From QASC to QASCIP: successful Australian translational scale-up and spread of a proven intervention in acute stroke using a prospective pre-test/post-test study design

Objectives: To embed an evidence-based intervention to manage FEver, hyperglycaemia (Sugar) and Swallowing (the FeSS protocols) in stroke, previously demonstrated in the Quality in Acute Stroke Care (QASC) trial to decrease 90-day death and dependency, into all stroke services in New South Wales (NSW), Australia’s most populous state. Design: Pre-test/post-test prospective study. Setting: 36 NSW stroke services. Methods: Our clinical translational initiative, the QASC Implementation Project (QASCIP), targeted stroke services to embed 3 nurse-led clinical protocols (the FeSS protocols) into routine practice. Clinical champions attended a 1-day multidisciplinary training workshop and received standardised educational resources and ongoing support. Using the National Stroke Foundation audit collection tool and processes, patient data from retrospective medical record self-reported audits for 40 consecutive patients with stroke per site pre-QASCIP (1 July 2012 to 31 December 2012) were compared with prospective self-reported data from 40 consecutive patients with stroke per site post-QASCIP (1 November 2013 to 28 February 2014). Inter-rater reliability was substantial for 10 of 12 variables. Primary outcome measures: Proportion of patients receiving care according to the FeSS protocols pre-QASCIP to post-QASCIP. Results: All 36 (100%) NSW stroke services participated, nominating 100 site champions who attended our educational workshops. The time from start of intervention to completion of post-QASCIP data collection was 8 months. All (n=36, 100%) sites provided medical record audit data for 2144 patients (n=1062 pre-QASCIP; n=1082 post-QASCIP). Pre-QASCIP to post-QASCIP, proportions of patients receiving the 3 targeted clinical behaviours increased significantly: management of fever (pre: 69%; post: 78%; p=0.003), hyperglycaemia (pre: 23%; post: 34%; p=0.0085) and swallowing (pre: 42%; post: 51%; p=0.033). Conclusions: We obtained unprecedented statewide scale-up and spread to all NSW stroke services of a nurse-led intervention previously proven to improve long-term patient outcomes. As clinical leaders search for strategies to improve quality of care, our initiative is replicable and feasible in other acute care settings

Smoking prevalence, its determinants and short-term health implications in the Australian Defence Force

The objectives of this study were to determine the prevalence of smoking, identify the effects of deployment on smoking behavior and risk factors for smoking, and determine the short-term health outcomes associated with smoking in Australian Defence Force (ADF) personnel. Participants were randomly sampled from ADF members who deployed to the Solomon Islands between 2003 and 2005 and from a nondeployed comparison group. In total, 435 of 995 (44%) eligible individuals completed the study questionnaires. The prevalence of current smoking was highest in those who had completed less formal education and those who served in the Navy. Nearly two-thirds (63%) of current or former smokers smoked more while on overseas deployment. Current smokers were more likely to report current wheeze, shortness of breath, and persistent cough compared with nonsmokers. The ADF should continue to address cigarette smoking through its health promotion and health review programs and implement activities to reduce cigarette smoking on deployment

The PFAS health study: systematic literature review

This review examined all published research into the human health effects of exposure to perfluoroalkyl and polyfluoroalkyl substances, commonly known collectively as PFAS. PFAS chemicals are very resistant to heat and to degradation in the environment, and they persist for quite long periods in the human body. They were extensively used in fire-fighting foams, which were commonly used in fire drills at airports, and in household products, such as protective coatings on furniture and non-stick surfaces on cookware. PFOS (perfluorooctane sulfonic acid) and PFOA (perfluorooctanoic acid) were the two most commonly used PFAS chemicals. We reviewed research published up until February 7th 2017. We found 221 separate scientific publications that reported new results of relevant research in humans. These publications covered effects on reproduction, on pregnant women and their newborn babies, on body metabolism, on major body systems, including brain and nerves, heart and blood vessels, airways and lungs and the immune system, on specific conditions such as overweight, diabetes and cancer, and on thyroid gland function. The people they studied included people who worked in plants manufacturing these chemicals, firefighters, people with higher than usual exposure because of contamination of water supplies and people in the general community, whose exposure was ascertained by measuring PFAS chemicals in their blood. We found sufficient evidence that higher levels of PFOS or PFOA in a person’s blood can lead to higher blood cholesterol levels. High blood cholesterol is associated with heart disease. PFOS and PFOA, however, appeared only to increase cholesterol levels by a small amount. We found limited evidence that higher levels of PFAS in the blood resulted in slightly higher levels of uric acid in the blood. Uric acid is a normal body product and is removed by the kidneys. In a small number of studies, however, we also found limited evidence that high PFAS levels in the blood reduced kidney function or were associated with chronic kidney disease. Since PFAS chemicals are excreted by the kidneys it is possible PFAS does not cause poor kidney function, rather that poor kidney function caused by something else causes increase in PFAS levels in blood. This possibility of “reverse causation” might also explain the association of higher uric acid levels with higher PFAS levels in blood. We found limited evidence in a small number of relevant studies that PFAS exposure caused kidney and testicular cancers and that higher levels of PFAS in the blood resulted in lower levels of antibodies than usual following vaccination against some vaccine preventable infections. We found inadequate evidence that PFAS caused other health effects.This Systematic Literature Review was commissioned by the Australian Government Department of Health

