Improving the identification and management of aspiration after stroke

Dysphagia, a common clinical corollary following stroke, may contribute to aspiration pneumonia, malnutrition, and dehydration which may significantly impair patient rehabilitation. Survey Aim: Establish current clinical practice regarding nurse dysphagia screening. Method: A cross-sectional regional postal survey was undertaken with 60 nurses and 45 Speech and Language Therapists. Results: Nurses were taught to use water swallow screening tools but, in reality, used a variety of testing materials. Conclusion: This demonstrated the need for a clinically useful bedside swallow screening tool. Pilot Study Aim: Develop and evaluate the diagnostic accuracy of a new BEdside Swallow Screening Tool (BESST), for use by nurses with acute stroke patients. Method: A literature search was undertaken to inform the BESST. Face validity was established using an iterative process of semi-structured interviews with eight specialist SLTs and eight nurses. The tool was piloted on 12 purposefully selected stroke patients by comparing the management options chosen by two nurses using the BESST with those of the Specialist SLT using their bedside assessment (gold standard). Results: The BESST demonstrated excellent sensitivity (100%) but specificity demonstrated by both nurses was poor (< 45% for both). Conclusion: A larger validation study of a modified BEEST would be appropriate. Main Study Aim: Establish the diagnostic accuracy and utility of the BESST. Method: Ratings by nurses using the BESST were compared with experienced SLT bedside assessment in 124 consecutively admitted stroke patients. Results: The BESST demonstrated good agreement between nurses (81%) and within nurses (87% nurse 1, 86% nurse 2), 93% sensitivity, 82% specificity; 71% positive iii predictive value, 95% negative predictive value; and overall efficiency was 84%. The BESST dictated the same management as the SLT in 75% of cases, and safely allowed 92% of patients modified oral intake when compared to the water swallow screening tool. Conclusion: The BESST has potential use in clinical practice, but further research is needed

Fidelity to a motivational interviewing intervention for those with post-stroke aphasia : A small-scale feasibility study

Objective: Depression after stroke is common, and talk-based psychological therapies can be a useful intervention. While a third of stroke survivors will experience communication difficulties impeding participation in talk-based therapies, little guidance exists to guide delivery for those with aphasia. We need to understand how to adapt talk-based therapies in the presence of aphasia. This study aimed to explore the feasibility of motivational interviewing (MI) in people with post-stroke aphasia. Methods: In a small-scale feasibility study, consecutive patients admitted to an acute stroke ward were screened for eligibility. People with moderate to severe aphasia were eligible. Those consenting received an intervention consisting of up to eight MI sessions delivered twice per week over four weeks. Sessions were modified using aids and adaptations for aphasia. Session quality was measured using the Motivational Interviewing Skills Code (MISC) to assess MI fidelity. Results: Three consenting patients identified early post-stroke took part; one male and two females ages ranging between 40s and 80s. Participants attended between five and eight MI sessions over four weeks. Aids and adaptations included visual cues, rating scales, and modified reflections incorporating verbal and non-verbal behaviors. Sessions were tailored to individual participant need. Threshold MISC ratings could be achieved for all participants however, ratings were reduced when aids and adaptations were not used. Discussion: This small-scale feasibility study suggests that it is feasible to adapt MI for people with moderate to severe post-stroke aphasia. These findings merit further exploration of adapted MI as an intervention for this patient group

Oral Care after Stroke: Where are we now?

Purpose There appears to be an association between poor oral hygiene and increased risk of aspiration pneumonia – a leading cause of mortality post-stroke. We aim to synthesise what is known about oral care after stroke, identify knowledge gaps and outline priorities for research that will provide evidence to inform best practice. Methods A narrative review from a multidisciplinary perspective, drawing on evidence from systematic reviews, literature, expert and lay opinion to scrutinise current practice in oral care after a stroke and seek consensus on research priorities. Findings Oral care tends to be of poor quality and delegated to the least qualified members of the caring team. Nursing staff often work in a pressured environment where other aspects of clinical care take priority. Guidelines that exist are based on weak evidence and lack detail about how best to provide oral care. Discussion Oral health after a stroke is important from a social as well as physical health perspective, yet tends to be neglected. Multidisciplinary research is needed to improve understanding of the complexities associated with delivering good oral care for stroke patients. Also to provide the evidence for practice that will improve wellbeing and may reduce risk of aspiration pneumonia and other serious sequelae. Conclusion Although there is evidence of an association, there is only weak evidence about whether improving oral care reduces risk of pneumonia or mortality after a stroke. Clinically relevant, feasible, cost –effective, evidence based oral care interventions to improve patient outcomes in stroke care are urgently needed

