FeSS Protocols

Every 19 minutes someone in Australia will suffer a new stroke. By 2050, without action, this number will increase to one new stroke every 10 minutes. An estimated 27,428 Australians experienced a stroke for the first time in their lives in 2020 with 445,087 stroke survivors living across the country.1

Three expert panels developed the FeSS Protocols in alignment with National Stroke and Diabetes clinical practice guidelines. High quality research has demonstrated that use of the FeSS Protocols directly benefits patients with:

  • a 16% reduction in death and dependency at 90 days post stroke,2
  • longer-term reduction in mortality out to four years,3 and
  • significant cost savings to the healthcare system ($281M saving over 12 months if received by 65% of eligible patients).4

The FeSS Protocols have three components:

Fever Protocol

The Fever Protocol consists of monitoring the patients’ temperature at least four times a day and the prompt treatment of a temperature 37.5°C or greater in the first 72 hours, following stroke unit admission.

Elevated body temperature post stroke is common (>30%).5 Fever is consistently associated with worse outcomes that include marked increase in morbidity and mortality and length of hospital stay.6-11

Sugar Protocol

The Sugar Protocol consists of monitoring the patient's blood glucose levels at least four times a day for the first 48 hours following stroke unit admission (continue for 72 hours if blood glucose levels unstable), and the prompt treatment of a blood glucose level greater than 10mmols/L (180 mg/dl) in the first 48 hours following stroke unit admission.

Hyperglycaemia is common after both ischaemic and haemorrhagic stroke- affecting between 40% - 60% of patients.12-13 Monitoring blood glucose levels is important for both diabetic and non-diabetic patients. Non-diabetic stroke patients with BGL>8mmol/L are three times more likely to die than non-diabetic patients without hyperglycaemia.14 Elevated blood glucose levels within the first 48 hours from stroke onset, are a predictor of poor outcomes (death and disability).12, 15-17

Swallow Protocol

The Swallow Protocol consists of keeping patients nil by mouth (including no oral medications) until they have been screened for dysphagia by a nurse that has demonstrated competency using an approved dysphagia screening tool or assessed by a speech pathologist/ speech and language therapist. The QASC trial used the ASSIST screening tool which is also available for download but you can use your hospital-approved screening tool.

Dysphagia post stroke is common affecting about 42% of patients.18 Early dysphagia screening reduces the risk of pneumonia, mortality, overall dependency and length of stay in hospital.19-20

Implementation strategy

  • Audit and feedback
  • Multidisciplinary Workshops
    • Presentation of baseline audit results
    • To present details of FeSS
    • Identification of barriers and enablers to FeSS Protocol use
    • Development of local Action Plan
    • To identify local site clinical champion
    • To develop action plan
  • Didactic and interactive education
  • Clinical site champions
  • Reminders

Get the FeSS Protocols

Download the FeSS Protocols and other resources

We recommend you undertake a medical record audit to see how well your hospital is currently managing fever, hyperglycaemia and swallowing. This will give you a baseline prior to implementing the FeSS Protocols. We then recommend you conduct a follow-up audit to measure your improvement.

We have developed an audit tool for this purpose.

The Fever, Sugar and Swallowing (FeSS) Medical Record Audit Manual includes a medical record audit tool, instructions for use and a data dictionary.

