The Quality in Acute Stroke Care trial was conducted in 19 NSW stroke units from 2005-2011 (ACTRN12608000563369). This cluster randomised controlled trial developed, implemented and rigorously evaluated, an intervention to improve evidence-based management of fever, hyperglycaemia (sugar) and swallow (FeSS Protocols) in the first 72 hours following acute stroke. Stroke units were randomised to receive support to implement the evidence-based FeSS Protocols or to only receive a copy of the national clinical guidelines for stroke, with no added support to implement them.
Our results showed that patients who were cared for in stroke units that were randomised to the intervention group were 16% more likely to be alive and independent 90 days post-stroke when compared with patients who were cared for in stroke units that had been allocated to the control group.1 They were also more likely to have their temperature and blood glucose monitored and to receive a swallow screen within 24 hours.1
This study was funded by the National Health & Medical Research Council (Project Grant ID 535803), St Vincent’s Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.
Professor Sandy Middleton (PhD)
Professor Sandy Middleton RN PhD FACN FAAN FAHMS
NHMRC Investigator Leadership Fellow
Director, Nursing Research Institute
St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and Australian Catholic University
Director, Implementation Science
Director, Nursing and Midwifery Implementation Science Academy
Maridulu Budyari Gumal (Sydney Partnership in Health, Education, Research & Enterprise – SPHERE) Advanced Health Research and Translation Centre
Honorary Clinical Professor, University of Central Lancashire (UK), Research Institute For global Health and Wellbeing (LIFE)
Professor Christopher Levi (MBBS)
Hunter Medical Research Institute, The University of Newcastle, University Drive, Callaghan, Newcastle NSW 2300, Australia and
Director, Priority Centre for Brain & Mental Health Research. The University of Newcastle, University Drive, Callaghan, Newcastle NSW 2300, Australia
Professor Rhonda Griffiths (PhD)
Head, School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC NSW 1797, Australia
Professor Jeremy M. Grimshaw (PhD)
Director, Clinical Epidemiology Program, Ottawa Health Research Institute, 1053 Carling Avenue, Administration Building, Room 2-017, Ottawa, Ontario K1Y 4E9, Canada and
Professor, Department of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada
Professor Jeanette Ward (PhD)
Department of Epidemiology and Community Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada
Professor Catherine D’Este (PhD)
Professor, Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health, The University of Newcastle, University Drive, Callaghan, Newcastle NSW 2300, Australia
Dr Patrick McElduff (PhD)
Senior Statistician, Hunter Medical Research Institute, the University of Newcastle, University Drive, Callaghan, Newcastle NSW 2300, Australia
Ms Simeon Dale (BAHons)
Clinical Research Fellow, Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and Australian Catholic University
Ms Peta Drury (MN)
PhD candidate (2009 to 2014), Nursing Research Institute, St Vincent’s & Mater Health Sydney and School of Nursing (NSW & ACT) Australian Catholic University, and
National Centre for Clinical Outcomes Research (NaCCOR), Australian Catholic University, Level 5, deLacy Building, St Vincent’s Hospital, Darlinghurst, NSW 2010, Australia
Professor N Wah Cheung (PhD)
Co-Director, Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Westmead NSW 2145, Australia
Ms Clare Quinn (MSc)
Manager, Speech Pathology Department, Prince of Wales Hospital, High St, Randwick NSW 2031, Australia
Mr Malcolm Evans (MN)
Priority Centre for Brain & Mental Health Research. The University of Newcastle, University Drive, Callaghan, Newcastle NSW 2300, Australia
Professor Dominique Cadilhac (PhD)
Head, Translational Public Health, Stroke and Ageing Research Centre, Monash Medical Centre, Southern Clinical School, Monash University, Clayton VIC 3168, Australia
National Stroke Research Institute, Florey Neuroscience Institutes, Melbourne Brain Centre, 245 Burgundy St Heidelberg, VIC 3084, Australia and
University of Melbourne, Melbourne, VIC 3010,
We also would like to acknowledge the valuable contribution of the Stroke Unit Directors, Stroke Clinical Nurse Consultants, Clinical Nurse Educators, Stroke Liaison Nurses, Stroke Unit Coordinators, Clinical Research Assistants and others who have assisted our trial. Without their contribution, this trial would not have been possible:
Bankstown Hospital
Christine Fuller, Louise Bolling, Daniel Chan, Samila Hatimia, Denise Houston
Blacktown Hospital
Camelia Burdesul, Francis Hoult, Nigel Wolfe
Calvary Mater Hospital
Tina Barry, Fiona Dee, Kim Kolmajer, Andrea Moore, Mark Parsons, Roy Strong
Campbelltown Hospital
Kelly Dunn, Sharon Edwards, Stan Levy, Christine Lynham, Kerrie O’Leary
Concord Hospital
Alastair Corbett, David McFadyn, Helen Ryan, Katica Siric, Carol Vogelsberger, Alison Wilson
Gosford Hospital
Alex Blanch, Jenny Burrows, Denis Crimmins, Greg Harris, Jane-Maree Hunter, Ben Kissick, Lan Mi, Linjing Piao, Jonathon Sturm, Jessica Weight
Hornsby Hospital
Emma Coyle, Lucy Churchill, Malcolm Kanard, Nicole Morrisey, Nikki Pullen, Christine Tait-Lees, John Watson, Ashley Wattus
John Hunter Hospital
Kate Day, Malcolm Evans, Christopher Levi, Glody Mabbott, Angela Royan
Liverpool Hospital
Stella Andrijevic, Cathy Crow, Myra Drummond, Suzanne Hodgkinson, Agnes Jakielska, Alan McDougal
