Level 2: Mid-level evidence

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 (Stroke. 2007;38:1655-1711).

A cluster-randomized trial evaluated the use of explicit management protocols at 19 acute stroke centers in Australia. Centers were randomized to one of two treatment approaches (Lancet. 2011; 378:1699-1706). 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.

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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). 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).

Alan Ehrlich, MD, is a deputy editor for DynaMed, in Ipswich, Mass., and assistant clinical professor in Family Medicine, University of Massachusetts Medical School in Worcester.

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