title: Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial.
abstract: 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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  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.
authors: Nursing Research Institute, St Vincent's & Mater Health Sydney and School of Nursing, Australian Catholic University, NSW, Australia. sandy.middleton@acu.edu.au
authors: Sandy
authors: S
authors: Middleton
authors: Patrick
authors: P
authors: McElduff
authors: Jeanette
authors: J
authors: Ward
authors: Jeremy M
authors: JM
authors: Grimshaw
authors: Simeon
authors: S
authors: Dale
authors: Catherine
authors: C
authors: D'Este
authors: Peta
authors: P
authors: Drury
authors: Rhonda
authors: R
authors: Griffiths
authors: N Wah
authors: NW
authors: Cheung
authors: Clare
authors: C
authors: Quinn
authors: Malcolm
authors: M
authors: Evans
authors: Dominique
authors: D
authors: Cadilhac
authors: Christopher
authors: C
authors: Levi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001315:Australia / Q000453:epidemiology; D003680:Deglutition Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000451:nursing*; D004185:Disability Evaluation; D019317:Evidence-Based Medicine; D005260:Female; D005334:Fever / Q000453:epidemiology / Q000451:nursing*; D006757:Hospital Units; D006801:Humans; D006943:Hyperglycemia / Q000453:epidemiology / Q000451:nursing*; D007318:Inservice Training; D007902:Length of Stay; D008297:Male; D009730:Nursing Assessment; D010348:Patient Care Team; D011015:Pneumonia, Aspiration / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D012720:Severity of Illness Index; D016037:Single-Blind Method; D020521:Stroke / Q000401:mortality* / Q000451:nursing*