Transcript The Quality in Acute Stroke Care (QASC) Implementation Project

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:
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Decreased death and dependency
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16% more likely to be alive and independent if
cared for on an intervention unit
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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 mortality1 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 patients2&3
2Reith
et al1996, 3Azzimondi et al 1995
Hyperglycaemia
Sugar Post Stroke
• Associated with a significant increase in
morbidity and mortality4 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 patients5&6
• Across all stroke subtypes6&7
• Glucose above 8 mmol/l predictor
increased mortality and poorer
functional outcome8
5Allport
et al 2006, 6Scott et all 1999, 7Capes 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
hyperglycaemic7
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 onset10
9Martino
et al 2005, 10NSF Clinical Audit 2007
National Stroke Guidelines11
11 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°C
Measure BSL 1-6 hourly (see flow chart)
Treat if BSL > 10mmols
Nurses 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
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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. 2011. Journal of Neurology, 258(2), 302-307.
2. Reith et al. 1996. Lancet. 347(8999), 422-425.
3. Azzimondi et al. 1995. Stroke. 26(11), 2040-2043.
4. Clement et al. 2004. Diabetes Care, 27(2), 553.
5. Allport et al 2006. Diabetes Care, 29(8), 1839-1844.
6. Scott et al. 1999. Lancet, 353, 376-377.
7. Capes et al. 2001. Stroke, 32(10), 2426-2432.
8. Weir et al. 1997. British Medical Journal, 314(7090), 1303.
9. Martino et al. 2005. Stroke, 36(12), 2756-2763.
10. National Stroke Foundation. 2007. Victoria: NSF.
11. National Stroke Foundation. 2010. Victoria: NSF.