How registry data are used to inform activities for stroke care quality improvement across 55 countries: A cross-sectional survey of Registry of Stroke Care Quality (RES-Q) hospitals.

BACKGROUND AND PURPOSE: The Registry of Stroke Care Quality (RES-Q) is a worldwide quality improvement data platform that captures performance and quality measures, enabling standardized comparisons of hospital care. The aim of this study was to determine if, and how, RES-Q data are used to influence stroke quality improvement and identify the support and educational needs of clinicians using RES-Q data to improve stroke care. METHODS: A cross-sectional self-administered online survey was administered (October 2021-February 2022). Participants were RES-Q hospital local coordinators responsible for stroke data collection. Descriptive statistics are presented. RESULTS: Surveys were sent to 1463 hospitals in 74 countries; responses were received from 358 hospitals in 55 countries (response rate 25%). RES-Q data were used "always" or "often" to: develop quality improvement initiatives (n = 213, 60%); track stroke care quality over time (n = 207, 58%); improve local practice (n = 191, 53%); and benchmark against evidence-based policies, procedures and/or guidelines to identify practice gaps (n = 179, 50%). Formal training in the use of RES-Q tools and data were the most frequent support needs identified by respondents (n = 165, 46%). Over half "strongly agreed" or "agreed" that to support clinical practice change, education is needed on: (i) using data to identify evidence-practice gaps (n = 259, 72%) and change clinical practice (n = 263, 74%), and (ii) quality improvement science and methods (n = 255, 71%). CONCLUSION: RES-Q data are used for monitoring stroke care performance. However, to facilitate their optimal use, effective quality improvement methods are needed. Educating staff in quality improvement science may develop competency and improve use of data in practice.

The Quality in Acute Stroke Care (QASC) global scale-up using a cascading facilitation framework: a qualitative process evaluation.

BACKGROUND: Variation in hospital stroke care is problematic. The Quality in Acute Stroke (QASC) Australia trial demonstrated reductions in death and disability through supported implementation of nurse-led, evidence-based protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS Protocols) following stroke. Subsequently, a pre-test/post-test study was conducted in acute stroke wards in 64 hospitals in 17 European countries to evaluate upscale of the FeSS Protocols. Implementation across countries was underpinned by a cascading facilitation framework of multi-stakeholder support involving academic partners and a not-for-profit health organisation, the Angels Initiative (the industry partner), that operates to promote evidence-based treatments in stroke centres. .We report here an a priori qualitative process evaluation undertaken to identify factors that influenced international implementation of the FeSS Protocols using a cascading facilitation framework. METHODS: The sampling frame for interviews was: (1) Executives/Steering Committee members, consisting of academics, the Angels Initiative and senior project team, (2) Angel Team leaders (managers of Angel Consultants), (3) Angel Consultants (responsible for assisting facilitation of FeSS Protocols into multiple hospitals) and (4) Country Co-ordinators (senior stroke nurses with country and hospital-level responsibilities for facilitating the introduction of the FeSS Protocols). A semi-structured interview elicited participant views on the factorsthat influenced engagement of stakeholders with the project and preparation for and implementation of the FeSS Protocol upscale. Interviews were recorded, transcribed verbatim and analysed inductively within NVivo. RESULTS: Individual (n = 13) and three group interviews (3 participants in each group) were undertaken. Three main themes with sub-themes were identified that represented key factors influencing upscale: (1) readiness for change (sub-themes: negotiating expectations; intervention feasible and acceptable; shared goal of evidence-based stroke management); (2) roles and relationships (sub-themes: defining and establishing roles; harnessing nurse champions) and (3) managing multiple changes (sub-themes: accommodating and responding to variation; more than clinical change; multi-layered communication framework). CONCLUSION: A cascading facilitation model involving a partnership between evidence producers (academic partners), knowledge brokers (industry partner, Angels Initiative) and evidence adopters (stroke clinicians) overcame multiple challenges involved in international evidence translation. Capacity to manage, negotiate and adapt to multi-level changes and strategic engagement of different stakeholders supported adoption of nurse-initiated stroke protocols within Europe. This model has promise for other large-scale evidence translation programs.

Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention: QASC Trial (Quality in Acute Stroke Care) Follow-Up.