Clinical practice guidelines for Videofluoroscopic Swallowing Studies: A systematic review

Introduction: Clinical practice guidelines (CPGs) are expected to make evidence-based recommendations, thus guiding practice and reducing unwarranted variation. CPGs are particularly helpful in guiding complex procedures such as the Videofluoroscopic Swallowing Study (VFSS) for the assessment of dysphagia, but there is a suspected high level of variability among them. To explore the extent of this variation, this study aimed to systematically identify and appraise all VFSS CPGs available worldwide. Methods: A systematic search of 3 academic databases and other sources was conducted to identify relevant CPGs; independent reviews of each CPG were undertaken by a Speech and Language Therapist and a Radiographer. Both reviewers completed a pre-determined checklist of expected professional content for each CPG. CPGs were then assessed for quality using the Appraisal of Guidance for Research & Evaluation II (AGREE II) instrument. Findings from the professional content review and the methodological quality review were synthesised to inform an assessment of suitability of each CPG to inform clinical practice. Results: Seven VFSS CPGs were identified worldwide, none of which were co-designed by radiographers or aimed at a radiographer audience. Each differs in their professional content, recommendations, underpinning evidence base and professional focus. Average AGREE ll scores across the quality domains vary considerably, ranging from 93-22%. No CPGs scored highly on all six AGREE II domains. Conclusion: There is no standardisation between VFSS guidelines. Six CPGs are not recommended for clinical use; only one of the seven identified CPGs is recommended for use following significant modification. Implications for practice: The lack of a comprehensive, evidence-based guideline encourages unwarranted variation in clinical practice which potentially compromises clinical care. Further research is needed to define VFSS best practice

Dysphagia screening and risks of pneumonia and adverse outcomes after acute stroke: An international multicenter study

Background Dysphagia is associated with aspiration pneumonia after stroke. Data are limited on the influences of dysphagia screen and assessment in clinical practice. Aims To determine associations between a “brief” screen and “detailed” assessment of dysphagia on clinical outcomes in acute stroke patients. Methods A prospective cohort study analyzed retrospectively using data from a multicenter, cluster cross-over, randomized controlled trial (Head Positioning in Acute Stroke Trial [HeadPoST]) from 114 hospitals in nine countries. HeadPoST included 11,093 acute stroke patients randomized to lying-flat or sitting-up head positioning. Herein, we report predefined secondary analyses of the association of dysphagia screening and assessment and clinical outcomes of pneumonia and death or disability (modified Rankin scale 3–6) at 90 days. Results Overall, 8784 (79.2%) and 3917 (35.3%) patients were screened and assessed for dysphagia, respectively, but the frequency and timing for each varied widely across regions. Neither use of a screen nor an assessment for dysphagia was associated with the outcomes, but their results were compared to “screen-pass” patients, those who failed had higher risks of pneumonia (adjusted odds ratio [aOR] = 3.00, 95% confidence interval [CI] = 2.18–4.10) and death or disability (aOR = 1.66, 95% CI = 1.41–1.95). Similar results were evidence for the results of an assessment for dysphagia. Subsequent feeding restrictions were related to higher risk of pneumonia in patients failed dysphagia screen or assessment (aOR = 4.06, 95% CI = 1.72–9.54). Conclusions Failing a dysphagia screen is associated with increased risks of pneumonia and poor clinical outcome after acute stroke. Further studies concentrate on determining the effective subsequent feeding actions are needed to improve patient outcomes

Microbiological analysis of water and thickeners used for people with dysphagia

Thickened fluids are a recognised intervention strategy in use for people with dysphagia. However, their bacterial profile has not previously been examined. Aims: To identify bacteria and changes in bacterial profiles in a range of water sources and thickener preparations over a 5-day period. Methods: Nine experiments were performed using a range of preparations (sterile, drinking, non-drinking tap water) and a thickening agent (sterile sachet and a used tin). Findings: No bacteria were grown on serial subcultures of sterile water, both with and without thickener. Drinking, tap and thickened water left at room temperature for 24 hours may become contaminated with environmental organisms. Conclusions: The growth of bacteria in preparations of thickening agent appears to be dependent upon water quality, while the proliferation of bacteria is dependent upon the length of time the preparation is allowed to stand at room temperature. </jats:p