Abstract NS23: Changing State-wide Stroke Practice: The QASC Implementation Project

Background: The Quality in Acute Stroke Care (QASC) Trial 1 determined that a multidisciplinary supported, nurse-initiated, evidence-based intervention involving supported implementation of clinical protocols to manage fever, hyperglycaemia and swallowing (FeSS protocols) following stroke decreased death and dependency by 16% (p=0.002); reduced temperatures (p=0.001) and glucose levels (p=0.02); and improved swallowing management (p=&lt;0.001). Yet, upscale and spread of even proven interventions on a state-wide level is challenging. Aim: To implement the FeSS protocols from the QASC Trial in all 36 stroke services in NSW, Australia. Method: Our 14 month translational project replicated the intervention from the original QASC Trial. We conducted barrier and enabler assessments and an educational workshop, engaged local opinion leaders, used reminders, and provided ongoing site champion support. Participating sites audited 40 pre-, and 40 post- implementation medical records using the National Stroke Foundation clinical audit web-based tool. Results: All (n=36, 100%) sites participated in the medical record audit (100% response rate) providing data for a total of 2144 patients (pre-implementation: n= 1062; post-implementation: n=1082). Significantly increased proportions of patients received care according to the fever (pre: 69%; post: 78%; p=0.0031), hyperglycaemia (pre: 23%; post: 34%; p=0.0085), and swallowing (pre: 42%; post: 51%; p=0.0331) protocols post-implementation. Conclusion: Our results provide rare evidence of successful research translation of Class 1 Level B evidence across an entire state in a short time-frame and in the real world of clinical practice. </jats:p

Cluster-Randomized Trial of Thrombolysis Implementation Support in Metropolitan and Regional Australian Stroke Centers: Lessons for Individual and Systems Behavior Change

Background Intravenous thrombolytic therapy (IVT) with tissue plasminogen activator for acute ischemic stroke is underutilized in many parts of the world. Randomized trials to test the effectiveness of thrombolysis implementation strategies are limited. Methods and Results This study aimed to test the effectiveness of a multicomponent, multidisciplinary tissue plasminogen activator implementation package in increasing the proportion of thrombolyzed cases while maintaining accepted benchmarks for low rates of intracranial hemorrhage and high rates of functional outcomes at 3 months. A cluster randomized controlled trial of 20 hospitals in the early stages of thrombolysis implementation across 3 Australian states was undertaken. Monitoring of IVT rates during the baseline period allowed hospitals (the unit of randomization) to be grouped into 3 baseline IVT strata-very low rates (0% to ≤4.0%); low rates (>4.0% to ≤10.0%); and moderate rates (>10.0%). Hospitals were randomized to an implementation package (experimental group) or usual care (control group) using a 1:1 ratio. The 16-month intervention was based on behavioral theory and analysis of the steps, roles, and barriers to rapid assessment for thrombolysis eligibility and involved comprehensive strategies addressing individual and system-level change. The primary outcome was the difference in tissue plasminogen activator proportions between the 2 groups postintervention. The absolute difference in postintervention IVT rates between intervention and control hospitals adjusted for baseline IVT rate and stratum was not significant (primary outcome rate difference=1.1% (95% CI -1.5% to 3.7%; P=0.38). Rates of intracranial hemorrhage remained below international benchmarks. Conclusions The implementation package resulted in no significant change in tissue plasminogen activator implementation, suggesting that ongoing support is needed to sustain initial modifications in behavior. Clinical Trial Registration URL: www.anzctr.org.au Unique identifiers: ACTRN12613000939796 and U1111-1145-6762

Delayed rectal and urinary symptomatology in patients treated for prostate cancer by radiotherapy with or without short term neo-adjuvant androgen deprivation

Background and purpose: To identify contributing factors to delayed rectal and urinary symptoms in a randomised trial comparing different durations of maximal androgen deprivation (MAD), given prior to radiotherapy, for locally advanced prostate cancer