U.S. could benefit from compliance studies, expert says.
Implementation of nursing protocols aimed at careful monitoring of patient temperature, blood sugar, and swallowing in the first days of stroke care can improve mortality outcomes, according to a new Australian study.
In a telephone interview with Neurovascular Exchange, outside expert Deborah Summers, MSN (Saint Luke's Brain and Stroke Institute, Kansas City, MO), said that research into the impact of organized nursing care on outcomes of stroke patients is lacking. While multiple studies are investigating stroke discovery and treatment approaches, research into nursing care remains in its infancy.
For the Quality in Acute Stroke Care (QASC) trial, Sandy Middleton, PhD, (St. Vincent’s Health Australia, Sydney), and colleagues examined the effect of various nurse-initiated protocols for the management of stroke patients admitted to a stroke unit in 19 Australian acute stroke units between 2005 and 2010. Overall, 1,076 participants were followed for a mean of 4.1 years, and outcomes of the 600 patients treated using the protocol were compared with the 476 who received usual care. The study was published online recently ahead of the May 2017 issue of Stroke.
The protocol was implemented during the first 72 hours following admission and was comprised of the following key elements:
Temperature
- Monitor and chart every 4 hours
- Fever ≥ 37.5°C treated with acetaminophen unless contraindicated
Sugar
- Venous blood measurement at admission to hospital or stroke unit
- Finger prick measurement at admission to stroke unit
- 6-hour saline infusion on admission if sugars out of optimal range (8-11 mmol/L if diabetic, 8-16 mmol/L if not diabetic)
- Insulin infusion in the first 48 hours if elevated blood sugars (≥ 11 mmol/L if diabetic, ≥ 16 mmol/L if not diabetic)
Swallowing
- Education program for nurses on dysphagia
- Competency assessment for nurses on screening for dysphagia
- Patients screened for dysphagia within 24 hours of admission to stroke unit and results documented
- Patients who fail screening referred to speech pathologist
Education
- Two multidisciplinary team-building workshops
- Two site-based educational outreach meetings
- Involvement of local stroke unit coordinators
Cardiovascular disease, which included stroke, was listed as the primary or secondary cause of death in 80% of patients. Those treated using the new protocol had increased long-term survival rates after adjusting for correlations within stroke units, age, sex, marital status, education, and stroke severity (adjusted HR 0.77; 95% CI 0.59-0.99, P = 0.045).
Both older age of 75-84 years (HR 4.10, 95% CI 1.67-10.06, P = 0.002) and increasing stroke severity (HR 3.15 95% CI 1.26-7.87, P = 0.014) correlated with increased morality, while being married was associated with lower mortality (HR 0.70, 95% CI 0.49-0.99, P = 0.042).
“Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction,” conclude the authors. “These protocols should be a routine part of acute stroke care.
Data on Monitoring in US Needed
Summers said that the protocol addresses factors that stroke care nurses in the United States are monitoring already. This study is among the first, however, to provide hard evidence that such monitoring improves patient outcomes. In addition, it demonstrates the importance of very tight control, which may not be occurring in US stroke centers.
“Earlier work [by the QASC team] found that compliance with following those protocols was not high,” she pointed out. “My biggest concern is that, we do all of these [in the United States], but do we actually treat a temperature of 37.5 or 38? Nurses are so busy and organizations are giving us more and more responsibilities and tasks.”
Research and education are key, she added. “Years ago, there was a study done by the American Association of Neuroscience Nurses on traumatic brain injury and compliance with treating fever was not good enough. So, I don’t know where we stand in the United States.”
Summers would like to see US hospitals collect baseline information on how closely they are monitoring and treating these elements, which she said is the first step toward improving care.
Sources:
Middleton S, Coughlan K, Mnatzaganian G, et al. Mortality reduction for fever, hyperglycemia, and swallowing nurse-initiated stroke intervention: QASC Trial (Quality in Acute Stroke Care) Follow-Up. Stroke. 2017;Epub ahead of print.
Disclosures:
- Middleton reports being appointed to the Research Committee of the National Health & Medical Research Council (NHMRC) subsequent to trial completion.
- Summers reports no relevant conflicts of interest.
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