Nurse-Initiated Acute Stroke Care in Emergency Departments: The Triage, Treatment, and Transfer Implementation Cluster Randomized Controlled Trial.

Background and Purpose- We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). Methods- A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke <48 hours from symptom onset and were admitted to the stroke unit via ED. Our nurse-initiated T3 intervention targeted (1) Triage to Australasian Triage Scale category 1 or 2; (2) Treatment: tPA eligibility screening and appropriate administration; clinical protocols for managing fever, hyperglycemia, and swallowing; (3) prompt (<4 hours) stroke unit Transfer. It was implemented using (1) workshops to identify barriers and solutions; (2) face-to-face, online, and written education; (3) national and local clinical opinion leaders; and (4) email, telephone, and site visit follow-up. Outcomes were assessed at the patient level. Primary outcome: 90-day death or dependency (modified Rankin Scale score of ≥2); secondary outcomes: functional dependency (Barthel Index ≥95), health status (Short Form [36] Health Survey), and ED quality of care (Australasian Triage Scale; monitoring and management of tPA, fever, hyperglycemia, swallowing; prompt transfer). Intention-to-treat analysis adjusted for preintervention outcomes and ED clustering. Patients, outcome assessors, and statisticians were masked to group allocation. Results- Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%]; control n=266 [48.7%]; P=0.24) or secondary outcomes. Conclusions- This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care. Clinical Trial Registration- URL: http://www.anzctr.org.au. Unique identifier: ACTRN12614000939695.

Compliance with Australian stroke guideline recommendations for outdoor mobility and transport training by post-inpatient rehabilitation services: An observational cohort study.

BACKGROUND: Community participation is often restricted after stroke, due to reduced confidence and outdoor mobility. Australian clinical guidelines recommend that specific evidence-based interventions be delivered to target these restrictions, such as multiple escorted outdoor journeys. The aim of this study was to describe post-inpatient outdoor mobility and transport training delivered to stroke survivors in New South Wales, Australia and whether therapy differed according to type, sector or location of service provider. METHODS: Using an observational retrospective cohort study design, 24 rehabilitation service providers were audited. Provider types included outpatient (n = 8), day therapy (n = 9), home-based rehabilitation (n = 5) and transitional aged care services (TAC, n = 2). Records of 15 stroke survivors who had received post-hospital rehabilitation were audited per service, for wait time, duration, amount of therapy and outdoor-related therapy. RESULTS: A total of 311 records were audited. Median wait time for post-hospital therapy was 13 days (IQR, 5-35). Median duration of therapy was 68 days (IQR, 35-109), consisting of 11 sessions (IQR 4-19). Overall, a median of one session (IQR 0-3) was conducted outdoors per person. Outdoor-related therapy was similar across service providers, except that TAC delivered an average of 5.4 more outdoor-related sessions (95% CI 4.4 to 6.4), and 3.5 more outings into public streets (95% CI 2.8 to 4.3) per person, compared to outpatient services. CONCLUSION: The majority of service providers in the sample delivered little evidence-based outdoor mobility and travel training per stroke participant, as recommended in national stroke guidelines. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12611000554965.

Factors associated with 28-day hospital readmission after stroke in Australia.

BACKGROUND AND PURPOSE: Understanding the factors that contribute to early readmission after discharge following stroke is limited. We aimed to describe the factors associated with 28-day readmission after hospitalization for stroke. METHODS: Factors associated with readmission were classified from the medical record standardized audits of 50 to 100 consecutively admitted patients with stroke from 35 Australian hospitals during multiple time periods (2000-2010). Factors were compared between patients readmitted and not readmitted after stroke hospitalization (n=43) grouped using 5 categories: patient characteristics (n=16; eg, age), clinical processes of care (n=13; eg, admitted into a stroke unit), social circumstances (n=3; eg, living home alone prior), health system (n=6; eg, location of hospital), and health outcome (n=5; eg, length of stay). Multilevel logistic regression modeling was used to examine the association with these independent factors selected if statistical significance P<0.15 or if considered clinically important and readmission status. RESULTS: Among 3328 patients, 6.5% were readmitted within 28 days (mean age, 75; 48% female; 92% ischemic). After bivariate analyses 14/43 factors from 4/5 categories were associated with readmission after hospitalization for stroke. Two factors from patient and health outcome categories remained independently associated with readmission after multivariable analyses. These were dependent premorbid functional status (adjusted odds ratio, 1.87; 95% confidence interval, 1.25-2.81) and having a severe adverse event during the initial hospitalization for stroke (adjusted odds ratio, 2.81; 95% confidence interval, 1.55-5.12). CONCLUSIONS: This is the first study to comprehensively evaluate factors associated with 28-day readmission after stroke. The factors associated with 28-day readmission are diverse and include potentially modifiable and nonmodifiable factors.

Evaluation of rural stroke services: does implementation of coordinators and pathways improve care in rural hospitals?

