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Quality in Acute Stroke Care (QASC): process evaluation of an intervention to improve the management of fever, hyperglycemia, and swallowing dysfunction following acute stroke

Authors

  • Peta Drury,

    1. Nursing Research Institute, St.Vincent's & Mater Health Sydney, Australian Catholic University, Sydney, NSW, Australia
    2. School of Nursing, Midwifery & Paramedicine (NSW & ACT), Australian Catholic University, NSW, Australia
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  • Christopher Levi,

    1. Priority Centre for Brain & Mental Health Research, The University of Newcastle, Newcastle, NSW, Australia
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  • Catherine D'Este,

    1. Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Newcastle, NSW, Australia
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  • Patrick McElduff,

    1. Hunter Medical Research Institute, Clinical Research Design, IT and Statistical Support Unit, School of Medicine and Public Health University of Newcastle, Newcastle, NSW, Australia
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  • Elizabeth McInnes,

    1. Nursing Research Institute, St.Vincent's & Mater Health Sydney, Australian Catholic University, Sydney, NSW, Australia
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  • Jennifer Hardy,

    1. Sydney Nursing School, University of Sydney, Camperdown, NSW, Australia
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  • Simeon Dale,

    1. Nursing Research Institute, St.Vincent's & Mater Health Sydney, Australian Catholic University, Sydney, NSW, Australia
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  • N Wah Cheung,

    1. Department of Diabetes and Endocrinology, Westmead Hospital and University of Sydney, Wentworthville, NSW, Australia
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  • Jeremy M Grimshaw,

    1. Ottawa Health Research Institute, Ottawa, ON, Canada
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  • Clare Quinn,

    1. Speech Pathology Department, Prince of Wales Hospital, Randwick, NSW, Australia
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  • Jeanette Ward,

    1. Department of Epidemiology & Community Medicine, University of Ottawa, Ottawa, ON, Canada
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  • Malcolm Evans,

    1. Priority Centre for Brain & Mental Health Research, The University of Newcastle, Newcastle, NSW, Australia
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  • Dominique Cadilhac,

    1. Stroke and Ageing Research Centre, Monash Medical Centre, Southern Clinical School, Monash University, Clayton, VIC, Australia
    2. National Stroke Research Institute, Florey Neuroscience Institutes, Melbourne Brain Centre, Heidelberg, VIC, Australia
    3. University of Melbourne, Melbourne, VIC, Australia
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  • Rhonda Griffiths,

    1. School of Nursing and Midwifery, University of Western Sydney, Liverpool, NSW, Australia
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  • Sandy Middleton

    Corresponding author
    1. Nursing Research Institute, St.Vincent's & Mater Health Sydney, Australian Catholic University, Sydney, NSW, Australia
    • Correspondence: Sandy Middleton*, Director, Nursing Research Institute, St Vincent's & Mater Health Sydney – Australian Catholic University. St Vincent's Hospital, Level 5, deLacy Building, 379 Victoria St, Sydney NSW 2010, Australia. E-mail: sandy.middleton@acu.edu.au

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  • [Corrections added on 10 January 2014, after first online publication: Data related to the primary outcome measure for the fever, hyperglycaemia (sugar) and swallowing protocol adherence have been revised. Data with less-than or equal to (≤) symbols have been amended to less-than (<) symbols. Under the section, ‘Hyperglycemia (sugar) protocol adherence,’ and with reference to the patients who had a finger-prick glucose on admission to the stroke unit, ‘P = 0·0.07’ has been amended to ‘P = 0·07’ respectively.]
  • Trial Registration: Australia New Zealand Clinical Trial Registry (ANZCTR) No: ACTRN12608000563369.
  • Conflict of interest: None declared.
  • 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.

Abstract

Background

Our randomized controlled trial of a multifaceted evidence-based intervention for improving the inpatient management of fever, hyperglycemia, and swallowing dysfunction in the first three-days following stroke improved outcomes at 90 days by 15%. We designed a quantitative process evaluation to further explain and illuminate this finding.

Methods

Blinded retrospective medical record audits were undertaken for patients from 19 stroke units prior to and following the implementation of three multidisciplinary evidence-based protocols (supported by team-building workshops, and site-based education and support) for the management of fever (temperature ≥37·5°C), hyperglycemia (glucose >11 mmol/l), and swallowing dysfunction in intervention stroke units.

Results

Data from 1804 patients (718 preintervention; 1086 postintervention) showed that significantly more patients admitted to hospitals allocated to the intervention group received care according to the fever (n = 186 of 603, 31% vs. n = 74 of 483, 15%, P < 0·001), hyperglycemia (n = 22 of 603, 3·7% vs. n = 3 of 483, 0·6%, P = 0·01), and swallowing dysfunction protocols (n = 241 of 603, 40% vs. n = 19 of 483, 4·0%, P ≤ 0·001). Significantly more patients in these intervention stroke units received four-hourly temperature monitoring (n = 222 of 603, 37% vs. n = 90 of 483, 19%, P < 0·001) and six-hourly glucose monitoring (194 of 603, 32% vs. 46 of 483, 9·5%, P < 0·001) within 72 hours of admission to a stroke unit, and a swallowing screen (242 of 522, 46% vs. 24 of 350, 6·8%, P ≤ 0·0001) within the first 24 hours of admission to hospital. There was no difference between the groups in the treatment of patients with fever with paracetamol (22 of 105, 21% vs. 38 of 131, 29%, P = 0·78) or their hyperglycemia with insulin (40 of 100, 40% vs. 17 of 57, 30%, P = 0·49).

Interpretation

Our intervention resulted in better protocol adherence in intervention stroke units, which explains our main trial findings of improved patient 90-day outcomes. Although monitoring practices significantly improved, there was no difference between the groups in the treatment of fever and hyperglycemia following acute stroke. A significant link between improved treatment practices and improved outcomes would have explained further the success of our intervention, and we are still unable to explain definitively the large improvements in death and dependency found in the main trial results. One potential explanation is that improved monitoring may have led to better overall surveillance of deteriorating patients and faster initiation of treatments not measured as part of the main trial.

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