Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study

Sandy Middleton; Simeon Dale; Benjamin McElduff; Kelly Coughlan; Elizabeth McInnes; Robert Mikulik; Thomas Fischer; Jan Van der Merwe; Dominique Cadilhac; Catherine D'Este; Christopher Levi; Jeremy M Grimshaw; Andreea Grecu; Clare Quinn; Ngai Wah Cheung; Tereza Koláčná; Sabina Medukhanova; Estela Sanjuan Menendez; Susana Salselas; Gert Messchendorp; Anne-Kathrin Cassier-Woidasky; Marcelina Skrzypek-Czerko; Merce Slavat-Plana; Urso Antonella; Waltraud Pfeilschifter

doi:10.1177/23969873221126027

Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study

Eur Stroke J. 2023 Mar;8(1):132-147. doi: 10.1177/23969873221126027. Epub 2022 Oct 24.

Authors

Sandy Middleton^{1

2}, Simeon Dale^{1

2}, Benjamin McElduff^{1

2}, Kelly Coughlan^{1

2}, Elizabeth McInnes^{1

2}, Robert Mikulik³, Thomas Fischer⁴, Jan Van der Merwe⁴, Dominique Cadilhac⁵, Catherine D'Este^{6

7}, Christopher Levi^{8

9}, Jeremy M Grimshaw^{10

11}, Andreea Grecu³, Clare Quinn¹², Ngai Wah Cheung¹³, Tereza Koláčná¹⁴, Sabina Medukhanova¹⁵, Estela Sanjuan Menendez¹⁶, Susana Salselas¹⁷, Gert Messchendorp¹⁸, Anne-Kathrin Cassier-Woidasky¹⁹, Marcelina Skrzypek-Czerko²⁰, Merce Slavat-Plana²¹, Urso Antonella²², Waltraud Pfeilschifter^{23

24}

Affiliations

¹ Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia.
² School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia.
³ International Clinical Research Centre, Neurology Department, St. Ann's University Hospital and Masaryk University, Brno, Czech Republic.
⁴ Angels Initiative, Boehringer Ingelheim International GmbH, Hamburg, Germany.
⁵ Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.
⁶ National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australia.
⁷ Sax Institute, Sydney, Australia.
⁸ John Hunter Health and Innovation Precinct, HNE LHD, New Lambton, NSW, Australia.
⁹ Department of Medicine, University of Newcastle, Callaghan, NSW, Australia.
¹⁰ University of Ottawa, Ottawa, ON, Canada.
¹¹ Ottawa Hospital Research Institute, Ottawa, ON, Canada.
¹² Prince of Wales Hospital, Randwick, Australia.
¹³ Centre for Diabetes and Endocrinology Research, Westmead Hospital, University of Sydney, Sydney, NSW, Australia.
¹⁴ Fakultní nemocnice Motol, Prague, Czech Republic.
¹⁵ National Center for Neurosurgery, Nur-Sultan, Kazakhstan.
¹⁶ Vall d'Hebron Hospital Universitari, Barcelona, Spain.
¹⁷ ULSNE Macedo de Cavaleiros, Macedo de Cavaleiros, Portugal.
¹⁸ University Medical Center Groningen, Groningen, Netherlands.
¹⁹ Saarland University of Applied Sciences, Saarbrücken, Germany.
²⁰ Medical University of Gdańsk, Gdansk, Poland.
²¹ Health Department, Agency for Health Quality and Assessment (AQuAS), CIBER Epidemiología y Salud Pública, CIBERESP, Stroke Programme, Barcelona, Spain.
²² Hospital Network Area-Regional Health Department, Regione Lazio, Rome, Italy.
²³ Department of Neurology and Clinical Neurophysiology, Städtisches Klinikum Lüneburg, Lüneburg, Germany.
²⁴ Department of Neurology, Goethe University, Frankfurt am Main, Germany.

Abstract

Introduction: Poor adoption of stroke guidelines is a problem internationally. The Quality in Acute Stroke Care (QASC) trial demonstrated significant reduction in death and disability with facilitated implementation of nurse-initiated.

Methods: This was a multi-country, multi-centre, pre-test/post-test study (2017-2021) comparing post implementation data with historically collected pre-implementation data. Hospital clinical champions, supported by the Angels Initiative conducted multidisciplinary workshops discussing pre-implementation medical record audit results, barriers and facilitators to FeSS Protocol implementation, developed action plans and provided education, with ongoing support co-ordinated remotely from Australia. Prospective audits were conducted 3-month after FeSS Protocol introduction. Pre-to-post analysis and country income classification comparisons were adjusted for clustering by hospital and country controlling for age/sex/stroke severity.

Results: Data from 64 hospitals in 17 countries (3464 patients pre-implementation and 3257 patients post-implementation) showed improvement pre-to-post implementation in measurement recording of all three FeSS components, all p < 0.0001: fever elements (pre: 17%, post: 51%; absolute difference 33%, 95% CI 30%, 37%); hyperglycaemia elements (pre: 18%, post: 52%; absolute difference 34%; 95% CI 31%, 36%); swallowing elements (pre: 39%, post: 67%; absolute difference 29%, 95% CI 26%, 31%) and thus in overall FeSS Protocol adherence (pre: 3.4%, post: 35%; absolute difference 33%, 95% CI 24%, 42%). In exploratory analysis of FeSS adherence by countries' economic status, high-income versus middle-income countries improved to a comparable extent.

Discussion and conclusion: Our collaboration resulted in successful rapid implementation and scale-up of FeSS Protocols into countries with vastly different healthcare systems.

Keywords: FeSS; QASC; Stroke; dysphagia; fever; hyperglycaemia; implementation; nurses; swallow; translation.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Australia
Deglutition
Deglutition Disorders* / diagnosis
Fever / diagnosis
Humans
Hyperglycemia* / diagnosis
Stroke* / diagnosis