Aspiration pneumonia is one of the biggest risks in patients with stroke. Our June 26, 2007 Patient Safety Tip of the Week ““ 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 is typically in the 12-13% range with incremental costs of about $15,000 cost per case and pneumonia increases the risk of dying within 30 days threefold.
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). 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”.
Our February 2012 What’s New in the Patient Safety World column “Swallowing Evaluation in Stroke” noted that the ideal screening tool remains elusive. A 2011 study (Schepp 2011) 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).
One of the tests mentioned in the Schepp article (Schepp 2011) was the Modified Mann Assessment of Swallowing Ability (MMASA). However, they spent little time discussing this test because it had been validated only in small sample sizes. Now researchers from the Frenchay Hospital in the UK (Keller 2012) have reported a 75% reduction in pneumonia in stroke patients after implementation of a screening program in stroke patients using the Modified Mann Assessment of Swallowing Ability (MMASA). This tool can be administered at the bedside in 5 minutes, compared to almost one hour for the full Mann Assessment of Swallowing Ability. Previous studies have documented sensitivities, specificities, and positive and negative predictive values similar to the other tests mentioned in the Schepp article (Schepp 2011) mentioned in our previous column.
Prior to implementation of the MMASA screening the pneumonia rate in stroke patients was 12%. After implementation it dropped to 3%, while corresponding national rates in the UK were still in the 13% range.
So some progress is being made in identifying screening tools for dysphagia in stroke patients. More importantly, the studies are beginning to show that use of such tools has an impact on important clinical outcomes.
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
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
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
Keller DM. New Swallowing Test Reduces Pneumonia in Stroke Patients. Medscape Medical News May 30, 2012 referencing Baldwin N et al. Abstract #24 at the XXI European Stroke Conference. Presented May 22, 2012