Hyperglycaemia, swallowing dysfunction and elevated temperature continue to be well documented physiological variables associated with poor outcomes after stroke (Bellolio, Gilmore, & Ganti, 2014; den Hertog et al., 2011; Joundi et al., 2017; Ntaios, Papavasileiou, Bargiota, Makaritsis, & Michel, 2014). Increasingly management of these are being featured in international guidelines as priorities for inpatient stroke management (Blanca Fuentes, 2017; Intercollegiate Stroke Working Party, 2016; Stroke Foundation, 2017)
The Quality in Acute Stroke Care (QASC) Trial, demonstrated that evidence-based nurse-initiated interventions to manage fever, hyperglycaemia and swallow difficulties following acute stroke significantly reduces death and dependency at 90 days (S. Middleton et al., 2011). More recently, through data linkage with the Australian National Death Index, investigators were able to report these short term benefits are also sustained longer term (median follow-up time 4 years). Results showed those patients who were treated in stroke units allocated to receive the intervention in the QASC trial had significantly improved long-term survival (>20%) (S Middleton et al., 2017).
Subsequently, the QASC clinical protocols were implemented throughout all thirty-six stroke services in New South Wales (Australia) over an eight-month period with commensurate improvements in the proportion of patients receiving this packaged intervention, grounded in implementation science methodological framework (S. Middleton et al., 2016).
This study demonstrated the possibility of successful evidence translation across an entire state of a proven nurse-initiated intervention to improve patient outcomes. The significance of this translational implementation project has received international attention prompting a new collaboration with the European Stroke Organisation. The QASC Europe project aims to implement the QASC clinical protocols in up to 300 stroke services in 12 European countries using the similar methods used in the original large clinical trial and in the state-wide implementation project. The ‘upscale and spread’ of this ten year program of significant implementation research is of interest to clinicians, researchers and health policy makers globally.
Methods:
Methods include a cluster randomised controlled trial to generate evidence of effectiveness of our evidence-based intervention; a pre-test/ post-test design to determine success of its subsequent state-wide roll out; and a pre-test/ post-test design of the European implementation (in progress). Barriers and facilitators to large-scale system change experienced at all three stages will be discussed, as will challenges to the rapid international translation and spread that is being co-ordinated from Australia.
Results:
QASC clinical protocols have been translated into several different languages. Expression of interest has been received from 37 international stroke centers with complete organisational data to be analysed for 14 sites in Europe. Pre-test baseline data is being collected concurrently for pilot sites in 3 countries at the time of submission.
Conclusion:
This will be the first time that a study of this size with a focus on a proven nursing intervention to improve stroke outcomes has been translated at this scale. Results will demonstrate the rapid ‘upscale and spread’ of a nursing intervention to ‘real-world’ conditions to reach a greater proportion of stroke patients. Lessons learnt will provide invaluable insights for the translation of other effective nursing interventions.