International clinical guidelines recommend early management of stroke on arrival to the emergency department (ED) in order to improve patient outcomes [
3‐
5]. Key elements of stroke care applicable to EDs are appropriate
triage;
treatment by administration of tissue plasminogen activator (tPA) to eligible patients and management of fever, hyperglycaemia and swallowing; followed by prompt
transfer to an acute stroke unit. Data available at the time of our T
3 (triage, treatment and transfer) Trial commencement demonstrated variable practices. With regard to triage, allocation of an Australasian Triage Scale (ATS) category 1 (to be seen immediately) or category 2 (to be seen within 10 min) is recommended for patients presenting to EDs with signs or symptoms of acute stroke [
6]. However, these targets are not always met; an analysis of Victorian ambulance data demonstrated that 30 % of patients with stroke were not allocated an ATS category of 1 or 2 [
7]. Inappropriate triage allocation resulting in delays in assessment and diagnosis also may have a flow-on adverse effect on provision of thrombolysis to patients who may benefit and create delays in implementation of other elements of evidence-based stroke care.
In terms of treatment, Australian data from the 2013 Stroke Foundation national acute audit found that only 45 % of patients with ischaemic stroke presenting to hospital within 3 h of stroke were assessed for tPA eligibility [
8]. Only 7 % of eligible patients received tPA [
8] with pockets of excellence where rates from individual sites were up to 21 % [
9]. Less than optimal tPA rates also have been reported internationally; 12 % in the UK [
10] and less than 5 % in the USA [
11]. However, data from Norway, where collaboration for pre-hospital, ED and acute services is streamlined, demonstrate higher rates (31 %) are achievable [
12]. In relation to the management of fever, hyperglycaemia and swallowing in Australia, pre-trial data from the 2013 Stroke Foundation national acute audit showed that only 60 % of patients received temperature monitoring four times a day during the first 72 h of admission, with only 36 % of those with a fever (>37.5 °C) receiving paracetamol within 1 h [
8]. Less than a quarter (21 %) received four times a day glucose monitoring in the first 72 h of admission, and only 25 % patients with hyperglycaemia (blood glucose >10 mmol/L) received insulin within 1 h [
8]. Two thirds (66 %) of patients received a swallowing screen or assessment within 24 h of admission [
8], and of concern, only 52 % received a swallow screen/assessment prior to oral intake [
8]. Our own Quality in Acute Stroke Care (QASC) trial data from the intervention group showed that 18 % of patients with stroke were given oral fluid or food before screening and 37 % were given oral medications [
13]. Similarly, at the T
3 Trial commencement, variable practices were reported regarding prompt transfer from ED to stroke units with ED length of stays ranging from a median of 7 h (maximum 20 h) [
13] up to 11 h [
14].
In summary, EDs must deliver time-critical, best-practice clinical care to optimise outcomes for patients with stroke. A specific challenge for EDs is the delivery of optimal care for patients with stroke whilst managing other patients with a range of illnesses and injuries of varying degrees of clinical urgency. It is clear that EDs need greater support to deliver evidence-based triage, treatment and transfer for patients presenting with acute stroke in order to improve patient outcomes. Building on our previous trial results [
15], we aim to rigorously evaluate, using a cluster randomised controlled trial design, the effectiveness of a theory-informed, nurse-initiated, organisational intervention to improve multidisciplinary care for patients with acute stroke in EDs measuring outcomes at 90 days.