In search of consensus on aphasia management.

Morag Bixley and colleagues discuss their analysis of current UK aphasia practice

Aphasia management in an acute setting, what are we doing and why?

TITLE OF PAPER: APHASIA MANAGEMENT IN AN ACUTE SETTING, WHAT ARE WE DOING AND WHY? KEYWORDS: THERAPY, RATIONALES, EXPERTS • WHY THE STUDY WAS UNDERTAKEN The Specific Interest Group in Aphasia Therapy has been involved with two projects looking into what Speech and Language Therapists (SLTs) do for people with aphasia in the acute setting. In the first phase of their research Bixley et al (2011) collated the different activities reported by 86 SLTs from 55 different adult trusts. This research suggested that therapist activity could be divided into five categories. A follow up study (Bixley et al, 2013) asked SLTs to confirm these groups, estimate the amount of time spent on each activity and provide a rationale for why this therapy intervention was important. Twenty two therapists confirmed that their activities could be categorised into the five different types. Eight of these therapists were able to estimate the amount of time spent on each type of activity. These activities were: 1) Assessment - 32% 2) Multidisciplinary team working (MDT) - 26% 3) Therapy choices - 23% 4) SLT administration - 13% and 5) Support training and education (STE) - 6%. This paper expands on this research by presenting a grounded theme analysis of the rationales for intervention for people with aphasia in the acute setting. • HOW THE STUDY WAS DONE Therapists were asked to complete a short questionnaire that had been distributed opportunistically through the SIG network. Twenty two SLTs from 14 different NHS trusts participated in this research. Twenty one participants (95%) estimated that they spent an average of 43% of their time in work providing aphasia management. Typically they worked in departments of three therapists providing 17 sessions of acute aphasia care. Eleven therapists (50%) had less than five years SLT experience and typically were on pay scale 5 or 6. Four very experienced therapists (18%) who had worked for ten to twenty years were paid at band 8. • WHAT WAS FOUND AND IMPLICATIONS FOR FUTURE POLICY AND PRACTICE Rationales were provided for each of the five management options. Assessment: Words used to describe reasons for assessment activities (basis, develop, establish, estimate, focus, gain, guide, indicate, inform, make, plan, provide and suggest) indicate that assessment is an active, ongoing, reflective process. Assessment was linked to both therapist belief and recommended practice (Royal College of Physicians, 2012 and National Institute for Health and Clinical Excellence, 2013). MDT: Therapists reported that the role of MDT working was goal setting for the benefit of the client management. However some therapists were not employed as part of an MDT and found it difficult to influence this decision making process. Therapy: SLTs thought that impairment, functional and psychological therapies were equally important. They acknowledged that this was challenging in the acute sector where clients were discharged quickly and were not always well enough to engage fully with rehabilitation. 19/22 therapists (86%) suggested they would like more time to provide SLT input. This paper presents a consensus of current SLT expert opinion. Despite the small sample size this research could be used to guide targets for future SLT intervention in the acute sector and it could be used as a focus for discussion about intervention choices within the SLT profession. REFERENCES Bixley, M., Blagdon, B., Dean, M., Langley, J. & Stanton, D. (2013) Best practice for aphasia in the acute sector: a consensus of expert opinions. British Aphasiology Society Biennial International Conference Book of Abstracts, 8-9. Bixley, M., Blagdon, B., Dean, M., Langley, J. & Stanton, D. (2011) In search of consensus on aphasia management. Royal College of Speech and Language Therapists Bulletin, October, 18-20. Intercollegiate Stroke Working Party. (2012) National clinical guideline for stroke, 4th edition. London: Royal College of Physicians. National Institute For Health And Clinical Excellence. (2013) Stroke rehabilitation: 2nd guideline consultation

Ward based feeding and swallowing training.

