Elsevier

The Lancet

Volume 378, Issue 9804, 12–18 November 2011, Pages 1699-1706
The Lancet

Articles
Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial

https://doi.org/10.1016/S0140-6736(11)61485-2Get rights and content

Summary

Background

We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs).

Methods

In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale [mRS] ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369.

Findings

19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 [42%] of 558 patients in the intervention group vs 259 [58%] of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% [95% CI 5·8–25·4]). They also had a better SF-36 mean physical component summary score (45·6 [SD 10·2] in the intervention group vs 42·5 [10·5] in the control group, p=0·002; adjusted absolute difference 3·4 [95% CI 1·2–5·5]) but no improvement was recorded in mortality (21 [4%] of 558 in intervention group and 24 [5%] of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 [10·9] in the intervention group vs 49·4 [10·6] in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 [92%] of 532 patients vs 380 [90%] of 423 patients; p=0·44).

Interpretation

Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care.

Funding

National Health & Medical Research Council ID 353803, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.

Introduction

Although organised stroke unit care significantly reduces death and disability from cerebrovascular events,1 three physiological variables are not yet universally well managed despite their importance for long-term patient recovery.2, 3, 4 In the first days of an acute stroke, temperature higher than 37·5°C occurs in 20–50% of patients;2 up to 50% become hyperglycaemic;3 and 37–78%4 have dysphagia; all result in increased morbidity and mortality.2, 3, 4 Hence, international guidelines recommend that fever and high blood glucose concentrations be monitored and managed proactively and that every stroke patient have their swallowing status evaluated before receiving food, fluid, or oral medication.5, 6 All these recommendations are the responsibility of the stroke multidisciplinary team.7 Care is not always consistent with these recommendations however.6, 8 We designed the Quality in Acute Stroke Care (QASC) study, a cluster randomised controlled trial,9, 10 to assess the effect of multidisciplinary team building workshops and a standardised interactive education programme to implement evidence-based treatment protocols for the management of fever, hyperglycaemia, and swallowing dysfunction on patient outcomes 90 days after admission for stroke. These three variables were selected because they implicate multidisciplinary teamwork, which has been shown to improve health-care processes and patient outcomes,11 a priority for stroke care.

Section snippets

Trial design and participants

Our single-blind cluster randomised controlled trial randomised Acute Stroke Units (ASUs) to minimise contamination because our team building intervention was designed for implementation at the ASU level.12 Outcomes before and after intervention were assessed at the patient level. The trial protocol has been published previously.9 All treatment protocols, the ASSIST dysphagia screening tool, and further information about implementation of the intervention are available at the Australian

Results

19 (95%) ASUs agreed to participate (figure 1). The length of time ASUs had been established before trial commencement was similar between intervention and control groups. Data for the pre-intervention patient cohort have been published.10 Age, sex, 90-day death, 90-day death and dependency, 90-day functional dependency (BI), and health status (PCS score and MCS score) were similar for the intervention and control groups.

For the post-intervention cohort, of the 1292 eligible patients, 166 (13%)

Discussion

Our results show that patients of ASUs allocated to receive our multidisciplinary intervention to support proactive evidence-based management of fever, hyperglycaemia, and swallowing were significantly more likely to be alive and independent at 90 days after admission. Specifically, we showed a 15·7% adjusted absolute difference in rates of 90-day death and dependency. The clinical significance of these results is more remarkable when compared against other established clinical and

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