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

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

Quality in Acute Stroke Care Trial (QASC) Cluster randomised controlled trial Two patient cohorts: pre and post intervention (Aug 2005 – Jan 2011) (n=1696) 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

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

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

Vol. 378 No 9804

The QASC Implementation Project The NSW Agency for Clinical Innovation has partnered with the Nursing Research Institute, a joint initiative between St Vincent’s and Mater Health Sydney and Australian Catholic University Translational quality improvement project

Fever

Fever Post Stroke Associated with a significant increase in morbidity and mortality 1 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

Fever Post Stroke Causes infarct expansion In the first days following acute stroke, fever (temperature >37.5ºC) develops in one fifth to almost one half of patients 2&3 2 Reith et al1996, 3 Azzimondi et al 1995

Hyperglycaemia

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

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

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 hyperglycaemic 7 7 Capes et al 2001

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

Swallowing

Swallowing Difficulty (Dysphagia) Aspiration can lead to: chest infections aspiration pneumonia death Dysphagia occurs in 65% of acute stroke patients and aspiration pneumonia in 10% 9 In NSW, 28% - 63% of patients receive swallowing assessment within 24 hours of stroke onset 10 9 Martino et al 2005, 10 NSF Clinical Audit 2007

National Stroke Guidelines National Stroke Foundation 2010

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 patient’s status (Grade C)

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

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 )

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)

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)

FeSS Clinical Protocols

Fever : 4 -6 hourly temperature readings for 72 hours Temperature > 37.5°C treat with paracetamol

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

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

In Summary In the first 72 hours post stroke: Measure temperature 4-6 hourly (see flow chart)Treat if temperature > 37.5°CMeasure BSL 1-6 hourly (see flow chart)Treat if BSL > 10mmolsNurses should be trained in ASSIST routinely All stroke patients should have their swallow screen completed within 24 hours of admission

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)

References 1.Den Hertog HM, et al Journal of Neurology, 258(2), Reith et al Lancet. 347(8999), Azzimondi et al Stroke. 26(11), Clement et al Diabetes Care, 27(2), Allport et al Diabetes Care, 29(8), Scott et al Lancet, 353, Capes et al Stroke, 32(10), Weir et al British Medical Journal, 314(7090), Martino et al Stroke, 36(12), National Stroke Foundation Victoria: NSF. 11.National Stroke Foundation Victoria: NSF.