Nutrition and hydration management among stroke patients in inpatient rehabilitation: a best practice implementation project : JBI Evidence Implementation

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Nutrition and hydration management among stroke patients in inpatient rehabilitation: a best practice implementation project

Mullins, Natalie BND

Author Information
JBI Evidence Implementation: March 2021 - Volume 19 - Issue 1 - p 56-67
doi: 10.1097/XEB.0000000000000244


What is known about the topic?

  • Prevalence of poststroke malnutrition in Australia has risen from 4% in 2014 to 9% in 2016.
  • Only 51% of patients poststroke receive education about modifiable stroke risk factors, including relating to dietary change.
  • Stroke clinical guidelines recommend multidisciplinary screening, assessment, monitoring and treatment of dehydration and malnutrition; as well as provision of nutrition education and counselling relating to secondary prevention of stroke.

What does this article add?

  • Hydration management is an area regularly included in clinical guidelines and highly valued by staff, however, a dearth of literature about implementation of hydration assessment and monitoring limits practice change.
  • Development of aphasia friendly nutrition resources and staff education supports increased rates of secondary prevention dietary education for stroke survivors.
  • Consistent malnutrition screening is heavily reliant on thorough staff training and effective processes which are integrated with site-based systems for documentation and clinical management. When documentation or clinical systems are changed, there is risk of decreased screening rates and subsequent increase in untreated or hospital acquired malnutrition.


The term ‘stroke’ describes a rapid loss of brain function resulting from altered blood supply to the brain. An ischemic stroke is the most common type of stroke in Australia, and occurs due to blockage of blood supply to the brain. A haemorrhagic stroke occurs due to bleeding in the brain tissue or the space around the brain. Data from 2012 indicated over 420 000 Australians are currently living with the effects of stroke, and by 2032 this number will rise to approximately 709 000, representing 2.4% of the population.1 In 2012, the financial cost of stroke in Australia was estimated at $5 billion, increasing to $49.3 billion in total disease cost when accounting for the loss of healthy life through disability adjusted life years and the value of a statistical life year.1 Australian stroke survivors are affected by significant physical and cognitive deficits and their risk of subsequent stroke increases by 43% over 10 years in comparison with the general population.2 This is in addition to standard population risk factors: high blood pressure (BP), high cholesterol, cigarette smoking, poor diet quality, lack of exercise, excessive alcohol intake, age, sex, family history and presence of co-morbidities including atrial fibrillation and diabetes.3 Effective and evidence-based management of stroke patients is essential across the continuum of healthcare.

The Stroke Foundation is an Australian not-for-profit organization working to reduce the burden of stroke in partnership with survivors, carers, health professionals, government and the public. The Stroke Foundation has developed stroke guidelines since 2002, most recently publishing the Clinical Guidelines for Stroke Management 2017.4 The guidelines were updated by an interdisciplinary working group according to the best available evidence and the 2011 National Health and Medical Research Council Standard for clinical practice guidelines. In addition to publishing guidelines, the Stroke Foundation completes National Stroke Audits, alternating annually between acute and rehabilitation services. The National Clinical Guidelines for Stroke Management 20174 were used in this implementation project to define best practice audit criteria. The guidelines apply to adults, and do not apply to patients with subarachnoid haemorrhage. The Australian stroke guidelines align with international guidelines such as: Canadian Stroke Best Practice Recommendations5; New Zealand Clinical Guidelines for Stroke Management 20106; European Stroke Organisation Guidelines for Management of ischaemic stroke and transient ischaemic attack 20087; Scottish National Clinical Guidelines for Management of patients with stroke: Rehabilitation, prevention and management of complications and discharge planning8; and Singapore Ministry of Health Clinical Practice Guidelines on Stroke and Transient Ischemic Attacks.9

As per Australian and international guidelines, dietitians are valuable in the multidisciplinary management of stroke patients. There are two key components of nutrition assessment and intervention relevant to stroke rehabilitation inpatients. First is the screening, assessment, monitoring and treatment of dehydration and malnutrition; common issues poststroke associated with poor outcomes.10,11 Second is the provision of nutrition education and counselling relating to secondary prevention of stroke, which may reduce stroke recurrence when combined with other lifestyle modifications.4 The 2016 National Stroke Audit showed that prevalence of malnutrition during inpatient rehabilitation has increased from 4% in 2014 to 9% in 2016 and only 51% of patients receive education about modifiable stroke risk factors,12 offering significant opportunity for improvement.

