New nurse-led protocols for stroke patients, based on ACU research, led by the Nursing Research Institute, have resulted in changes to policy, guidelines and clinical practice across the globe. The protocols were developed through the Quality in Acute Stroke Care (QASC) Trial (published in the Lancet, 2011) to manage fever, hyperglycaemia and swallowing (FeSS) post-stroke.

Previous research had shown that patients with FeSS difficulties experienced higher rates of death and disability following a stroke than those without these symptoms. The improved approaches tested by the ACU researchers to manage FeSS difficulties in the first 72 hours of hospitalisation following stroke significantly reduced mortality and disability and resulted in shorter hospital stays. An economic evaluation also demonstrated potential to reduce healthcare costs.

In Australia, the FeSS indicators are now part of the Australian Stroke Clinical Registry voluntary indicator set. The team is currently undertaking the QASC Europe Project, implementing the protocols in 14 European countries.

Lead researcher, Professor Sandy Middleton, Professor of Nursing and Director of the Nursing Research Institute said many of the countries covered by the project were located in Eastern Europe.

“Stroke care is often rudimentary in Eastern Europe with poor or no access to reperfusion therapy, so use of the FeSS protocols for stroke patients could make a big difference in reducing death and dependency in these countries” she said.

“The team is also exploring the feasibility of ‘QASC Global’—a translational study to demonstrate further improvements and sustainability of the FeSS intervention within Australia, and upscale the intervention into other hospitals internationally.

“To date, 75 hospitals in 27 non-European countries have filled in expressions of interest to be involved in QASC Global.”

The protocols have been adopted by healthcare and supporting services in Australia and have informed the development of guidelines in the United Kingdom.

The QASC trial has won a series of awards including:

  • Commonwealth Health Minister and Australian College of Nursing Inaugural Nursing Trailblazer Finalist, 2019
  • NSW Premier's Public Sector Award for Improving Performance and Accountability, 2014
  • NSW Health Excellence in Nursing and Midwifery Award (Excellence in Innovation), 2014
  • Canadian Stroke Congress Award for Impact, 2011
  • American Heart Association Council on Cardiovascular Nursing, Stroke Article of the year, 2012

It was also included in the Faculty of 1000 Library (top two per cent of international articles—biology and medical research).

Learn more about the QASC trial

"Implementing evidenced-based interventions into practice and changing clinical behaviour is challenging, but has been achieved by ACU's Nursing Research Institute."
Professor Sandy Middleton
Professor of Nursing and Director of the Nursing Research Institute

Impacts of this research


Change that improves health and well-being outcomes in society.

QASC Trial results, published in the Lancet (2011), showed that patients who were cared for in stroke units that received supported implementation of FeSS protocols had:
  • Decreased 90-day death and dependency by 16 per cent.
  • Reduced temperatures and glucose levels.
  • Improved swallowing management.
  • Clinically important reduced hospital stay by an average of two days.


Change in economic participation and activity. 

Independent economic evaluation of FeSS protocols and behaviour change showed that if 65 per cent of eligible Australian stroke patients were managed with these protocols, over a 12 month period there would be a saving of $281 million.


Change in professional behaviour and standards within a sector.

  • Changed clinician behaviour through barrier identification, reinforcement of multidisciplinary teamwork, local adaptation, and use of site champions.
  • Training workshops and education sessions with all clinical staff and managers identified barriers and enablers to using the protocols facilitating implementation at each site.


Change in policy, organisational structure and formal processes.

  • Change to NSW Health Fever Policy Directive based on FeSS protocols.
  • Implementation of FeSS Protocols into all 36 NSW stroke services.
  • More patients across NSW received care in line with the FeSS protocols.
  • UK National Clinical Guidelines for Stroke reference QASC Trial for physiological management.
  • FeSS indicators included in Western Australia Health Stroke Data & Quality Framework.
  • FeSS indicators incorporated in Stroke Foundation national stroke audit.


New technology, tools, software and design that improves people's lives.

  • QASC Resources placed on ACU and NSW Agency for Clinical Innovation websites.
  • Professional development and capacity building resources co-created with Stroke Foundation Australia, including an educational video and self-directed activity to help clinicians apply protocols.
  • QASC audit tool publicly available for health services to use for evaluation.
  • FeSS indicators incorporated into the Australian Stroke Data Tool.


The person, people or organisations directly impacted by this research.

  • Patients and their families.
  • Clinicians.
  • NSW Agency for Clinical Innovation.
  • WA Department of Health.
  • Stroke Foundation Australia.
  • Royal College of Physicians, UK.
  • Clinicians.

2018 ARC Engagement and Impact Assessment

ACU submitted this research as an impact study in the 2018 ARC Engagement and Impact Assessment. The research received the rank of 'High', meaning the impact made a highly significant contribution to economy, society, environment, or culture, beyond the contribution to academic research.

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Lead researchers

Professor Sandy Middleton
Professor of Nursing and Director, Nursing Research Institute
St Vincent’s Health Australia (Sydney) and ACU

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Simeon Dale
Clinical Research Fellow, Nursing Research Institute
St Vincent’s Health Australia (Sydney) and ACU

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Nursing Research Institute (NRI)

The NRI brings together researchers and clinicians to conduct clinically relevant research. The NRI specialises in implementation science research examining ways to promote evidence translation in the areas of stroke management, hospital-acquired complications, and de-implementation of low-value nursing care.

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