BACKGROUND AND PURPOSE: Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005-2010). We now examine long-term all-cause mortality. METHODS: Mortality was ascertained using Australia's National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber-White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates. RESULTS: One thousand and seventy-six participants (intervention n=600; control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival (>20%), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.58-1.07; P=0.13; adjusted HR, 0.77; 95% CI, 0.59-0.99; P=0.045). Older age (75-84 years; HR, 4.9; 95% CI, 2.8-8.7; P<0.001) and increasing stroke severity (HR, 1.5; 95% CI, 1.3-1.9; P<0.001) were associated with increased mortality, while being married (HR, 0.70; 95% CI, 0.49-0.99; P=0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths. CONCLUSIONS: Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care. CLINICAL TRIAL REGISTRATION: URL: http://www.anzctr.org.au. Unique identifier: ACTRN12608000563369.

Fever, Hyperglycemia, and Swallowing Management in Stroke Unit and Non-Stroke-Unit European Hospitals: A Quality in Acute Stroke Care (QASC) Europe Substudy.

ABSTRACT: BACKGROUND: Stroke unit care reduces patient morbidity and mortality. The Quality in Acute Stroke Care Europe Study achieved significant large-scale translation of nurse-initiated protocols to manage Fever, hyperglycemia (Sugar), and Swallowing (FeSS) in 64 hospitals across 17 European countries. However, not all hospitals had stroke units. Our study aimed to compare FeSS protocol adherence in stroke unit versus non-stroke-unit hospitals. METHODS: An observational study using Quality in Acute Stroke Care Europe Study postimplementation data was undertaken. Hospitals were categorized using 4 evidence-based characteristics for defining a stroke unit, collected from an organizational survey of participating hospitals. Differences in FeSS Protocol adherence between stroke unit and non-stroke-unit hospitals were investigated using mixed-effects logistic regression, adjusting for age, sex, and National Institutes of Health Stroke Scale. RESULTS: Of the 56 hospitals from 16 countries providing organizational data, 34 (61%) met all 4 stroke unit characteristics, contributing data for 1825 of 2871 patients (64%) (stroke unit hospitals). Of the remaining 22 hospitals (39%), 17 (77%) met 3 of the 4 stroke unit characteristics (non-stroke-unit hospitals). There were no differences between hospitals with a stroke unit and those without for postimplementation adherence to fever (49% stroke unit vs 57% non-stroke unit; odds ratio [OR], 0.400; 95% confidence interval [CI], 0.087-1.844; P = .240), hyperglycemia (50% stroke unit vs 57% non-stroke unit; OR, 0.403; 95% CI, 0.087-1.856; P = .243), swallowing (75% stroke unit vs 60% non-stroke unit; OR, 1.702; 95% CI, 0.643-4.502; P = .284), or overall FeSS Protocol adherence (36% stroke unit vs 36% non-stroke unit; OR, 0.466; 95% CI, 0.106-2.043; P = .311). CONCLUSION: Our results demonstrate that the nurse-initiated FeSS Protocols can be implemented by hospitals regardless of stroke unit status. This is noteworthy because hospitals without stroke unit resources that care for acute stroke patients can potentially implement these protocols. Further effort is needed to ensure better adherence to the FeSS Protocols.

Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study.

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. 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.

Continence management in acute stroke: a survey of current practices in Australia.

AIM: The aim of the study was to determine current national urinary incontinence management practices in Australian acute stroke units and their concordance with the National Stroke Foundation guidelines. BACKGROUND: Urinary incontinence is a common consequence after stroke and a statistically significant indicator of poor outcome, including disability and admission to institutional care. The National Stroke Foundation has produced guidelines for the acute and post-acute phase of care, offering Australian nurses evidence-based recommendations regarding stroke management including the management of urinary incontinence. METHOD: In 2007-2008, dedicated acute stroke units in Australia were identified and a senior nurse from each unit was invited to participate in a 10-minute telephone survey to ascertain their current urinary continence management practices. RESULTS: Representatives from 41 acute stroke units participated in the survey (response rate 98%). Participants from less than half of the units reported that they had a formal plan for urinary incontinence management (n=19, 46%), and the majority of those who did not would find a formal plan useful (n=15, 79%). Two-thirds of respondents stated that they would manage urinary incontinence with indwelling catheterization (n=25, 61%). Only 30% (n=12) were 'satisfied' or 'very satisfied' with urinary continence management in their acute stroke unit. CONCLUSION: A large proportion of acute stroke units were yet to establish formal urinary incontinence management plans. The implementation of evidence-based urinary incontinence management plans after stroke is integral to improving patient outcomes. An increase in resources for professional development in the assessment, treatment and management of urinary incontinence is essential to improve and maintain skills in after-stroke care.

