ArticlesImplementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial
Introduction
Although organised stroke unit care significantly reduces death and disability from cerebrovascular events,1 three physiological variables are not yet universally well managed despite their importance for long-term patient recovery.2, 3, 4 In the first days of an acute stroke, temperature higher than 37·5°C occurs in 20–50% of patients;2 up to 50% become hyperglycaemic;3 and 37–78%4 have dysphagia; all result in increased morbidity and mortality.2, 3, 4 Hence, international guidelines recommend that fever and high blood glucose concentrations be monitored and managed proactively and that every stroke patient have their swallowing status evaluated before receiving food, fluid, or oral medication.5, 6 All these recommendations are the responsibility of the stroke multidisciplinary team.7 Care is not always consistent with these recommendations however.6, 8 We designed the Quality in Acute Stroke Care (QASC) study, a cluster randomised controlled trial,9, 10 to assess the effect of multidisciplinary team building workshops and a standardised interactive education programme to implement evidence-based treatment protocols for the management of fever, hyperglycaemia, and swallowing dysfunction on patient outcomes 90 days after admission for stroke. These three variables were selected because they implicate multidisciplinary teamwork, which has been shown to improve health-care processes and patient outcomes,11 a priority for stroke care.
Section snippets
Trial design and participants
Our single-blind cluster randomised controlled trial randomised Acute Stroke Units (ASUs) to minimise contamination because our team building intervention was designed for implementation at the ASU level.12 Outcomes before and after intervention were assessed at the patient level. The trial protocol has been published previously.9 All treatment protocols, the ASSIST dysphagia screening tool, and further information about implementation of the intervention are available at the Australian
Results
19 (95%) ASUs agreed to participate (figure 1). The length of time ASUs had been established before trial commencement was similar between intervention and control groups. Data for the pre-intervention patient cohort have been published.10 Age, sex, 90-day death, 90-day death and dependency, 90-day functional dependency (BI), and health status (PCS score and MCS score) were similar for the intervention and control groups.
For the post-intervention cohort, of the 1292 eligible patients, 166 (13%)
Discussion
Our results show that patients of ASUs allocated to receive our multidisciplinary intervention to support proactive evidence-based management of fever, hyperglycaemia, and swallowing were significantly more likely to be alive and independent at 90 days after admission. Specifically, we showed a 15·7% adjusted absolute difference in rates of 90-day death and dependency. The clinical significance of these results is more remarkable when compared against other established clinical and
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