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.

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.

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.

Hydration and nutrition care practices in stroke: findings from the UK and Australia.

BACKGROUND: Dehydration and malnutrition are common in hospitalised patients following stroke leading to poor outcomes including increased mortality. Little is known about hydration and nutrition care practices in hospital to avoid dehydration or malnutrition, and how these practices vary in different countries. This study sought to capture how the hydration and nutrition needs of patients' post-stroke are assessed and managed in the United Kingdom (UK) and Australia (AUS). AIM: To examine and compare current in-hospital hydration and nutrition care practice for patients with stroke in the UK and Australia. METHODS: A cross-sectional survey was conducted between April and November 2019. Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing post-stroke inpatient acute care or rehabilitation. Non-respondents were contacted up to five times. RESULTS: We received 150/174 (86%) completed surveys from hospitals in the UK, and 120/162 (74%) in Australia. Of the 270 responding hospitals, 96% reported undertaking assessment of hydration status during an admission, with nurses most likely to complete assessments (85%). The most common methods of admission assessment were visual assessment of the patient (UK 62%; AUS 58%), weight (UK 52%; AUS 52%), and body mass index (UK 47%; AUS 42%). Almost all (99%) sites reported that nutrition status was assessed at some point during admission, and these were mainly completed by nurses (91%). Use of standardised nutrition screening tools were more common in the UK (91%) than Australia (60%). Similar proportions of hydration management decisions were made by physicians (UK 84%; AUS 83%), and nutrition management decisions by dietitians (UK 98%; AUS 97%). CONCLUSION: Despite broadly similar hydration and nutrition care practices after stroke in the UK and Australia, some variability was identified. Although nutrition assessment was more often informed by structured screening tools, the routine assessment of hydration was generally not. Nurses were responsible for assessment and monitoring, while dietitians and physicians undertook decision-making regarding management. Hydration care could be improved through the development of standardised assessment tools. This study highlights the need for increased implementation and use of evidence-based protocols in stroke hydration and nutrition care to improve patient outcomes.

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.

Organisational survey for acute stroke care in Vietnam: Regional Collaboration Programme.

OBJECTIVES: Low-middle income countries, such as Vietnam have a greater burden from stroke than high-income countries. Few health professionals have stroke specialist training, and the quality of care may vary between hospitals. To support improvements to stroke care, we aimed to gain a better understanding of the resources available in hospitals in Vietnam to manage acute stroke. MATERIALS AND METHODS: The survey questions were adapted from the Australian Organisational Survey of Stroke Services (Stroke Foundation). The final 65 questions covered the topics: hospital size and admissions for stroke; use of clinical protocols and assessments conducted; team structure and coordination; communication and team roles. The survey was distributed electronically or via paper form in Vietnamese to clinical leaders of 91 eligible hospitals (November-December 2020). Data were summarised descriptively. RESULTS: Sixty-six (73%) hospitals responded, and doctors predominately completed the survey (98%). Approximately 70% of hospitals had a stroke unit; median 630 acute strokes/year (IQR: 250-1200) and >90% used stroke clinical protocols. The daytime nurse-patient ratio was 1:4. There was a perceived lack of access to allied health staff, including psychologists/neuropsychologists, occupational therapists, and speech pathologists. Only 50% reported having a standardised rehabilitation assessment process. CONCLUSIONS: This is the first large-scale cross-sectional, national overview of stroke services in Vietnam. Future research should include a systematic clinical audit of stroke care to confirm aspects of the data from these hospitals. Repeating the survey in future years will enable the tracking of progress and may influence capacity building for stroke care in Vietnam.

Group Clinical Supervision for midwives and burnout: a cluster randomized controlled trial.