South Australian stroke survivors are managed in numerous contexts depending on the severity of poststroke deficits. This project is based in the inpatient rehabilitation setting at Hampstead Rehabilitation Centre (HRC), a 94-bed hospital within the Central Adelaide Local Health Network (CALHN). Stroke rehabilitation occurs on the General Rehabilitation East (GRE) ward. Suitable rehabilitation candidates are patients with physical and cognitive deficits that may be significantly improved or compensated for through intensive multidisciplinary therapy, ideally allowing transition back to the community. The GRE multidisciplinary stroke team comprises medical, nursing, physiotherapy, occupational therapy, speech pathology, social work, dietetics and psychology, resulting in a comprehensive package of care that optimises patient recovery and function. The focus of this project is the dietetics component of stroke management.

Dietetics services at HRC are limited by low-staffing levels, with the department operating below benchmark standards set by the Australasian Faculty of Rehabilitation Medicine.13 Management of high-risk nutrition concerns such as enteral feeding, malnutrition and severe nonhealing wounds are prioritized. This maintains the safety of patients whose rehabilitation is significantly compromised by their nutrition status, however, limits capacity for proactive nutrition intervention which could improve outcomes and safeguard future health, particularly for stroke survivors. This project commenced with a clinical audit comparing current practice to best practice as defined by the Stroke Foundation Guidelines. Results were reviewed collaboratively with dietetics, nursing, medical and other allied health staff to identify opportunities for change, creating systems and processes which align with best practice recommendations and enable most effective use of dietetics staffing. A follow-up audit was completed to assess effectiveness of the implementation strategies, and provide a platform for ongoing improvement.

The Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) audit and feedback tool was used to complete baseline and follow-up audit. Audit criteria were defined from the Australian National Clinical Guidelines for Stroke Management 20174 with a focus on issues identified previously including nutrition, hydration and secondary prevention. The project was led by a clinical dietitian, and the team included medical and nursing staff that fulfilled relevant roles including nutritional screening, hydration monitoring and provision of information relating to secondary prevention. This allowed for a holistic approach to implementing evidence-based healthcare, and incorporation of multidisciplinary perspectives.

Aim and objectives

The implementation project aimed to promote evidence-based nutrition management for stroke inpatients at HRC, aligning with best practice guidelines to improve health outcomes of stroke survivors and better utilize dietetics resources.

The objectives of the project were:

  • (1) Determine compliance with Australian Clinical Guidelines of Stroke Management 2017 relating to nutrition, hydration and secondary prevention.
  • (2) Engage a multidisciplinary team in developing strategies to address areas of non or low compliance with best practice guidelines.
  • (3) Implement strategies which encourage best practice and align with the FAME (feasible, appropriate, meaningful and effective) approach.
  • (4) Measure change in practice through a follow-up audit.


The JBI PACES and Getting Research into Practice (GRIP) audit and feedback tools were used. This involved three phases:

  • (1) Establishment of a project team and completion of a baseline audit based on criteria informed by the evidence.
  • (2) Reflection on baseline audit results to design and implement practice improvement strategies.
  • (3) Completion of a follow-up audit to assess intervention outcomes and change in practice, as well as identify future practice areas to be addressed in subsequent audits.

The project was registered on the CALHN Nutrition and Dietetics Action Plan as a quality improvement activity. It did not require ethics approval.

Phase 1: Stakeholder engagement and baseline audit

Stakeholder engagement and establishment of a project team

A project team was engaged to support the implementation of best practice nutrition and hydration management for stroke rehabilitation inpatients. The team comprised a Clinical Dietitian (Project Lead), the Manager of Nutrition and Dietetics, the Nursing Director, the Nurse Unit Manager (Stroke), the Assistant Nurse Unit Manager (Stroke) and the Registrar (Stroke). Stakeholders had sufficient experience with stroke patients to provide insight into potential implementation strategies, and possessed knowledge that was relevant to project aims and objectives. They provided project support, expert opinion and leadership to engage wider teams. Stakeholders were invited to participate through 1 : 1 discussion including explanation of aims, objectives, proposed timeframes and required commitment. Meeting dates and project documentation were provided via e-mail.