Manly Hospital
Anna Butcher, Tara Chambers, Hannah Rose, John Worthington
Nepean Hospital
Linda Campbell, Craig Harris, Susan Lane. Peter Williams and Jonathan Wood
Prince of Wales
Clare Connor, Sharon Errikson, Zsazsa Ferrer, Eva Katalinic, Clare Quinn, Chris Taylor, Alessandro Zagami
Royal North Shore Hospital
Pattie Crummack, Sue Day, Susan Flanagan, Caryn Love, Shae Millar, Elizabeth O’Brien, Cate Storey, Susan Williams
Royal Prince Alfred Hospital
Anna May Abordo, Craig Anderson, Karen Bowen, Robin Grenenger, Simon Latham, Nadia Schweizer, Wayne Zemcevicius
St George Hospital
Louise Allport, Roz Millar, Emma Ramirez, Lynne Roberts, Melisa Tinsley
St Vincent’s Hospital
Val Bramah, Rebecca Errey, Romesh Markus, Cheryl Trudinger, Naomi de Vries
Sutherland Hospital
Philip Conroy, Tina Kulevska, Christine Turner
Westmead Hospital
Peter Landau, Richard Lindley, Maria Molano, Rebecca Robertson, Mila Romerosa
Wollongong Hospital
Jessica Boehm, Michelle Doughty, Stephen Etheridge, Trina Morris, Narelle Walton, Robert McGrath, David Serisier
Agency for Clinical Innovation – Statewide Stroke Services NSW
Mark Longworth
When nurses in stroke units were helped to introduce the fever, hyperglycaemia (sugar) and swallow (FeSS) Protocols, patients’ risk of death and disability was reduced by 16% at 90-days post-stroke.1 Four years after completion of the QASC trial, we linked our study data with the National Death Index. We found that the patients in the intervention group of the study had improved long-term survival of more than 20%, (adjusted HR, 0.77; 95% CI, 0.59-0.99; P=0.045) when compared to the control group. This follow-up analysis of the patients in the QASC Trial shows the potential for longer term benefits of supported implementation of the FeSS Protocols in the acute stroke setting.2
Professor Sandy Middleton RN PhD FACN FAAN FAHMS
NHMRC Investigator Leadership Fellow
Director, Nursing Research Institute
St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and Australian Catholic University
Director, Implementation Science
Director, Nursing and Midwifery Implementation Science Academy
Maridulu Budyari Gumal (Sydney Partnership in Health, Education, Research & Enterprise – SPHERE) Advanced Health Research and Translation Centre
Honorary Clinical Professor, University of Central Lancashire (UK), Research Institute For global Health and Wellbeing (LIFE)
Professor, School of Physiotherapy, Faculty of Health Sciences, Australian Catholic University, Queensland
Research Officer
Nursing Research Institute
St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and Australian Catholic University
Clinical epidemiologist
College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Victoria, Australia
Clinical Research Fellow, Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and Australian Catholic University
Research Officer, Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and Australian Catholic University
Hunter Medical Research Institute, The University of Newcastle, University Drive, Callaghan, Newcastle NSW 2300, Australia and Director, Priority Centre for Brain & Mental Health Research. The University of Newcastle, University Drive, Callaghan, Newcastle NSW 2300, Australia
Director, Clinical Epidemiology Program, Ottawa Health Research Institute, 1053 Carling Avenue, Administration Building, Room 2-017, Ottawa, Ontario K1Y 4E9, Canada and Professor, Department of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada
Department of Epidemiology and Community Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada
Head, Translational Public Health, Stroke and Ageing Research Centre, Monash Medical Centre, Southern Clinical School, Monash University, Clayton VIC 3168, Australia
National Stroke Research Institute, Florey Neuroscience Institutes, Melbourne Brain Centre, 245 Burgundy St Heidelberg, VIC 3084, Australia and University of Melbourne, Melbourne, VIC 3010,
Senior Statistician, Hunter Medical Research Institute, the University of Newcastle, University Drive, Callaghan, Newcastle NSW 2300, Australia
Dean School of Health Sciences, Faculty of Health Sciences, Swinburne University of Technology, Victoria, Australia and School of Public Health, University of Adelaide, South Australia, Australia
Professor, Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health, The University of Newcastle, University Drive, Callaghan, Newcastle NSW 2300, Australia
Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D'Este C, Drury P, Griffiths R, Cheung NW, Quinn C, Evans M, Cadilhac D & Levi C. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. The Lancet . 2011;378 (9804):1699-706.2
Middleton, S., C. Levi, J. Ward, J. Grimshaw, R. Griffiths, C. D'Este, S. Dale, W. Cheung, C. Quinn, M. Evans and D. Cadilhac. Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: A cluster randomised controlled trial of knowledge transfer. Implementation Science 2009; 4(1) p. 16
Middleton S, Levi C, D’Este C, Dale S, Griffiths R, Grimshaw J, Ward J, Evans M, Quinn C, Cadilhac D. Death, dependency and health status 90-days following stroke in NSW: Preliminary results from the Quality in Acute Stroke Care (QASC) Project. Internal Medicine Journal . 2011; 41(10) 736-743
Drury P, Levi C, McInnes L, Hardy J, Ward J, Grimshaw J, D’Este C, Dale S, McElduff P, Cheung W, Quinn C, Griffiths R, Evans M, Cadhilac D, Middleton S. Management of fever, hyperglycaemia and swallowing dysfunction following hospital admission for acute stroke in New South Wales, Australia. International Journal of Stroke . 2014;9(1):23-31.