BACKGROUND: There are major shortfalls in the midwifery workforce which has been exacerbated by the COVID 19 pandemic. Midwives have high levels of burnout and many, often early career midwives, are planning to leave the profession. There are reports of a poor workplace culture in maternity units, including bullying. Support is essential for the welfare of the workforce to be able to cope with the demands of their jobs. Supportive strategies, such as Clinical Supervision, a recognised approach in healthcare, enable reflection in a facilitated, structured way, and can enhance professional standards. The purpose of this research is to study burnout levels in midwives, those exiting their workplace and perceptions of workplace culture in relation to access to, and attendance of, monthly Clinical Supervision. METHODS: This study will be a cluster randomised controlled trial of maternity sites within Sydney and the surrounding districts. Twelve sites will be recruited and half will receive monthly Clinical Supervision for up to two years. Midwives from all sites will be requested to complete 6-monthly surveys comprising validated measurement tools: the Copenhagen Burnout Inventory (CBI), the Australian Midwifery Workplace Culture (AMWoC) tool and the Clinical Supervision Evaluation Questionnaire (CSEQ) (the latter for intervention sites only). Primary outcomes are the levels of burnout in midwives (using the CBI). Secondary outcomes will be the quality of the intervention (using the CSEQ), perceptions of workplace culture (using the AMWoC tool) and midwives' intention to stay in their role/profession, as well as sick leave rates and numbers of exiting staff. We will also determine the dose effect - ie the impact in relation to how many Clinical Supervision sessions the midwives have attended, as well as other supportive workplace strategies such as mentoring/coaching on outcomes. DISCUSSION: Through attending monthly Clinical Supervision we hypothesise that midwives will report less burnout and more positive perceptions of workplace culture than those in the control sites. The potential implications of which are a productive workforce giving high quality care with the flow-on effect of having physically and psychologically well women and their babies. TRIAL REGISTRATION: The ACTRN Registration number is ACTRN12621000545864p , dated 10/05/2021,.

The role of stroke nurses in thrombolysis administration in Australia and the United Kingdom: A cross-sectional survey of current practice.

BACKGROUND: The role of stroke nurses in patient selection and administration of recombinant tissue plasminogen activator (rt-PA) for acute ischaemic stroke is evolving. OBJECTIVES: To compare differences in stroke nurses' practices related to rt-PA administration in Australia and the United Kingdom (UK) and to examine whether these differences influence rt-PA treatment rates. METHODS: A cross-sectional, self-administered questionnaire administered to a lead stroke clinician from hospitals known to provide rt-PA for acute ischaemic stroke. Chi-square tests were used to analyse between-country differences in ten pre-specified rt-PA practices. Non-parametric equality of medians test was used to assess within-country differences for likelihood of undertaking practices and association with rt-PA treatment rates. Reporting followed STROBE checklist. RESULTS: Response rate 68%; (Australia: 74% [n = 63/85]; UK: 65% [n = 93/144]). There were significant differences between countries for 7/10 practices. UK nurses were more likely to: request CT scan; screen patient for rt-PA suitability; gain informed consent; use telemedicine to assess, diagnose or treat; assist in the decision for rt-PA with Emergency Department physician or neurologist; and undergo training in rt-PA administration. Reported median hospital rt-PA treatment rates were 12% in the UK and 7.8% in Australia: (7.8%). In Australia, there was an association between higher treatment rates and nurses involvement in 5/10 practices; read and interpret CT scans; screen patient for rt-PA suitability; gain informed consent; assess suitability for rt-PA with neurologist/stroke physician; undergo training in rt-PA administration. There was no relationship between UK treatment rates and likelihood of a stroke nurse to undertake any of the ten rt-PA practices. CONCLUSION: Stroke nurses' active role in rt-PA administration can improve rt-PA treatment rates. Models of care that broaden stroke nurses' scope of practice to maximise rt-PA treatment rates for ischaemic stroke patients are needed. RELEVANCE TO CLINICAL PRACTICE: This study demonstrates that UK and Australian nurses play an important role in thrombolysis practices; however, they are underused. Formalising and extending the role of stroke nurses in rt-PA administration could potentially increase thrombolysis rates with clinical benefits for patients.

Oral care practices in stroke: findings from the UK and Australia.

