Protocol for Stroke Saves Lives, Cuts Disability

Allison Gandey

October 25, 2011

October 25, 2011 — A new intervention targeting fever, hyperglycemia, and swallowing dysfunction in patients with stroke lowers mortality and severe disability, say researchers.

"Results showed that, irrespective of stroke severity, intervention acute stroke unit patients were significantly less likely to be dead or dependent at 90 days than control patients," report the researchers.

Dr. Sandy Middleton

"Our work demonstrates that teamwork and good nursing care can improve death and dependency in patients following acute stroke," lead investigator Sandy Middleton, PhD, from the Nursing Research Institute, St. Vincent's and Mater Health in Sydney, Australia, told Medscape Medical News.

"We were pleasantly surprised by the size of the effect," Dr. Middleton said. "These results are better than any current drug or treatment for stroke including clot-busting therapy and can be universally applied in acute stroke units."

International guidelines already recommend monitoring and prompt treatment of these 3 variables.

The findings are part of the Quality in Acute Stroke Care trial and were published online October 12 in The Lancet.

The study was a single-blind, cluster randomized controlled trial in 19 acute stroke units in New South Wales, Australia. Investigators looked at 1696 patients with ischemic stroke or intracerebral hemorrhage who presented within 48 hours of symptom onset.

Intervention acute stroke units received treatment protocols to manage fever, hyperglycemia, and swallowing dysfunction, with multidisciplinary team-building workshops to address implementation barriers. Control stroke units received an abridged version of existing guidelines.

Investigators compared 90-day death or dependency rates, using a modified Rankin scale 2 or higher, functional dependency with the Barthel index, and Short Form–36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intent-to-treat.

For fever, the intervention included temperature monitoring every 4 hours and paracetamol when required.

Hyperglycemia management included regular blood glucose monitoring and infusion of saline or insulin, depending on blood sugar levels and presence or absence of diabetes.

For swallowing, nurses underwent preintervention training, including education by a speech pathologist, watching a training DVD, and knowledge and competency testing.

Investigators observed less mortality and severe disability in patients receiving these interventions after stroke.

Mortality and Severe Disability After Stroke

Outcome Intervention (%) Control (%) P Value
Dead or dependent 42 58 .002

The number needed to treat was 6.4. The adjusted absolute difference was 15.7%, with a 95% confidence interval of 5.8 to 25.4.

Patients receiving the intervention also had a better Short Form–36 mean physical component summary score (45.6 [SD, 10.2] vs 42.5 [SD, 10.5]; P = .002). The adjusted absolute difference is 3.4 points, with a 95% confidence interval of 1.2 to 5.5.

The Quality in Acute Stroke Care trial "provides high-quality evidence that a guideline implementation strategy to support multidisciplinary teamwork and good nursing care focused on evidence-based management of 3 key physiological variables in acute stroke units delivers significantly better post-discharge outcomes for stroke patients," the authors note. "Clinical leaders of stroke services can adopt this strategy with confidence that their outcomes will improve."

Rising Stroke Admissions

In an accompanying editorial, Charles Wolfe, MD, and Anthony Rudd, MD, from King's College London in the United Kingdom, called the improvements dramatic. "Patients in intervention acute stroke units had significantly lower mean temperatures, lower mean glucose levels, and improved swallowing screening during the first 72 hours of admission."

The editorialists add: "The findings from Middleton and colleagues are highly pertinent to health systems worldwide since admissions for stroke care are set to increase by 30% in the next 20 years."

Importantly, they point out, the trial not only focuses on appropriate management of fever, hyperglycemia, and dysphagia but also uses implementation science theory to maximize the chances of the intervention being sustainable in the longer term.

The next step, the editorialists say, must be to assess this methodology in other healthcare systems and to undertake long-term studies to show a sustainable effect.

"However, the main message that should be taken from Middleton and colleagues' study is that more detailed observation and correction of physiological abnormalities after acute stroke is logical, and that studies of this sort should be developed alongside drug and other acute interventions."

This study was supported by the National Health and Medical Research Council, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and the Australian Catholic University. The investigators and editorialists have disclosed no relevant financial relationships.

Lancet. Published online October 12, 2011. Abstract

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