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Background and aim: The QASC Europe project significantly improved nurse-initiated management of fever, hyperglycaemia (sugar) and swallowing (FeSS) in European stroke units with vastly different health care systems. We examined pre-post country management using the 2021-2022 World Bank income classifications. Method(s): This pan-European pre-test/post-test study (2018-2021) collected data at baseline and three months after FeSS protocol implementation. Clinical champions conducted multidisciplinary workshops to feedback baseline audit data, provided education, and identified barriers to protocol implementation. Outcomes were adjusted for age, sex, NIHSS and for clustering by site and country. The interaction between country classification (high income countries [HIC] vs middle income countries [MIC]) and time (pre/post) tested differences in proportions. Result(s): Pre-implementation data were analysed from 76 hospitals in 18 countries (eight HIC, ten MIC) (n=3999 patients); and post-implementation from 64 hospitals in 17 countries (seven HIC and the same ten MIC) (3257 patients). Significant pre-to-post improvements were made in both HIC and MIC (Adjusted difference in proportion HIC:(24% (16%,33%), MIC:(25% (15%,34%)). Post-implementation FeSS Protocol adherence were broadly similar between HIC and MIC. There was no difference in post-implementation overall FeSS Protocol adherence between HIC and MIC (p=0.8909). Conclusion(s): Our nurse-initiated intervention was highly effective in improving stroke management in all countries irrespective of their income level classification. The clinical significance of these improvements in MIC is noteworthy in that many of these hospitals have limited access to stroke care including acute reperfusion therapies. Upscaling of effective stroke interventions is essential to improving stroke care globally.

BACKGROUND: Audit and feedback entails systematic documentation of clinical performance based on explicit criteria or standards which is then fed back to professionals in a structured manner. There are potential significant returns on investment from partnerships between existing clinical audit programmes in coordinated programmes of research to test ways of improving the effect of their feedback to drive greater improvements in health care delivery and population outcomes. We explored barriers to and enablers of embedding audit and feedback trials within clinical audit programmes. METHODS: We purposively recruited participants with varied experience in embedded trials in audit programmes. We conducted qualitative semi-structured interviews, guided by behavioural theory, with researchers, clinical audit programme staff and health care professionals. Recorded interviews were transcribed, and data coded and thematically analysed. RESULTS: We interviewed 31 participants (9 feedback researchers, 14 audit staff and 8 healthcare professionals, many having dual roles). We identified barriers and enablers for all 14 theoretical domains but no relationship between domains and participant role. We identified four optimal conditions for sustainable collaboration from the perspectives of stakeholders: resources, that is, recognition that audit programmes need to create capacity to participate in research, and research must be adapted to fit within each programme's constraints; logistics, namely, that partnerships need to address data sharing and audit quality, while securing research funding to ensure operational success; leadership, that is, enthusiastic and engaged audit programme leaders must motivate their team and engage local stakeholders; and relationships, meaning that trust between researchers and audit programmes must be established over time by identifying shared priorities and meeting each partner's needs. CONCLUSION: Successfully embedding research within clinical

IMPORTANCE: Auditing and feedback are frequently used to improve patient care. However, it remains unclear how to optimize feedback effectiveness for the appropriate use of treatments such as blood transfusion, a common but costly procedure that is more often overused than underused. OBJECTIVE: To evaluate 2 theoretically informed feedback interventions to improve the appropriate use of blood transfusions. DESIGN, SETTING, AND PARTICIPANTS: Two sequential, linked 2 × 2 cluster randomized trials were performed in hospitals in the UK participating in national audits of transfusion for perioperative anemia and management of hematological disorders. Data were collected for a surgical trial from October 1, 2014, to October 31, 2016, with follow-up completed on October 31, 2016. Data were collected for a hematological trial through follow-up from July 1, 2015, to June 30, 2017. Trial data were analyzed from November 1, 2016, to June 1, 2019. INTERVENTIONS: Hospitals were randomized to standard content or enhanced content to improve feedback clarity and usability and to standard support or enhanced support for staff to act on feedback. MAIN OUTCOMES AND MEASURES: The primary end point was appropriateness of transfusions audited at 12 months. Secondary end points included volume of transfusions (aiming for reductions at patient and cluster levels) and transfusion-related adverse events and reactions. RESULTS: One hundred thirty-five of 152 eligible clusters participated in the surgical audit (2714 patients; mean [SD] age, 74.9 [14.0] years; 1809 women [66.7%]), and 134 of 141 participated in the hematological audit (4439 patients; median age, 72.0 [IQR, 64.0-80.0] years; 2641 men [59.5%]). Fifty-seven of 69 clusters (82.6%) in the surgical audit randomized to enhanced content downloaded reports compared with 52 of 66 clusters (78.8%) randomized to standard reports. Fifty-nine of 68 clusters (86.8%) randomized to enhanced support logged onto the toolkit. The proportion of pa

