The Quality in Acute Stroke Care (QASC) global scale-up using a cascading facilitation framework: a qualitative process evaluation

Elizabeth McInnes^{1

2}, Simeon Dale^{3

4}, Kathleen Bagot¹, Kelly Coughlan^{1

2}, Jeremy Grimshaw⁵, Waltraud Pfeilschifter^{6

7}, Dominique A Cadilhac^{8

9}, Thomas Fischer¹⁰, Jan van der Merwe¹⁰; QASC Europe Steering Committee; QASC Europe Implementation Committee; Sandy Middleton^{1

2}

Affiliations

¹ Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia.
² School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia.
³ Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia. simeon.dale@acu.edu.au.
⁴ School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia. simeon.dale@acu.edu.au.
⁵ Centre for Practice-Changing Research (CPCR), Ottawa Health Research Institute, Ottawa Hospital - General Campus; and University of Ottawa, Ottawa, ON, Canada.
⁶ Department of Neurology and Clinical Neurophysiology, Städtisches Klinikum Lüneburg, Lüneburg, Germany.
⁷ Department of Neurology, Germany Centre of Neurology and Neurosurgery, Goethe University, Frankfurt am Main, University Hospital Frankfurt, Frankfurt, Germany.
⁸ Translational Public Health Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Melbourne, Australia.
⁹ Public Health, Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.
¹⁰ Angels Initiative, Ingelheim, Germany.

PMID: 38287332
PMCID: PMC10823736
DOI: 10.1186/s12913-024-10617-9

The Quality in Acute Stroke Care (QASC) global scale-up using a cascading facilitation framework: a qualitative process evaluation

Elizabeth McInnes et al. BMC Health Serv Res. 2024.

. 2024 Jan 29;24(1):144.

doi: 10.1186/s12913-024-10617-9.

Authors

Affiliations

¹ Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia.
² School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia.
³ Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia. simeon.dale@acu.edu.au.
⁴ School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia. simeon.dale@acu.edu.au.
⁵ Centre for Practice-Changing Research (CPCR), Ottawa Health Research Institute, Ottawa Hospital - General Campus; and University of Ottawa, Ottawa, ON, Canada.
⁶ Department of Neurology and Clinical Neurophysiology, Städtisches Klinikum Lüneburg, Lüneburg, Germany.
⁷ Department of Neurology, Germany Centre of Neurology and Neurosurgery, Goethe University, Frankfurt am Main, University Hospital Frankfurt, Frankfurt, Germany.
⁸ Translational Public Health Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Melbourne, Australia.
⁹ Public Health, Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.
¹⁰ Angels Initiative, Ingelheim, Germany.

PMID: 38287332
PMCID: PMC10823736
DOI: 10.1186/s12913-024-10617-9

Abstract

Background: Variation in hospital stroke care is problematic. The Quality in Acute Stroke (QASC) Australia trial demonstrated reductions in death and disability through supported implementation of nurse-led, evidence-based protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS Protocols) following stroke. Subsequently, a pre-test/post-test study was conducted in acute stroke wards in 64 hospitals in 17 European countries to evaluate upscale of the FeSS Protocols. Implementation across countries was underpinned by a cascading facilitation framework of multi-stakeholder support involving academic partners and a not-for-profit health organisation, the Angels Initiative (the industry partner), that operates to promote evidence-based treatments in stroke centres. .We report here an a priori qualitative process evaluation undertaken to identify factors that influenced international implementation of the FeSS Protocols using a cascading facilitation framework.

Methods: The sampling frame for interviews was: (1) Executives/Steering Committee members, consisting of academics, the Angels Initiative and senior project team, (2) Angel Team leaders (managers of Angel Consultants), (3) Angel Consultants (responsible for assisting facilitation of FeSS Protocols into multiple hospitals) and (4) Country Co-ordinators (senior stroke nurses with country and hospital-level responsibilities for facilitating the introduction of the FeSS Protocols). A semi-structured interview elicited participant views on the factorsthat influenced engagement of stakeholders with the project and preparation for and implementation of the FeSS Protocol upscale. Interviews were recorded, transcribed verbatim and analysed inductively within NVivo.

Results: Individual (n = 13) and three group interviews (3 participants in each group) were undertaken. Three main themes with sub-themes were identified that represented key factors influencing upscale: (1) readiness for change (sub-themes: negotiating expectations; intervention feasible and acceptable; shared goal of evidence-based stroke management); (2) roles and relationships (sub-themes: defining and establishing roles; harnessing nurse champions) and (3) managing multiple changes (sub-themes: accommodating and responding to variation; more than clinical change; multi-layered communication framework).

Conclusion: A cascading facilitation model involving a partnership between evidence producers (academic partners), knowledge brokers (industry partner, Angels Initiative) and evidence adopters (stroke clinicians) overcame multiple challenges involved in international evidence translation. Capacity to manage, negotiate and adapt to multi-level changes and strategic engagement of different stakeholders supported adoption of nurse-initiated stroke protocols within Europe. This model has promise for other large-scale evidence translation programs.

Keywords: Clinical protocols; Facilitation; Implementation science; Learning health system.; Nursing research; Quality improvement; Stroke.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SD, SM received speakers’ fees, conference registration and travel expenses from the Angels Initiative. DC is supported by a National Health and Medical Research Council Senior Research Fellowship (#1154273). Other authors have no competing interests.

Figures

**Fig. 1**
Cascading facilitation: Key stakeholder organisations and individual groups involved in implementing evidence-based clinical protocols for acute stroke care. Yellow font (left hand side) = role outside of project, name, Green font (right hand side) = project role action

See this image and copyright information in PMC

References

1. Feigin VL, Stark BA, Johnson CO, Roth GA, Bisignano C, Abady GG, et al. Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the global burden of disease study 2019. Lancet Neurol. 2021;20(10):795–820. doi: 10.1016/S1474-4422(21)00252-0. - DOI - PMC - PubMed
1. Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D’Este C, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. The Lancet. 2011;378(9804):1699–1706. doi: 10.1016/S0140-6736(11)61485-2. - DOI - PubMed
1. Middleton S, Coughlan K, Mnatzaganian G, Low Choy N, Dale S, Jammali-Blasi A, et al. Mortality reduction for fever, hyperglycemia, and swallowing nurse-initiated stroke intervention QASC trial (quality in Acute Stroke Care). Follow-Up. Stroke. 2017;48(5):1331. doi: 10.1161/STROKEAHA.116.016038. - DOI - PubMed
1. Cadilhac DA, Andrew NE, Lannin NA, Middleton S, Levi CR, Dewey HM, et al. Quality of acute care and long-term quality of life and survival: the australian stroke clinical registry. Stroke. 2017;48(4):1026–1032. doi: 10.1161/STROKEAHA.116.015714. - DOI - PubMed
1. Middleton S, McElduff P, Drury P, D’Este C, Cadilhac DA, Dale S, et al. Vital sign monitoring following stroke associated with 90-day independence: a secondary analysis of the QASC Cluster randomized trial. Int J Nurs Stud. 2019;89:72–79. doi: 10.1016/j.ijnurstu.2018.09.014. - DOI - PubMed

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The Quality in Acute Stroke Care (QASC) global scale-up using a cascading facilitation framework: a qualitative process evaluation

Affiliations

The Quality in Acute Stroke Care (QASC) global scale-up using a cascading facilitation framework: a qualitative process evaluation

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

MeSH terms

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Full Text Sources

Medical