Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention: QASC Trial (Quality in Acute Stroke Care) Follow-Up

Affiliations

¹ From the Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, St Vincent's Hospital, New South Wales (S.M., K.C., S.D., A.J.-B.); College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Victoria, Australia (G.M.); School of Physiotherapy, Faculty of Health Sciences, Australian Catholic University, Queensland (N.L.C.); John Hunter Hospital and Centre for Translational Neuroscience and Mental Health, University of Newcastle/Hunter Medical Research Institute, New South Wales, Australia (C.L.); Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital-General Campus, Centre for Practice-Changing Research (CPCR), Ontario, Canada and Department of Medicine, University of Ottawa, Ontario, Canada (J.M.G.); School of Epidemiology, Public Health and Preventive Medicine (SEPHPM), University of Ottawa, Ontario, Canada and Nulungu Research Institute, University of Notre Dame Australia, Western Australia (J.W.); Translational Public Health Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Australia and Public Health, Stroke Division, The Florey Institute of Neuroscience and Mental Health, Victoria, Australia (D.A.C.); School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia (P.M.); Health Sciences, Faculty of Health Sciences, Swinburne University of Technology, Victoria, Australia and School of Public Health, University of Adelaide, South Australia, Australia (J.E.H.); and National Centre for Epidemiology and Population Health (NCEPH), Research School of Population Health, Australian National University, Australian Capital Territory (C.D.). sandy.middleton@acu.edu.au.
² From the Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, St Vincent's Hospital, New South Wales (S.M., K.C., S.D., A.J.-B.); College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Victoria, Australia (G.M.); School of Physiotherapy, Faculty of Health Sciences, Australian Catholic University, Queensland (N.L.C.); John Hunter Hospital and Centre for Translational Neuroscience and Mental Health, University of Newcastle/Hunter Medical Research Institute, New South Wales, Australia (C.L.); Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital-General Campus, Centre for Practice-Changing Research (CPCR), Ontario, Canada and Department of Medicine, University of Ottawa, Ontario, Canada (J.M.G.); School of Epidemiology, Public Health and Preventive Medicine (SEPHPM), University of Ottawa, Ontario, Canada and Nulungu Research Institute, University of Notre Dame Australia, Western Australia (J.W.); Translational Public Health Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Australia and Public Health, Stroke Division, The Florey Institute of Neuroscience and Mental Health, Victoria, Australia (D.A.C.); School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia (P.M.); Health Sciences, Faculty of Health Sciences, Swinburne University of Technology, Victoria, Australia and School of Public Health, University of Adelaide, South Australia, Australia (J.E.H.); and National Centre for Epidemiology and Population Health (NCEPH), Research School of Population Health, Australian National University, Australian Capital Territory (C.D.).

PMID: 28389609
DOI: 10.1161/STROKEAHA.116.016038

Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention: QASC Trial (Quality in Acute Stroke Care) Follow-Up

Sandy Middleton et al. Stroke. 2017 May.

. 2017 May;48(5):1331-1336.

doi: 10.1161/STROKEAHA.116.016038. Epub 2017 Apr 7.

Affiliations

¹ From the Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, St Vincent's Hospital, New South Wales (S.M., K.C., S.D., A.J.-B.); College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Victoria, Australia (G.M.); School of Physiotherapy, Faculty of Health Sciences, Australian Catholic University, Queensland (N.L.C.); John Hunter Hospital and Centre for Translational Neuroscience and Mental Health, University of Newcastle/Hunter Medical Research Institute, New South Wales, Australia (C.L.); Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital-General Campus, Centre for Practice-Changing Research (CPCR), Ontario, Canada and Department of Medicine, University of Ottawa, Ontario, Canada (J.M.G.); School of Epidemiology, Public Health and Preventive Medicine (SEPHPM), University of Ottawa, Ontario, Canada and Nulungu Research Institute, University of Notre Dame Australia, Western Australia (J.W.); Translational Public Health Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Australia and Public Health, Stroke Division, The Florey Institute of Neuroscience and Mental Health, Victoria, Australia (D.A.C.); School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia (P.M.); Health Sciences, Faculty of Health Sciences, Swinburne University of Technology, Victoria, Australia and School of Public Health, University of Adelaide, South Australia, Australia (J.E.H.); and National Centre for Epidemiology and Population Health (NCEPH), Research School of Population Health, Australian National University, Australian Capital Territory (C.D.). sandy.middleton@acu.edu.au.
² From the Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, St Vincent's Hospital, New South Wales (S.M., K.C., S.D., A.J.-B.); College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Victoria, Australia (G.M.); School of Physiotherapy, Faculty of Health Sciences, Australian Catholic University, Queensland (N.L.C.); John Hunter Hospital and Centre for Translational Neuroscience and Mental Health, University of Newcastle/Hunter Medical Research Institute, New South Wales, Australia (C.L.); Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital-General Campus, Centre for Practice-Changing Research (CPCR), Ontario, Canada and Department of Medicine, University of Ottawa, Ontario, Canada (J.M.G.); School of Epidemiology, Public Health and Preventive Medicine (SEPHPM), University of Ottawa, Ontario, Canada and Nulungu Research Institute, University of Notre Dame Australia, Western Australia (J.W.); Translational Public Health Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Australia and Public Health, Stroke Division, The Florey Institute of Neuroscience and Mental Health, Victoria, Australia (D.A.C.); School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia (P.M.); Health Sciences, Faculty of Health Sciences, Swinburne University of Technology, Victoria, Australia and School of Public Health, University of Adelaide, South Australia, Australia (J.E.H.); and National Centre for Epidemiology and Population Health (NCEPH), Research School of Population Health, Australian National University, Australian Capital Territory (C.D.).

PMID: 28389609
DOI: 10.1161/STROKEAHA.116.016038

Abstract

Background and purpose: Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005-2010). We now examine long-term all-cause mortality.

Methods: Mortality was ascertained using Australia's National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber-White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates.

Results: One thousand and seventy-six participants (intervention n=600; control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival (>20%), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.58-1.07; P=0.13; adjusted HR, 0.77; 95% CI, 0.59-0.99; P=0.045). Older age (75-84 years; HR, 4.9; 95% CI, 2.8-8.7; P<0.001) and increasing stroke severity (HR, 1.5; 95% CI, 1.3-1.9; P<0.001) were associated with increased mortality, while being married (HR, 0.70; 95% CI, 0.49-0.99; P=0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths.

Conclusions: Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care.

Clinical trial registration: URL: http://www.anzctr.org.au. Unique identifier: ACTRN12608000563369.

Keywords: fever; hyperglycemia; implementation; mortality; stroke; swallowing.

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Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention: QASC Trial (Quality in Acute Stroke Care) Follow-Up

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Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention: QASC Trial (Quality in Acute Stroke Care) Follow-Up

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Abstract

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