Conference posterTITLE OF PAPER: WARD BASED FEEDING AND SWALLOWING TRAINING KEYWORDS: DYSPHAGIA, EVIDENCE BASE WHY THE STUDY WAS UNDERTAKEN This paper summarises the findings of the Northamptonshire Healthcare (NH) Feeding and Swallowing Training programme initiative. The results of the pilot study for this programme were presented at the Royal College of Speech and Language Therapists Conference in 2012. Speech and Language Therapists (SLTs) in the acute setting spend half of their time involved in providing feeding and swallowing care (Bixley, Blagdon, Dean, Langley & Stanton, 2011). As part of the multidisciplinary team, the overall aim of feeding and swallowing intervention is to help clients to meet their nutritional need. A recent Care Quality Commission (2011) report suggested that 51% of hospital trusts were not achieving this standard. Hospital based policies such as protected mealtimes highlight the importance of feeding within the acute sector. Inter professional guidelines (Boaden, 2006) and the evidence base for dysphagia management (Magnus, 2001) also support the use of specific feeding and swallowing training. However delivering comprehensive training within large hospitals is difficult using classroom based packages. Especially in environments where ward teams are large, staff teams change regularly and releasing staff for off ward training is difficult. The Northamptonshire feeding and swallowing programme was introduced to provide a sustainable swallowing training package that could overcome some of these difficulties, by providing training to nursing staff on the ward HOW THE STUDY WAS DONE The NHSLT team evaluated the impact of their innovative feeding and swallowing project by comparing the results of three ward based measures: B1, B2 and B3. The research was carried out on four acute wards, one after another. It was conducted during the hospital wide, one hour protected lunchtime slot. In each of the wards observational and questionnaire measurements (B1) were taken before implementation of a two week, eight day, training package. After the ward based training had occurred two further evaluations were conducted, one immediately after the training package had been delivered (B2) and one two weeks after the programme had been completed (B3). Observational measures were qualitative and recorded general impressions of the feeding practise on the ward. Questionnaire measurements were both quantitative and qualitative and were designed to identify what ward staff understood about feeding and swallowing difficulties. WHAT WAS FOUND Over the course of the ten month research project, twenty four hours of training was provided for fifty four people, on four different wards. Training was provided to 31 health care assistants, 17 nurses, 3 student nurses and 2 assistants and 2 others .Statistical analysis of the ward based knowledge questionnaires suggested that there was a significant difference between the scores obtained in B1 and B2 and B3 (Kruskal Wallis H (2) = 15.537, p=0.014 with a mean rank of 18.64 for B1, 34.83 for B2 and 37.78 for B3). These findings suggest that the feeding training programme had resulted in a measurable difference in ward staff knowledge and this difference was evident after the training programme had been completed. IMPLICATIONS FOR FUTURE POLICY AND PRACTICE The results of this study suggest that ward based feeding programmes are an effective way to deliver training. This type of training targets people who do not normally attend swallowing training courses because they cannot be released from their work. It also means that training can be individualised to the needs of different wards and staff members. This type of training delivery may be a valuable supplement or alternative to classroom based teaching programmes. • REFERENCES Blagdon, B., Bixley, M., Levis, N., Bird, L., Hood, G. & Murphy, K. (2012). Taking dysphagia management out of the classroom: A ward based feeding and swallowing project. Royal College of Speech and Language Therapists Conference, Driving transformation Using Evidence Based Practice, 52. Bixley, M., Blagdon, B., Dean, M., Langley, J. & Stanton, D. (2011). In search of consensus on aphasia management. Royal College of Speech and Language Therapists Bulletin, October, 18-20. Boaden, E. & Davies, S., Storey, L., & Watkins, C. (2006). Interprofessional Dysphagia Framework. www.uclan.aca.uk/facs/health/nursing/research/groups/stroke Care Quality Commission (2011). Dignity and Nutrition Inspection Programme. Newcastle upon Tyne: Care Quality Commission. Magnus, V. (2001). Dysphagia training for nurses in an acute hospital setting – a pragmatic approach. International Journal of Language and Communication Disorders, 36, 375-378

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.

Best practice for aphasia in the acute sector: a consensus of expert opinions

Background Information Historically Speech and Language Therapy (SLT) intervention has been guided by a, sometimes bewildering, plethora of standards and guidelines. Publications such as those written by the Royal College of Physicians (2012), the National Institute for Health and Clinical Excellence (2013) and Bowen et al (2012), guide our input within the acute setting. In 2011, the SIG Aphasia Therapy published the results of a survey into the practices of 86 SLTs who worked in 55 different adult SLT trusts (Bixley et al, 2011). The results of the 2011 study suggested that 172 different and appropriate management options could be sorted into five categories. This current study was designed to investigate whether the hypothesised categories in the original research described current working practices. Method Twenty two therapists, from 14 different NHS trusts, responded to a questionnaire that was distributed opportunistically through the SIG network. Thirteen (59%) had less than five years SLT experience and typically were on pay scale 5, 6 or 7. Four very experienced therapists (18%) who had worked for ten to twenty years were paid at band 8. Ten (45%) were employed full time. Fourteen (64%) worked in posts split between acute stroke units and the community. On average, the twenty two SLTs worked in departments of three therapists providing 17 sessions of acute aphasia care per week. Twenty one SLTs (95%) estimated that they spent on average 43% of their time in work providing aphasia management. Results All twenty two therapists confirmed the five categories and twenty five intervention aims derived from the original research and eight therapists were able to estimate the time spent on each type of activity. Definitions were: 1) Assessment (32%) informal, formal, case history, outcome, screening, mental capacity 2) Multidisciplinary team working (MDT) (26%) writing guidelines and documentation, joint sessions, attending discharge and MDT meetings, goal setting 3) Therapy choices (23%) language therapy, establishing functional communication, low tech AAC, providing accessible environment, group work, computer therapy, outings 4) SLT administration (13%) plan discharge liaise and refer onwards, prioritise and make resources, write notes and keep statistics 5) Support training and education (STE) (6%) client, family, assistant practitioners, MDT. Discussion This description of SLT management choices adds a classification system and a level of detail that is not available elsewhere in the literature. Detail and differentiation about SLT intervention is important in much the same way different doses of a drug affect pharmacological outcomes. Our findings confirm that assessment, STE and conversation therapy should be located firmly within the basic remit of SLT. Significantly 52/86 therapists (60%) in our initial investigation and 19/22 (86%) therapists in our follow up research suggested that they did not have enough time to provide therapy for people with aphasia in the acute setting. References BIXLEY, M., BLAGDON, B., DEAN, M., LANGLEY, J. & STANTON, D. (2011) In search of consensus on aphasia management. Royal College of Speech and Language Therapists Bulletin, 2011, October, 18-20. BOWEN, A., HESKETH, A., PATCHICK, E., YOUNG, A., DAVIES, L., VAIL, A., LONG, A.F., WATKINS, C., PEARL, G., LAMBON RALPH, M. A. & TYRELL, P. Effectiveness of enhanced communication therapy in the first four months after a stroke for aphasia and dysarthria: a randomised controlled trial. British Medical Journal, 2012, 345, 1-15. INTERCOLLEGIATE STROKE WORKING PARTY. (2012) National clinical guideline for stroke, 4th edition. London: Royal College of Physicians. NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. (2013) Stroke rehabilitation: 2nd guideline consultation

