Development of Clinical Practice Guidelines for Post-Stroke Pneumonia Prevention among Stroke Patients in Phetchabun Hospital

Abstract

Introduction Post-stroke pneumonia is a clinical condition that typically occurs within 48 hours to 7 days after the onset of stroke in non-intubated stroke patients, with the highest incidence observed during the first 72 hours. When pneumonia develops in the acute phase of stroke, it can expand the ischemic area, thereby reducing recovery potential and increasing disability. All stroke patients are at risk of aspiration due to multiple factors, such as decreased consciousness, advanced age, or dysphagia. These conditions elevate the risk of post-stroke pneumonia, with subsequently increase the likelihood of respiratory failure, prolong hospitalization, and increase in-hospital mortality. Prevention of post-stroke pneumonia requires coordinated care among multidisciplinary teams. Thus, the development and implementation of evidence-based clinical practice guidelines can provide a unified framework for healthcare teams, ensuring consistent patient management and reducing the incidence of post-stroke pneumonia. 

Objectives: To develop clinical practice guidelines and to assess the quality and feasibility of preventing post-stroke pneumonia in patients with stroke.

Design This study employed an operational research design to develop clinical practice guidelines (CPGs) according to the ADAPTE Collaboration, version 2.0. The process comprised three phases: (1) set-up phase: checking whether the adaptation is feasible, establishing the guideline development team, reviewing relevant existing guidelines, identifying essential team competencies, outlining team activities, and drafting the guideline development protocol. (2) adaptation phase: defining the scope and objectives of the guideline, conducting systematic searches, screening and appraising existing guidelines, selecting appropriate guidelines, and drafting the adapted guideline with revised core content. (3) evaluation phase: assessing guideline quality by external experts, pilot testing with patients and revising accordingly, and finalizing the guideline for institutional implementation. Data collection was conducted over a period of 22 weeks.

Methodology The participants comprised three groups: (1) six healthcare professionals who served as the guideline development team, (2) seven healthcare personnel who acted as guideline users, and (3) five stroke patients admitted to the stroke unit at Phetchabun Hospital who received care based on the developed guideline. Patients were eligible if they were aged 20 years or older, diagnosed with either ischemic or hemorrhagic stroke, had a glasgow coma scale, (GCS) score greater than 8, and demonstrated stable clinical symptoms and hemodynamic status for at least 24 hours. Exclusion criteria included respiratory failure, brain surgery or other conditions requiring endotracheal intubation, severe receptive aphasia, absence of a primary caregiver, and presence of pre-existing post-stroke pneumonia. Participation was terminated in cases of death or transfer to another ward. The sample size was determined in accordance with recommendations for operational research in guideline development. Research instruments included (1) a guideline screening form including a table for summarizing guideline characteristics and a table for summarizing guideline content, (2) Appraisal of Guidelines for Research and Evaluation II (AGREE II), (3) the GCS, and (4) outcome evaluation tools including an aspiration pneumonia assessment form, patient and caregiver satisfaction questionnaires regarding the CPGs, staff satisfaction questionnaires, and CPGs practice adherence checklists. All instruments were validated for quality prior to use. Data were analyzed using descriptive statistics, including frequency and percentage.

Results The CPG developed in this study was intended for use by multidisciplinary healthcare professionals involved in the care of stroke patients, including physicians, nurses, nutritionists, occupational therapists, and nurse aides. The guideline comprised 81 recommendations organized into six categories, aligned with The Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The categories were: (1) patient rights protection and ethics, ensuring that all stroke patients receive care consistent with principles of patient rights and health ethics; (2) screening and assessment of dysphagia, requiring all stroke patients to undergo dysphagia screening, with high-risk patients assessed using validated tools; (3) prevention of post-stroke pneumonia, recognizing that all stroke patients are at risk of pneumonia due to physical impairments and therefore should receive preventive measures; (4) patient and family education, providing knowledge to patients and caregivers regarding pneumonia prevention; (5) management of dysphagia, ensuring effective care for stroke patients with swallowing difficulties; and (6) continuous monitoring and quality improvement, promoting ongoing evaluation and enhancement of care practices. The strength of recommendations was determined according to the evidence-based criteria of the Oxford Centre for Evidence-Based Medicine. A quality assessment of the CPGs by five experts indicated that all domains achieved AGREE II scores exceeding 90%. The CPGs were judged to be comprehensive, clearly written, and feasible for implementation. Feasibility testing was conducted with five stroke patients: one without dysphagia, two with dysphagia who were able to eat orally, and two receiving nasogastric tube feeding. Of the 81 recommendations, 77 were applied in practice, while four were not applicable due to the absence of relevant conditions among the sample patients. Implementation of the guideline in this patient group resulted in no incidence of post-stroke pneumonia. Overall satisfaction with the guideline-based care was rated at a high level by both patients and their families, as well as by the healthcare personnel who applied the CPGs.

Recommendation: It is recommended that the CPGs be promoted for implementation in routine practice, and that further studies be conducted to evaluate their effectiveness on both clinical outcomes and process-related outcomes.