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Nurse-Initiated Acute Stroke Care in Emergency Departments: The Triage, Treatment, and Transfer Implementation Cluster Randomized Controlled Trial

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Version 2 2024-06-04, 01:10
Version 1 2019-06-14, 14:14
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posted on 2024-06-04, 01:10 authored by S Middleton, S Dale, NW Cheung, DA Cadilhac, JM Grimshaw, C Levi, E McInnes, Julie ConsidineJulie Considine, P McElduff, R Gerraty, LE Craig, V Schadewaldt, M Fitzgerald, C Quinn, G Cadigan, S Denisenko, M Longworth, J Ward, C D'Este
Background and Purpose— We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). Methods— A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke <48 hours from symptom onset and were admitted to the stroke unit via ED. Our nurse-initiated T 3 intervention targeted (1) Triage to Australasian Triage Scale category 1 or 2; (2) Treatment: tPA eligibility screening and appropriate administration; clinical protocols for managing fever, hyperglycemia, and swallowing; (3) prompt (<4 hours) stroke unit Transfer. It was implemented using (1) workshops to identify barriers and solutions; (2) face-to-face, online, and written education; (3) national and local clinical opinion leaders; and (4) email, telephone, and site visit follow-up. Outcomes were assessed at the patient level. Primary outcome: 90-day death or dependency (modified Rankin Scale score of ≥2); secondary outcomes: functional dependency (Barthel Index ≥95), health status (Short Form [36] Health Survey), and ED quality of care (Australasian Triage Scale; monitoring and management of tPA, fever, hyperglycemia, swallowing; prompt transfer). Intention-to-treat analysis adjusted for preintervention outcomes and ED clustering. Patients, outcome assessors, and statisticians were masked to group allocation. Results— Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%]; control n=266 [48.7%]; P =0.24) or secondary outcomes. Conclusions— This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care. Clinical Trial Registration— URL: http://www.anzctr.org.au . Unique identifier: ACTRN12614000939695.

History

Journal

Stroke

Volume

50

Pagination

1346-1355

Location

United States

Open access

  • Yes

ISSN

0039-2499

eISSN

1524-4628

Language

English

Publication classification

C1 Refereed article in a scholarly journal

Copyright notice

2019, American Heart Association, Inc.

Issue

6

Publisher

LIPPINCOTT WILLIAMS & WILKINS