Baseline audit

The baseline audit objective was to determine the difference between current practice and best practice as per clinical guidelines in the management of nutrition and hydration for stroke rehabilitation inpatients. Audit criteria were derived from best practice recommendations based on a JBI Evidence Summary.14Table 1 shows the audit criteria, a description of the sample and measures of compliance.

Table 1 - Audit criterion as derived from best practice guidelines and assessment measures used for data collection
Audit criterion Method used to measure % compliance with best practice Yes No N/A
Stroke patients are screened for malnutrition upon admission using a validated malnutrition screening tool Review patient case notesBaseline n = 12Follow-up n = 14 Completed MUST printed and filed Nil evidence of MUST completed
Stroke patients are rescreened for malnutrition weekly using a validated malnutrition screening tool Review patient case notes and bed chartsBaseline n = 12Follow-up n = 14 Completed MUST printed and filed weekly Nil evidence of MUST completed weekly
Nondysphagic stroke patients with confirmed malnutrition or at risk for malnutrition are offered oral nutrition supplements Review patient case notes and meal management system recordsBaseline n = 12Follow-up n = 14 Patient identified as high risk of malnutrition (MUST = 2)andDietetics documentation states oral nutrition supplements were offeredand/orMeal management system record states patient commenced on high energy high protein diet Nil documentation of oral nutrition supplements providedandPatient remains on standard diet code Patients with diagnosed dysphagiaNon dysphagic patients with low risk of malnutrition (MUST = 0)
Stroke patients who are malnourished or at risk of malnutrition are referred to a dietitian for individualised medical nutrition therapy Review patient case notes and dietetics referral databaseBaseline n = 12Follow-up n = 14 Patient identified as high risk of malnutrition (MUST = 2)andDietetics referral received Patient identified as high risk of malnutrition (MUST = 2) but no dietetics referral received Patient identified as low risk of malnutrition (MUST = 0)
The hydration status of stroke patients is assessed, monitored and managed throughout their hospital admission Review patient case notes and bed chartsBaseline n = 12Follow-up n = 14 Patient has fluid balance chart completedandMedical officer, nurse or dietitian documented an assessment of hydration ± intervention as indicated Patient has nil fluid balance chartandNil documentation of hydration assessment or intervention
Stroke survivors are referred to a Dietitian for the provision of individualized dietary advice which incorporates secondary prevention strategies Review patient case notes and dietetics referral databaseBaseline n = 12Follow-up n = 14 Dietitian documented that stroke secondary prevention education has been providedorDietetics referral received for secondary prevention educationorPatient has been referred to community dietitian for outpatient education Nil dietary education provided while an inpatientorNo inpatient referral receivedandNo outpatient referral placed
A collaborative goal setting approach which includes the stroke survivor, their families and carers and the rehabilitation care team is implemented Review patient case notesBaseline n = 12Follow-up n = 14 Multidisciplinary patient goal setting document is completed, printed and filedandFamily meeting is completed with clear documentation of collaborative goal setting Nil documentation of patient, family and multidisciplinary goal setting
MUST, malnutrition universal screening tool.

To complete the audit, a checklist was created. The project lead was responsible for data collection, marking Yes/No/NA on the checklist for audited records. Baseline data was collected over eight weeks due to delays in accessing medical records. Audit results were entered into JBI PACES.

Phase 2: Design and implementation of strategies to improve practice Getting Research into Practice

Baseline audit results were presented to the implementation team, nursing staff and the dietetics department. Discussion was structured as per the JBI GRiP framework, identifying perceived barriers, potential improvement strategies and the resources required. The GRiP framework was applied to audit criteria individually, then collated to minimize duplication and improve efficiencies.

The project was broken down by relevant specialty, and the work shared between team members. The GRiP framework encouraged collaboration by identifying multiple strategies to each barrier, with different perspectives offered by diverse team members.

Phase 2 was implemented from June to August 2018 and was followed by Phase 3, the post implementation audit.

Phase 3: Follow-up audit post implementation of change strategy

The final phase of the project was a follow-up audit. Outcomes were measured against the same evidence-based criteria as the baseline audit to ensure consistency. Sample size was similar to baseline audit, and inclusion criteria differed only in admission date, to reflect patients who were admitted postimplementation. Auditing was completed using the same method as Phase 1, however, only took place on one day as electronic medical records were used, improving availability and efficiency. Audit results were entered into JBI PACES and the data was reviewed alongside baseline audit to identify change in compliance.


