Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study
Abstract
:1. Introduction
2. Methods
3. Results
3.1. Sample
3.2. Themes
4. Delay
4.1. Patient Factors
‘Number 1 the reason I can see for delays is the patient’s inappropriateness to complete the screen…they’re not alert enough or not awake enough or medically not able to have to have it’.(H1P2)
‘Delays are obviously due to the fact that subtle swallowing difficulties… are not really picked up the junior doctors or senior doctors or even nursing staff’.(H4P1)
‘If it’s a stroke but atypical stroke presentation…patient can go somewhere else and basically the screen will not be done because there’s no risk of any swallowing problems. The patient might be fed and then realised that patient is coughing or having difficulty 24–48 h later CT (Computerised tomography) is done then realising there is a stroke’.(H2P2)
4.2. Staff Factors
‘They don’t have any trained nurses down there [Emergency Department] it’s normally the [stroke] nurse that does it so only one person’.(H5P4)
‘It depends on the level of sort of competence in managing the time and how quick and efficient they are as well’.(H2P1)
‘If they’ve come from a different ward and that ward may not be as knowledgeable as our staff regarding how quickly they should be screened’.(H4P4)
‘The typical scenario might be 3 or 4 patients arrive in ED (Emergency Department) at any one time and then obviously the emphasis would be very much on trying to restore brain function so where there can be an intervention early and that can take priority over a swallow screen on the initial patient you were seeing’.(H3P1)
‘I suppose I’m still a bit unclear about whose responsibility it is. I know that several people do the swallow screen but I’m just not sure that it’s one person’s role particularly. And I don’t really know who is going around monitoring when swallow screens are happening’.(H1P3)
‘So maybe using those above the bed forms so even if they’ve passed their swallow assessment…perhaps putting a form up to say normal diet so we all know the swallow assessment has been done’.(H1P3)
‘7 day working…so there’s always going to be day where there’s no screeners where’s no assessments to take place’.(H2P3)
‘Staffing that is our main reason for us not being able to see the patient if we’ve got 2 people on leave’.(H2P1)
‘Sometimes they forget to do follow the correct admin procedures’.(H2P1)
‘Sometimes they forget to let us know so they’ll do the screen put them on something’.(H2P1)
4.3. Service Factors
‘Because it’s so busy sometimes they don’t get seen by a doctor for 4 5 or 6 hours so that has an impact on getting the screen quickly’.(H3P4)
‘They know they are not to leave A&E (Accident and Emergency) until they’ve swallow screened them so that tends to hit our four-hour window’.(H5P2)
‘They won’t tell the stroke nurse about them until they’ve assessed them and accepted them under stroke which can often be pushing the four hour period and that’s when we would have issues with compliance’.(H5P2)
‘If they were in this hospital then they [the ward] would probably ring us and we would try and go down if we could. If they were in another hospital it would be reliant on whoever they’ve got to screen or assess but I would be doubtful whether it would be done within the four-hour time frame’.(H1P1)
‘I guess the swallow screen wouldn’t be forgotten but might be, wouldn’t be the first thing in the minds of the doctors and nurses’.(H1P3)
‘It’s a bit different at night time because there’s not many radiographers around so sometimes can take a bit longer to get that done’(H3P4)
‘I actually really don’t like my patients going down for X-Rays they end up going to a different part of the hospital where they pick up infection they don’t get the standard of care we would expect on the stroke unit and sometimes they miss out on a therapy session…just for the purpose of the X-ray and it’s not necessarily the best approach’.(H3P1)