AIMS: To examine current practice, perceptions of healthcare professionals and factors affecting provision for oral care post-stroke in the UK and Australia. BACKGROUND: Poor oral care has negative health consequences for people post-stroke. Little is known about oral care practice in hospital for people post-stroke and factors affecting provision in different countries. DESIGN: A cross-sectional survey. METHODS: Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing inpatient acute or rehabilitation care post-stroke. The survey was conducted between April and November 2019. Non-respondents were contacted up to five times. RESULTS: Completed questionnaires were received from 150/174 (86%) hospitals in the UK, and 120/162 (74%) in Australia. A total of 52% of UK hospitals and 30% of Australian hospitals reported having a general oral care protocol, with 53% of UK and only 13% of Australian hospitals reporting using oral care assessment tools. Of those using oral care assessment tools, 50% of UK and 38% of Australian hospitals used local hospital-specific tools. Oral care assessments were undertaken on admission in 73% of UK and 57% of Australian hospitals. Staff had received oral care training in the last year in 55% of UK and 30% of Australian hospitals. Inadequate training and education on oral care for pre-registration nurses were reported by 63% of UK and 53% of Australian respondents. CONCLUSION: Unacceptable variability exists in oral care practices in hospital stroke care settings. Oral care could be improved by increasing training, performing individual assessments on admission, and using standardised assessment tools and protocols to guide high quality care. The study highlights the need for incorporating staff training and the use of oral care standardised assessments and protocols in stroke care in order to improve patient outcomes.

Measuring organizational context in Australian emergency departments and its impact on stroke care and patient outcomes.

BACKGROUND: Emergency departments (ED) are challenging environments but critical for early management of patients with stroke. PURPOSE: To identify how context affects the provision of stroke care in 26 Australian EDs. METHOD: Nurses perceptions of ED context was assessed with the Alberta Context Tool. Medical records were audited for quality of stroke care and patient outcomes. FINDINGS: Collectively, emergency nurses (n = 558) rated context positively with several nurse and hospital characteristics impacting these ratings. Despite these positive ratings, regression analysis showed no significant differences in the quality of stroke care (n = 1591 patients) and death or dependency (n = 1165 patients) for patients in EDs with high or low rated context. DISCUSSION: Future assessments of ED context may need to examine contextual factors beyond the scope of the Alberta Context Tool which may play an important role for the understanding of stroke care and patient outcomes in EDs.

Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study.

BACKGROUND: The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake. METHODS: Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups. RESULTS: Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols. CONCLUSIONS: Despite initial high 'buy-in' from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).

Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA.

BACKGROUND: Strict criteria for recombinant tissue plasminogen activator (rtPA) eligibility are stipulated on licences for use in ischaemic stroke; however, practitioners may also add non-standard rtPA criteria. We examined eligibility criteria variation in 3 English-speaking countries including use of non-standard criteria, in relation to rtPA treatment rates. METHODS: Surveys were mailed to 566 eligible hospitals in Australia (AUS), the UK, and the USA. Criteria were pre-classified as standard (approved indication and contraindications) or non-standard (approved warning or researcher "decoy"). Percentage for criterion selection was calculated/compared; linear regression was used to assess the association between use of non-standard criteria and rtPA treatment rates, and to identify factors associated with addition of non-standard criteria. RESULTS: Response rates were 74% AUS, 65% UK, and 68% USA; mean rtPA treatment rates were 8.7% AUS, 12.7% UK, and 8.7% USA. Median percentage of non-standard inclusions was 33% (all 3 countries) and included National Institutes of Health Stroke Scale (NIHSS) scores > 4, computed tomography (CT) angiography documented occlusion, and favourable CT perfusion. Median percentage of non-standard exclusions was 25% AUS, 28% UK, and 60% USA, and included depressed consciousness, NIHSS > 25, and use of antihypertensive infusions. No AUS or UK sites selected 100% of standard exclusions. CONCLUSIONS: Non-standard criteria for rtPA eligibility were evident in all three countries and could, in part, explain comparably low use of rtPA. Differences in the use of standard criteria may signify practitioner intolerance for those derived from original efficacy studies that are no longer relevant.

Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a National Audit for acute stroke: evidence of upscale and spread.

