According to a new study published Online First by The Lancet, Stroke patients in acute stroke units following a multidisciplinary intervention that targets hyperglycemia, swallowing management and fever are less likely to die or be dependent and have improved physical function at 90 days compared to patients given standard care. Clinical leaders of stroke services can confidently adopt this strategy knowing that their outcomes will improve say the researchers. The report was written by Professor Sandy Middleton, Nursing Research Institute, St Vincent’s & Mater Health, Sydney, Australia, and Australian Catholic University and his team.

Even though deaths and disability from cerebrovascular events are considerably reduced with organized stroke unit care, universally, hyperglycaemia, swallowing management and fever are still not well managed even though they are highly important for long-term patient recovery.

In the initial days following an acute stroke 20-50% of patients had a temperature higher than 37.5°C, 37-38% had difficulty swallowing, and up to 50% of patients became hyperglycemia, all of these conditions are connected with increased morbidity and mortality.

The study – Quality in Acute Stroke Care (QASC), a randomized controlled trial, an evidence-based intervention targeting the management of fever, hyperglycaemia, and swallowing management was tested in 19 acute stroke units (ASUs) in New South Wales, Australia.

Management for fever included monitoring the patients’ temperature each 4 hours, and where required, paracetamol to lower temperature. For swallowing management, nurses went through pre-intervention training which included, watching a training DVD, education by a speech pathologist, and knowledge and competency testing. The intervention for hyperglycemia included frequent blood glucose monitoring as well as infusion of insulin or saline depending on blood sugar levels and whether diabetes was presence or absence.

Patients in the 19 ASUs were randomly assigned to two groups intervention (10) or control (9). Out of the 6,564 patients evaluated for eligibility, data from 1,699 patients were obtained (687 pre-intervention and 1,009 post-intervention). Results revealed that regardless of how severe the stroke, patients in the intervention group were considerably less likely to die or be dependant at 90 days (42%) compared to patients in the control group (58%). Those in the intervention group also had better results on a standard physical performance assessment (the SF-36 mean physical component summary score) 45.6 compared to 42.5 in the control group (with approximately 95% of individuals scoring between 30 and 70 on this scale).

Although, in overall mortality no improved was recorded 4% in the intervention group versus 5% in the control group, or mental functioning or physical dependency assessment.

The researchers explain that compared with other established clinical and organizational interventions, such as stroke unit care, administration of aspirin within 48 hours and thrombolysis within 4.5 hours, the difference in rates of 90-day death and dependency were incredible.

They conclude:

“The QASC trial provides high-quality evidence that a guideline implementation strategy to support multidisciplinary teamwork and good nursing care focused on evidence-based management of three key physiological variables in ASUs delivers significantly better post-discharge outcomes for stroke patients. Clinical leaders of stroke services can adopt this strategy with confidence that their outcomes will improve.”

In a joint comment, Professor Charles D A Wolfe and Dr Anthony G Rudd, King’s College London, London, and National Institute for Health Research Comprehensive Biomedical Research Center, Guy’s and St Thomas’ NHS Trust and King’s College London, explain:

“The findings from Middleton and colleagues are highly pertinent to health systems worldwide since admissions for stroke care are set to increase by 30% in the next 20 years.”

They warn that further research is needed to know more about the baseline level of care in these units in Australia so that they can accurately evaluate the true benefit of the intervention in QASC. They conclude:

“The next step must be to assess this methodology in other healthcare systems and to undertake long-term studies to show a sustainable effect. However, the main message that should be taken from Middleton and colleagues study is that more detailed observation and correction of physiological abnormalities after acute stroke is logical, and that studies of this sort should be developed alongside drug and other acute interventions.”

Written by Grace Rattue