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 Mikulík, Thomas J. Fischer, Jan van der Merwe, Dominique A. Cadilhac, Catherine D’Este, Christopher Levi, Jeremy Grimshaw, Andreea Grecu, Clare Quinn, N. Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuán, Susana Catarina Sarmento Banrezes Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Antonella Urso, Waltraud Pfeilschifter
Abstract
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 protocols to manage fever, hyperglycaemia and swallowing (FeSS Protocols) following stroke. We aimed to determine real-world effectiveness of supported implementation of the FeSS Protocols across Europe. 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.