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The Quality in Acute Stroke Care (QASC) Implementation Project

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Title: The Quality in Acute Stroke Care (QASC) Implementation Project


1
The Quality in Acute Stroke Care (QASC)
Implementation Project
  • Local Stroke Champion Presentation

2
Quality in Acute Stroke Care Trial (QASC)
  • AIM
  • To evaluate a nurse-initiated, multidisciplinary
    organisational intervention to improve
    evidence-based management of fever,
    hyperglycaemia and swallowing in patients
    following acute stroke

3
Quality in Acute Stroke Care Trial (QASC)
  • Cluster randomised controlled trial
  • Two patient cohorts pre and post intervention
    (Aug 2005 Jan 2011) (n1696)
  • Data collection Computer Assisted Telephone
    Interviews (CATI) medical record audits
  • Outcome measures Modified Rankin Score Barthel
    Index SF-36 Processes of care for fever,
    glucose and swallowing

4
Intervention
  • Fever, Sugar, Swallowing (FeSS) clinical
    protocols
  • Implementation Support
  • Multidisciplinary team building workshops
  • Education
  • Support (site visits, reminders)

5
Results
  • FeSS intervention resulted in 90-day
  • Decreased death and dependency
  • 16 more likely to be alive and independent if
    cared for on an intervention unit
  • Effective for both severe and mild strokes
  • Improved physical functioning
  • Decreased mean temperature and mean glucose
  • Improved swallow screening

6
Vol. 378 No 9804
7
The QASC Implementation Project
  • The NSW Agency for Clinical Innovation has
    partnered with the Nursing Research Institute, a
    joint initiative between St Vincents and Mater
    Health Sydney and Australian Catholic University
  • Translational quality improvement project

8
Fever
9
Fever Post Stroke
  • Associated with a significant increase in
    morbidity and mortality1 attributed to
  • Increased cerebral metabolic demands
  • Changes in the blood-brain barrier permeability
  • Acidosis
  • Increased release of excitatory amino acids
  • 1 Den Hertog HM, et al. 2011

10
Fever Post Stroke
  • Causes infarct expansion
  • In the first days following acute stroke, fever
    (temperature gt37.5ºC) develops in one fifth to
    almost one half of patients23
  • 2Reith et al1996, 3Azzimondi et al 1995

11
Hyperglycaemia
12
Sugar Post Stroke
  • Associated with a significant increase in
    morbidity and mortality4 attributed to
  • Toxic to the brain
  • Insulin deficiency
  • Undiagnosed vascular disease
  • Blood brain barrier disruption
  • 4 Clement et al. 2004

13
Sugar Post Stroke
  • In the first 48hrs incidence can be up to 45 of
    patients56
  • Across all stroke subtypes67
  • Glucose above 8 mmol/l predictor increased
    mortality and poorer functional outcome8
  • 5Allport et al 2006, 6Scott et all 1999, 7Capes
    et al 2001, 8 Weir et al 1997

14
Mortality Following Stroke in Hyperglycaemic
Subjects
  • A meta-analysis of patients admitted to hospital
    with stroke has shown that hyperglycaemic
    subjects who were not known to have diabetes are
    about 3 times more likely to die than those who
    are not hyperglycaemic7

7 Capes et al 2001
15
Fever and Sugar Management
  • Salvaging the ischaemic penumbra
  • Critically hypoperfused but still viable brain
    tissue
  • Penumbral brain tissue exists out to 48 hours
    post stroke onset and is generally considered to
    be the target of most acute stroke therapies

16
(No Transcript)
17
Swallowing
18
Swallowing Difficulty (Dysphagia)
  • Aspiration can lead to
  • chest infections
  • aspiration pneumonia
  • death
  • Dysphagia occurs in 65 of acute stroke patients
    and aspiration pneumonia in 109
  • In NSW, 28 - 63 of patients receive swallowing
    assessment within 24 hours of stroke onset10
  • 9Martino et al 2005, 10NSF Clinical Audit 2007

19
National Stroke Guidelines11
11 National Stroke Foundation 2010
20
Guideline 4.7 Physiological Monitoring
  • Patients should have their neurological status
    (e.g. Glasgow Coma Scale), vital signs (including
    pulse, blood pressure, temperature, oxygen
    saturation and glucose levels) and respiratory
    pattern monitored and documented regularly during
    the acute phase, the frequency of such
    observations being determined by the patients
    status (Grade C)

21
Guideline 4.11 Pyrexia
  • Antipyretic therapy, comprising regular
    paracetamol and/or physical cooling measures,
    should be used routinely where fever occurs
    (Grade C)

22
Guideline 4.9 Glycaemic Control
  • a) On admission all patients should have their
    blood glucose level monitored and appropriate
    glycaemic therapy instituted to ensure
    euglycaemia, especially if the patient is
    diabetic (Grade GPP)
  • b) Intensive, early maintenance of euglycaemia is
    currently NOT recommended (Grade B)

23
Guideline 6.2.1 Dysphagia
  • a)Patients should be screened for swallowing
    deficits before being given food, drink or oral
    medications. Personnel specifically trained in
    swallowing screening using a validated tool
    should undertake screening (Grade B)
  • b) Swallowing should be screened for as soon as
    possible but at least within 24 hours of
    admission (Grade GPP)

24
Guideline 6.2.1 Dysphagia
  • c) The gag reflex is not a valid screen for
    dysphagia and should NOT be used as a screening
    tool
  • d) Patients who fail the swallowing screening
    should be referred to a speech pathologist for a
    comprehensive assessment (Grade GPP)

25
FeSS Clinical Protocols
26
  • Fever
  • 4 -6 hourly temperature readings for 72 hours
  • Temperature gt 37.5C treat with paracetamol

27
  • Sugar
  • Formal venous glucose on admission
  • 1-6 hourly finger-prick glucose for 72 hours
  • Glucose gt 10 mmol/L treat with insulin

28
  • Swallow
  • Education program and online competency
    assessment
  • Screen within 24 hours of stroke service
    admission and before oral intake
  • Referral to speech pathologist for full swallow
    assessment for those who failed the screen

29
In Summary
30
How will we implement this?
  • Site champions
  • Local Implementation plan
  • Local barriers and enablers assessment
  • Engagement of multidisciplinary team
  • Local education of clinical staff
  • Support from the NRI/ ACI (site visit phone
    support)

31
References
  • Den Hertog HM, et al. 2011. Journal of Neurology,
    258(2), 302-307.
  • Reith et al. 1996. Lancet. 347(8999), 422-425.
  • Azzimondi et al. 1995. Stroke. 26(11), 2040-2043.
  • Clement et al. 2004. Diabetes Care, 27(2), 553.
  • Allport et al 2006. Diabetes Care, 29(8),
    1839-1844.
  • Scott et al. 1999. Lancet, 353, 376-377.
  • Capes et al. 2001. Stroke, 32(10), 2426-2432.
  • Weir et al. 1997. British Medical Journal,
    314(7090), 1303.
  • Martino et al. 2005. Stroke, 36(12), 2756-2763.
  • National Stroke Foundation. 2007. Victoria NSF.
  • National Stroke Foundation. 2010. Victoria NSF.
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