BACKGROUND AND PURPOSE: The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes. METHODS: A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented. SAMPLE: pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD, 13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66). CONCLUSIONS: Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.

A behavior change program to increase outings delivered during therapy to stroke survivors by community rehabilitation teams: The Out-and-About trial.

BACKGROUND: Australian guidelines recommend that outdoor mobility be addressed to increase participation after stroke. AIM: To investigate the efficacy of the Out-and-About program at increasing outings delivered during therapy by community teams, and outings taken by stroke survivors in real life. METHOD: Cluster-randomized trial involving 22 community teams providing stroke rehabilitation. Experimental teams received the Out-and-About program (a behavior change program comprising a training workshop with barrier identification and booster session, printed educational materials, audit, and feedback). Control teams received printed clinical guidelines only. The primary outcome was the percentage of stroke survivors receiving four or more outings during therapy. Secondary outcomes included the number of outings received by stroke survivors during therapy and undertaken in real life. RESULTS: At 12 months after implementation of the behavior change program, 9% of audited experimental group stroke survivors received four or more outings during therapy compared with 5% in the control group (adjusted risk difference 4%, 95% CI - 9 to 17, p = 0.54). They received 1.1 (SD 0.9) outings during therapy compared with 0.6 (SD 1.0) in the control group (adjusted mean difference 0.5, 95% CI - 0.4 to 1.4; p = 0.26). After six months of rehabilitation, observed experimental group stroke survivors took 9.0 (SD 3.0) outings per week in real life compared with 7.4 (SD 4.0) in the control group (adjusted mean difference 0.5, 95% CI - 1.8 to 2.8; p = 0.63). CONCLUSION: The Out-and-About program did not change team or stroke survivor behavior.

From QASC to QASCIP: successful Australian translational scale-up and spread of a proven intervention in acute stroke using a prospective pre-test/post-test study design.

OBJECTIVES: To embed an evidence-based intervention to manage FEver, hyperglycaemia (Sugar) and Swallowing (the FeSS protocols) in stroke, previously demonstrated in the Quality in Acute Stroke Care (QASC) trial to decrease 90-day death and dependency, into all stroke services in New South Wales (NSW), Australia's most populous state. DESIGN: Pre-test/post-test prospective study. SETTING: 36 NSW stroke services. METHODS: Our clinical translational initiative, the QASC Implementation Project (QASCIP), targeted stroke services to embed 3 nurse-led clinical protocols (the FeSS protocols) into routine practice. Clinical champions attended a 1-day multidisciplinary training workshop and received standardised educational resources and ongoing support. Using the National Stroke Foundation audit collection tool and processes, patient data from retrospective medical record self-reported audits for 40 consecutive patients with stroke per site pre-QASCIP (1 July 2012 to 31 December 2012) were compared with prospective self-reported data from 40 consecutive patients with stroke per site post-QASCIP (1 November 2013 to 28 February 2014). Inter-rater reliability was substantial for 10 of 12 variables. PRIMARY OUTCOME MEASURES: Proportion of patients receiving care according to the FeSS protocols pre-QASCIP to post-QASCIP. RESULTS: All 36 (100%) NSW stroke services participated, nominating 100 site champions who attended our educational workshops. The time from start of intervention to completion of post-QASCIP data collection was 8 months. All (n=36, 100%) sites provided medical record audit data for 2144 patients (n=1062 pre-QASCIP; n=1082 post-QASCIP). Pre-QASCIP to post-QASCIP, proportions of patients receiving the 3 targeted clinical behaviours increased significantly: management of fever (pre: 69%; post: 78%; p=0.003), hyperglycaemia (pre: 23%; post: 34%; p=0.0085) and swallowing (pre: 42%; post: 51%; p=0.033). CONCLUSIONS: We obtained unprecedented statewide scale-up and spread to all NSW stroke services of a nurse-led intervention previously proven to improve long-term patient outcomes. As clinical leaders search for strategies to improve quality of care, our initiative is replicable and feasible in other acute care settings.

Triage, treatment and transfer of patients with stroke in emergency department trial (the T3 Trial): a cluster randomised trial protocol.

