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 always remained 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.
There has not been a significant change in the evidence base for assessment and management of dysphagia in the stroke patient since then. However, this month the Scottish Intercollegiate Guidelines Network released its 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. There is also a good quick reference guide with appropriate algorithms.
The Scottish guideline notes that there is videofluoroscopic evidence of dysphagia in 64-90% of conscious stroke patients acutely, with confirmed aspiration in 22-42%. Hence, assessing patients for dysphagia and aspiration risk is crucial. Note that seeing a patient cough on attempted swallowing is a good indicator of aspiration but the lack of coughing does not indicate safe swallowing. Factors associated with risk of aspiration are a wet, hoarse voice, a weak voluntary cough, any indication of reduced laryngeal function, and impaired level of consciousness. Factors that have not proven to be accurate predictors of aspiration are pharyngeal sensation and status of the gag reflex. The gag reflex is commonly reduced in the acute phase after stroke. However, some patients with bilateral lesions develop pseudobulbar palsy and may have a normal or even increased gag reflex when their swallowing is impaired.
The water swallow test is typically used as a first line tool to screen for aspiration risk. This screening test is administered by a healthcare professional trained in the procedure, usually a nurse. The Quick Referral Guide and Annex 2 of the full Scottish guideline provide an algorithm for the swallowing screen. If the patient can sit up and is alert and cooperative and has a clean mouth (or has received oral hygiene), the water swallow test can proceed. The patient is sat up and given a teaspoon of water times three. With each teaspoon, the observer watches for absent swallow, cough, delayed cough, and altered voice quality. It the patient shows any of those abnormalities, he/she is kept NPO and formal swallowing studies are ordered (usually done by speech therapy in most facilities). If the patient passes that initial screen, the patient is observed drinking a full glass of water, again looking for those same abnormalities. If none are witnessed, the patient may start feeding (soft options) cautiously and observation for coughing or evidence of chest infection are continued.
If the patient fails the initial swallowing screen, a formal assessment should be done by an individual appropriately trained in swallowing assessment, such as a speech therapist. A clinical bedside assessment (CBA) of swallowing can be done using a standardized tool such as the 28-item Logemann assessment (Annex 3 in the full Scottish guideline). Most may go on to either a modified barium swallow (MBS) or fiberoptic endoscopic evaluation of swallowing (FEES). The decision of which of these to perform is usually dependent upon individual circumstances (eg. test availability, whether the patient can be transported or not, risk of radiation exposure, etc.). Both tests allow for determination of penetration and aspiration. MBS may be better at determining the reason for dysphagia and aspiration and allow experimentation with various postures, maneuvers and food consistencies to see what might improve the effectiveness and safety of swallowing for each patient. Diet modification, compensatory techniques, texture modification, and approaches such as muscle strengthening exercises, electrical stimulation and biofeedback are discussed in detail in the guideline.
The initial assessment should include not only screening for dysphagia but also screening for risk of malnutrition and risk of dehydration. Because malnutrition and dehydration may impact on ultimate patient outcomes, they should be addressed by the multidisciplinary team and include a dietitian. For those patients who are unable to safely swallow and are at risk of malnutrition, tube feedings will need to be considered. The guideline has an excellent discussion of the pros and cons of nasogastric tubes and percutaneous gastrostomies (PEG’s) and the timing for conversion from NG to PEG if needed. They also have a nice section on ethical and quality of life issues and feeding. And a short section on the need for pharmacists to be involved in looking at alternative formulations for necessary medications in those being tube fed.
Some of the most important sections deal with those things we tend to often overlook. One is one on the need for regular review of the patient’s status. Dysphagia in stroke patients often resolves within the first few weeks. Hence, there is a continuing need to reassess the patient’s swallowing ability and other risk factors for pneumonia and malnutrition. The guideline stresses that one professional should be identified who will be responsible for this ongoing assessment and reassessment, especially for any patient being tube fed or fed a modified diet. The second has to do with auditing. As you begin implementing the guideline you need to audit current practice to determine where your gaps in care and areas for improvement are. They provide a nice checklist to help you with that audit. But don’t forget that audit and feedback are critical parts in the durability and sustainability of any quality improvement or patient safety activity.
The guideline also contains good advice on issues of communication, training of staff, and provision of information for staff, patients and their caregivers.
Implementing this guideline for all stroke patients is a pretty low cost patient safety intervention and, with a savings of $15,000 for each pneumonia prevented, one that has an excellent ROI. Again, this is another good example of how good patient safety programs can be very cost-effective for most hospitals.
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
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Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The
effect of pneumonia on mortality among patients hospitalized for acute stroke.
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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