The Quality in Acute Stroke Care Project (QASC)

Middleton S, Levi C, Griffiths R, Grimshaw J, Ward J, D’Este C, Dale S, Drury P, McInnes E, Hardy J, Cheung N, McElduff P, Cadilhac D, Evans M, Quinn C

Fever

 Quarter to third of patients >37.5

° c within first few days 1-3  Marked increase in morbidity & mortality 3,4-6  Indication of poor outcome 1,6,7 1 Azzimondi et al. (1995), 2 Castillo et al. (1998) 3 Turaj et al. (2008), 4 Reith et al. (1996) 5 Wang et al. (2000), 6 Hajat et al. (2000), 7 Kammersgaard et al. (2002)

Fever

 Associated with a significant increase in morbidity and mortality attributed to:      Increased cerebral metabolic demands Changes in the blood-brain barrier permeability Acidosis Increased release of excitatory amino acids Causes infarct expansion

Hyperglycaemia

 In the first 48hrs incidence can be up to 45% of patients 8,9  Across all stroke subtypes 9,10  Glucose above 8 mmol/l predictor increased mortality & poorer functional outcome 10,11 8 Allport et al . (2006) , 9 Scott et al. (1999) , 10 Capes et al. (2001) , 11 Weir et al. (1997)

Hyperglycaemia in non-diabetics

 Meta-analysis: hyperglycaemic (BGL > 8 mmol/L) non-diabetic patients admitted to hospital with stroke are approximately 3 times more likely to die than non-diabetic patients without hyperglycaemia 10 Capes et al. (2001)

Fever and Sugar Management

Aimed at ‘Salvaging’ the ischaemic penumbra  The penumbral is critically hypoperfused but still viable brain tissue  Thought to exists out to 48 hours post stroke and is the ‘target’ of most acute stroke therapies

Swallowing Difficulty (Dysphagia)

 Dysphagia occurs in 37 - 78% of acute stroke patients and aspiration pneumonia in 10% 12  Aspiration can lead to:  Chest infections  Aspiration pneumonia  Death 12 Martino et al. (2005)

Swallowing Difficulty (Dysphagia)

 Adherence to formal dysphagia screening protocol decreases incidence of pneumonia 13,14  Gag reflex is NOT a valid screen for dysphagia 13 Odderson et al. (1995), 14 Hinchey et al. (2005)

Clinical Guidelines for Acute Stroke Management^

 Four specific recommendations concerned with the management of fever, hyperglycaemia and swallowing in National Stroke Foundation (NSF) Clinical Guidelines for Stroke Management 2010 ^ NSF 2010

FeSS: Fe ver, S ugar & S wallowing Intervention

 Evidence-based clinical treatment protocols for management of:   Fever Hyperglycaemia   Swallowing Implementation strategies:    Workshops to identify barriers & enablers Interactive and didactic educational outreach meetings Reminders

Duration

 All elements of the intervention will run for the first 72 hours of admission to the stroke unit

Fever Protocol

 Monitor temperature for 72 hours  Treat temperature > 37.5

° C  Standing order for paracetamol  Paracetamol on nurse-initiated medication list

Sugar (Hyperglycaemia) Protocol

 Formal glucose measured on admission to hospital/stroke unit  Fingerprick Blood Glucose Level (BGL) on admission to the stroke unit  Before/after meals & bedtime fingerprick BGL’s for 72 hours if BGL <10 mmols/L

Sugar (Hyperglycaemia) Protocol

 1-2 hourly fingerpricks to monitor BGL for 48 hours following admission when admission BGL > 10 mmols /L  If BGL > 10 mmols/L at any time in first 48 hours following admission then insulin infusion commenced

Swallowing Protocol

 Nurses trained to screen   Successfully screen 3 patients Pass written test  Patients should be screened   Before being given food, drink or medications Within 24 hrs of admission to hospital  Referral to speech pathologist for a full swallowing assessment if failed screen

References

1. Azzimondi G, Bassein L, Nonino F, Fiorani L, Vignatelli L, Re G, et al. Stroke. 1995 Nov;26(11):2040-3.

2. Castillo J, Davalos A, Marrugat J & Noya M. Stroke. 1998;29(12):2455-60.

3. Turaj W, Slowik A, & Szczudlik A. Neurol Neurochir Pol. 2008 Jul-Aug;42(4):316-22.

4. Reith J, Jorgensen HS, Pedersen PM, Nakayama H, Raaschou HO, Jeppesen LL, et al. Lancet. 1996 Feb 17;347(8999):422-5.

5. Wang Y, Lim LL, Levi C, Heller RF & Fisher J. Stroke. 2000;31(2):404-9.

6. Hajat C, Hajat S & Sharma P. Stroke. 2000 Feb;31(2):410-4.

7. Kammersgaard LP, Jorgensen HS, Rungby JA, Reith J, Nakayama H, Weber UJ, et al. Stroke. 2002 Jul;33(7):1759-62.

8. Allport L, Baird T, Butcher K, Macgregor L, Prosser J, Colman P, et al. Diabetes Care. 2006;29(8):1839 44.

9. Scott JF, Robinson GM, French JM, O'Connell JE, Alberti KGMM & Gray CS. Lancet. 1999;353:376-7.

10.Capes SE, Hunt D, Malmberg K, Pathak P, & Gerstein HC. Stroke. 2001 October 1, 2001;32(10):2426 32.

11.Kammersgaard LP, Jorgensen HS, Rungby JA, Reith J, Nakayama H, Weber UJ, et al. Stroke. 2002 Jul;33(7):1759-62.

12.Martino R, Foley N, Bhogal S, Diamant N, Speechley M, & Teasell R.. Stroke. 2005;36(12):2756-63.

13.Odderson IR, Keaton JC & McKenna BS.Arch Phys Med Rehabil. 1995 Dec;76(12):1130-3.

14.Hinchey JA, Shephard T, Furie K, Smith D, Wang D & Tonn S. Stroke. 2005;36(9):1972-6.

15.National Stroke Foundation. 2010. Victoria: NSF; 2010.