From QASC to QASCIP: successful Australian translational scale-up and spread of a proven intervention in acute stroke using a prospective pre-test/post-test study design

Sandy Middleton, Anna Lydtin, Daniel Comerford, Dominique A Cadilhac, Patrick McElduff, Simeon Dale, Kelvin Hill, Mark Longworth, Jeanette Ward, N Wah Cheung, Cate D'Este, QASCIP Working Group and Steering Committee, James Dunne, Peta Drury, Jeremy Grimshaw, Eva Katalinic, Christopher Levi, Elizabeth O'Brien, Sigrid Patterson, Clare Quinn, Fiona Ryan, Melissa Tinsley, Sonia Wutzke, Nancy Dixon, Sandy Middleton, Anna Lydtin, Daniel Comerford, Dominique A Cadilhac, Patrick McElduff, Simeon Dale, Kelvin Hill, Mark Longworth, Jeanette Ward, N Wah Cheung, Cate D'Este, QASCIP Working Group and Steering Committee, James Dunne, Peta Drury, Jeremy Grimshaw, Eva Katalinic, Christopher Levi, Elizabeth O'Brien, Sigrid Patterson, Clare Quinn, Fiona Ryan, Melissa Tinsley, Sonia Wutzke, Nancy Dixon

Abstract

Objectives: To embed an evidence-based intervention to manage FEver, hyperglycaemia (Sugar) and Swallowing (the FeSS protocols) in stroke, previously demonstrated in the Quality in Acute Stroke Care (QASC) trial to decrease 90-day death and dependency, into all stroke services in New South Wales (NSW), Australia's most populous state.

Design: Pre-test/post-test prospective study.

Setting: 36 NSW stroke services.

Methods: Our clinical translational initiative, the QASC Implementation Project (QASCIP), targeted stroke services to embed 3 nurse-led clinical protocols (the FeSS protocols) into routine practice. Clinical champions attended a 1-day multidisciplinary training workshop and received standardised educational resources and ongoing support. Using the National Stroke Foundation audit collection tool and processes, patient data from retrospective medical record self-reported audits for 40 consecutive patients with stroke per site pre-QASCIP (1 July 2012 to 31 December 2012) were compared with prospective self-reported data from 40 consecutive patients with stroke per site post-QASCIP (1 November 2013 to 28 February 2014). Inter-rater reliability was substantial for 10 of 12 variables.

Primary outcome measures: Proportion of patients receiving care according to the FeSS protocols pre-QASCIP to post-QASCIP.

Results: All 36 (100%) NSW stroke services participated, nominating 100 site champions who attended our educational workshops. The time from start of intervention to completion of post-QASCIP data collection was 8 months. All (n=36, 100%) sites provided medical record audit data for 2144 patients (n=1062 pre-QASCIP; n=1082 post-QASCIP). Pre-QASCIP to post-QASCIP, proportions of patients receiving the 3 targeted clinical behaviours increased significantly: management of fever (pre: 69%; post: 78%; p=0.003), hyperglycaemia (pre: 23%; post: 34%; p=0.0085) and swallowing (pre: 42%; post: 51%; p=0.033).

Conclusions: We obtained unprecedented statewide scale-up and spread to all NSW stroke services of a nurse-led intervention previously proven to improve long-term patient outcomes. As clinical leaders search for strategies to improve quality of care, our initiative is replicable and feasible in other acute care settings.

Keywords: Nursing care; bundle; implementation.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

Figure 1
Figure 1
Inter-rater reliability for 12 key individual variables.

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Source: PubMed

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