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.

Influence of experimental snow removal on root and canopy physiology of sugar maple trees in a northern hardwood forest.

Due to projected increases in winter air temperatures in the northeastern USA over the next 100 years, the snowpack is expected to decrease in depth and duration, thereby increasing soil exposure to freezing air temperatures. To evaluate the potential physiological responses of sugar maple (Acer saccharum Marsh.) to a reduced snowpack, we measured root injury, foliar cation and carbohydrate concentrations, woody shoot carbohydrate levels, and terminal woody shoot lengths of trees in a snow manipulation experiment in New Hampshire, USA. Snow was removed from treatment plots for the first 6 weeks of winter for two consecutive years, resulting in lower soil temperatures to a depth of 50 cm for both winters compared to reference plots with an undisturbed snowpack. Visibly uninjured roots from trees in the snow removal plots had significantly higher (but sub-lethal) levels of relative electrolyte leakage than trees in the reference plots. Foliar calcium: aluminum (Al) molar ratios were significantly lower, and Al concentrations were significantly higher, in trees from snow removal plots than trees from reference plots. Snow removal also reduced terminal shoot growth and increased foliar starch concentrations. Our results are consistent with previous research implicating soil freezing as a cause of soil acidification that leads to soil cation imbalances, but are the first to show that this translates into altered foliar cation pools, and changes in soluble and structural carbon pools in trees. Increased soil freezing due to a reduced snowpack could exacerbate soil cation imbalances already caused by acidic deposition, and have widespread implications for forest health in the northeastern USA.

Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO'.

BACKGROUND: Information communicated by ambulance paramedics to Emergency Department (ED) staff during handover of patients has been found to be inconsistent and incomplete, and yet has major implications for patients' subsequent hospital treatment and trajectory of care. AIM: The study's aims were to: (1) identify the existing structure of paramedic-to-emergency staff handovers by video recording and analysing them; (2) involve practitioners in reflecting on practice using the footage; (3) combine those reflections with formal analyses of these filmed handovers to design a handover protocol; (4) trial-run the protocol; and (5) assess the protocol's enactment. METHOD: The study was a 'video-reflexive ethnography' involving: structured analysis of videoed handovers (informed by ED clinicians' and ambulance paramedics' comments); ED clinicians and ambulance paramedics viewing their own practices; and rapid at-work training and feedback for paramedics. A five-question pre- and post-survey measured ED triage nurses' perceptions of the new protocol's impact. In total, 137 pre- and post-handovers were filmed involving 291 staff, and 368 staff were educated in the use of the new protocol. RESULTS: There was agreement that Identification of the patient, Mechanism/medical complaint, Injuries/information relative to the complaint, Signs, vitals and GCS, Treatment and trends/response to treatment, Allergies, Medications, Background history and Other (social) information (IMIST-AMBO) was the preferred protocol for non-trauma and trauma handovers. Uptake of IMIST-AMBO showed improvements: a greater volume of information per handover that was more consistently ordered; fewer questions from ED staff; a reduction in handover duration; and fewer repetitions by both paramedics and ED clinicians that may suggest improved recipient comprehension and retention. CONCLUSION: IMIST-AMBO shows promise for improving the ambulance-ED handover communication interface. Involving paramedics and ED clinicians in its development enhanced the resulting protocol, strengthened ED clinicians' and ambulance paramedics' sense of ownership over the protocol and bolstered their peers' willingness to adopt it.