BACKGROUND: In the Quality in Acute Stroke Care (QASC) trial undertaken in stroke units (SUs) located in New South Wales (NSW), Australia (2005-2010), facilitated implementation of a nurse-led care bundle to manage fever, hyperglycaemia and swallowing (FeSS protocols) reduced death and disability for patients with stroke. We aimed to determine subsequent adherence to the bundled FeSS processes (reflective of the protocols) between 2013 and 2017 in Australian hospitals, and examine whether changes in adherence to these processes varied based on previous participation in the QASC trial or subsequent statewide scale-up (QASCIP-Quality in Acute Stroke Care Implementation Project) and presence of an SU. METHODS: Cross-sectional, observational study using self-reported organisational survey and retrospective clinical audit data from the National Acute Services Stroke Audit (2013, 2015, 2017). Mixed-effects logistic regression was performed with dependent variables: (1) composite outcome measure reflecting compliance with the FeSS protocols and (2) individual FeSS processes, including the year of audit as an independent variable, adjusted for correlation of outcomes within hospital. Separate models including interaction terms between the year of audit and previous participation in QASC/QASCIP and year of audit and SU were also generated. RESULTS: Hospital participation included the following: 2013-124 hospitals, 3741 cases; 2015-112 hospitals, 4087 cases; and 2017-117 hospitals, 4192 cases. An 80% increase in the odds of receiving the composite outcome in 2017 compared to 2013 was found (2013, 30%; 2017, 41%; OR 1.8; 95% CI 1.6, 2.0; p < 0.001). The odds of FeSS adherence from 2013 to 2017 was greater for hospitals that had participated in QASC/QASCIP relative to those that had not (participated OR 2.1; 95% CI 1.7, 2.7; not participated OR 1.6; 95% CI 1.4, 1.8; p = 0.03). Similar uptake in adherence was evident in hospitals with and without an SU between 2013 and 2017. CONCLUSION: The use of the FeSS protocols within Australia increased from 2013 to 2017 with the inclusion of these care processes in the National Audit. Greater uptake in hospitals previously involved in QASC/QASCIP was evident. Our implementation methods may be useful for other national initiatives for improving access to evidence-based practice.

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.

Validating the Alberta Context Tool in a multi-site Australian Emergency Department nurse population.

The organisational context of healthcare settings has an essential role in how research evidence is used in clinical practice. The Alberta Context Tool (ACT) measures 10 concepts of organisational context with higher scores indicating a more positive work environment and potentially better use of research evidence in patient care. We assessed the psychometric properties of the ACT in Emergency Departments (EDs). This validation study was conducted as part of a multi-centre trial of triage, treatment and transfer (T3 Trial) of patients with stroke admitted to EDs. Stratified sampling with proportional allocation was used to recruit ED nurses from 26 participating hospitals at baseline. Nurses completed a survey containing the ACT. Structural validity was investigated by exploratory and confirmatory factor analysis. Reliability was assessed using Cronbach's alpha and intraclass correlation coefficients. Item-rest correlations and the average inter-item correlations were also assessed. 558 ED nurses completed the survey, comprised of 433 surveys without missing data. Our exploratory factor analysis produced a 14-factor structure, explaining 62% of variance of organisational context. For eight of ten concepts, item loadings matched the factor structure of the original ACT. Confirmatory factor analysis of the 10 ACT concepts showed moderate model fit (p = 0.001, root mean square error of approximation: 0.049, standardised root mean squared residual: 0.048). Cronbach's alphas showed very good internal consistency for nine of ten ACT concepts (α>0.7; 0.45-0.90). Item-rest correlations indicated that most ACT items (50 of 56 items) within any concept related well to the total score of the concept. Average inter-item correlations indicated potential redundant items for three concepts (feedback processes, leadership, staffing) that were above the threshold of 0.5. While identifying a few shortcomings for some ACT concepts in an ED context, the majority of findings confirm reliability and validity of the original ACT in an Australian population of ED nurses.

Vital sign monitoring following stroke associated with 90-day independence: A secondary analysis of the QASC cluster randomized trial.