Paramedic diagnosis of stroke: examining long-term use of the Melbourne Ambulance Stroke Screen (MASS) in the field.

BACKGROUND AND PURPOSE: Recent evidence suggests the Cincinnati Prehospital Stroke Scale is ineffectively used and lacks sensitivity and specificity. Melbourne (Australia) paramedics have been using the Melbourne Ambulance Stroke Screen (MASS) since 2005. The aim of this study was to review the real-world use of MASS 3 years after city wide implementation. METHODS: Two groups of consecutively admitted patients to an Australian hospital between January and May 2008 were used: (1) patients for whom paramedics performed MASS; and (2) patients with a discharge diagnosis of stroke or transient ischemic attack. Use of MASS was examined for all transports and for patients diagnosed with stroke or transient ischemic attack. The sensitivity and specificity of paramedic diagnosis, MASS, and Cincinnati Prehospital Stroke Scale were calculated. Paramedic diagnosis of stroke among patients with stroke was statistically compared with those obtained immediately post-MASS implementation in 2002. RESULTS: For the study period, MASS was performed for 850 (16%) of 5286 emergency transports, including 199 of 207 (96%) patients with confirmed stroke and transient ischemic attack. In patients in whom MASS was performed (n=850), the sensitivity of paramedic diagnosis of stroke (93%, 95% CI: 88% to 96%) was higher than the MASS (83%, 95% CI: 77% to 88%, P=0.003) and equivalent to Cincinnati Prehospital Stroke Scale (88%, 95% CI: 83% to 92%, P=0.120), whereas the specificity of the paramedic diagnosis of stroke (87%, 95% CI: 84% to 89%) was equivalent to MASS (86%, 95% CI: 83% to 88%, P=0.687) and higher than Cincinnati Prehospital Stroke Scale (79%, 95% CI: 75% to 82%, P<0.001). The initial improvement in stroke paramedic diagnosis seen in 2002 (94%, 95% CI: 86% to 98%) was sustained in 2008 (89%, 95% CI: 84% to 94%, P=0.19). CONCLUSIONS: In our experience, paramedics have successfully incorporated MASS into the assessment of neurologically compromised patients. The initial improvement to the paramedics' diagnosis of stroke with MASS was sustained 3 years after city wide implementation.

Can the ABCD Score be dichotomised to identify high-risk patients with transient ischaemic attack in the emergency department?

BACKGROUND: Recent evidence shows a substantial short-term risk of ischaemic stroke after transient ischaemic attack (TIA). Identification of patients with TIA with a high short-term risk of stroke is now possible through the use of the "ABCD Score", which considers age, blood pressure, clinical features and duration of symptoms predictive of stroke. AIM: To evaluate the ability of dichotomising the ABCD Score to predict stroke at 7 and 90 days in a population with TIA presenting to an emergency department. METHODS: A retrospective audit was conducted on all probable or definite TIAs presenting to the emergency department of a metropolitan hospital from July to December 2004. The ABCD Score was applied to 98 consecutive patients with TIA who were reviewed for subsequent strokes within 90 days. Patients obtaining an ABCD Score > or = 5 were considered to be at high risk for stroke. RESULTS: Dichotomising the ABCD Score categorised 48 (49%) patients with TIA at high risk for stroke (ABCD Score > or = 5). This high-risk group contained all four strokes that occurred within 7 days (sensitivity 100% (95% confidence interval (CI) 40% to 100%), specificity 53% (95% CI 43% to 63%), positive predictive value 8% (95% CI 3% to 21%) and negative predictive value 100% (95% CI 91% to 100%)), and six of seven occurring within 90 days (sensitivity 86% (95% CI 42% to 99%), specificity 54% (95% CI 43% to 64%), positive predictive value 12.5% (95% CI 5% to 26%) and negative predictive value 98% (95% CI 88% to 100%)). Removal of the "age" item from the ABCD Score halved the number of false-positive cases without changing its predictive value for stroke. CONCLUSION: In this retrospective analysis, dichotomising the ABCD Score was overinclusive but highly predictive in identifying patients with TIA at a high short-term risk of stroke. Use of the ABCD Score in the emergency care of patients with TIA is simple, efficient and provides a unique opportunity to prevent stroke in this population of patients.