Phase 1: Baseline audit

At baseline (Fig. 1), two audit criteria achieved high rates of compliance: Criterion 1 – admission malnutrition screening, and Criterion 7 – collaborative goal setting. These areas have previously had significant time and energy invested in education, training and systems development; they also align with previously defined focus areas for the site. The longstanding multidisciplinary commitment to best practice is demonstrated in the audit results of 100% compliance.

Figure 1:
Results of the baseline audit.

Compliance was lower in all other audit criteria. Weekly malnutrition screening (Criterion 2), offering of oral nutrition supplements to patients at risk of or confirmed malnutrition (Criterion 3) and provision of dietary advice relating to secondary stroke prevention (Criterion 6) all scored 0%. This was unsurprising, as each of these criteria identify areas limited by dietetics staffing or not currently addressed by site systems. Monitoring and assessment of hydration (Criterion 5) was completed intermittently, and often in response to other clinical issues rather than as standard poststroke management. This resulted in low compliance of 17%. Referral to a dietitian for patients at risk of malnutrition or with confirmed malnutrition (Criterion 4) occurred 60% of the time, indicating that the dietitian's role in managing malnutrition is acknowledged, but the referral pathway is not fully embedded into practice.

Phase 2: Strategies for Getting Research into Practice

The project team agreed upon two key strategies for practice improvement: education and systems change. Education was provided to dietitians to update their knowledge in line with best practice recommendations for malnutrition screening, provision of oral nutrition supplements and provision of dietary advice incorporating secondary prevention strategies. Patient education materials relating to diet modification and stroke secondary prevention were developed; Appendix I, Written evidence summaries were provided regarding weekly malnutrition screening4,15 and provision of oral nutrition supplements16 in stroke survivors. These were utilized in department-based education sessions and saved for ongoing use.

System change was planned through initiation of a malnutrition working group comprising dietitians, nurses and food service staff. An initial meeting was completed which identified numerous challenges associated with current malnutrition screening practice including limitations of the electronic patient administration system (EPAS) for completing the screening tool; out of date organizational work instruction; differing staff perceptions regarding the importance of malnutrition screening; and inability of current information technology systems to communicate malnutrition screening results to food service staff. It was decided that the implementation of weekly malnutrition screening would require additional time, collaboration and resources not planned for within the scope of the project. This work will continue past the end date of the project, and change in malnutrition screening will be reflected in future annual audits rather than within this report.

Full details of barriers, strategies, resources and outcomes can be seen in Table 2.

Table 2 - Getting research into practice framework describing barriers, strategies and resources required to improve health outcomes and improve compliance with best practice guidelines
Barriers Strategies Resources Outcomes
Current medical record format does not support monitoring of weight trend and therefore, weekly review of malnutrition risk Liaise with EPAS staff to identify easiest way to order weekly malnutrition screeningFormation of a malnutrition working group with overarching goal to implement weekly malnutrition screening and update current OWI EPAS Implementation AdvisorsEvidence to support need for change: research highlighting need for weekly malnutrition screening, hospital wide MUST audit, current OWI Improved follow-up audit results for Criterion 2Decreased risk of hospital acquired malnutrition due to regular review of weight status/change
Lack of appropriate and comprehensive diet education resources relevant to stroke secondary prevention Development of rehabilitation specific suite of stroke education materials Stroke Foundation nutrition guidelinesDiabetes Centre suite of materials aligned with chronic disease/preventive education principles Improved follow-up audit results for Criterion 6Increase patient knowledge of dietary strategies for stroke secondary prevention
Dietetics staffing capacity does not allow for regular provision of preventive dietary education Standardize practice such that all stroke patients who receive dietetic assessment and intervention are assessed for current level of knowledge, readiness to change and offered education as an inpatient or referred for community follow-up Readiness to change toolQuestionnaire assessing current level of knowledgeList of appropriate community providers (DRS, RITH, DT under NDIS, private practice via GP healthcare plan) Improved results in follow-up audit for Criterion 6Increase patient knowledge of dietary strategies for stroke secondary prevention
Nursing staff uncertainty about MUST completion and referral pathways due to change in medical records Formation of a malnutrition working group including clinical nurse educator to plan education sessions EPAS Implementation AdvisorsClinical Nurse EducatorPowerpoint presentation Improved follow-up audit results for Criteria 1 and 2Increased knowledge and confidence of nursing staff to complete MUST in EPAS
Limited evidence base to guide best practice hydration assessment and monitoring (no tool to screen for risk and no consensus on best practice assessment) Liaise with JBI to complete more comprehensive literature review and develop evidence summaryDevelop scope for honours project reviewing this area JBI Research FellowFlinders University dietetics academic staff Completion of an Honours Project in 2019Further study and research
Need to validate evidence summary and prove relevance to setting to engage stakeholders who have not previously been exposed to JBI programme In depth review of primary research included in evidence summaryPresentation of primary research - linked to evidence summary and proposed implementation strategies Nutrition in Stroke evidence summary Increased engagement and support from stakeholders
Management concerns about financial and workforce cost of implementing best practice Demonstration of clinical efficiencies through presentation of the current evidence/literature JBI Evidence Summary providing links to primary researchBusiness case development/change template Improvement in all criteria
DRS, day rehabilitation service; DT, dietitian ; EPAS, electronic patient administration system; GP, general practitioner; JBI, Joanna Briggs institute; MUST, malnutrition universal screening tool; NDIS, national disability insurance scheme; OWI, organizational work instruction; RITH, rehabilitation in the home.