‘It’s not a good thing that the patient’s having to frequently go off the ward for Chest X-Rays repeatedly because it delays feeding it delays administration of medications so it could have a negative effect on the patient and the resource issue’.(H1P3)
5. Lack of Standardisation
5.1. Dysphagia Screening Protocols (DSPs)
‘I can’t understand why we’ve got so many different screens so much variance around the country I just think is absolutely crazy as a profession’.(H4P4)
5.2. SLT Swallow Assessment
‘It’s been a long time ago that we devised it …we all devised our own when we were training’. ‘So, it’s something that’s engrained at this stage’.(H1P1)
5.3. Oral Care
‘I don’t think there’s a formal policy there no written policy’ (H2P3) ‘no there’s no written policy’.(H2P2)
‘The practice educator forum have asked for a…report to be submitted for each of the individual areas… because it seems like everyone is doing their own thing either doing it differently or repeating what other people are doing which probably both aren’t particularly appropriate’.(H5P2)
5.4. NGT Insertion
‘So, the policy is just been updated…to say maximum of 3 NG (Nasogastric) tubes with a 24-hour period’.(H5P2)
‘It’s very easy to get stuck into a pathway when treating somebody who’s maybe a modified Rankin score of 5 at baseline who’s naturally at the end of their life’.(H3P1)
‘So, in our community hospitals they are perfectly able to manage NGTs (Nasogastric Tubes) without radiology most of the time they don’t need it so there is a standard of care there, what’s the difference probably more senior nursing staff and a more holistic approach that maybe we need to find’.(H3P1)
6. Variability in Resources
6.1. Resources to Assess Patients Swallowing
‘Speech therapists on the stroke unit aren’t thinking about FEES (Fibreoptic Endoscopic Evaluation of Swallowing)’.(H5P4)
6.2. Medical Interventions
6.3. Care Processes
‘Potentially a lot of patients with swallowing impairments are fed by healthcare assistants who have had training but not perhaps the background knowledge of anatomy and physiology to the same extent as qualified nurses have’.(H5P2)
‘I think what the big thing we noticed at lunchtime everything is great, at breakfast time things were awful patients weren’t able to sit out of bed, when they’re in bed they weren’t positioned upright necessarily’.(H4P4)
7. Discussion
8. Conclusions
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
Data Availability
References
- Smith, C.J.; Kishore, A.K.; Vail, A.; Chamorro, A.; Garau, J.; Hopkins, S.J.; Di Napoli, M.; Kalra, L.; Langhorne, P.; Montaner, J.; et al. Diagnosis of stroke-associated pneumonia: Recommendations from the pneumonia in stroke consensus group. Stroke 2015, 46, 2335–2340. [Google Scholar] [CrossRef] [PubMed]
- Kishore, A.K.; Vail, A.; Chamorro, A.; Garau, J.; Hopkins, S.J.; Di Napoli, M.; Kalra, L.; Langhorne, P.; Montaner, J.; Roffe, C.; et al. How is pneumonia diagnosed in clinical stroke research? A systematic review and meta-analysis. Stroke 2015, 46, 1202–1209. [Google Scholar] [CrossRef] [PubMed]
- Katzan, I.L.; Cebul, R.D.; Husak, S.H.; Dawson, N.V.; Baker, D.W. The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology 2003, 60, 620–625. [Google Scholar] [CrossRef]
- Finlayson, O.; Kapral, M.; Hall, R.; Asllani, E.; Selchen, D.; Saposnik, G. Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology 2011, 77, 1338–1345. [Google Scholar] [CrossRef]
- Hannawi, Y.; Hannawi, B.; Rao, C.P.; Suarez, J.I.; Bershad, E.M. Stroke-Associated Pneumonia: Major advances and obstacles. Cerebrovasc. Dis. 2013, 35, 430–443. [Google Scholar] [CrossRef] [PubMed]
- Martino, R.; Foley, N.; Bhogal, S.; Diamant, N.; Speechley, M.; Teasell, R. Dysphagia after stroke: Incidence, diagnosis, and pulmonary complications. Stroke 2005, 36, 2756–2763. [Google Scholar] [CrossRef]
- Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke, 5th ed.; Royal College of Physicians: London, UK, 2016; Available online: https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx (accessed on 4 September 2019).