BACKGROUND: Internationally recognised evidence-based guidelines recommend appropriate triage of patients with stroke in emergency departments (EDs), administration of tissue plasminogen activator (tPA), and proactive management of fever, hyperglycaemia and swallowing before prompt transfer to a stroke unit to maximise outcomes. We aim to evaluate the effectiveness in EDs of a theory-informed, nurse-initiated, intervention to improve multidisciplinary triage, treatment and transfer (T3) of patients with acute stroke to improve 90-day death and dependency. Organisational and contextual factors associated with intervention uptake also will be evaluated. METHODS: This prospective, multicentre, parallel group, cluster randomised trial with blinded outcome assessment will be conducted in EDs of hospitals with stroke units in three Australian states and one territory. EDs will be randomised 1:1 within strata defined by state and tPA volume to receive either the T3 intervention or no additional support (control EDs). Our T3 intervention comprises an evidence-based care bundle targeting: (1) triage: routine assignment of patients with suspected stroke to Australian Triage Scale category 1 or 2; (2) treatment: screening for tPA eligibility and administration of tPA where applicable; instigation of protocols for management of fever, hyperglycaemia and swallowing; and (3) transfer: prompt admission to the stroke unit. We will use implementation science behaviour change methods informed by the Theoretical Domains Framework [1, 2] consisting of (i) workshops to determine barriers and local solutions; (ii) mixed interactive and didactic education; (iii) local clinical opinion leaders; and (iv) reminders in the form of email, telephone and site visits. Our primary outcome measure is 90 days post-admission death or dependency (modified Rankin Scale >2). Secondary outcomes are health status (SF-36), functional dependency (Barthel Index), quality of life (EQ-5D); and quality of care outcomes, namely, monitoring and management practices for thrombolysis, fever, hyperglycaemia, swallowing and prompt transfer. Outcomes will be assessed at the patient level. A separate process evaluation will examine contextual factors to successful intervention uptake. At the time of publication, EDs have been randomised and the intervention is being implemented. DISCUSSION: This theoretically informed intervention is aimed at addressing important gaps in care to maximise 90-day health outcomes for patients with stroke. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12614000939695 . Registered 2 September 2014.

Are patients with intracerebral haemorrhage disadvantaged in hospitals?

BACKGROUND AND AIMS: Providing evidence-based clinical care reduces disability and mortality rates following stroke. We examined if compliance with evidence-based processes of care were different for patients with intracerebral haemorrhage when compared with ischemic stroke and sought to describe differences in health outcomes during hospitalization and at time of discharge for these stroke subtypes. METHODS: The New South Wales acute stroke dataset was used. This included data from 50-100 consecutively admitted patients' medical records collected from 32 New South Wales hospitals between 2003 and 2010. Multivariable logistic regression analyses were conducted taking into account patient factors and clustering of patients by hospital. RESULTS: Ischemic stroke and intracerebral haemorrhage cases had similar demographic features (ischemic stroke n = 3467, mean age 74 years [standard deviation 13], 50% female; intracerebral haemorrhage n = 275, mean age 74 years [standard deviation 13], 48% female). Following multivariable analyses patients with intracerebral haemorrhage were less likely to be admitted to a stroke unit (adjusted odds ratio 0.65; 95% confidence interval 0.45-0.94) or receive an assessment from allied health (adjusted odds ratio 0.54; 95% confidence interval 0.33-0.89) than patients with ischemic stroke. Patients with intracerebral haemorrhage are also less likely to be independent (adjusted odds ratio 0.36; 95% confidence interval 0.3-0.5) at time of hospital discharge and had a greater odds of dying in hospital (adjusted odds ratio 2.1; 95% confidence interval 1.3-3.5). Patients that were admitted to a stroke unit had a greater odds of being independent (modified Rankin Score 0-2) at day 7-10 irrespective of stroke type or severity on admission (adjusted odds ratio 1.3; 95% confidence interval 1.01-1.66). CONCLUSIONS: Following intracerebral haemorrhage, patients were less likely to be admitted to an acute stroke unit and receive allied health interventions. Admission to stroke units improved the likelihood of being independent at days 7-10 and, therefore, more should be done to encourage evidence-based care for intracerebral haemorrhage.

Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice--protocol for a cluster randomised controlled trial in acute stroke care.

BACKGROUND: Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke. OBJECTIVES: To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months. METHODS AND DESIGN: A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks. DISCUSSION: TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12613000939796.

Improving quality of life by increasing outings after stroke: study protocol for the Out-and-About trial.

RATIONALE: Almost one-third of Australians need help to travel outdoors after a stroke. Ambulation training and escorted outings are recommended as best practice in Australian clinical guidelines for stroke. Yet fewer than 20% of people with stroke receive enough of these sessions in their local community to change outcomes. AIMS: The Out-and-About trial aims to determine the efficacy and cost effectiveness of an implementation program to change team behavior and increase outings by people with stroke. DESIGN: A two-group cluster-randomized trial will be conducted using concealed allocation, blinded assessors, and intention-to-treat analysis. Twenty community teams and their stroke clients (n = 300) will be recruited. Teams will be randomized to receive either the Out-and-About program or written guidelines only. STUDY OUTCOMES: The primary outcome is the proportion of people with stroke receiving multiple escorted outings during therapy sessions, measured at baseline and 13 months postintervention. Secondary outcomes include number of outings and distance traveled, measured using a self-report diary at baseline and six months postbaseline, and a global positioning system after six months. Cost effectiveness will measure quality-adjusted life years and health service use, measured at baseline and six months postbaseline. DISCUSSION: A potential outcome of this study will be evidence for a costed, transferable implementation program. If successful, the program will have international relevance and transferability. Another potential outcome will be validation of a novel and objective method of measuring outdoor travel (global positioning system) to supplement self-report methods.