Implementing a Screen-Clean-Hydrate bundle of care for improving swallow screening, oral health and hydration in acute stroke: Protocol for a Type 2 hybrid-effectiveness pre-post study

Abstract

Abstract Background Stroke clinical guidelines recommend care processes that optimise patient outcomes and minimise hospital-acquired complications. However, compliance audits and surveys illustrate that recommended care is not always consistently or thoroughly implemented. This paper outlines the methods for a study implementing and evaluating a new bundle of care, named Screen-Clean-Hydrate, aiming to improve compliance with stroke guidelines in the areas of swallow screening, oral healthcare and hydration. Methods The study is a pre-post Type 2 Hybrid Effectiveness/Implementation design with an embedded process evaluation. The integrated-Promoting Action on Research Implementation in Health Services (iPARIHS) framework will be used to guide the study design, conduct and evaluation. The study will be conducted in two acute stroke units in a capital city of Australia. Screen-Clean-Hydrate bundles together recommendations from the Australian Clinical Guidelines for Stroke Management and supplements these with evidence-informed best practice from the literature for: swallow screening within four hours of presentation to hospital (Screen); oral health assessment and delivery of routine oral care (Clean); and hydration assessment and management (Hydrate). Clinical effectiveness will be measured by rates of ICD-10AM coded hospital-acquired complications and proxy measures of cost (length of stay, procedure costs) for 60 patient participants pre- and post-implementation. Implementation outcomes will focus on acceptability, feasibility, uptake and fidelity, and identification of barriers and enablers to implementation through staff interviews, medical record audits and researcher field notes. Discussion Bundles of health care processes to target hospital-acquired complications have successfully been implemented in other areas of healthcare. Screen-Clean-Hydrate bundles together and makes explicit the recommendations from the Australian clinical stroke guidelines for swallow screening, oral health and hydration and their importance for functional recovery and avoidance of hospital-acquired complications. Due to its design as a hybrid effectiveness/implementation study, once completed, the study will provide information on both intervention and implementation effectiveness, including details of successful and unsuccessful multidisciplinary implementation strategies. This will inform a larger multi-site effectiveness/implementation trial and promote upscale across other settings for improved compliance with stroke guidelines and therefore stroke outcomes.