Steve Davies

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Screening for Dysphagia After Stroke
Steve Davies Clinical Nurse Specialist in
Nutrition Support Gateshead Health Foundation NHS
Trust steve.davies_at_ghnt.nhs.net
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Background

• Dysphagia a major problem in acute stroke.
• Associated with a five to 10-fold increase in the
  risk of chest infection during the first week.
• 27 dysphagic patients had chest infections
  compared to 7 of non-dysphagic patients.
• Chest infections may substantially delay recovery
  increase the risk of further complications of
  prolonged immobility and could be one important
  reason why around one-third of patients
  deteriorate neurologically during the first 72
  hours.
• Malnutrition is also common, being present in
  about 15 of all patients admitted to hospital,
  and increasing to about 30 over the first week.

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Journey

• Traditional
• Collaborative Dysphagia Audit (CODA) Study
• CODA demonstrated that following appropriate
  training nurses could screen for swallowing
  problems and improve the day to day management of
  the dysphagic patient

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CODA

• Benefits
• reduced the number of dysphagic patients with
  inadequate precautions against aspiration
• improved the appropriateness of referrals to SaLT
• reduced the number of patients kept nil by mouth
  unnecessarily

• Shortcomings
• patients still starved whilst waiting for SaLT
  assessment
• ward staff skills not maintained without
  continuous support
• SaLT departments still swamped by swallowing
  referrals

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Way Forward Gateshead Dysphagia Management Model
(GDMM)

• 2 levels within the model
• Level 1 (screen and refer)
• Level 2 (management of routine and non-
  persistent cases)
• Supported by a Dysphagia Nurse Specialist

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DefinitionsLevel of Screening / Assessment

• Screening (DTN1) Use of a simple bedside
  assessment (usually a water swallow) to identify
  swallowing problems in patients with acute
  stroke. (10 minutes)
• Limited Assessment (DTN2) As above but liquids
  may be modified with the use of thickeners. (15
  minutes)
• Detailed Assessment Complete dysphagia
  assessment as performed by a speech and language
  therapist or a dysphagia nurse specialist. (40
  minutes)

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CODA Study

• of patients Before After
• (N 204) (N 241)
• With unsafe swallowing 24 29
• Safe swallowing but restricted feeding 14
  10
• Unsafe swallowing but no precautions taken
  29 11
• Referred to SaLT for swallow assessment 34
  36
• Referred but with safe swallowing 51
  29
• Unsafe swallowing but not referred to SaLT 29
  12
• p 0.02 p 0.01

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Gateshead Dysphagia Study

• of patients Before After
• (N 71) (N 79)
• With unsafe swallowing 27 29
• Safe swallowing but restricted feeding 4
  7
• Unsafe swallowing but no precautions taken 26
  16
• Referred to SaLT for swallow assessment 37
  14
• Referred but with safe swallowing 42
  27
• Unsafe swallowing but not referred to SaLT 21
  58
• p 0.02 p 0.01

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DTN Assessment Register (4 Month Pilot)

• 194 assessment slips returned
• 91 (47) classified as having a safe swallow
• 56 (29) classified as requiring modified
  consistency
• 47 (24) classified as unsafe (NBM)

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Improving Stroke Services a guide for
commissioners (2006)

• Small changes, big impact
• safer swallowing screening and management

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Small Change Big Impact
Table 1. DNS contacts during 39 week evaluation
period
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Small Change Big Impact (2)
Table 2. Impact upon SaLT Out Patient Waiting List
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Next Step

• Should professions other than SaLT be involved in
  dysphagia management?
• If yes what levels of involvement?
• How do we decide?

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Inter Professional Dysphagia Framework (IDF)
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Inter-professional Dysphagia Framework

• Background
• The project originated from a desire to produce
  a comprehensive inter-professional dysphagia
  competence framework and make available a common
  language to a mobile workforce. Although its
  focus is oro-pharyngeal difficulties, it
  considers the effects of reflux in the
  oesophageal stage and its influence on swallowing
  management. It also encompasses the whole of the
  feeding process.
• Aim
• The Inter-professional Dysphagia Framework (IDF)
  informs strategies for developing the skills,
  knowledge and ability of speech and language
  therapists, nurses and other healthcare
  professionals/non-registered staff, to contribute
  more effectively in the identification of people
  with, and in the management of,
  feeding/swallowing difficulties.
• Steering Group
• The Steering Group comprised key stakeholders
  The authors NHS Changing Workforce Development
  Program National Patients Safety Agency Royal
  College of Physicians Royal College of Nurses
  Royal College of Speech and Language Therapists
  British Dietetics Association Skills for Health
  and user and carer representation.

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Role Descriptors

• Awareness Aware of the presenting signs and
  symptoms of dysphagia
• Assistant Contributes to the implementation of
  dysphagia management plan
• Foundation Implements protocol-guided assessment
  and management
• Specialist Undertakes comprehensive assessment
  and management
• Consultant Undertakes expert assessment and
  management of complex or co-existing difficulties
  with a responsibility for policy development
  and/or consultative opinions

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Patient Pathway
Key AW Awareness AS Assistant F
Foundation S Specialist

• Patient ill/unconscious
• Ambulance call (Aw)
• Ambulance journey (Aw)
• Medical assessment unit (F)
• (Acute medical ward) (Aw) (F)
• Stroke Unit (Aw) (As) (F) ((S))
• Rehabilitation unit (Aw) (As) (F)
  ((S))
• Intermediate care (Aw) (As) (F)
  ((S))
• Day Hospital (Aw) (As)
  (F) ((S))
• Home /Nursing home (As) (F)

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• People should be having their swallow assessed
  in AE, not waiting 7,8,9,10,hours on a trolley
  without a drink

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• it was his second stroke wasnt it and he had
  difficulty swallowing, erm, he came in and they
  kept giving him drinks and giving him things to
  eat and I kept on saying ,but my dad cant
  swallow, hes aspirating and in the end he got
  aspiration and and he died as a result of --- .
• That was on the death certificate ---
• nobody listened, they carried on giving him
  diet and fluids even though he was coughing and
  he was blue, carried on doing that for four days

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• she has quite a healthy cocktail of medication
  that she takes daily that she wouldnt have any
  access to at all as some of its steroids, some
  of its Warfarin. I know shed be going well off
  the boil by 48 hours because shed be withdrawing
  from her Prozac and God knows what else at the
  same time.
• But I think that no-one else would probably
  consider that in a hospital environment, its
  only my mum, shes not a person, shes a patient.

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• its actually quite frightening feeding somebody
  thats coughing . and people avoid feeding
  people.
• They lose weight you know , just because people
  are avoiding them.

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National Stroke Strategy

• Executive Sumary
• They should receive an early multidisciplinary
  assessment, including swallow screening, and have
  prompt access to a high-quality stroke unit
• Markers of a Quality Service
• Patients diagnosed with stroke receive early
  multidisciplinary assessment to include swallow
  screening (within 24 hours) and identification of
  cognitive and perceptive problems.
• Once diagnosed with a stroke, patients need to be
  screened for swallowing before eating or drinking
  and at least within the first 24 hours.
• Measure of Success
• Greater proportion of patients screened for
  swallow disorders within 24 hours

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• Thank you for listening
• Any questions?