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Background Variation in stroke care among hospitals is problematic. The Quality in Acute Stroke (QASC) Australia trial demonstrated reductions in death and disability through supported implementation of nurse-led, evidence-based protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS Protocols) following stroke. We conducted a pre-test/post-test study to evaluate the effect of supported implementation on FeSS Protocol uptake into acute stroke wards in 64 hospitals in 17 European countries. Implementation across countries was underpinned by a cascading facilitation framework of multi-stakeholder’s support involving academic partners and a not-for-profit health care initiative. The aim of this a priori qualitative process evaluation was to identify factors that influenced the implementation of the international up-scale of the FeSS Protocols using a cascading facilitation framework. Methods The sampling frame for interviews was: 1) Executives/Steering Committee members from academic and industry partners (from the Angels Initiative, a not-for-profit arm of industry) some of whom comprised the senior project team, 2) Angel Team leaders (managers of Angel Consultants), 3) Angel Consultants (responsible for assisting facilitation of FeSS Protocols into multiple hospitals) and 4) Country Co-ordinators (senior stroke nurses with country and hospital-level responsibilities for facilitating the introduction of the FeSS Protocols). A semi-structured interview elicited participant views on factors influencing engagement, preparation for FeSS Protocol upscale and implementation. Interviews were recorded, transcribed verbatim and analysed inductively within NVivo. Results Individual (n=13) and three group interviews (3 participants in each group) were undertaken. Three main themes were identified with sub-themes: readiness for change; roles and relationships and managing multiple changes. These themes illustrate the factors that enabled multi-country FeSS Protocol scale-up through a cascading facilitation model based on a collaboration between evidence producers (academics), knowledge brokers (not-for-profit arm of industry), and evidence adopters (stroke clinicians). Conclusion A cascading facilitation model involving academic, clinical and industry partners overcame multiple challenges involved in international evidence translation. Capacity to manage, negotiate and adapt to multi-level changes, a shared goal of optimal stroke care and strategic engagement of different stakeholders supported adoption of nurse-initiated stroke protocols within Europe. This model has promise for other large-scale evidence translation programs.

Objectives: Low-middle income countries, such as Vietnam have a greater burden from stroke than high-income countries. Few health professionals have stroke specialist training, and the quality of care may vary between hospitals. To support improvements to stroke care, we aimed to gain a better understanding of the resources available in hospitals in Vietnam to manage acute stroke. \ud Materials and Methods: The survey questions were adapted from the Australian Organisational Survey of Stroke Services (Stroke Foundation). The final 65 questions covered the topics: hospital size and admissions for stroke; use of clinical protocols and assessments conducted; team structure and coordination; communication and team roles. The survey was distributed electronically or via paper form in Vietnamese to clinical leaders of 91 eligible hospitals (November–December 2020). Data were summarised descriptively. \ud Results: Sixty-six (73%) hospitals responded, and doctors predominately completed the survey (98%). Approximately 70% of hospitals had a stroke unit; median 630 acute strokes/year (IQR: 250-1200) and >90% used stroke clinical protocols. The daytime nurse-patient ratio was 1:4. There was a perceived lack of access to allied health staff, including psychologists/neuropsychologists, occupational therapists, and speech pathologists. Only 50% reported having a standardised rehabilitation assessment process.\ud Conclusions: This is the first large-scale cross-sectional, national overview of stroke services in Vietnam. Future research should include a systematic clinical audit of stroke care to confirm aspects of the data from these hospitals. Repeating the survey in future years will enable the tracking of progress and may influence capacity building for stroke care in Vietnam.

Supplemental material, sj-docx-7-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Supplemental material, sj-docx-3-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Supplemental material, sj-docx-8-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Supplemental material, sj-docx-6-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Supplemental material, sj-docx-5-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Supplemental material, sj-docx-11-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Supplemental material, sj-docx-9-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Supplemental material, sj-docx-2-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Supplemental material, sj-docx-4-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Supplemental material, sj-pdf-1-eso-10.1177_23969873221126027 for Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study by Sandy Middleton, Simeon Dale, Benjamin McElduff, Kelly Coughlan, Elizabeth McInnes, Robert Mikulik, Thomas Fischer, Jan Van der Merwe, Dominique Cadilhac, Catherine D’Este, Christopher Levi, Jeremy M Grimshaw, Andreea Grecu, Clare Quinn, Ngai Wah Cheung, Tereza Koláčná, Sabina Medukhanova, Estela Sanjuan Menendez, Susana Salselas, Gert Messchendorp, Anne-Kathrin Cassier-Woidasky, Marcelina Skrzypek-Czerko, Merce Slavat-Plana, Urso Antonella and Waltraud Pfeilschifter in European Stroke Journal

Additional file 2: Table S1. Likelihood of undertaking oral care assessments in the UK and in Australia. Categories unsure, not applicable and no response have been omitted. Table S2. Patient factors reported to influence whether an oral care assessment was undertaken for the UK and Australia. Categories unsure and no response have been omitted. Table S3. Staff factors, organisational factors and patient factors reported to influence oral care provision in the UK and Australia. Categories unsure and no response have been omitted. Figure S1. Oral care products available in UK (left) and Australian (right) hospitals.

Additional file 1.

Resource 3: technique definition and examples. (DOCX 71 kb)

Resource 1: barrier extracts and TDF definitions. (DOCX 23 kb)

Resource 2: domains with corresponding BCT and definitions. (DOCX 25 kb)

Resource 4: enabler data from the barrier and enabler workshops. (DOCX 26 kb)

Resource 5: Cochrane Effective Practice and Organisation of Care [EPOC] reviews. (DOCX 25 kb)

Background: Socio-economic factors are associated with mortality, morbidity and access to health services. For optimal outcomes, it is critical for patients with stroke symptoms to attend Emergency Departments (ED) with minimal delay.Purpose: To identify the relationship between Socio-Economic Indexes For Areas (SEIFA), and time to ED presentation following stroke symptoms.Methods: Using data from the pre-implementation cohort (n=689) of an Australian cluster-RCT, (T3 Trial) SEIFA index scores (which rank geographical areas by socioeconomic advantage) were categorised into tertiles. A Cox regression modeled the relationship between SEIFA groups and time to ED presentation from symptom onset, adjusting for highest education level, age, sex, modified Rankin Scale (mRS), stroke severity and correlation of arrival time within hospitals using the cluster Huber-White sandwich estimator. Results: Time to arrival was available for 669 (97%). Median arrival time was 2 hours (hrs) (IQR 5.5, range 0.05-46). Median arrival time for lowest SEIFA group was 3 hrs (IQR 6.5, range 0.05-46) compared to 2 hrs (IQR 3.5, range 0.5-38) and 2.5 hrs (IQR 6, range 0.5-26) for middle and higher SEIFA strata respectively (p=0.2). Older age (Hazard ratio (HR); 1.56, 95% CI: 1.14-2.13), female sex (HR; 1.15, 95% CI: 1.03-1.28), moderate or severe stroke severity (HR; 1.44, 95% CI: 1.08-1.92) and middle SEIFA level (HR; 1.29, 95% CI: 1.04-1.59) were significantly associated with longer time to ED presentation. Conclusions: Ongoing community education that stroke is a medical emergency responsive to time-critical treatment remains a priority. Further exploration of other reasons for slower ED arrival time is warranted.