Phase 3: Follow-up audit

Comparison of baseline and follow-up audit (% compliance) is shown in Fig. 2. Criterion 1 decreased by 36% due to external changes to the site-based clinical documentation system which will be further explored in the Discussion. Criterion 2 demonstrated no change as the implementation strategy for this area was deemed outside the scope of this project. Criteria 3–6 improved and Criterion 7 remained consistently high, indicating overall improvement in nutrition and hydration management for stroke rehabilitation inpatients. Criteria 5 and 6 did however remain below 75% compliance which would still be considered poor in comparison with best practice.

Figure 2:
Follow-up audit results and comparison with baseline audit results.


Due to historically low dietetics staffing at HRC, nutrition and hydration management for stroke rehabilitation inpatients has prioritized high-risk areas such as enteral feeding and malnutrition. While the dietetics department are committed to moving towards a proactive approach aligned with best practice guidelines, this takes time, effort and resources. The focus has been on areas which intersect with other disciplines such as nursing, physiotherapy, occupational therapy and social work, presenting the most value for effort. Audit results reflect this, with criteria having been previously embedded into the multidisciplinary management of patients (admission malnutrition screening and collaborative goal setting), demonstrating the highest rates of compliance.

The strong result for malnutrition screening on admission (Criterion 1 – 100% compliance) contrasted sharply with the low result for weekly malnutrition screening (Criterion 2 – 0% compliance). This is due to the current site protocol, in which nursing staff complete malnutrition screening on admission, and then plot weekly weight on a visual chart to demonstrate trends. A dietitian referral would be triggered by significant weight changes. Previously, this has effectively identified hospital acquired malnutrition, however, moving to EPAS in March 2018 displaced the paper-based visual weight chart, allowing potential for hospital acquired malnutrition to be undetected. Despite strong staff support for the implementation of weekly malnutrition screening, the introduction of EPAS proved to be a significant limitation. To successfully implement weekly malnutrition screening via EPAS, software changes were required and these were not able to be achieved within the timeframe or scope of this project. As such, recommendations for the implementation of ongoing malnutrition screening (in addition to screening on admission) were provided to the CALHN Nutrition and Hydration Committee for consideration when revising the organizational work instruction. Additional note was made that weekly screening should be the minimum requirement as per the clinical guidelines, with patients at higher risk or those who are admitted with an existing diagnosis of malnutrition likely to benefit from being screened more regularly if staff capacity allows, whereas for those at low risk of malnutrition weekly screening is adequate. Changeover to EPAS also decreased Criterion 1 compliance from the baseline audit (paper records) and follow-up audit (electronic records) because nursing staff are still adjusting to the new system. Follow-up audit showed that nursing staff were completing weight, height and weight history, however, often missed the ‘Little or no nutritional intake for more than 5 days’ question which sits in a separate section of EPAS (Figs. 3 and 4) hence no malnutrition risk was generated and the audit criteria was not met. This indicated that despite excellent baseline results, there is education and support required to maintain the high rate of malnutrition screening completion despite the software limitations. Staff education and support will be a focus of the nutrition and hydration committee moving forward and will integrate well with the future introduction of weekly screening.