Background: The QASC Europe project is an international collaboration between the Nursing Research Institute (NRI); Australian Catholic University; European Stroke Organisation and Angels Initiative. The project evaluated implementation of nurse-initiated protocols for Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) into stroke units in 64 European countries. Aim(s): A qualitative process evaluation was conducted to understand barriers and facilitators to nurseled protocol implementation from the viewpoint of stakeholders who were involved in promotion of protocol uptake. Method(s): Focus groups and individual face-to-face videoconference interviews were audiotaped. Purposive sampling was used to recruit: i) high-level project governance representatives (clinicians, researchers; industry executives); ii) Angels Initiative team leaders; iii) Angels Initiative consultants and iv) senior stroke nurse country co-ordinators. Transcripts were thematically analysed and mapped to barriers and facilitators. Result(s): Participant numbers were: n=12 interviews and n=5 in each of two focus groups. Barriers and facilitators that influenced facilitation were mapped to five themes: 1) negotiating expectations; 2) roles and responsibilities; 3) readiness for change; 4) communication systems and 5) tailoring and adapting implementation processes. Conclusion(s): A shared goal across stakeholders of improved stroke care was an overarching enabler to the implementation process. Barriers were: commencing the implementation process prior to the establishment of an agreed communication system, system readiness and uncertainty about some roles and responsibilities. Despite differences in perspectives and foci, implementing evidence-based clinical change within hospitals can be initiated outside of the healthcare system and facilitated by academic-industry partnerships.

Background and Aims: The Quality in Acute Stroke (QASC) trial demonstrated a significant reduction in death and disability when clinicians were assisted to introduce protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS) following stroke. A unique international collaboration between the Nursing Research Institute, Australian Catholic University; the European Stroke Organisation; and the Angels Initiative is underway to implement the FeSS Protocols into 20 European countries. We present baseline (pre-FeSS implementation) results for management of these important physiological parameters post-stroke Methods: Data were entered into the European Registry of Stroke Care Quality (RES-Q) for 7 indicators of FeSS care between 2017-2019. Result(s): Forty hospitals from 13 countries completed baseline data entry (n=2266 patients). Paracetamol was administered within one hour following temperature >37.5degreeC C for 58% of patients (n=214/367). When glucose was >10mmols/L, 60% of patients (n=241/403) received insulin within one hour. 57% of patients (1293/2266) received a swallow screen or assessment before being given oral food, fluids or medications. Conclusion(s): All FeSS processes of care need improving, and we are actively working with the Angels Initiative and clinicians to implement the FeSS protocols which have been translated into 13 different languages. Successful large-scale implementation of these evidence-based, nurse-initiated protocols into countries with vastly different health care systems, many of whom also have no access to reperfusion therapies, is likely to make a significant impact on reducing death and disability after stroke.

Contains fulltext : 225443.pdf (publisher's version ) (Open Access), This paper is the initial Position Statement of Evidence Synthesis International, a new partnership of organizations that produce, support and use evidence synthesis around the world. The paper (i) argues for the importance of synthesis as a research exercise to clarify what is known from research evidence to inform policy, practice and personal decision making; (ii) discusses core issues for research synthesis such as the role of research evidence in decision making, the role of perspectives, participation and democracy in research and synthesis as a core component of evidence ecosystems; (iii) argues for 9 core principles for ESI on the nature and role of research synthesis; and (iv) lists the 5 main goals of ESI as a coordinating partnership for promoting and enabling the production and use of research synthesis.