across acute, rehabilitation and the combined service. Investigating adherence across both acute and rehabilitation services could lead to a co-ordinated approach to improving adherence towards Stroke Foundation clinical guidelines.