Figure 3:
Malnutrition universal screening tool incomplete in electronic patient administration system.
Figure 4:
Malnutrition universal screening tool fully completed in electronic patient administration system.

A further limitation of the lower malnutrition screening rate demonstrated by the decrease in compliance for Criterion 1, is the potential for decreased malnutrition screening to falsely inflate the rate of improvement for provision of nutrition support (Criterion 3) and referral to a dietitian (Criterion 4). It must be recognized that the decreased rate of malnutrition screening may have led to decreased identification of patients at risk of or with diagnosed malnutrition, therefore, leading to lower number of patients requiring further intervention. As such, the postaudit improvements in provision of oral nutrition support and referral to a dietitian may have been less significant if a larger number of patients were identified as at risk or confirmed malnutrition as this would increase the number of patients requiring intervention.

Significant discussion as to what constituted oral nutrition supplements occurred within the dietetics department when assessing Criterion 3. The British Association for Parenteral and Enteral Nutrition define oral nutrition supplements as providing macro and micro nutrients in liquid, semi-solid or powder form.17 This was supported by research reviewing the efficacy of a medically formulated liquid supplement.18–20 Clinical opinion within the department, however, was that provision of standardized nutritional supplements to all stroke patients with high risk of or confirmed malnutrition would lead to wastage and subsequent ineffectiveness if the patient was not first provided with education regarding the purpose of the nutrition supplement. There was discussion as to whether a therapeutic high-energy high-protein diet was adequate to meet this criterion, or whether a formulated nutritional supplement was essential. For the purposes of the audit, both were considered appropriate, as this suited the site when reviewing the FAME framework of implementation strategies as budget limitations meant that implementation of oral nutrition supplements for all stroke patients was not possible.

During implementation, a parallel food service project was undertaken. Inpatients at high risk of malnutrition (Malnutrition Universal Screening Tool ≥2) were to be commenced automatically on a high energy high-protein diet. This gives access to high energy high-protein main meals and snacks for patients on a ward diet. It does not include any formulated nutrition supplements. Improved compliance for Criterion 3 on the follow-up audit therefore, is attributed to the successful completion of this parallel project, as all nondysphagic stroke patients at risk of malnutrition were commenced on the high energy high-protein diet. This enabled patients who had not received full dietetic assessment and intervention to receive a level of nutrition support. When the patients were seen by a dietitian, nutrition support could be tailored and individualized to ensure it comprehensively met their needs. This area presents an opportunity for future research assessing whether there is a difference between nutrition support provided through a high energy high-protein diet versus standardized nutritional supplementation in nondysphagic stroke patients. Alternate interventions could be assessed for impact on nutritional status, quality of life, functional and cognitive recovery, as well as product cost and wastage to ensure feasibility of future interventions.

Hydration management is an area with strong staff investment, however, practice change was limited by a lack of relevant literature to support changes to practice. There are no consensus best practice recommendations for the implementation of hydration assessment and monitoring, despite it being included in many clinical guidelines.21 Some site-based screening tools were found (GULP Dehydration Risk Screening Tool), and various measures of hydration had been tested (fluid intake chart, BP, skin turgor, heart rate, dry mouth), however, there was no agreement or validation for effectiveness. Observationally during audit, hydration management was initiated only in response to a clinical problem such as recurrent hypotension or renal/cardiac disease. This approach seemed reactive rather than a standard part of best practice care. Nursing and medical staff feedback indicated that hydration management was important, particularly given the role of hydration in relevant clinical issues such as urinary tract infections, falls and delirium; however, there was no agreement on the best objective measure of hydration. All staff reported making subjective assessments on a case by case basis, and that they would appreciate having a standardized tool to use. Given the lack of guidelines, fluid balance charts were initiated for all patients admitted on thickened fluids (known to be at high risk of dehydration)22 as a one month trial. The commencement of the trial led to a modest improvement in the audit criterion, however, nursing burden limited this as a feasible implementation strategy for incorporation into standard practice. There remains significant work to be completed in this area to achieve proactive hydration management, and future research investigating methods of hydration assessment and measuring the efficacy of hydration interventions to increase oral fluid intake, is necessary to achieve improvements in practice.

