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miércoles, 16 de noviembre de 2011

MBE y el tratamiento en atención Primaria del ECV.


Aplicación de protocolos basados ​​en la evidencia del tratamiento para manejar la fiebre, la hiperglucemia y la disfunción de la deglución en el accidente cerebrovascular agudo (QASC): un estudio controlado aleatorizado



Un nuevo protocolo para el tratamiento de la fiebre, de la hiperglucemia y la disfunción de la deglución en pacientes con accidente cerebrovascular, reduce la mortalidad y la discapacidad severa de estos enfermos. Los resultados, publicados en la revista The Lancet, muestran que, independientemente de la gravedad del accidente cerebrovascular, la intervención aguda de pacientes en unidades de ictus reducen significativamente la probabilidad de muerte o la dependencia a los 90 días en comparación con los pacientes control. Para la fiebre, el protocolo incluye el control de la temperatura cada 4 horas y el uso de paracetamol cuando sea necesario. El control de la hiperglucemia incluye la monitorización de la glucemia en sangre y la infusión de solución salina o insulina, según sean los niveles de azúcar en sangre y la existencia de diabetes. En relación a los problemas de deglución, el protocolo plantea el entrenamiento del personal sanitario.






The Lancet, Volume 378, Issue 9804, Pages 1699 - 1706, 12 November 2011
doi:10.1016/S0140-6736(11)61485-2Cite or Link Using DO
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Published Online: 12 October 2011

Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial

Prof Sandy Middleton PhD a b Corresponding AuthorEmail AddressPatrick McElduff PhD cProf Jeanette Ward PhD fProf Jeremy M Grimshaw PhD gSimeon Dale BAHons a bProf Catherine D'Este PhD dPeta Drury MN a bProf Rhonda Griffiths PhD hN Wah Cheung PhD iClare QuinnMSc jMalcolm Evans MN eDominique Cadilhac PhD k l mProf Christopher Levi PhD c eon behalf of the QASC Trialists Group

Summary

Background

We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs).

Methods

In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale [mRS] ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369.

Findings

19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 [42%] of 558 patients in the intervention group vs 259 [58%] of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% [95% CI 5·8—25·4]). They also had a better SF-36 mean physical component summary score (45·6 [SD 10·2] in the intervention group vs 42·5 [10·5] in the control group, p=0·002; adjusted absolute difference 3·4 [95% CI 1·2—5·5]) but no improvement was recorded in mortality (21 [4%] of 558 in intervention group and 24 [5%] of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 [10·9] in the intervention group vs 49·4 [10·6] in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 [92%] of 532 patients vs 380 [90%] of 423 patients; p=0·44).

Interpretation

Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care.

Funding

National Health & Medical Research Council ID 353803, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.

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Vale acotar que en la etiqueta se Sistema Nervioso, encontrarán más recursos sobre PBE y todo lo que tenga que ver con el manejo Rehabilitador de la Enfermedad Cardiovascular y sus secuelas, al igual que en la etiqueta de MBE y Fisioterapia Basada en la Evidencia.



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