Oral Presentation Australian Diabetes Society and the Australian Diabetes Educators Association Annual Scientific Meeting 2014

Glucose Management in a Cluster Randomized Trial of Evidence-Based Treatment Protocols for Acute Stroke (QASC) (#12)

N Wah Cheung 1 , Chris Levi 2 , Peta Drury 3 , Simeon Dale 3 , Patrick McElduff 2 , Cate D'Este 4 , Jeanette Ward 5 , Jeremy M Grimshaw 6 , Rhonda Griffiths 7 , Clare Quinn 8 , Malcolm Evans 5 , Dominique Cadilhac 9 , Sandy Middleton 3
  1. Westmead Hospital, Westmead, NSW, Australia
  2. Hunter Medical Research Institute, Newcastle, NSW, Australia
  3. Nursing Research Institute, Australian Catholic University, Darlinghurst, NSW, Australia
  4. National Centre for Epidemiology and Population Health, ANU, Canberra, ACT, Australia
  5. University of Newcastle, Newcastle, NSW, Australia
  6. Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
  7. School of Nursing and Midwifery, University of Western Sydney, Penrith, NSW, Australia
  8. Speech Pathology Department,, Prince of Wales Hospital, Randwick, NSW, A
  9. Stroke and Ageing Research Centre, Monash University, Clayton, Victoria, Australia

Performed in Australia, the Quality in Acute Stroke Care (QASC) trial was the first study to demonstrate a reduction in death and dependency following stroke with a treatment protocol which included glucose control (1).

QASC was a single blind cluster randomised trial with 19 acute stroke units (ASUs) randomised to control (n=9) or an intervention (n=10) utilising three treatment protocols for hyperglycaemia, fever and swallowing management implemented following local barrier assessments, education and using reminders. The glucose protocol comprised an algorithm for 4-6 hourly glucose monitoring and hyperglycaemia management (including insulin infusion if glucose level ≥11 mmol/L for patients with diabetes, and ≥16 mmol/L for patients with new onset hyperglycaemia) for the first 72 hours. Our sub-analysis examines the predictive value of glucose parameters for 90-day death and dependency (modified Rankin Scale [mRS] ≥2).

There were 1126 participants with a significant reduction in death and dependency at 90 days in the intervention ASU subjects (42% vs 58%, p=0.002). The mean glucose was 7.0±2.0 mmol/L in the intervention and 6.8±1.8 mmol/L in the control ASU subjects (absolute difference 0.54, 95%CI 0.08-1.01, p=0.02). Patients with a lower mean glucose in the first 72 hours of admission (p=0.003); those who had a formal venous glucose measurement taken in the Emergency Department (p=0.05); and those who had at least one finger prick glucose in the first 72 hours of admission to an ASU (p=0.03) were significantly less likely to be dead or dependent 90-days post stroke. More patients dead or dependent at 90-days had at least one finger prick blood glucose reading >11mMol/L (p=0.02).

Implementation of a protocol which included glucose control improved stroke outcomes. Patients who were alive and independent 90-days post stroke had lower glucose levels and were more likely to have been managed in accordance with elements of the glucose protocol.