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Quality in Acute Stroke Care (QASC): process evaluation of an intervention to improve the management of fever, hyperglycemia, and swallowing dysfunction following acute stroke

Drury, Peta; Levi, Christopher; D'Este, Catherine; McElDuff, Patrick; McInnes, Elizabeth; Hardy, Jennifer; Dale, Simeon; Cheung, N Wah; Grimshaw, Jeremy M; Quinn, Clare; Ward, Jeanette; Evans, Malcolm; Cadilhac, Dominique; Griffiths, Rhonda; Middleton, Sandy

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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...[Show more]

dc.contributor.authorDrury, Peta
dc.contributor.authorLevi, Christopher
dc.contributor.authorD'Este, Catherine
dc.contributor.authorMcElDuff, Patrick
dc.contributor.authorMcInnes, Elizabeth
dc.contributor.authorHardy, Jennifer
dc.contributor.authorDale, Simeon
dc.contributor.authorCheung, N Wah
dc.contributor.authorGrimshaw, Jeremy M
dc.contributor.authorQuinn, Clare
dc.contributor.authorWard, Jeanette
dc.contributor.authorEvans, Malcolm
dc.contributor.authorCadilhac, Dominique
dc.contributor.authorGriffiths, Rhonda
dc.contributor.authorMiddleton, Sandy
dc.date.accessioned2016-06-14T23:18:51Z
dc.identifier.issn1747-4930
dc.identifier.urihttp://hdl.handle.net/1885/102646
dc.description.abstractBackground: 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). Interpretation: 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.
dc.publisherBasil Blackwell
dc.sourceInternational Journal of Stroke
dc.titleQuality in Acute Stroke Care (QASC): process evaluation of an intervention to improve the management of fever, hyperglycemia, and swallowing dysfunction following acute stroke
dc.typeJournal article
local.description.notesImported from ARIES
local.identifier.citationvolume9
dc.date.issued2014
local.identifier.absfor111705 - Environmental and Occupational Health and Safety
local.identifier.absfor111706 - Epidemiology
local.identifier.ariespublicationa383154xPUB2485
local.type.statusPublished Version
local.contributor.affiliationDrury, Peta, Australian Catholic University
local.contributor.affiliationLevi, Christopher, University of Newcastle
local.contributor.affiliationD'Este, Catherine, College of Medicine, Biology and Environment, ANU
local.contributor.affiliationMcElDuff, Patrick, University of Newcastle
local.contributor.affiliationMcInnes, Elizabeth, Australian Catholic University
local.contributor.affiliationHardy, Jennifer, University of Sydney
local.contributor.affiliationDale, Simeon, Australian Catholic University
local.contributor.affiliationCheung, N Wah, University of Sydney
local.contributor.affiliationGrimshaw, Jeremy M, University of Ottawa
local.contributor.affiliationQuinn, Clare, Prince of Wales Hospital
local.contributor.affiliationWard, Jeanette, University of Ottawa
local.contributor.affiliationEvans, Malcolm, University of Newcastle
local.contributor.affiliationCadilhac, Dominique, Monash University
local.contributor.affiliationGriffiths, Rhonda, University of Western Sydney
local.contributor.affiliationMiddleton, Sandy, Australian Catholic University
local.description.embargo2037-12-31
local.bibliographicCitation.issue6
local.bibliographicCitation.startpage766
local.bibliographicCitation.lastpage776
local.identifier.doi10.1111/ijs.12202
dc.date.updated2016-06-14T08:29:58Z
local.identifier.scopusID2-s2.0-84904674079
CollectionsANU Research Publications

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