A multidisciplinary intervention targeting fever, hyperglycaemia and swallowing management in acute stroke units means stroke patients are less likely to be dead or dependent at 90 days and have better physical functioning than those given standard care. The authors of the study say that clinical leaders of stroke services can adopt this strategy with confidence that their outcomes will improve. The findings appear in an Article published Online First by The Lancet, written by Professor Sandy Middleton, Nursing Research Institute, St Vincent's & Mater Health, Sydney, Australia, and Australian Catholic University, and colleagues.
Although organised stroke unit care significantly reduces death and disability from cerebrovascular events, the 3 physiological variables above are not yet universally well managed despite their importance for long-term patient recovery. In the first days of an acute stroke, temperature higher than 37.5°C occurs in 20-50% of patients; up to 50% become hyperglycaemic; and 37-78% have problems swallowing; all of these problems are associated with increased morbidity and mortality. In this study (Quality in Acute Stroke Care [QASC]), a randomised controlled trial, an evidence-based intervention targeting management of these 3 problems was trialled in 19 acute stroke units (ASUs) in New South Wales, Australia.
For fever, the intervention included temperature monitoring every 4 hours and use of paracetamol to lower temperature where required. Hyperglyaemia management included regular blood glucose monitoring and infusion of saline or insulin depending on blood sugar levels and presence or absence of diabetes. For swallowing, nurses underwent pre-intervention training, including education by a speech pathologist, watching a training DVD, and knowledge and competency testing.
The 19 ASUs were randomly assigned to intervention (10) or control (9). Of 6564 patients assessed for eligibility, 1699 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent at 90 days (42% vs 58% in control group). They also had better results on a standard physical performance assessment (the SF-36 mean physical component summary score): 45.6 in the intervention group vs 42.5 in the control group (with around 95% of the population falling between 30 and 70 on this scale). However, no improvement was recorded in overall mortality (4% intervention vs 5% control), or mental functioning or physical dependency assessment.
The authors say that the difference in rates of 90-day death and dependency are remarkable when compared against other established clinical and organisational interventions, namely administration of aspirin within 48 hours, stroke unit care, and thrombolysis within 4.5 hours. All deliver absolute benefit for independent survival of no more than 10%, and thrombolysis is available only to a very specific ischaemic stroke population, unlike the QASC intervention, which has relevance for all stroke patients.
The authors conclude: "The QASC trial provides high-quality evidence that a guideline implementation strategy to support multidisciplinary teamwork and good nursing care focused on evidence-based management of three key physiological variables in ASUs delivers significantly better post-discharge outcomes for stroke patients. Clinical leaders of stroke services can adopt this strategy with confidence that their outcomes will improve."
In a linked Comment, Professor Charles D A Wolfe and Dr Anthony G Rudd, King's College London, London, and National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Trust and King's College London, say: "The findings from Middleton and colleagues are highly pertinent to health systems worldwide since admissions for stroke care are set to increase by 30% in the next 20 years."
They caution that more must be known about the baseline level of care in these Australian units in order to accurately assess the true benefit of the intervention in QASC. They conclude: "The next step must be to assess this methodology in other healthcare systems and to undertake long-term studies to show a sustainable effect. However, the main message that should be taken from Middleton and colleagues' study is that more detailed observation and correction of physiological abnormalities after acute stroke is logical, and that studies of this sort should be developed alongside drug and other acute interventions."
Professor Sandy Middleton, Nursing Research Institute, St Vincent's Hospital, Sydney, Australia. T) +61 410 661 424 (mob) / + 61 2 8382 3790 E) sandy.middleton@acu.edu.au
Professor Charles D A Wolfe, King's College London, London, and National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Trust and King's College London. T) +44 (0) 207 8486604 E) charles.wolfe@kcl.ac.uk
Journal
The Lancet