Quality in Acute Stroke Care (QASC)

A project to implement and evaluate nurse-initiated evidence-based stroke care in Europe, to manage fever, hyperglycaemia and swallowing difficulties

– To implement the QASC Fever, Sugar, Swallowing clinical protocols in up to 300 stroke services in Europe
– To evaluate successful uptake of the clinical protocols
– To draw comprehensive lessons on translation of evidence-based results on a large scale across multiple countries

Approximately 15 million people worldwide suffer a stroke each year (1). There is compelling evidence that improved patient outcomes are achieved through early intervention in acute stroke care including thrombolysis, endovascular clot retrieval (2) and access to specialised in-patient stroke units (3). Hyperglycaemia, swallowing dysfunction and elevated temperature are physiological variables known to be associated with poorer stroke outcomes (4-7). Optimal management of fever, hyperglycaemia and dysphagia have been identified in international guidelines as priorities for inpatient stroke management (8-10).

The Quality in Acute Stroke Care (QASC) Trial demonstrated that multidisciplinary, nurse-led interventions to manage fever, hyperglycaemia and swallow difficulties following acute stroke significantly improved health outcomes.  Results showed that supported implementation of the Fever, Sugar, Swallow (FeSS) clinical protocols resulted in 16% decreased death and dependency at 90-days, and in-hospital: reduced mean temperatures, reduced mean glucose levels and improved swallow screening management.  There also was a non-significant reduction in length of stay by two days (11). Results were fast-tracked for publication in The Lancet, with a commentary, winning the Canadian Stroke Congress Award for Impact in 2011 and the 2012 American Heart Association Council on Cardiovascular Nursing Stroke Article of the year.

In 2014, the New South Wales (NSW) Agency for Clinical Innovation partnered with the Nursing Research Institute, a joint initiative between St Vincent’s Health Australia (Sydney) and Australian Catholic University, to conduct a translational quality improvement project to implement the FeSS clinical protocols in all 36 Stroke Services throughout New South Wales (NSW).  Our clinical translational initiative, the QASC Implementation Project (QASCIP), targeted stroke services to embed the FeSS Protocols into routine practice.  Clinical site champions attended a one-day multidisciplinary training workshop, received standardised educational resources and ongoing support. Patient data were collected by self-reported retrospective medical record audits for up to 40 consecutive stroke patients per site both pre-and post-QASCIP (n=2144 patients). The FeSS protocols were successfully implemented resulting in significantly increased proportion of patients receiving care according to the protocols.

For more information, please contact:
Project Director, Professor Sandy Middleton RN PhD, St Vincent’s Health Australia (Sydney) and Australian Catholic University, Sydney, Australia

In collaboration with the Nursing Research Institute St.Vincent’s Health Australia, Sidney – Australian Catholic University and in collaboration with the Boehringer-Ingelheim Angels Initiative.


  1. Mackay J, Mensah G. The atlas of heart disease and stroke. August 2016].
  2. Balami JS, Sutherland BA, Edmunds LD, Grunwald IQ, Neuhaus AA, Hadley G, Karbalai H, Metcalf KA, DeLuca GC, Buchan AM: A systematic review and meta-analysis of randomized controlled trials of endovascular thrombectomy compared with best medical treatment for acute ischemic stroke. International Journal of Stroke 2015, 10:1168-1178.
  3. Stroke Unit Trialists’ Collaboration: Organised inpatient (stroke unit) care for stroke. The Cochrane database of systematic reviews 2013, 9:CD000197.
  4. Greer DM, Funk SE, Reaven NL, Ouzounelli M, Uman GC: Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke 2008, 39:3029-3035.
  5. Williams LS, Rotich J, Fineberg N, Espay A, Bruno A, Fineberg S, Tierney W: Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke. Neurology 2002, 59:67-71.
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  7. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R: Dysphagia After Stroke: Incidence, Diagnosis, and Pulmonary Complications. Stroke 2005, 36:2756-2763.
  8. European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee: Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovascular Diseases 2008, 25:457-507.
  9. Garofolo K, Yeatts S, Ramakrishnan V, Jauch E, Johnston K, Durkalski V: The effect of covariate adjustment for baseline severity in acute stroke clinical trials with responder analysis outcomes. Trials 2013, 14:98.
  10. Intercollegiate Stroke Working Party: National clinical guideline for stroke, 4th edition London: Royal College of Physicians 2012.
  11. Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D’Este C, Drury P, Griffiths R, Cheung NW, Quinn C, C. L: 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 1699-1706.