Preventive dietary advice is regularly overlooked in the face of nutrition issues presenting higher clinical risk for stroke survivors such as enteral feeding, malnutrition and dehydration. It is, however, an important part of recovery and rehabilitation, particularly for young stroke survivors. While workforce capacity limits blanket referral to all stroke patients for preventive dietary education, it was agreed within the dietetics department that patients already receiving dietitian input would be offered education to support dietary change focussing on limiting intake of saturated fat, salt and sugar, while increasing vegetable consumption in line with clinical guidelines. If they do not identify this as an inpatient goal, or are not demonstrating readiness to change, they will be referred for community follow-up. This meets best practice recommendations, and gives patients the best opportunity to decrease subsequent stroke risk. To support this education, resources were developed covering the knowledge and behaviours required to implement dietary change including healthy eating principles, decreasing salt intake and reducing alcohol consumption. Please see Appendix I, or contact the author for full resources. Access to this preventive dietary education remains a limitation to achieving best practice in relation to this audit criterion, as only patients referred to a dietitian are currently offered this information and the support to implement it. This will continue to be limited by inadequate staffing capacity, therefore, ongoing work needs to be undertaken to make the guidelines regarding preventive dietary education accessible to all stroke survivors. This may include ward-based visual resources such as posters or flyers which are used for other health messaging such as Think F.A.S.T, Act Fast and the Stroke Foundation handouts. Basic information on how to access the dietary guidelines could also be provided to all stroke survivors on admission in their information pack, and reinforced by members of the multidisciplinary team who have a blanket referral and fulfil the role of rehabilitation coordinator.

It was clear throughout this project that there is strong multidisciplinary interest and engagement in the nutrition and hydration management of stroke survivors. This demonstrates that while dietitian staffing capacity may limit implementation of best practice guidelines through 1 : 1 patient assessment and intervention, there is a role for dietitians to provide training, education and support for other staff in areas such as malnutrition screening, hydration monitoring and provision of secondary prevention education. Similarly, through dietetics leadership, it is possible to create service-wide systems which meet the nutrition and hydration needs of stroke survivors, while not requiring additional dietetics staff. While the scope and numbers of this project were small, it demonstrated that simple interventions in a multidisciplinary environment can improve the nutrition and hydration status of stroke survivors without increasing dietetics staff. The implementation strategies discussed in this article would benefit from being applied to a larger cohort of patients, and over a longer period of time. This would offer the opportunity to measure the outcomes of stroke survivors who receive best practice nutrition and hydration management, as well as increasing understanding of the capacity building opportunities dietitians have to lead multidisciplinary nutrition and hydration interventions.


The project aimed to promote evidence-based nutrition and hydration management for stroke inpatients at HRC, aligning with best practice guidelines to improve health outcomes of stroke survivors and better utilize dietetics resources. Change in practice measured through baseline and follow-up audits indicates that this aim was partly achieved, with particular improvement noted in the provision of oral nutrition support to stroke patients at risk of malnutrition, an increased focus on hydration monitoring and provision of secondary prevention education to stroke survivors. These changes will contribute to improved patient outcomes at HRC, making a small difference to the nation-wide burden of stroke. This project also highlighted areas which need a renewed focus moving forward. Ongoing work from the project includes the development of a multidisciplinary malnutrition pathway, as well as an Honours Research Project reviewing hydration assessment, monitoring and management. Further audits will be carried out annually to monitor and maintain the practice change.


The author wishes to acknowledge the Nutrition and Dietetics department at Hampstead Rehabilitation Center, and the medical, nursing and allied health staff on General Rehabilitation East ward for their support, expertise and participation in this project. Acknowledgements and thanks are also extended to the Adelaide team at the Joanna Briggs Institute, particularly Alexa McArthur, for giving such valuable time, guidance and wisdom.

Conflicts of interest

The author reports no conflicts of interest.


