INTRODUCTION: Poor adoption of stroke guidelines is a problem internationally. The Quality in Acute Stroke Care (QASC) trial demonstrated significant reduction in death and disability with facilitated implementation of nurse-initiated. METHODS: This was a multi-country, multi-centre, pre-test/post-test study (2017-2021) comparing post implementation data with historically collected pre-implementation data. Hospital clinical champions, supported by the Angels Initiative conducted multidisciplinary workshops discussing pre-implementation medical record audit results, barriers and facilitators to FeSS Protocol implementation, developed action plans and provided education, with ongoing support co-ordinated remotely from Australia. Prospective audits were conducted 3-month after FeSS Protocol introduction. Pre-to-post analysis and country income classification comparisons were adjusted for clustering by hospital and country controlling for age/sex/stroke severity. RESULTS: Data from 64 hospitals in 17 countries (3464 patients pre-implementation and 3257 patients post-implementation) showed improvement pre-to-post implementation in measurement recording of all three FeSS components, all p < 0.0001: fever elements (pre: 17%, post: 51%; absolute difference 33%, 95% CI 30%, 37%); hyperglycaemia elements (pre: 18%, post: 52%; absolute difference 34%; 95% CI 31%, 36%); swallowing elements (pre: 39%, post: 67%; absolute difference 29%, 95% CI 26%, 31%) and thus in overall FeSS Protocol adherence (pre: 3.4%, post: 35%; absolute difference 33%, 95% CI 24%, 42%). In exploratory analysis of FeSS adherence by countries' economic status, high-income versus middle-income countries improved to a comparable extent. DISCUSSION AND CONCLUSION: Our collaboration resulted in successful rapid implementation and scale-up of FeSS Protocols into countries with vastly different healthcare systems.

Angels Initiative Boehringer Ingelheim International GmbH Hamburg Germany

Centre for Diabetes and Endocrinology Research Westmead Hospital University of Sydney Sydney NSW Australia

Department of Medicine University of Newcastle Callaghan NSW Australia

Department of Neurology and Clinical Neurophysiology Städtisches Klinikum Lüneburg Lüneburg Germany

Department of Neurology Goethe University Frankfurt am Main Germany

Fakultní nemocnice Motol Prague Czech Republic

Health Department Agency for Health Quality and Assessment CIBER Epidemiología y Salud Pública CIBERESP Stroke Programme Barcelona Spain

Hospital Network Area Regional Health Department Regione Lazio Rome Italy

International Clinical Research Centre Neurology Department St Ann's University Hospital and Masaryk University Brno Czech Republic

John Hunter Health and Innovation Precinct HNE LHD New Lambton NSW Australia

Medical University of Gdańsk Gdansk Poland

National Center for Neurosurgery Nur Sultan Kazakhstan

National Centre for Epidemiology and Population Health Australian National University Canberra Australia

Nursing Research Institute St Vincent's Health Network Sydney St Vincent's Hospital Melbourne and Australian Catholic University Sydney NSW Australia

Ottawa Hospital Research Institute Ottawa ON Canada

Prince of Wales Hospital Randwick Australia

Saarland University of Applied Sciences Saarbrücken Germany

Sax Institute Sydney Australia

School of Nursing Midwifery and Paramedicine Australian Catholic University Sydney Australia

Stroke and Ageing Research Department of Medicine School of Clinical Sciences at Monash Health Monash University Clayton VIC Australia

ULSNE Macedo de Cavaleiros Macedo de Cavaleiros Portugal

University Medical Center Groningen Groningen Netherlands

University of Ottawa Ottawa ON Canada

Vall d'Hebron Hospital Universitari Barcelona Spain

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Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide