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Quality in Acute Stroke Care Implementation Project (QASCIP)

St Vincent's Health Network
Project Added:
27 May 2015
Last updated:
27 May 2015

Quality in Acute Stroke Care Implementation Project (QASCIP)

Summary

Following results of a successful trial, the Quality in Acute Stroke Care Implementation Project (QASCIP) implemented three clinical protocols to manage fever, hyperglycaemia and swallowing in stroke (the Fever Sugar, Swallow (FeSS) clinical protocols). The Nursing Research Institute partnered with the NSW Agency for Clinical Innovation (ACI), 15 local health districts (LHDs), clinicians and the National Stroke Foundation (NSF) to implement the FeSS clinical protocols in all 36 NSW stroke services. 

This project was a finalist in the Translational Research category of the 2014 NSW Health Awards. Download a poster from the 2014 NSW Health Awards.

Aim

To improve patient outcomes and reduce death and dependency in stroke patients.

Benefits

  • Improves outcomes for stroke patients and stroke services.
  • Reduces length of stay (LoS) in hospital.
  • Decreases death and dependency caused by stroke.
  • Achieves sustainability by working in synergy with the NSF clinical audit program.
  • Improves efficiency and productivity in stroke units and services.

Project Status

Project dates April 2013 - June 2014.

Project status: Sustained - the project has been implemented and is sustained in standard business.

Background

Stroke is Australia’s second most common cause of death and disability, costing an estimated $5 billion a year. The Quality Acute Stroke Care (QASC) trial was conducted in 19 stroke units throughout NSW, with implementation of the FeSS clinical protocols for 72-hours following stroke. 10 stroke units received the interventions, while nine control stroke units did not.

Patients treated in the intervention stroke units had a 16% reduction in death and dependency at 90 days post-admission; reduced temperatures and glucose levels; improved swallow screening; and significantly improved fever, hyperglycaemia and swallowing management. While not statistically significant, they also had a clinically important two-day decrease in LoS.

The clinical significance of these results was remarkable, as they are better results than any known proven intervention for stroke. This includes administration of aspirin within 48 hours (1%), stroke unit care (5%) and thrombolysis within 4.5 hours (10%) with thrombolysis available only to a very specific ischaemic stroke population.

Given the significant reduction in death and dependency and improved processes of care shown by the QASC trial, it was determined that all 36 stroke services in NSW implement the clinical protocols to manage fever, hyperglycaemia and swallowing in stroke patients.

Implementation 

  • A steering committee and working group was established, to foster openness and transparency between collaborators and team members.
  • To recruit participating services, invitation letters were sent using a ‘top down’ and ‘bottom up’ strategy to key LHD stakeholders.
  • All 36 NSW stroke services participated, with 2144 patients (1062 pre-implementation and 1082 post-implementation).
  • Stroke services nominated clinical champions at each site, who were pivotal in managing the implementation locally. Stroke site champions were empowered by becoming local leaders in the implementation process.
  • The statewide rollout used the proven QASC trial implementation strategies: examining barriers and enablers, education, reminders and clinician champion support.
  • QASCIP implemented FeSS protocols in stroke units and in smaller hospitals that had a stroke service rather than an organised stroke unit, which allowed rural and remote hospitals and their patients to benefit from the project.
  • Medical record audits measured protocol adherence using a pre- and post-study design.
  • The National Stroke Foundation (NSF) clinical audit tool was used, which allowed evaluation of the project and established a process for sites to measure sustainability beyond the conclusion of the project.
  • Patient confidentiality was maintained and only de-identified data was analysed.
  • A model was developed to support translational activities at the local level, including provision of tools for clinical champion empowerment, audit training and benchmarked individual hospital reports to participating sites.

Lead organisation

Nursing Research Institute, St Vincent’s Hospital Sydney (SVHS) 

Partnerships

  • NSW Agency for Clinical Innovation
  • Australian Catholic University
  • Local Health Districts
  • National Stroke Foundation

Implementation sites

Armidale, Bankstown, Bathurst, Belmont, Blacktown, Bowral, Broken Hill, Calvary, Campbelltown, Coffs Harbour, Concord, Dubbo, Fairfield, Gosford, Hornsby, John Hunter Hospital, Lismore, Liverpool, Maitland, Manly, Manning, Nepean, Orange, Port Macquarie, Prince of Wales, Royal North Shore, Royal Prince Alfred, Shoalhaven, St George, St Vincent’s, Sutherland, Tamworth, Wagga Wagga, Westmead, Wollongong, Wyong.

Results

Results showed a significant increase in the proportion of patients who received care according to the FeSS protocols. Specifically, increased proportions of patients received care according to the fever (pre:68%; post:78%; p=0.003), sugar (pre:23%; post:34%; p=0.009) and swallowing (pre:43%; post:51%; p=0.039) protocols. Not only were these results statistically significant, they were also of high clinical importance and resulted in better care for stroke patients.

Awards Received

  • 2014 NSW Premier's Public Sector Award for Improving Performance and Accountability
  • 2014 Finalist, NSW Health Awards 2014, Translational Research
  • 2014 National Lead Clinicians Group Awards for Excellence in Innovative Implementation of Clinical Practice. Runner up in General Category.

Lessons Learnt

  • The tools, processes and education models used in this project are applicable beyond stroke care and can be used in any specialty where evidence-based results need to be translated into statewide clinical practice. They are available on the QASC page of the ACU website.
  • The strategic collaboration between industry, academia and professional bodies show that research can be translated into the real world of clinical practice.
  • Challenges of the project include maintenance of implementation fidelity, i.e. adherence to the evidence provided in the QASC trial with no change to the original successful intervention.
  • Rapid translation of evidence to practice is often challenging. Research shows it can take up to 17 years to get evidence into practice, however this project took only 14 months and within three years of publication of the evidence (2011-2014).

Further Reading

  1. Middleton S, McElduff P, Ward J et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. The Lancet 2011; 378(9804): 1699-706.
  2. Middleton S. Keeping It Simple: The power of three clinical protocols. Journal of Clinical Nursing 2012; 21: 3195-3197.
  3. Drury P, Levi C, D’Este C et al. Quality in Acute Stroke Care (QASC): Process evaluation of an intervention to improve the management of fever, hyperglycaemia, and swallowing dysfunction following acute stroke. International Journal of Stroke 2014; 9(6): 766-776.
  4. Dale S, Levi C, Ward J et al. Barriers and enablers to implementation clinical treatment protocols for fever, hyperglycaemia and swallowing dysfunction in the Quality in Acute Stroke Care (QASC) Project: a mixed methods study. Worldviews on Evidence Based Nursing. Web. 21 January 2015.
  5. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine; 2011: 104(12): 510-20.
  6. Statistics ABoH. 3303.0 - Causes of Death, Australia, 2013.
  7. National Stroke Foundation. The Economic Impact of Stroke in Australia. Melbourne: National Stroke Foundation; 2013.
  8. Sandercock P, Counsell C, Gubitz G et al. Antiplatelet therapy for acute ischaemic stroke. Cochrane Database of Systematic Reviews; 2008: (3).
  9. Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews; 2013: (9).
  10. Hacke W, Kaste M, Bluhmki E et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. New England Journal of Medicine; 2008: 359(13): 1317-29.
  11. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue Plasminogen Activator for Acute Ischemic Stroke. New England Journal of Medicine; 1995: 333(24): 1581-8.

Contact

Professor Sandy Middleton
Director, Nursing Research Institute
St Vincent’s Health Australia (Sydney) and Australian Catholic University
Phone: 02 8382 3790
Email: Sandy.middleton@acu.edu.au

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