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Middleton S, Levi C, Dale S, Cheung NW, McInnes E, Considine J, D’Este C, Cadilhac DA, Grimshaw J, Gerraty R, Craig L, Schadewaldt V, McElduff P, Fitzgerald M, Quinn C, Cadigan G, Denisenko S, Longworth M, Ward J. Triage, treatment and transfer of patients with stroke in emergency department trial (the T 3 Trial): a cluster randomised trial protocol. Implement Sci 2016; 11:139. [PMID: 27756434 PMCID: PMC5069775 DOI: 10.1186/s13012-016-0503-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/07/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Internationally recognised evidence-based guidelines recommend appropriate triage of patients with stroke in emergency departments (EDs), administration of tissue plasminogen activator (tPA), and proactive management of fever, hyperglycaemia and swallowing before prompt transfer to a stroke unit to maximise outcomes. We aim to evaluate the effectiveness in EDs of a theory-informed, nurse-initiated, intervention to improve multidisciplinary triage, treatment and transfer (T3) of patients with acute stroke to improve 90-day death and dependency. Organisational and contextual factors associated with intervention uptake also will be evaluated. METHODS This prospective, multicentre, parallel group, cluster randomised trial with blinded outcome assessment will be conducted in EDs of hospitals with stroke units in three Australian states and one territory. EDs will be randomised 1:1 within strata defined by state and tPA volume to receive either the T3 intervention or no additional support (control EDs). Our T3 intervention comprises an evidence-based care bundle targeting: (1) triage: routine assignment of patients with suspected stroke to Australian Triage Scale category 1 or 2; (2) treatment: screening for tPA eligibility and administration of tPA where applicable; instigation of protocols for management of fever, hyperglycaemia and swallowing; and (3) transfer: prompt admission to the stroke unit. We will use implementation science behaviour change methods informed by the Theoretical Domains Framework [1, 2] consisting of (i) workshops to determine barriers and local solutions; (ii) mixed interactive and didactic education; (iii) local clinical opinion leaders; and (iv) reminders in the form of email, telephone and site visits. Our primary outcome measure is 90 days post-admission death or dependency (modified Rankin Scale >2). Secondary outcomes are health status (SF-36), functional dependency (Barthel Index), quality of life (EQ-5D); and quality of care outcomes, namely, monitoring and management practices for thrombolysis, fever, hyperglycaemia, swallowing and prompt transfer. Outcomes will be assessed at the patient level. A separate process evaluation will examine contextual factors to successful intervention uptake. At the time of publication, EDs have been randomised and the intervention is being implemented. DISCUSSION This theoretically informed intervention is aimed at addressing important gaps in care to maximise 90-day health outcomes for patients with stroke. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ACTRN12614000939695 . Registered 2 September 2014.
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Affiliation(s)
- Sandy Middleton
- Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University, Executive Suite, Level 5 DeLacy Building, St Vincent’s Hospital, Victoria Road, Darlinghurst, 2010 New South Wales Australia
| | - Chris Levi
- John Hunter Hospital, Newcastle, Australia
- Centre for Translational Neuroscience and Mental Health, University of Newcastle/Hunter Medical Research Institute, Newcastle, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University, Executive Suite, Level 5 DeLacy Building, St Vincent’s Hospital, Victoria Road, Darlinghurst, 2010 New South Wales Australia
| | - N. Wah Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Westmead, Sydney, New South Wales Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University, Executive Suite, Level 5 DeLacy Building, St Vincent’s Hospital, Victoria Road, Darlinghurst, 2010 New South Wales Australia
| | - Julie Considine
- Faculty of Health, Eastern Health - Deakin University Nursing and Midwifery Research Centre School of Nursing and Midwifery, Burwood, Victoria 3125 Australia
| | - Catherine D’Este
- National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australian Capital Territory Australia
| | - Dominique A. Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, Melbourne, Victoria Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria Australia
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, 1053 Carling Avenue, Administration Building, Room 2-017, Ottawa, Ontario K1Y 4E9 Canada
- Department of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5 Canada
| | - Richard Gerraty
- Department of Medicine, Monash University, Melbourne, Australia
- Neurosciences Clinical Institute, Epworth Hospital, Richmond, Victoria 3121 Australia
| | - Louise Craig
- Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University, Executive Suite, Level 5 DeLacy Building, St Vincent’s Hospital, Victoria Road, Darlinghurst, 2010 New South Wales Australia
| | - Verena Schadewaldt
- Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University, Executive Suite, Level 5 DeLacy Building, St Vincent’s Hospital, Victoria Road, Darlinghurst, 2010 New South Wales Australia
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales 2300 Australia
| | - Mark Fitzgerald
- Alfred Hospital, Melbourne, Victoria 3004 Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
- Faculty of Science, Engineering and Technology, Swinburne University of Technology, Melbourne, Australia
| | - Clare Quinn
- Speech Pathology Department, Prince of Wales Hospital, High St, Randwick, New South Wales 2031 Australia
| | - Greg Cadigan
- Statewide Stroke Clinical Network, Brisbane, 4000 Australia
| | - Sonia Denisenko
- Department of Health Victoria, Victorian Stroke Clinical Network, Melbourne, Victoria 3000 Australia
| | - Mark Longworth
- Stroke Services NSW, NSW Agency for Clinical Innovation, Chatswood, New South Wales Australia
| | - Jeanette Ward
- School of Epidemiology, Public Health and Preventive Medicine (SEPHPM), University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5 Canada
- Nulungu Research Institute, University of Notre Dame Australia, Broome, Western Australia Australia
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