Download the FeSS Medical Record Audit Manual

  1. Stroke Foundation. (2020). No Postcode Untouched: Stroke in Australia 2020. Sydney: Deloitte Access Economics.
  2. Middleton, S., McElduff, P., Ward, J., Grimshaw, J. M., Dale, S., D'Este, C., ... & Levi, C. (2011). Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. The Lancet, 378(9804), 1699-1706.
  3. Middleton, S., Coughlan, K., Mnatzaganian, G., Low Choy, N., Dale, S., Jammali-Blasi, A., ... & D’Este, C. (2017). Mortality reduction for fever, hyperglycemia, and swallowing nurse-initiated stroke intervention: QASC trial (quality in acute stroke care) follow-up. Stroke48(5), 1331-1336.
  4. Australian Clinical Trials Alliance. (2017). Economic evaluation of investigator-initiated clinical trials conducted by networks. Sydney: ACSHQC.
  5. Phipps, M. S., Desai, R. A., Wira, C., & Bravata, D. M. (2011). Epidemiology and outcomes of fever burden among patients with acute ischemic stroke. Stroke, 42(12), 3357-3362. doi:10.1161/STROKEAHA.111.621425
  6. Chen, H., Qian, H., Gu, Z., & Wang, M. (2018). Temperature management with paracetamol in acute stroke patients: Evidence From randomized controlled trials. Front Neurol, 9, 917. doi:10.3389/fneur.2018.00917
  7. Prasad, K., & Krishnan, P. R. (2010). Fever is associated with doubling of odds of short-term mortality in ischemic stroke: an updated meta-analysis. Acta Neurol Scand, 122(6), 404-408. doi:10.1111/j.1600-0404.2010.01326.x
  8. Greer, D. M., Funk, S. E., Reaven, N. L., Ouzounelli, M., & Uman, G. C. (2008). Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke, 39(11), 3029-3035. doi:10.1161/STROKEAHA.108.521583
  9. Wang, S. L., Pan, W. H., Lee, M. C., Cheng, S. P., & Chang, M. C. (2000). Predictors of survival among elders suffering strokes in Taiwan: observation from a nationally representative sample. Stroke, 31(10), 2354-2360. doi:10.1161/01.str.31.10.2354
  10. Hajat, C., Hajat, S., & Sharma, P. (2000). Effects of poststroke pyrexia on stroke outcome : a meta-analysis of studies in patients. Stroke, 31(2), 410-414. doi:10.1161/01.str.31.2.410
  11. Seo, W. K., Yu, S. W., Kim, J. H., Park, K. W., & Koh, S. B. (2008). The impact of hyperthermia and infection on acute ischemic stroke patients in the intensive care unit. Neurocrit Care, 9(2), 183-188. doi:10.1007/s12028-008-9056-0
  12. Gentile, N. T., Seftchick, M. W., Huynh, T., Kruus, L. K., & Gaughan, J. (2006). Decreased mortality by normalizing blood glucose after acute ischemic stroke. Acad Emerg Med, 13(2), 174-180. doi:10.1197/j.aem.2005.08.009
  13. Saxena, A., Anderson, C. S., Wang, X., Sato, S., Arima, H., Chan, E., . . . Investigators, I. (2016). Prognostic Significance of Hyperglycemia in Acute Intracerebral Hemorrhage: The INTERACT2 Study. Stroke, 47(3), 682-688. doi:10.1161/STROKEAHA.115.011627
  14. Stead, L. G., Gilmore, R. M., Bellolio, M. F., Mishra, S., Bhagra, A., Vaidyanathan, L., . . . Brown, R. D., Jr. (2009). Hyperglycemia as an independent predictor of worse outcome in non-diabetic patients presenting with acute ischemic stroke. Neurocrit Care, 10(2), 181-186. doi:10.1007/s12028-008-9080-0
  15. Fuentes, B., Castillo, J., San Jose, B., Leira, R., Serena, J., Vivancos, J., . . . Stroke Project of the Cerebrovascular Diseases Study Group, S. S. o. N. (2009). The prognostic value of capillary glucose levels in acute stroke: the GLycemia in Acute Stroke (GLIAS) study. Stroke, 40(2), 562-568. doi:10.1161/STROKEAHA.108.519926
  16. Capes, S. E., Hunt, D., Malmberg, K., Pathak, P., & Gerstein, H. C. (2001). Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke, 32(10), 2426-2432. doi:10.1161/hs1001.096194
  17. Parsons, M. W., Barber, P. A., Desmond, P. M., Baird, T. A., Darby, D. G., Byrnes, G., . . . Davis, S. M. (2002). Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol, 52(1), 20-28. doi:10.1002/ana.10241
  18. Sherman, V., Greco, E., & Martino, R. (2021). The Benefit of Dysphagia Screening in Adult Patients With Stroke: A Meta-Analysis. J Am Heart Assoc, 10(12), e018753. doi:10.1161/JAHA.120.018753
  19. Bray, B. D., Smith, C. J., Cloud, G. C., Enderby, P., James, M., Paley, L., ... & Rudd, A. G. (2017). The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia. Journal of Neurology, Neurosurgery & Psychiatry88(1), 25-30.
  20. Banda, K.J., Chu, H., Kang, X.L. et al. Prevalence of dysphagia and risk of pneumonia and mortality in acute stroke patients: a meta-analysis. BMC Geriatr22, 420 (2022). doi:10.1186/s12877-022-02960-5

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