Transcript Document

The Quality in Acute Stroke Care
Project (QASC)
Middleton S, Levi C,
Griffiths R, Grimshaw J,
Ward J, D’Este C, Dale S,
Drury P, McInnes E, Hardy J,
Cheung N, McElduff P,
Cadilhac D, Evans M,
Quinn C
Fever
 Quarter to third of patients >37.5°c
1-3
within first few days
 Marked increase in morbidity &
3,4-6
mortality
1,6,7
 Indication of poor outcome
1Azzimondi
et al. (1995), 2Castillo et al. (1998) 3Turaj et al. (2008), 4Reith et al. (1996)
5Wang
et al. (2000), 6Hajat et al. (2000), 7Kammersgaard et al. (2002)
Fever
 Associated with a significant increase in
morbidity and mortality attributed to:
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


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Increased cerebral metabolic demands
Changes in the blood-brain barrier
permeability
Acidosis
Increased release of excitatory amino acids
Causes infarct expansion
Hyperglycaemia
 In the first 48hrs incidence can be up to
8,9
45% of patients
 Across all stroke subtypes
9,10
 Glucose above 8 mmol/l predictor
increased mortality & poorer functional
10,11
outcome
Allport et al . (2006), 9Scott et al. (1999), 10Capes et al. (2001), 11Weir et al. (1997)
8
Hyperglycaemia in non-diabetics
 Meta-analysis: hyperglycaemic (BGL > 8
mmol/L) non-diabetic patients admitted to
hospital with stroke are approximately 3
times more likely to die than non-diabetic
patients without hyperglycaemia
10Capes
et al. (2001)
Fever and Sugar Management
Aimed at ‘Salvaging’ the ischaemic
penumbra
 The penumbral is critically
hypoperfused but still viable brain
tissue
 Thought to exists out to 48 hours post
stroke and is the ‘target’ of most acute
stroke therapies
Swallowing Difficulty (Dysphagia)
 Dysphagia occurs in 37 - 78% of acute
stroke patients and aspiration
12
pneumonia in 10%
 Aspiration can lead to:
 Chest infections
 Aspiration pneumonia
 Death
12Martino
et al. (2005)
Swallowing Difficulty (Dysphagia)
 Adherence to formal dysphagia screening
protocol decreases incidence of
13,14
pneumonia
 Gag reflex is NOT a valid screen for
dysphagia
13Odderson
et al. (1995), 14Hinchey et al. (2005)
Clinical Guidelines for Acute Stroke
Management^
 Four specific recommendations concerned
with the management of fever,
hyperglycaemia and swallowing in
National Stroke Foundation (NSF) Clinical
Guidelines for Stroke Management 2010
^ NSF 2010
FeSS: Fever, Sugar & Swallowing
Intervention
 Evidence-based clinical treatment
protocols for management of:
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Fever
Hyperglycaemia
Swallowing
 Implementation strategies:
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Workshops to identify barriers & enablers
Interactive and didactic educational outreach
meetings
Reminders
Duration
 All elements of the intervention will run
for the first 72 hours of admission to the
stroke unit
Fever Protocol
 Monitor temperature for 72 hours
 Treat temperature > 37.5°C
 Standing order for paracetamol
 Paracetamol on nurse-initiated
medication list
Sugar (Hyperglycaemia) Protocol
 Formal glucose measured on
admission to hospital/stroke unit
 Fingerprick Blood Glucose Level (BGL)
on admission to the stroke unit
 Before/after meals & bedtime
fingerprick BGL’s for 72 hours if BGL
<10 mmols/L
Sugar (Hyperglycaemia) Protocol
 1-2 hourly fingerpricks to monitor BGL
for 48 hours following admission when
admission BGL > 10 mmols /L
 If BGL > 10 mmols/L at any time in first
48 hours following admission then
insulin infusion commenced
Swallowing Protocol
 Nurses trained to screen

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Successfully screen 3 patients
Pass written test
 Patients should be screened
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
Before being given food, drink or medications
Within 24 hrs of admission to hospital
 Referral to speech pathologist for a full
swallowing assessment if failed screen
References
1.
2.
3.
4.
Azzimondi G, Bassein L, Nonino F, Fiorani L, Vignatelli L, Re G, et al. Stroke. 1995 Nov;26(11):2040-3.
Castillo J, Davalos A, Marrugat J & Noya M. Stroke. 1998;29(12):2455-60.
Turaj W, Slowik A, & Szczudlik A. Neurol Neurochir Pol. 2008 Jul-Aug;42(4):316-22.
Reith J, Jorgensen HS, Pedersen PM, Nakayama H, Raaschou HO, Jeppesen LL, et al. Lancet. 1996 Feb
17;347(8999):422-5.
5. Wang Y, Lim LL, Levi C, Heller RF & Fisher J. Stroke. 2000;31(2):404-9.
6. Hajat C, Hajat S & Sharma P. Stroke. 2000 Feb;31(2):410-4.
7. Kammersgaard LP, Jorgensen HS, Rungby JA, Reith J, Nakayama H, Weber UJ, et al. Stroke. 2002
Jul;33(7):1759-62.
8. Allport L, Baird T, Butcher K, Macgregor L, Prosser J, Colman P, et al. Diabetes Care. 2006;29(8):183944.
9. Scott JF, Robinson GM, French JM, O'Connell JE, Alberti KGMM & Gray CS. Lancet. 1999;353:376-7.
10.Capes SE, Hunt D, Malmberg K, Pathak P, & Gerstein HC. Stroke. 2001 October 1, 2001;32(10):242632.
11.Kammersgaard LP, Jorgensen HS, Rungby JA, Reith J, Nakayama H, Weber UJ, et al. Stroke. 2002
Jul;33(7):1759-62.
12.Martino R, Foley N, Bhogal S, Diamant N, Speechley M, & Teasell R.. Stroke. 2005;36(12):2756-63.
13.Odderson IR, Keaton JC & McKenna BS.Arch Phys Med Rehabil. 1995 Dec;76(12):1130-3.
14.Hinchey JA, Shephard T, Furie K, Smith D, Wang D & Tonn S. Stroke. 2005;36(9):1972-6.
15.National Stroke Foundation. 2010. Victoria: NSF; 2010.