Taking dysphagia management out of the classroom: A ward-based feeding and swallowing training project.

INTRODUCTION The recent Care Quality Commission (2011) report into dignity and nutrition 2011 suggested that only 51% of hospital trusts were fully compliant with Outcome 5: Meeting nutritional needs. The Northamptonshire Healthcare Foundation NHS Trust (NHFT) Adult Speech and Language Therapy Department provides several levels of high quality dysphagia and feeding training to Northampton General Hospital (NGH) staff. They provide dysphagia training (Magnus, 2001) that is designed to increase the swallowing identification, management skills and knowledge base within hospitals. This approach is supported by interprofessional guidelines such as the framework proposed by Boaden, Davies, Storey & Watkins in 2006. It is suggested that this traditional approach to training reduces the likelihood of clients presenting with dehydration, malnutrition, choking and aspiration pneumonia. The Northampton ward based swallowing and feeding training initiative was introduced to provide a sustainable training package that would overcome the two problems that become apparent when training packages are provided within acute trusts. The Northampton package overcame the need for employees to be released from their primary and immediate role of providing patient care and it also accommodated the need to provide training comprehensively enough to reach the majority of NHS employees involved in direct patient care. RESEARCH METHOD This research was conducted in four phases on an acute/rehabilitation stroke unit in Northampton General Hospital: Baseline 1(B1), Teaching 1(T1), Baseline 2(B2) and Baseline 3(B3). NGH and De Montfort University gave ethical approval for the study. In the first baseline phase (B1) four members of nursing staff were asked to answer a feeding and swallowing knowledge questionnaire. In the second phase of this project ward based teaching was provided on eight consecutive working days. Training lasted up to one hour and was delivered by two therapists from the hospital SLT team. The feeding and swallowing awareness training was client centered and was offered to all ward staff. On the tenth day (B2) four members of staff were asked to answer the same questionnaire that had been answered in B1. Two weeks after the completion of the teaching phase, a further four members of staff were asked to complete the questionnaire for the B3 measure. The research design allowed the feeding and swallowing knowledge questionnaires to be completed by different participants. This overcame the problem of unpredictable ward staffing and was intended to capture the widespread increase in knowledge that should result from this type of generic intensive ward based training. SUMMARY OF RESULTS & CONCLUSIONS All twelve questionnaires were analysed independently without reference to the phase in which they had been produced. After the questionnaires had been scored they were sorted back into the phase in which they had been produced and the results from each phase were compared. Initial quantitative and qualitative analysis suggested that the training had significantly improved the feeding and swallowing knowledge of ward staff in this busy general hospital. It also suggested that this improvement was maintained two weeks after the training programme had been completed. As the training package proved successful the scheme is being extended to more hospital wards to see if the success of the pilot study can be replicated hospital wide. REFERENCES Bixley, M., Blagdon, B., Dean, M., Langley, J. & Stanton, D. (2011) In search of consensus on aphasia management. Royal College of Speech and Language Therapists Bulletin, October, 18-20. Boaden, E. & Davies, S., Storey, L., & Watkins, C. (2006) Interprofessional Dysphagia Framework. www.uclan.aca.uk/facs/health/nursing/research/groups/stroke Care Quality Commission (2011) Dignity and Nutrition Inspection Programme. Newcastle upon Tyne: Care Quality Commission. Magnus, V. (2001) Dysphagia training for nurses in an acute hospital setting – a pragmatic approach. International Journal of Language and Communication Disorders, 36, 375-378