The Quality in Acute Stroke Care Project (QASC)

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

Fever

Quarter to third of patients >37.5°c 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)

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

Fever

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)

Meta-analysis: hyperglycaemic (BGL > 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)

Hyperglycaemia in non-diabetics

Fever and Sugar Management

Aimed at ‘Salvaging’ the ischaemic penumbraThe penumbral is critically hypoperfused but still viable brain tissueThought to exists out to 48 hours post stroke and is the ‘target’ of most acute stroke therapies

Swallowing Difficulty (Dysphagia)

Dysphagia occurs in 37 - 78% of acute stroke patients and aspiration pneumonia in 10%12

Aspiration can lead to: Chest infections Aspiration pneumonia Death

12Martino et al. (2005)

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)

Swallowing Difficulty (Dysphagia)

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

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

Duration

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

Fever Protocol

Monitor temperature for 72 hours Treat temperature > 37.5°C

Standing order for paracetamol Paracetamol on nurse-initiated

medication list

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 BGL’s for 72 hours if BGL <10 mmols/L

Sugar (Hyperglycaemia) Protocol

1-2 hourly fingerpricks to monitor BGL for 48 hours following admission when admission BGL > 10 mmols /L

If BGL > 10 mmols/L at any time in first 48 hours following admission then insulin infusion commenced

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

References1. Azzimondi G, Bassein L, Nonino F, Fiorani L, Vignatelli L, Re G, et al. Stroke. 1995 Nov;26(11):2040-3.2. Castillo J, Davalos A, Marrugat J & Noya M. Stroke. 1998;29(12):2455-60.3. Turaj W, Slowik A, & Szczudlik A. Neurol Neurochir Pol. 2008 Jul-Aug;42(4):316-22.4. Reith J, Jorgensen HS, Pedersen PM, Nakayama H, Raaschou HO, Jeppesen LL, et al. Lancet. 1996 Feb

17;347(8999):422-5.5. Wang Y, Lim LL, Levi C, Heller RF & Fisher J. Stroke. 2000;31(2):404-9.6. Hajat C, Hajat S & Sharma P. Stroke. 2000 Feb;31(2):410-4.7. Kammersgaard LP, Jorgensen HS, Rungby JA, Reith J, Nakayama H, Weber UJ, et al. Stroke. 2002

Jul;33(7):1759-62.8. Allport L, Baird T, Butcher K, Macgregor L, Prosser J, Colman P, et al. Diabetes Care. 2006;29(8):1839-

44.9. Scott JF, Robinson GM, French JM, O'Connell JE, Alberti KGMM & Gray CS. Lancet. 1999;353:376-7.10.Capes SE, Hunt D, Malmberg K, Pathak P, & Gerstein HC. Stroke. 2001 October 1, 2001;32(10):2426-

32.11.Kammersgaard LP, Jorgensen HS, Rungby JA, Reith J, Nakayama H, Weber UJ, et al. Stroke. 2002

Jul;33(7):1759-62.12.Martino R, Foley N, Bhogal S, Diamant N, Speechley M, & Teasell R.. Stroke. 2005;36(12):2756-63.13.Odderson IR, Keaton JC & McKenna BS.Arch Phys Med Rehabil. 1995 Dec;76(12):1130-3.14.Hinchey JA, Shephard T, Furie K, Smith D, Wang D & Tonn S. Stroke. 2005;36(9):1972-6.15.National Stroke Foundation. 2010. Victoria: NSF; 2010.