- Al-Khaled, M.; Matthis, C.; Binder, A.; Mudter, J.; Schattschneider, J.; Pulkowski, U.; Strohmaier, T.; Niehoff, T.; Zybur, R.; Eggers, J.; et al. Dysphagia in patients with acute ischemic stroke: Early dysphagia screening may reduce stroke-related pneumonia and improve stroke outcomes. Cerebrovasc. Dis. 2016, 42, 81–89. [Google Scholar] [CrossRef]
- Bray, B.D.; Smith, C.J.; Cloud, G.C.; Enderby, P.; James, M.; Paley, L.; Tyrrell, P.J.; Wolfe, C.D.; Rudd, A.G. The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia. J. Neurol. Neurosurg. Psychiatry 2017, 88, 25–30. [Google Scholar] [CrossRef]
- Palli, C.; Fandler, S.; Doppelhofer, K.; Niederkorn, K.; Enzinger, C.; Vetta, C.; Trampusch, E.; Schmidt, R.; Fazekas, F.; Gattringer, T. Early dysphagia screening by trained nurses reduces pneumonia rate in stroke patients: A Clinical Intervention Study. Stroke 2017, 48, 2583–2585. [Google Scholar] [CrossRef]
- Eltringham, S.A.; Kilner, K.; Gee, M.; Sage, K.; Bray, B.D.; Pownall, S.; Smith, C.J. Impact of Dysphagia Assessment and Management on Risk of Stroke-Associated Pneumonia: A Systematic Review. Cerebrovasc. Dis. 2018, 46, 97–105. [Google Scholar] [CrossRef]
- Martino, R.; Silver, F.; Teasell, R.; Bayley, M.; Nicholson, G.; Streiner, D.L.; Diamant, N.E. The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and validation of a dysphagia screening tool for patients with stroke. Stroke 2009, 40, 555–561. [Google Scholar] [CrossRef] [PubMed]
- Leder, S.; Suiter, D. The Yale Swallow Protocol: An Evidence-Based Approach to Decision Making; Springer International Publishing: Basel, Switzerland, 2014. [Google Scholar]
- Trapl, M.; Enderle, P.; Nowotny, M.; Teuschl, Y.; Matz, K.; Dachenhausen, A.; Brainin, M. Dysphagia bedside screening for acute-stroke patients: The Gugging Swallowing Screen. Stroke 2007, 38, 2948–2952. [Google Scholar] [CrossRef] [PubMed]
- Hoffmann, S.; Harms, H.; Ulm, L.; Nabavi, D.G.; Mackert, B.M.; Schmehl, I.; Jungehulsing, G.J.; Montaner, J.; Bustamante, A.; Hermans, M.; et al. Stroke-induced immunodepression and dysphagia independently predict stroke-associated pneumonia—The PREDICT study. J. Cereb. Blood Flow Metab. 2017, 37, 3671–3682. [Google Scholar] [CrossRef] [PubMed]
- Gosney, M.; Martin, M.V.; Wright, A.E. The role of selective decontamination of the digestive tract in acute stroke. Age Ageing 2006, 35, 42–47. [Google Scholar] [CrossRef] [Green Version]
- Arai, N.; Nakamizo, T.; Ihara, H.; Koide, T.; Nakamura, A.; Tabuse, M.; Miyazaki, H. Histamine H2-blocker and proton pump inhibitor use and the risk of pneumonia in acute stroke: A retrospective analysis on susceptible patients. PLoS ONE 2017, 12, e0169300. [Google Scholar] [CrossRef]
- Brogan, E.; Langdon, C.; Brookes Budgeon, C.; Blacker, D. Dysphagia and Factors Associated with Respiratory Infections in the First Week Post Stroke. Neuroepidemiology 2014, 43, 140–1444. [Google Scholar] [CrossRef]
- Kalra, L.; Irshad, S.; Hodsoll, J.; Smithard, D.; Manawadu, D. Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients. Neurology 2016, 87, 1352–1359. [Google Scholar] [CrossRef]
- Langdon, P.C.; Lee, A.H.; Binns, C.W. High incidence of respiratory infections in ‘nil by mouth’ tube-fed acute ischemic stroke patients. Neuroepidemiology 2009, 32, 107–113. [Google Scholar] [CrossRef]
- Sentinel Stroke National Audit Programme. Available online: https://www.strokeaudit.org (accessed on 4 September 2019).