1. Deloitte Access Economics Pty Ltd, Deloitte Access Economics. The economic impact of stroke in Australia. 2013; Available from [Cited 12 March 2018].
2. Hardie KHG, Jamrozik K, Broadhurst RJ, Anderson C. Ten-year risk of first recurrent stroke and disability after first-ever stroke in the Perth Community Stroke Study. Stroke 2004; 35:731–735.
3. Stroke Foundation. Prevent stroke. 2018; Melbourne: Stroke Foundation – Australia, Available from: [Cited 12 March 2018].
4. MAGICapp, Stroke Foundation. Clinical guidelines for stroke management 2017. 2017; Available from: [Cited 6 March 2018].
5. Hebert D, Lindsay MP, Mclntyre A, et al. Canadian stroke best practice recommendations: stroke rehabilitation practice guidelines. Int J Stroke 2016; 11:459–484.
6. Stroke Foundation of New Zealand, Stroke Foundation of New Zealand. New Zealand clinical guidelines for stroke management 2010. 2010; Available from: [Cited 6 November 2018].
7. European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25:457–507.
8. Scottish Intercollegiate Guidelines Network, Scottish Intercollegiate Guidelines Network. Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning, a national clinical guideline. 2010; Available from: [Cited 6 November 2018].
9. Venketasubramanian N, Pwee KH, Chen CP. Singapore ministry of health clinical practice guidelines on stroke and transient ischemic attacks. Int J Stroke 2011; 6:251–258.
10. Gomes F, Emery P, Weekes E. Risk of malnutrition is an independent predictor of mortality, length of hospital stay, and hospitalization costs in stroke patients. J Stroke Cerebrovasc Dis 2016; 25:799–806.
11. Liu CH, Lin SC, Lin JR, et al. Dehydration is an independent predictor of discharge outcome and admission cost in acute ischaemic stroke. Eur J Neurol 2014; 21:1184–1191.
12. Stroke Foundation, Stroke Foundation. National stroke audit: rehabilitation services report 2016. 2016; Available from: [Cited 6 November 2018].
13. Australian Faculty of Rehabilitation Medicine. Standards for the provision of inpatient adult rehabilitation medicine services in public and private hospital. Sydney: Royal Australasian College of Physicians; 2011.
14. Craven D. Evidence Summary. Post stroke rehabilitation: nutrition management 2018; Adelaide, South Australia: Joanna Briggs Institute Database, JBI19321.
15. The National Institute for Health and Care Excellence, National Institute for Health and Care Excellence (NICE). Stroke and transient ischaemic attack in over 16 s: diagnosis and initial management (CG68). 2008; Available from: [Cited 15 March 2018].
16. Burgos R, Breton I, Cereda E, et al. ESPEN guideline clinical nutrition in neurology. Clin Nutr 2018; 37:354–396.
17. BAPEN: the British Association for Parenteral and Enteral Nutrition. Oral Nutritional Supplements (ONS). 2016; Adelaide, South Australia: BAPEN: the British Association for Parenteral and Enteral 21, Available from: [Cited 12 November 2018].
18. Gariballa SE, Parker SG, Taub N, Castleden CM. A randomized, controlled, a single-blind trial of nutritional supplementation after acute stroke. JPEN J Parenter Enteral Nutr 1998; 22:315–319.
19. Rabadi MH, Coar PL, Lukin M, Lesser M, Blass JP. Intensive nutritional supplements can improve outcomes in stroke rehabilitation. Neurology 2008; 71:1856–1861.
20. Ha L, Hauge T, Spenning AB, Iversen PO. Individual, nutritional support prevents undernutrition, increases muscle strength and improves QoL among elderly at nutritional risk hospitalized for acute stroke: a randomized, controlled trial. Clin Nutr 2010; 29:567–573.
21. Lizarondo L. Evidence summary. Dehydration in older people: assessment. Adelaide, South Australia: Joanna Briggs Institute Database of EBP; 2018.
22. Murray J, Miller M, Doeltgen S, Scholten I. Intake of thickened liquids by hospitalized adults with dysphagia after stroke. Int J Speech Lang Pathol 2013; 16:486–494.

audit; hydration; nutrition; rehabilitation; stroke

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A video commentary on implementation project titled: How do health professionals prioritise clinical areas for implementation of evidence into practice? The commentary is provided by Andrea Rochon RN, MNSc, Research Assistant, Queen's University, Ontario, Canada