BACKGROUND: The Quality in Acute Stroke Care Trial implemented nurse-initiated protocols to manage fever, hyperglycaemia and swallowing (Fever, Sugar, Swallow clinical protocols) achieving a 16% absolute improvement in death and dependency 90-day post-stroke. OBJECTIVE: To examine associations between 90-day death and dependency, and monitoring and treatment processes of in-hospital nursing stroke care targeted in the trial. DESIGN: Secondary data analysis from a single-blind cluster randomised control trial. SETTING: 19 acute stroke units in New South Wales, Australia. PARTICIPANTS: English-speakers ≥18 years with ischaemic stroke or intracerebral haemorrhage arriving at participating stroke units <48 h of stroke onset, excluding those for palliation and without a telephone. METHOD: Data from patients in the 10 intervention hospitals and the nine control hospitals in the QASC trial post-intervention cohort, who had both hospital process of care data and 90-day outcome data were included. Associations between independence at 90-day (modified Rankin Score ≤1) and processes of care for fever, hyperglycaemia, and dysphagia screening were examined using multiple logistic regression adjusting for treatment group, sex, age group, premorbid modified Rankin scale, marital status, education, stroke severity and correlation within hospitals. RESULTS: Of 1126 patients in the post-intervention cohort (intervention or control), 970 had both in-hospital processes of care data and 90-day outcome data. Patients had significantly lower odds of 90-day independence if, within the first 72 h of stroke unit admission, they had one or more: febrile event (≥37.5 °C) (OR 0.47; 95%CI:0.35-0.61; P < 0.0001), higher mean temperature (OR:0.25; 95%CI:0.14-0.45; P < 0.0001), finger-prick blood glucose reading ≥11 mmol/L (OR:0.61; 95%CI:0.47-0.79; P = 0.0002), higher mean blood glucose (OR 0.89; 95%CI:0.84-0.95; P = 0.0006), or failed the swallowing screen (OR 0.35; 95%CI:0.22-0.56; P < 0.0001). Patients had greater odds of independence when: venous blood glucose was taken on admission to hospital or within 2 h of stroke unit admission (OR 1.4; 95%CI:1.01-1.83; P = 0.04); finger-prick blood glucose was measured within 72 h of stroke unit admission (OR 1.3; 95%CI:1.02-1.55; P = 0.03); or when swallowing screening or assessment was performed within 24 h of stroke unit admission (OR 1.8; 95%CI:1.29-2.55; P = 0.0006). CONCLUSION: We have provided robust evidence of the importance of monitoring patients' temperature, blood glucose and swallowing status to improve 90-day stroke outcomes. Routine nursing care can result in significant reduction in death and dependency post-stroke.

International Uptake of a Proven Intervention to Reduce Death and Dependency in Acute Stroke: A Cross-Sectional Survey Following the QASC Trial.

BACKGROUND: Uptake of proven interventions requires dedicated resources that may only result in local implementation, thus precluding international practice change. We explored international uptake through online dissemination of the fever, sugar, and swallow (FeSS) protocols from the Quality in Acute Stroke Care (QASC) trial, which showed decreased death and dependency by 15.7% 90-day poststroke. AIMS: To identify: (a) the clinical discipline of healthcare professionals who downloaded the QASC resources; (b) the purpose for downloading; (c) successful implementation of any or all the FeSS protocols; (d) barriers to implementation; and (e) associations with self-reported successful implementation. METHODS: A cross-sectional, online survey of those who downloaded the QASC resources between October 2011 and August 2013. Associations between implementation and participant characteristics were determined. RESULTS: One-hundred and fifty-nine people from 21 countries participated. Nurses were the largest group to download the resources (n = 54, 38%), with the primary purpose to inform clinical practice (n = 97, 64%). Less than half (n = 77, 48%) downloaded, and less than a quarter (n = 38, 24%) attempted to implement all three protocols. Of those personally involved in implementation (n = 50) half reported doing so successfully for one or more protocols (n = 27, 54%) with 10 (20%) reporting successful implementation of all three protocols. Only about half (n = 13, 48%) used the proven implementation strategy with about one-third (n = 10, 29%) confirming successful uptake via audit. Implementation barriers were potential increase in nursing workload (n = 28, 56%) and lack of medical staff engagement (n = 27, 53%). Higher autonomy was associated with greater likelihood of implementation of all three protocols (p = .038). LINKING EVIDENCE TO ACTION: The QASC intervention required use of all three protocols. However, less than half downloaded them all and implementation was not guided by the proven implementation strategy. While encouraging that these resources were being used to drive practice change, piecemeal implementation of a proven intervention is unlikely to improve patient outcomes.

