A Cluster Randomised Controlled Trial of Implementation of Evidence-Based Treatment Protocols to Manage Fever, Hyperglycaemia, and Swallowing Dysfunction in Acute Stroke

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Title
A cluster randomised controlled trial of implementation of evidence-based treatment
protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke.
Abstract
A single-blind cluster randomised controlled trail was performed using randomised ASUs in
New South Wales, Australia. Patient outcomes were assessed after 90 days of hospital
admission, followed by a multidisciplinary intervention. The study results report that,
intervention ASU patients were significantly likely to be dead or dependent at a lesser rate
(mRS ≥2) at 90 days compared to control ASU patients which was 236 [42%] of 558
patients in the intervention group compared to 259 individuals [58%] of 449 in the control
group. This was irrespective of the stroke. Multidisciplinary supported evidence-based
protocols initiated by nurses was implemented for the management of fever, hyperglycaemia,
and swallowing dysfunction. This was successful in delivering better patient outcomes after
getting discharge from stroke units.
Introduction
Background and objectives
The responsibility of the multidisciplinary team is high in acute stroke patients hence the
Quality in Acute Stroke Care (QASC) study was designed. It assessed the effect of the team
in conducting an 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
Methods

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Trial design
A single-blind cluster randomised controlled trail was performed. Prior to allocation a pre-
intervention patient cohort was recruited. After implementation d a second post-intervention
patient cohort to provide a follow-up sample after intervention implementation.
Participants
The location of was the large and tertiary referral centres in the region of New South Wales
(NSW), Australia, which provided care for stroke patients who are in a geographically
defined location with immediate CT access and on-site high dependency units. Eligibility
criteria included English speaking ability and age group of 18 and more. The patients should
have been previously diagnosed with ischaemic stroke or intracerebral haemorrhage. They
must be presented to the Acute Stoke Units within 48 hours of onset of symptoms. Possession
of telephone required and the patients should not be admitted to palliative care.
Interventions
Fever, Sugar, Swallowing (FeSS) intervention was conducted, which was for the ASU
clinicians. It addressed the barriers, reinforcing the multidisciplinary teamwork, adapting to
local problems and using site champions. Using help from Australia’s national clinical
guidelines for stroke, management protocols developed for fever, hyperglycaemia and
dysphagia for first 72 hours after admission to ASU. Care was given to nursing assessment
and bedside care. Site based interactive and didactic educational interventions conducted for
protocol discussions by clinicians. It was administered from May 15, 2007 to August 25,
2010.

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Outcomes
Primary outcomes
Death or dependency (dependency: modified Rankin Scale (mRS) ≥2)17, functional
dependency, mean SF-36 mental component summary (MCS) and mean physical component
summary (PCS)
Conducted after 90 days of hospital admission
Secondary outcomes
Mean temperature for the first 72 h after acute stroke unit (ASU) admission, the mean of
finger-prick blood glucose for the first 72 h after ASU admission, proportion of swallowing
screening undertaken within the first 24 h of ASU admission, discharge diagnosis of
aspiration pneumonia and length of hospital stay
Included processes of care
Sample size
The initial sample size consisted of 20 clusters