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 that occur, many of which are potentially preventable. Those complications include decubiti, falls, DVT, UTI and pneumonia. Preventing these complications is good not only from a patient perspective but very important in avoiding unnecessary costs for the hospital. Most hospitals already incorporate risk assessments for decubiti, falls, and DVT into their nursing care plans and clinical pathways. In our May 8, 2007 Tip of the Week, we talked about how inappropriate use of Foley catheters causes many nosocomial UTI’s.
A paper in the last issue of the journal Neurology highlighted the human and financial impact of pneumonia in the acute stroke patient1. The occurrence of pneumonia was associated with about $15,000 incremental cost per case. Previous work by the same group showed that pneumonia increased the risk of dying within 30 days threefold in patients with acute stroke, after correction for severity of the stroke2.
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% range3,7.
Two of the most important factors in the stroke patient predisposing them to pneumonia are impaired swallowing ability and impaired cough reflex. There is currently no single “gold standard” for swallowing assessment and different hospitals may use different methods4. Some have suggested formal assessment of the cough reflex may be even more important5, though this has not been done at most facilities. The current standard of care is that all patients with acute stroke should have an assessment of their ability to swallow prior to being fed food or fluids orally. That assessment is one of the measures used in Joint Commission’s accreditation program for stroke centers6. Quite frankly, it should be a measure routinely followed in the quality improvement program of any hospital that cares for acute stroke patients, regardless of whether the hospital has stroke center designation.
Use of a formal dysphagia screening tool has been shown to reduce the risk of pneumonia in stroke patients by as much as half7. Some hospitals have the swallowing assessment done by nursing staff, others by speech therapy. Others may have nursing do a screening assessment, with speech therapy doing a more formal assessment only in abnormal cases. There are preliminary reports showing that hospitals can increase their compliance with swallowing assessment by using preprinted order sets and by using written care protocols8,9.
Given the relatively low cost of implementing a dysphagia screening program for all stroke patients, a savings of $15,000 for each pneumonia prevented is an excellent return on investment. Again, this is another good example of how good patient safety programs can be very cost-effective for most hospitals.