There is extensive evidence on the benefits of managing thrombolysis, fever, hyperglycaemia and swallowing following an acute stroke (. We previously demonstrated in the Quality in Acute Stroke Care (QASC) Trial, that supported implementation for three clinical protocols for the management of fever, hyperglycaemia and swallowing dysfunction in the stroke unit significantly decreased death and disability by 16% (Middleton et al., 2011) and longer-term mortality (Middleton et al., 2017). However, Emergency Department (ED) processes remain sub-optimal in managing acute stroke triage; thrombolysis administration; fever, hyperglycaemia and swallowing management; and rapid transfer to a stroke unit (Considine & McGillivray, 2010; Drury et al., 2014; National Stroke Foundation, 2013). The aim of the trial was to evaluate the effectiveness of a bundled protocol nurse-initiated, multi-faceted intervention to improve triage, treatment and transfer for patients with acute stroke admitted to ED compared with usual care.
Methods: We conducted a pragmatic, blinded multicentre, parallel group, cluster randomised controlled trial to receive either the T3 intervention or no support. The intervention targeted: (1) Triage: suspected stroke patients to be assigned to patients with suspected acute stroke triaged as Australian Triage Scale 1 or 2; (2) Treatment: screening for tPA eligibility and administration where applicable; management of fever, hyperglycaemia and swallowing; and (3) rapid Transfer to the stroke unit. The implementation strategy comprised: (i) workshops to determine barriers and solutions; (ii) education; (iii) clinical opinion leaders; (iv) reminders. Primary outcome: 90-days death or dependency (mRS>2). Secondary outcomes: 90-day: health status (SF-36), functional dependency (Barthel Index); and 11 in-hospital quality-of-care outcomes.
Results: Twenty six hospitals from three states and one territory participated out of 40 eligible hospitals, involving 2242 patients (pre-implementation n=645; post-implementation n=1597 including 748 patients in intervention sites and 546 in control sites). There were no statistically significant differences at follow-up between intervention (400/748 [53%]) or control group (266/546 [51%]; p=0.2432) for 90-day death or dependency, or any of the secondary outcomes.
Conclusion: This large evidence-based trial used an implementation strategy previously shown to be highly effective in stroke units. However, it did not change ED clinician behaviour. The ED environment is complex and challenging with competing priorities. Alternative ways to support implementation of evidence-based research into ED warrant investigation.