the quality in acute stroke care implementation project ... sandy middleton.pdf · the quality in...
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Professor Sandy Middleton Director, Nursing Research Institute
On behalf of the QASC Implementation Project Team
The Quality in Acute Stroke Care Implementation Project - a state wide translational quality
improvement project
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QASC Survivor cohort project
International uptake on
QASC resources
NUM study
QASC Implementation project
T3 Trial
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In the first days of an acute stroke:
> 37.5°C in 20-50%
patients1
Up to 68% become
hyperglycaemic2 37- 78%
experience dysphagia3
All result in increased morbidity and mortality and enlarged infarct size
1 Azzimondi et al. Stroke.1995 2 Scott et al. Stroke. 1999 3 Martino et al. Stroke. 2005
Background
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Background
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CLINICAL GUIDELINES FOR STROKE 4 Recommendations for management of fever, hyperglycaemia and swallowing Regular monitoring and documentation of
temperature and glucose levels Routine antipyretic therapy for fever Appropriate glycaemic therapy Swallowing screen within 24 hrs and before oral
intake
4 National Stroke Foundation. 2010
Background
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Overview of the QASC trial Implementation research, Quality improvement study Rigorously evaluated using a research framework (single-blind CRCT; ITT)Funded by NHMRC Study design and results To develop and implement a multidisciplinary, team building intervention to improve evidence-based management of fever, hyperglycaemia and swallowing dysfunction in patients following acute stroke To rigorously evaluate same using a clustered randomised controlled trial (CRCT) design Implementation research, Quality improvement study Rigorously evaluated using a research framework (single-blind CRCT; ITT)Funded by NHMRC Study design and results To develop and implement a multidisciplinary, team building intervention to improve evidence-based management of fever, hyperglycaemia and swallowing dysfunction in patients following acute stroke To rigorously evaluate same using a clustered randomised controlled trial (CRCT) design Implementation research, Quality improvement study Rigorously evaluated using a research framework (single-blind CRCT; ITT)Funded by NHMRC Study design and results To develop and implement a multidisciplinary, team building intervention to improve evidence-based management of fever, hyperglycaemia and swallowing dysfunction in patients following acute strokeImplementation research, Quality improvement study Rigorously evaluated using a research framework (single-blind CRCT; ITT)Funded by NHMRC Study design and results To develop implement a multidisciplinary, team building intervention to improve evidence-based management of fever, swallowing n in patients following acute stroke Implementation research, Quality improvement study Rigorously evaluated using a research framework (single-blind CRCT; ITT)Funded by NHMRC implement building intervention to improve evidence-based management of fever, hyperglycaemia and swallowing following acute stroke
• Implementation research • Quality improvement study • Rigorously evaluated using
a research framework (single-blind CRCT)
• Funded by NHMRC
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QASC Trial: Aim
• To develop and implement a multidisciplinary, team building intervention to improve evidence-based management of fever, hyperglycaemia and swallowing dysfunction in patients following acute stroke
• To rigorously evaluate same using a clustered randomised controlled trial (CRCT) design
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Intervention (1): FeSS protocols
Fever (n=2 elements)
4 -6 hourly temperature readings for 72 hours
Temperature > 37.5°C treated with paracetamol
Sugar
(n=5 elements)
Formal venous glucose on admission
1-6 hourly finger-prick glucose for 72 hours
On admission: 8-16 mmol/L (ND) or 8-11 mmol/L (D): saline infusion for the
first six hours
Glucose > 16 mmol/L (ND): IV insulin
Glucose > 11 mmol/L (D) : IV insulin
Swallowing (n=2 elements)
Education program and competency assessment for nurses run by speech
pathologists
Screen within 24 hours of stroke unit admission
Referral to speech pathologist for full
assessment for those who failed the screen
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Team building workshops
Reinforcement of multidisciplinary
teamwork
Local adaptation
Site-based education and
support
Interactive and didactic educational outreach
meetings
Reminders • Six weekly visits • Pro and reactive
phone calls and emails
Barriers and enablers identification
Intervention (2) on-site actions
Abridged NSF Guidelines (no FeSS protocols)
No support to identify local and unique
barriers, disseminate or implement
Control
Control stroke units received:
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P
Mean age: 70 years; 60% (n=607) male
Similarities between Ix and control group for age, sex,
stroke location or severity, time to arrival at stroke unit
Results
Pre-intervention cohort
n= 687 patients
Post-intervention cohort
n= 1009 patients
1696 patients from 19 NSW stroke Units
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Background: QASC Trial Results
• 15.7 % more likely to be alive and independent 90 days post-stroke (p=0.002)(mRS)
• Lower mean temperature in first 72 hours of stroke unit admission (p=0.001)
• Lower mean blood glucose levels in first 72 hours of stroke unit admission (p=0.02)
• Improved swallow screening within 24 hours of stroke unit admission (p=<0.001)
• Decreased length of stay (p>0.144) (13.7 days v 11.3 days)
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79
18
14
6.4
NNT 1%
Aspirin
5% Stroke unit
10% Thrombolysis < 4.5 hrs
15.7% FeSS Intervention
Results
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Middleton S, McElduff P, Ward J, Grimshaw JM et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. The Lancet 2011; 378(9804): 1699-1706
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Where to from here?