- Eltringham, S.A.; Kilner, K.; Gee, M.; Sage, K.; Bray, B.D.; Smith, C.J.; Pownall, S. Factors Associated with Risk of Stroke-Associated Pneumonia in Patients with Dysphagia: A Systematic Review. Dysphagia 2019. [Google Scholar] [CrossRef]
- Braun, V.; Clarke, V. Using thematic analysis in psychology. Qual. Res. Psychol. 2006, 3, 77–101. [Google Scholar] [CrossRef] [Green Version]
- Kvale, S. Doing interviews. In The Sage Qualitative Research Kit; Sage Publications: London, UK, 2007. [Google Scholar]
- O’Brien, B.C.; Harris, I.B.; Beckman, T.J.; Reed, D.A.; Cook, D.A. Standards for reporting qualitative research: A synthesis of recommendations. Acad. Med. 2014, 89, 1245–1251. [Google Scholar] [CrossRef] [PubMed]
- Morris, S.; Ramsay, A.I.; Boaden, R.J.; Hunter, R.M.; McKevitt, C.; Paley, L.; Perry, C.; Rudd, A.G.; Turner, S.J.; Tyrrell, P.J.; et al. Impact and sustainability of centralising acute stroke services in English metropolitan areas: Retrospective analysis of hospital episode statistics and stroke national audit data. BMJ 2019, 364, l1. [Google Scholar] [CrossRef] [PubMed]
- Sentinel Stroke National Audit Programme (SSNAP). Clinical Audit April 2013–March 2018 Annual Public Report. National Results. 2019. Available online: https://www.hqip.org.uk/wp-content/uploads/2019/06/apr2017mar2018-ssnap-annualreport-final.pdf (accessed on 21 June 2019).
- Beavan, J.; Conroy, S.P.; Harwood, R.; Gladman, J.R.; Leonardi-Bee, J.; Sach, T.; Bowling, T.; Sunman, W.; Gaynor, C. Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial. Age Ageing 2010, 39, 624–663. [Google Scholar] [CrossRef] [PubMed]
- Ilott, I.; Gerrish, K.; Eltringham, S.A.; Taylor, C.; Pownall, S. Exploring factors that influence the spread and sustainability of a dysphagia innovation: An instrumental case study. BMC Health Serv. Res. 2016, 16, 406. [Google Scholar] [CrossRef]
- Patient Safety Alert. Resources to Support Safer Modification of Food and Drink. 2018. Available online: https://improvement.nhs.uk/documents/2955/Patient_Safety_Alert_-_Resources_to_support_safer_modification_of_food_and_drink_v2.pdf (accessed on 19 June 2019).
- Care Quality Commission. Guidance for Providers. 2018. Available online: https://www.cqc.org.uk/guidance-providers/learning-safety-incidents/issue-6-caring-people-risk-choking (accessed on 19 June 2019).
Themes | Sub Themes |
---|---|
Delay | Patient, staff and service factors that contribute to delay in dysphagia screening, SLT swallow assessment and NGT feeding |
Lack of standardisation | DSP, SLT swallow assessment, oral care, NGT insertion and confirmation of positioning |
Variability in resources | Resources to assess and manage swallowing, medical interventions, care processes |
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Share and Cite
Eltringham, S.A.; Smith, C.J.; Pownall, S.; Sage, K.; Bray, B. Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study. Geriatrics 2019, 4, 60. https://doi.org/10.3390/geriatrics4040060
Eltringham SA, Smith CJ, Pownall S, Sage K, Bray B. Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study. Geriatrics. 2019; 4(4):60. https://doi.org/10.3390/geriatrics4040060
Chicago/Turabian StyleEltringham, Sabrina A., Craig J. Smith, Sue Pownall, Karen Sage, and Ben Bray. 2019. "Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study" Geriatrics 4, no. 4: 60. https://doi.org/10.3390/geriatrics4040060