Triage, Treatment, and Transfer of Patients With Stroke in Emergency Departments:The T3 Cluster Randomised Trial

Friday, 20 July 2018: 11:05 AM

Sandy Middleton, PhD, RN1
Simeon Dale, BA (Hons)2
N. Wah Cheung, PhD3
Elizabeth McInnes, PhD1
Cate D’Este, PhD4
Dominique Cadilhac, PhD5
Jeremy Grimshaw, MD, PhD6
Richard Gerraty, FRACP7
Louise Craig, PhD1
Verena Schadewaldt, PhD8
Patrick McElduff, PhD9
Clare Quinn, MSc10
Greg Cadigan, BN11
Sonia Denisenko, MPA12
Mark Longworth, BNA13
Christopher Levi, PhD, FRACP14
Mark Fitzgerald, MD15
Jeanette Ward, PhD16
Julie Considine, PhD, RN, BN, GDipNurs, MNurs, FNRCA17
(1)Nursing Research Institute, St. Vincent's Health Australia (Sydney) & Australian Catholic University, Darlinghurst, Australia
(2)Nursing Research Institute, St. Vincent's Health Australia (Sydney) & Australian Catholic University, Darlinghurst, Australia
(3)Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Sydney, Australia
(4)Biostatistics, National Centre for Epidemiology and Population Health (NCEPH), The Australian National University, Canberra, Australia
(5)Stroke and Ageing Research, School of Clinical Sciences & the Florey Institute of Neuroscience and Mental Health, Monash Health, Monash University and University of Melbourne, Melbourne, Australia
(6)Clinical Epidemiology Program & Department of Medicine, Ottawa Health Research Institute & University of Ottawa, Ottawa, ON, Canada
(7)Department of Medicine & Neurosciences Clinical Institute, Monash University & Epworth Hospital, Melbourne, Australia
(8)Nursing Research Institute, St. Vincent's Health Australia (Sydney) & Australian Catholic University, Melbourne, Australia
(9)School of Medicine and Public Health, University of Newcastle & Health Policy Analysis Pty Ltd, Sydney, Australia
(10)Speech Pathology Department, Prince of Wales Hospital, Sydney, Australia
(11)Statewide Stroke Clinical Network, Queensland Health, Brisbane, Australia
(12)Victorian Stroke Clinical Network (VSCN), Victoria State Government, Melbourne, Australia
(13)Stroke Services NSW, NSW Agency for Clinical Innovation, Sydney, Australia
(14)The Sydney Partnership for Health Education Research & Enterprise (SPHERE), Liverpool NSW, Australia
(15)Department of Surgery, The Alfred, Melbourne, Australia
(16)Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
(17)Centre for Quality and Patient Safety Research, Eastern Health Partnership, Eastern Health School of Nursing and Midwifery & Deakin University, Melbourne, Australia

Background and aim:

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.