Aspiration pneumonia is one of the biggest risks in patients with stroke. Our June 26, 2007 Patient Safety Tip of the Week “Aslanyan 2004, Hinchey 2005). The human and financial impact of pneumonia in the acute stroke patient are substantial. The occurrence of pneumonia was associated with about $15,000 incremental cost per case (Katzan 2007) and pneumonia increased the risk of dying within 30 days threefold in patients with acute stroke, after correction for severity of the stroke (Katzan 2003).“ focused on the evaluation of stroke patients for dysphagia prior to feeding them. Much of the morbidity and mortality in patients with acute stroke is related not just directly to the neurological deficit but rather to the complications such as pneumonia. The incidence of pneumonia in the acute stroke population varies considerably in the literature, largely because of stroke populations of varying severity and differences in definitions used. However, studies that have looked at stroke patients having at least some degree of paralysis present have noted incidences of pneumonia typically in the 12-13% range (
Use of a formal dysphagia screening tool has been shown to reduce the risk of pneumonia in stroke patients by as much as half (Hinchey 2005) and there are reports showing that hospitals can increase their compliance with swallowing assessment by using preprinted order sets and by using written care protocols (Hinchey 2006, Book 2006).
We were very disappointed when NQF waffled in 2008 on including swallowing assessment in stroke patients as one of its quality measures (NQF presumably was concerned because the evidence base was not robust enough). Nevertheless, swallowing assessment has been part of the American Heart Association/American Stroke Association guidelines for management of the acute stroke patient and has been a quality standard for The Joint Commission accreditation of Stroke Centers. But there has been little change in the evidence base for assessment and management of dysphagia in the stroke patient since then.
Our June 15, 2010 Patient Safety Tip of the Week “Dysphagia in the Stroke Patient: the Scottish Guideline” discussed the excellent Scottish Intercollegiate Guidelines Network guideline “Management of patients with stroke: identification and management of dysphagia.A national clinical guideline.” This is the most comprehensive such guideline we’ve seen. It reviews the evidence base and makes recommendations not only for the assessment of dysphagia in the stroke patient but provides great recommendations about interventions in the dysphagic patient, nutritional status of the stroke patient, issues related to tube feedings, medication issues in the dysphagic patient, oral hygiene in the stroke patient, and training of both professional staff and lay caregivers in important issues. It also provides good advice about implementing and auditing the guideline and has a variety of useful tools in its appendix section.
The Scottish guideline uses a water swallow test as a screening tool for dysphagia, then follows up abnormal tests with formal videofluoroscopic studies.
Yet the ideal screening tool remains elusive. A new study (Schepp 2011) shows we have not come a long way in identifying the best dysphagia screening tool. They identified 35 dysphagia screening tools in the literature but found only four that met the basic criteria of reliability, validity and feasibility. Each of the 4 protocols had sensitivities of at least 87% and negative predictive values of at least 91% (compared to the gold standard of a formal swallowing evaluation/videofluoroscopy).
Two of the 4 had been validated only in small samples. Of the remaining two, one (the Toronto Bedside Swallowing Screen Test) had been validated in multiple acute care and rehabilitation settings but was proprietary. The Barnes Jewish Hospital Acute Stroke Dysphagia Screen was validated in over 300 patients, requires minimal training, is easily administered, and has reasonable sensitivity and specificity.
The team discusses many of the challenges associated with dysphagia screening tools. Not only do they need to be valid, reliable and easy to administer but you also need to demonstrate that use of these tools actually leads to desired outcomes (fewer aspiration pneumonias, shorter lengths of stay, better QOL, lower mortality, etc.) and that they are cost-effective. They also stress the importance of false positive screening tests. They note that 23-46% of patients screened had false positive results, often leading to placement of feeding tubes or unnecessary withholding of oral feeds.
On a related note, the American Association of Critical-Care Nurses has recently released a practice alert on prevention of aspiration in critically-ill patients (AACN 2011). This evidence-based alert notes that microaspiration is very common in ICU patients, particularly those with various feeding tubes. They list 7 interventions that should be considered in such patients and summarize the levels of evidence for each.
Aslanyan S, Weir CJ, Diener H-C, Kaste M, Lees KR. Pneumonia
and urinary tract infection after acute ischaemic stroke: a tertiary analysis
of the GAIN international trial. Eur J Neurology 2004; 11: 49-53
Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal Dysphagia Screening Protocols Prevent Pneumonia. Stroke 2005; 36: 1972-1976 http://stroke.ahajournals.org/cgi/content/abstract/36/9/1972?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=hinchey&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
Katzan IL, Dawson NV, Thomas CL, Votruba ME Cebul RD. The
cost of pneumonia after acute stroke. Neurology 2007; 68:1938-1943
Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The
effect of pneumonia on mortality among patients hospitalized for acute stroke.
Neurology 2003; 60:620-625
Hinchey JA, Shephard TJ, Tonn S, Ruthazer R. Preprinted Orders Are Associated With High Adherence to Processes Required on Admission: P468. Stroke 2006; 37: 739
Book DS, Dostai J, Sama D. Compliance with Written Care Protocols Predicts Success in Achieving JCAHO Stroke Performance Measures: P469. Stroke 2006; 37: 739
Adams HP, del Zoppo G, Alberts MJ et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists.
Stroke 2007; 38;1655-1711; originally published online Apr 12, 2007;
The Joint Commission. Primary Stroke Center Certification.
Scottish Intercollegiate Guidelines Network. Management of patients with stroke: identification and management of dysphagia.A national clinical guideline. June 2010
Quick Reference Guideline
Schepp SK, Tirschwell DL, Miller RM, Longstreth WT. Swallowing Screens After Acute Stroke: A Systematic Review. Stroke 2011; published online before print December 8 2011
Edmiaston J, Connor LT, Loehr L, Nassief A. Validation of a Dysphagia Screening Tool in Acute Stroke Patients. Am J Crit Care 2010; 19: 357-364
AACN (American Association of Critical-Care Nurses). Prevention of aspiration practice alert. November 2011