Middleton S. Keeping It Simple: The power of three clinical protocols. Invited Editorial. Journal of Clinical Nursing 2012; 21, 3195–3197.
Middleton S. Doing the Simple Things Well. Invited Editorial. Collegian 2012; 19, 65-66.
Middleton S. An outcomes approach to stroke care: the importance of teamwork and evidence‐based nursing care. Leading Opinion. International Journal of Stroke . 2012;7(3):224-6.
Dale S, Levi C, Ward J, Grimshaw JM, Jammali,Blasi A, D'Este C, , Griffiths R, Quinn C, Evans M, Cadilhac D, Cheung NW, Middleton S. Barriers and Enablers to Implementing Clinical Treatment Protocols for Fever, Hyperglycaemia, and Swallowing Dysfunction in the Quality in Acute Stroke Care (QASC) Project—A Mixed Methods Study. Worldviews on Evidence‐Based Nursing . 2015;12(1):41-50.
Drury P, Levi C, D'Este C, McElduff P, McInnes E, Hardy J, et al. Quality in Acute Stroke Care (QASC): Process evaluation of an intervention to improve the management of fever, hyperglycemia, and swallowing dysfunction following acute stroke. International Journal of Stroke. 2014;9:766-76.
Jammali-Blasi A, McInnes E, Markus R, Faux S, O’Loughlin G, Dale S, Middleton S. 90-day outcomes for a cohort of patients admitted to a metropolitan acute stroke unit. Journal of Vascular Nursing 2011; 29(1): 3-10.
Middleton S, Bruch D, Martinez-Garduno C, Dale S, McNamara M. International Uptake of a Proven Intervention to Reduce Death and Dependency in Acute Stroke: A Cross-Sectional Survey Following the QASC Trial. Worldviews Evidence Based Nursing 2017; 14(6): 447-454.
Middleton S, McElduff P, Drury P, D’Este C, Cadilhac DA, Dale S, Grimshaw JM, Ward J, Quinn C, Cheung NW & Levi C. Vital sign monitoring following stroke associated with 90-day independence: A secondary analysis of the QASC cluster randomized trial. International Journal of Nursing Studies . 2019;89:72-79
Middleton S, Coughlan K, Mnatzaganian G, Low Choy N, Dale S, Jammali-Blasi A, Levi C, Grimshaw JM, Ward J, Cadilhac, DA, McElduff P, Hiller JE, D’Este C. Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention. Stroke 2017; 48(4): 1331-6.
Middleton S, Lyons N. In reply - Stroke care in Australia: why is it still the poor cousin of health care? Letter to the Editor. MJA 2013; 199 (3): 166.
Middleton S, D'Este C, Grimshaw J, Ward JE, Levi C. Team-building intervention to improve acute stroke care – Authors' reply. The Lancet . 2012;379(9824):1390.
Middleton S, Levi C, Ward J. QASC trial: swallow surveillance rates comparable with international data. The Lancet . 2012;379(9824):1389.
Middleton, S., Levi, C., & Dale, S. (2008). Arrival Time to Stroke Unit as Crucial a Measure as Arrival Time to Emergency Department. Stroke , 39(1), 5.
Commentary also published in The Lancet. See:
Wolfe CD, Rudd AG. Improvement of care in acute stroke units. Lancet. 2011 Nov 12;378(9804):1679-80.
Commentary published in Annals of Internal Medicine. See:
Alberts MJ. Targeting management of fever, hyperglycemia, and swallowing improved outcomes in acute stroke. Ann Intern Med . 2012;156(3).
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