The impact of good nursing care

A nurse-led study has profoundly influenced our understanding not only of stroke care but how to change clinicians' behaviour.

Acute stroke patients who receive three clinical protocols to manage fever, sugar and swallowing are 16 per cent more likely to be alive and independent three months later, a collaborative study led by Professor Sandy Middleton, director of the Nursing Research Institute at the Australian Catholic University and St Vincents and Mater Health Sydney has found. The research provided critical data demonstrating significant improvements for the management of patients following stroke and demonstrated the value of teamwork and good nursing care.

Stroke is Australia's second biggest cause of death and leading cause of disability. While a patient suffers irreversible brain damage as a result of the stroke, there is potential to salvage surrounding brain tissue and limit the damage by effectively managing fever, sugar and swallowing.

The Quality in Acute Stroke trial was funded by the National Health and Medical Research Council and is the first nurse-led trial in acute stroke of its kind carried out in Australia. It involved 19 acute stroke units across NSW and more than 1600 patients.

The trial developed, implemented and evaluated the effectiveness of team-building workshops and education to introduce three clinical protocols to manage fever, sugar and swallowing following an acute stroke. At the end of the trial, one in six patients with an acute stroke was alive and independent at 90 days.

Middleton said the results are better than any current drug or treatment for stroke including clot busting therapy, and can be universally applied in acute stroke units to all stroke patients.

The study was a collaboration between six universities both in Australia and Canada as well as a team of clinicians from NSW Health and the Agency for Clinical Innovation's Stroke Services NSW.
Published online in The Lancet last month, the study showed that patients who received care in stroke units using these protocols also were more likely to have fewer episodes of fever, lower average temperatures and blood glucose levels, and better screening for swallowing difficulties.

Middleton said these results provide some of the best evidence to date on how to change clinicians' behaviour and evidence for effective team work. Last month, the study won the co-chairs' Impact Award at the 2011 Canadian Stroke Congress.

In collaboration with colleagues, Middleton has also received $2.2 million in the latest National Health and Medical Research Council (NHMRC) grant rounds to undertake a trial of triage, treatment and transfer of stroke patients in Australian emergency departments.

Research with worldwide implications

The findings from this landmark trial have far-reaching implications beyond stroke care, writes Sandy Middleton.

Firstly, our findings contribute to the body of evidence for implementation research which is research around the science of 'getting evidence into practice'. Unfortunately, we know it can take up to 10 years to get evidence into practice and changing the way nurses, doctors and the multidisciplinary team work is very difficult. Our study's contribution to this evidence is of international importance. Of note for all nurses, these methods could be used to introduce new and improved ways of working in any clinical setting.

Secondly, our study is significant in that it had a dramatic effect on reducing death and dependency. As stated in our recently published Lancet paper, this effect is larger than any known current treatment for stroke. Our fever, sugar and swallowing intervention was only possible through the strong support we received from our stroke medical colleagues and the outstanding collaboration from stroke speech pathologists who embraced the notion of nurses undertaking a swallow screen. At the time, this concept was novel in NSW and involved nurses working closely with speech pathologists. Excitingly for nursing, however, our protocols to manage fever, hyperglycaemia and swallowing were nurse-initiated. It was the nurses who were asked to provide this bedside care for patients in the first 72 hours of stroke unit admission. Nurses delivering this intervention have told us in a follow-up survey that the protocols; "empowered them to approach members of the multidisciplinary team to discuss fever, glucose and swallowing management for their patients". This is an excellent testament to their value in clinical care.

This study was a large undertaking that spanned six years from conception to completion. We were very fortunate to receive funding from the National Health and Medical Research Council (NHMRC), one of only two nurse-led studies to be funded by the NHMRC in 2005. We also received top-up funding from a College Consortium grant, an Australian Diabetes Services-Servier grant, a St Vincent's Clinic Foundation grant, and financial assistance from St Vincent's Hospital, and Australian Catholic University. I take the time to list all these individually to acknowledge their contribution as without their vision about the value of this study, we would not have been able to complete this important work. We worked with over 150 clinicians across 19 hospitals and were one of the first research studies to collaborate with the Agency for Clinical Innovation Stroke Services NSW network to engage clinician support.

Our study emphasises the importance of doing simple things well. It shows the value of teamwork and good nursing care and the difference this can make to a patients' long-term outcome. This is one of the few studies ever published to clearly demonstrate the impact of nursing care on the hard endpoints of death and dependency.

The success of this large health services research study depended on the efforts of nurses in our NSW stroke units who made it all possible. They embraced the opportunity to be involved in a large nurse-led multidisciplinary trial. This level of collaboration shows what we can achieve when we work together to generate evidence for what we do as part of everyday care for our patients. It also is a testament to the value of teamwork and the commitment by nurses to supporting quality research.

Professor Sandy Middleton is the Director of the Nursing Research Institute at the Australian Catholic University and St Vincents and Mater Health Sydney.

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