Nursing Protocols for Fever, Hyperglycemia, and Swallowing Management May Reduce Dependence in Patients with Acute Stroke

DynaMed Weekly Update - Volume 6, Issue 45

Fever, hyperglycemia, and swallowing dysfunction after an acute stroke have been associated with poor outcomes. Guidelines call for monitoring and management of these symptoms over the first several days (NICE 2008 Jul:CG68, Stroke 2007 May;38(5):1655). A recent cluster-randomized trial evaluated the use of explicit management protocols at 19 acute stroke centers in Australia. Centers were randomized to 1 of 2 treatment approaches. The intervention centers implemented a multidisciplinary program using nursing protocols to manage fever, hyperglycemia, and swallowing dysfunction in patients with acute stroke during the first 72 hours following admission. The program included educational meetings to discuss the protocols and team building exercises to reduce barriers to their implementation. Control centers provided care based on an abridged version of existing guidelines. A total of 1,126 patients were enrolled.

In an analysis of 89.6% of randomized patients at 90 days follow-up, the intervention was associated with a significant decrease in death or dependence (42% vs. 58%, p = 0.002, NNT 7) (level 2 [mid-level] evidence). Dependence was defined as a modified Rankin score ≥ 2. (A score of 0 indicates no symptoms and a score of 1 indicates ability to carry out all usual activities despite some symptoms; higher scores indicate greater disability.) Mortality was not significantly different between the groups (4% vs. 5%). The intervention group had better physical function scores (p = 0.002), but there was no significant difference in mental function scores. There was also no significant difference in independence for activities of daily living (ADLs) as indicated by a Barthel Index score ≥ 60 (0-100 scale with higher score indicating better functioning). The intervention was associated with a trend toward greater complete independence (Barthel Index score ≥ 95, p = 0.07) (Lancet 2011 Nov 12;378(9804):1699).

For more information, see the Stroke (acute management) topic in DynaMed.