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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
  1. Sandy Middleton1,
  2. Anna Lydtin1,
  3. Daniel Comerford2,
  4. Dominique A Cadilhac3,4,
  5. Patrick McElduff5,
  6. Simeon Dale1,
  7. Kelvin Hill6,
  8. Mark Longworth3,
  9. Jeanette Ward7,8,
  10. N Wah Cheung9,10,
  11. Cate D'Este11
  12. on behalf of the QASCIP Working Group and Steering Committee
    1. 1Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
    2. 2NSW Agency for Clinical Innovation, Chatswood, New South Wales, Australia
    3. 3Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
    4. 4School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
    5. 5School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
    6. 6National Stroke Foundation, Melbourne, Victoria, Australia
    7. 7University of Notre Dame, Broom Campus, Broome, Western Australia, Australia
    8. 8University of Ottawa, Ottawa, Canada
    9. 9Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
    10. 10University of Sydney, Sydney, New South Wales, Australia
    11. 11National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australian Capital Territory, Australia
    1. Correspondence to Professor Sandy Middleton; sandy.middleton{at}


    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.

    • Nursing care
    • bundle
    • implementation

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