Development of a theory-informed implementation intervention to improve the triage, treatment and transfer of stroke patients in emergency departments using the Theoretical Domains Framework (TDF): the T3 Trial.

BACKGROUND: Theoretical frameworks and models based on behaviour change theories are increasingly used in the development of implementation interventions. Development of an implementation intervention is often based on the available evidence base and practical issues, i.e. feasibility and acceptability. The aim of this study was to describe the development of an implementation intervention for the T3 Trial (Triage, Treatment and Transfer of patients with stroke in emergency departments (EDs)) using theory to recommend behaviour change techniques (BCTs) and drawing on the research evidence base and practical issues of feasibility and acceptability. METHODS: A stepped method for developing complex interventions based on theory, evidence and practical issues was adapted using the following steps: (1) Who needs to do what, differently? (2) Using a theoretical framework, which barriers and enablers need to be addressed? (3) Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? A researcher panel was convened to review the list of BCTs recommended for use and to identify the most feasible and acceptable techniques to adopt. RESULTS: Seventy-six barriers were reported by hospital staff who attended the workshops (step 1: thirteen TDF domains likely to influence the implementation of the T3 Trial clinical intervention were identified by the researchers; step 2: the researcher panellists then selected one third of the BCTs recommended for use as appropriate for the clinical context of the ED and, using the enabler workshop data, devised enabling strategies for each of the selected BCTs; and step 3: the final implementation intervention consisted of 27 BCTs). CONCLUSIONS: The TDF was successfully applied in all steps of developing an implementation intervention for the T3 Trial clinical intervention. The use of researcher panel opinion was an essential part of the BCT selection process to incorporate both research evidence and expert judgment. It is recommended that this stepped approach (theory, evidence and practical issues of feasibility and acceptability) is used to develop highly reportable implementation interventions. The classifying of BCTs using recognised implementation intervention components will facilitate generalisability and sharing across different conditions and clinical settings.

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.

Testing a systematic approach to identify and prioritise barriers to successful implementation of a complex healthcare intervention.

BACKGROUND: Multiple barriers may inhibit the adoption of clinical interventions and impede successful implementation. Use of standardised methods to prioritise barriers to target when selecting implementation interventions is an understudied area of implementation research. The aim of this study was to describe a method to identify and prioritise barriers to the implementation of clinical practice elements which were used to inform the development of the T3 trial implementation intervention (Triage, Treatment [thrombolysis administration; monitoring and management of temperature, blood glucose levels, and swallowing difficulties] and Transfer of stroke patients from Emergency Departments [ED]). METHODS: A survey was developed based on a literature review and data from a complementary trial to identify the commonly reported barriers for the nine T3 clinical care elements. This was administered via a web-based questionnaire to a purposive sample of Australian multidisciplinary clinicians and managers in acute stroke care. The questionnaire addressed barriers to each of the nine T3 trial clinical care elements. Participants produced two ranked lists: on their perception of: firstly, how influential each barrier was in preventing clinicians from performing the clinical care element (influence attribute); and secondly how difficult the barrier was to overcome (difficulty attribute). The rankings for both influence and difficulty were combined to classify the barriers according to three categories ('least desirable', desirable' or 'most desirable' to target) to assist interpretation. RESULTS: All invited participants completed the survey; (n = 17; 35% medical, 35% nursing, 18% speech pathology, 12% bed managers). The barriers classified as most desirable to target and overcome were a 'lack of protocols for the management of fever' and 'not enough blood glucose monitoring machines'. CONCLUSIONS: A structured decision-support procedure has been illustrated and successfully applied to identify and prioritise barriers to target within an implementation intervention. This approach may prove to be a useful in other studies and as an adjunct to undertaking barrier assessments within individual sites when planning implementation interventions.