title: Quality in Acute Stroke Care (QASC): process evaluation of an intervention to improve the management of fever, hyperglycemia, and swallowing dysfunction following acute stroke.
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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Nursing Research Institute, St.Vincent's & Mater Health Sydney, Australian Catholic University, Sydney, NSW, Australia; School of Nursing, Midwifery & Paramedicine (NSW & ACT), Australian Catholic University, NSW, Australia.
authors.forename: Peta
authors.initials: P
authors.lastname: Drury
authors.forename: Christopher
authors.initials: C
authors.lastname: Levi
authors.forename: Catherine
authors.initials: C
authors.lastname: D'Este
authors.forename: Patrick
authors.initials: P
authors.lastname: McElduff
authors.forename: Elizabeth
authors.initials: E
authors.lastname: McInnes
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hardy
authors.forename: Simeon
authors.initials: S
authors.lastname: Dale
authors.forename: N Wah
authors.initials: NW
authors.lastname: Cheung
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Grimshaw
authors.forename: Clare
authors.initials: C
authors.lastname: Quinn
authors.forename: Jeanette
authors.initials: J
authors.lastname: Ward
authors.forename: Malcolm
authors.initials: M
authors.lastname: Evans
authors.forename: Dominique
authors.initials: D
authors.lastname: Cadilhac
authors.forename: Rhonda
authors.initials: R
authors.lastname: Griffiths
authors.forename: Sandy
authors.initials: S
authors.lastname: Middleton
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D003680:Deglutition Disorders / Q000503:physiopathology / Q000628:therapy*; D019317:Evidence-Based Medicine; D005260:Female; D005334:Fever / Q000503:physiopathology / Q000628:therapy*; D019983:Guideline Adherence; D006760:Hospitalization; D006801:Humans; D006943:Hyperglycemia / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000503:physiopathology* / Q000628:therapy*; D016896:Treatment Outcome
keywords: Fever; acute stroke; behavior change; dysphagia; hyperglycemia; process evaluation