• Where do Australian researchers go to obtain support for implementation of interventions proven to improve patient outcomes?
• What funding do we have for this in
Australia?
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The project
Partnership
Translational quality improvement project
Running from April 2013 - April 2014
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Changing clinician practice
Changing clinician practice remains a challenge
Production of up-to-date evidence-based clinical guidelines without targeted implementation strategies do not ensure evidence uptake
i.e. care in line with evidence-based or consensus-based guidelines
57% of Australian adult health care encounters received appropriate care5
5 Runciman et al. MJA 2012
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Aim
2) Evaluate project and draw comprehensive lessons learned for future projects on how to implement evidence based results on a large scale in a limited time frame
1) To implement the FeSS clinical treatment protocols in stroke services in NSW
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Method
• Design: Pre and post intervention • Eligibility: All NSW hospitals with stroke services • Recruitment letters to:
– Chief Executives of Local Health Districts with stroke services – Director of stroke service – Directors of nursing – Directors of allied health – Stroke CNCs/ Coordinator – Nurse Unit Manager
• Written consent obtained : – identify 2-3 key clinical stroke champions to attend a workshop – conduct pre and post medical record audits
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Method
• Design: Pre and post intervention • Eligibility: All NSW hospitals with stroke services • Recruitment letters to:
– Chief Executives of Local Health Districts with stroke services – Director of stroke service – Directors of nursing – Directors of allied health – Stroke CNCs/ Coordinator – Nurse Unit Manager
• Written consent obtained : – identify 2-3 key clinical stroke champions to attend a workshop – conduct pre and post medical record audits
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Fever (n=2 elements)
4 -6 hourly temperature readings
for 72 hours
Temperature > 37.5°C treated with paracetamol
Sugar
(n=5 elements)
Formal venous glucose on admission
1-6 hourly finger-prick glucose for 72 hours
Glucose > 10 mmol/L: Treat with insulin
Swallowing (n=2 elements)
Education program and online
competency assessment
Screen within 24 hours of stroke unit
admission and before oral intake
Referral to speech pathologist for full
assessment for those who failed the screen
FeSS clinical treatment Protocols
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Intervention n=10 intervention sites
Project Officer
Local team
Visits to each site every 6 weeks
Workshops
Education
Support
TRIA
L
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n=10 intervention sites
n=36 sites (implementation)
Workshop for site champions
Project Officer
Champions
Visits to each site every 6 weeks
Workshops
Education
Support
Local team
Workshops Education Support
TRIA
L
Intervention IM
PLEM
ENTA
TIO
N
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n=10 intervention sites
Project Officer
Local team
Champions
Visits to each site every 6 weeks
Workshops
Education
Support
TRIA
L IM
PLEM
ENTA
TIO
N
One education workshop for site champions
Intervention
n=36 sites (implementation)
Workshops Education Support
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Champions’ Implementation Training
1) The QASC Trial • Results • Physiology
2) FeSS clinical treatment protocols
3) ASSIST swallow screening training
4) Barrier assessments 5) Implementation
skills 6) Audit training
Champion Champion Champion Champion Champion
Champion Champion Champion
Champion
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QASC Implementation Team Support
• Project coordinator and QASC Implementation Team site visits
• Ongoing support via phone and email
Champion
Team
1 2
Implement
Team
Implement
Team
Project coordinator
Team
Champion
Project coordinator
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Evaluation
• Process of care evaluation (not patient outcomes)
– Medical record audit: pre and post (self report) – Unique and novel collaboration with the National Stroke Foundation as using their clinical audit tool
• Evaluation of implementation process to inform future projects conducted by the ACI
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Participating stroke units/services in NSW
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Results and Progress
Completion: April 2014 (12 months)
Post-audit: Jan 2014
Site visits completed
Pre- audit: 34 hospitals completed
Workshops completed (n=100 clinicians)
36 Stroke services in NSW taking part (100%)
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QASC Trial
Length 5 years Scope 10 sites Setting Stroke units
Challenges: Scale up and spread
QASC Implementation
12 months 36 sites Stroke services
Challenge: Intervention fidelity
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Acknowledgements
• NSW Agency for Clinical Innovation
• Clinical champions • QASC Implementation Project Team
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QASC Implementation project
QUESTIONS?