The Quality in Acute Stroke Care Project (QASC)

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• The Quality in Acute Stroke Care Project (QASC)

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

• Quarter to third of patients gt37.5c within first
  few days1-3
• Marked increase in morbidity mortality3,4-6
• Indication of poor outcome1,6,7
• 1Azzimondi et al. (1995), 2Castillo et al. (1998)
  3Turaj et al. (2008), 4Reith et al. (1996)
• 5Wang et al. (2000), 6Hajat et al. (2000),
  7Kammersgaard et al. (2002)

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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

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Hyperglycaemia

• In the first 48hrs incidence can be up to 45 of
  patients8,9
• Across all stroke subtypes9,10
• Glucose above 8 mmol/l predictor increased
  mortality poorer functional outcome10,11
• 8Allport et al . (2006), 9Scott et al.
  (1999), 10Capes et al. (2001), 11Weir et al.
  (1997)

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Hyperglycaemia in non-diabetics

• Meta-analysis hyperglycaemic (BGL gt 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
• 10Capes et al. (2001)

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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

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Swallowing Difficulty (Dysphagia)

• Dysphagia occurs in 37 - 78 of acute stroke
  patients and aspiration pneumonia in 1012
• Aspiration can lead to
• Chest infections
• Aspiration pneumonia
• Death
• 12Martino et al. (2005)

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Swallowing Difficulty (Dysphagia)

• Adherence to formal dysphagia screening protocol
  decreases incidence of pneumonia13,14
• Gag reflex is NOT a valid screen for dysphagia
• 13Odderson et al. (1995), 14Hinchey et al. (2005)

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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

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FeSS Fever, Sugar Swallowing 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

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Duration

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

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Fever Protocol

• Monitor temperature for 72 hours
• Treat temperature gt 37.5C
• Standing order for paracetamol
• Paracetamol on nurse-initiated medication list

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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 BGLs
  for 72 hours if BGL lt10 mmols/L

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Sugar (Hyperglycaemia) Protocol

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

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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

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References

• Azzimondi G, Bassein L, Nonino F, Fiorani L,
  Vignatelli L, Re G, et al. Stroke. 1995
  Nov26(11)2040-3.
• Castillo J, Davalos A, Marrugat J Noya M.
  Stroke. 199829(12)2455-60.
• Turaj W, Slowik A, Szczudlik A. Neurol
  Neurochir Pol. 2008 Jul-Aug42(4)316-22.
• Reith J, Jorgensen HS, Pedersen PM, Nakayama H,
  Raaschou HO, Jeppesen LL, et al. Lancet. 1996 Feb
  17347(8999)422-5.
• Wang Y, Lim LL, Levi C, Heller RF Fisher J.
  Stroke. 200031(2)404-9.
• Hajat C, Hajat S Sharma P. Stroke. 2000
  Feb31(2)410-4.
• Kammersgaard LP, Jorgensen HS, Rungby JA, Reith
  J, Nakayama H, Weber UJ, et al. Stroke. 2002
  Jul33(7)1759-62.
• Allport L, Baird T, Butcher K, Macgregor L,
  Prosser J, Colman P, et al. Diabetes Care.
  200629(8)1839-44.
• Scott JF, Robinson GM, French JM, O'Connell JE,
  Alberti KGMM Gray CS. Lancet. 1999353376-7.
• Capes SE, Hunt D, Malmberg K, Pathak P,
  Gerstein HC. Stroke. 2001 October 1,
  200132(10)2426-32.
• Kammersgaard LP, Jorgensen HS, Rungby JA, Reith
  J, Nakayama H, Weber UJ, et al. Stroke. 2002
  Jul33(7)1759-62.
• Martino R, Foley N, Bhogal S, Diamant N,
  Speechley M, Teasell R.. Stroke.
  200536(12)2756-63.
• Odderson IR, Keaton JC McKenna BS.Arch Phys Med
  Rehabil. 1995 Dec76(12)1130-3.
• Hinchey JA, Shephard T, Furie K, Smith D, Wang D
  Tonn S. Stroke. 200536(9)1972-6.
• National Stroke Foundation. 2010. Victoria NSF
  2010.