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

Exploring scale-up, spread, and sustainability: an instrumental case study tracing an innovation to enhance dysphagia care

Background Adoption, adaptation, scale-up, spread, and sustainability are ill-defined, undertheorised, and little-researched implementation science concepts. An instrumental case study will track the adoption and adaptation, or not, of a locally developed innovation about dysphagia as a patient safety issue. The case study will examine a conceptual framework with a continuum of spread comprising hierarchical control or ‘making it happen’, participatory adaptation or ‘help it happen’, and facilitated evolution or ‘let it happen’. Methods This case study is a prospective, longitudinal design using mixed methods. The fifteen-month (October 2012 to December 2013) instrumental case study is set in large, healthcare organisation in England. The innovation refers to introducing a nationally recognised, inter-disciplinary dysphagia competency framework to guide workforce development about fundamental aspects of care. Adoption and adaptation will be examined at an organisational level and along two, contrasting care pathways: stroke and fractured neck of femur. A number of educational interventions will be deployed, including training a cadre of trainers to cascade the essentials of dysphagia management and developing a Dysphagia Toolkit as a learning resource. Mixed methods will be used to investigate scale-up, spread, and sustainability in acute and community settings. A purposive sample of senior managers and clinical leaders will be interviewed to identify path dependency or the context specific particularities of implementation. A pre- and post-evaluation, using mealtime observations and a survey, will investigate the learning effect on staff adherence to patient specific dysphagia recommendations and attitudes towards dysphagia, respectively. Official documents and an ethnographic field journal allow critical junctures, temporal aspects and confounding factors to be explored. Discussion Researching spread and sustainability presents methodological and practical challenges. These include fidelity, adaptation latitude, time, and organisational changes. An instrumental case study will allow these confounding factors to be tracked over time and in place. The case study is underpinned by, and will test a conceptual framework about spread, to explore theoretical generalizability

Development of an Australian FASD Indigenous Framework: Aboriginal Healing-Informed and Strengths-Based Ways of Knowing, Being and Doing

Aboriginal culture intuitively embodies and interconnects the threads of life that are known to be intrinsic to human wellbeing connection Therefore Aboriginal wisdom and practices are inherently strengths based and healing informed Underpinned by an Indigenist research methodology this article presents findings from a collaboration of Aboriginal and non Aboriginal peoples to develop an Australian Fetal Alcohol Spectrum Disorder FASD Indigenous Framework during 2021 to 2023 The FASD Indigenous Framework unfolds the changes that non Aboriginal clinicians and Aboriginal peoples each need to make in their respective ways of knowing being and doing in order to facilitate access to healing informed strengths based and culturally responsive FASD knowledge assessment diagnosis and support services among Aboriginal peoples Drawing on the Aboriginal practices of yarning and Dadirri written and oral knowledges were gathered These knowledges were mapped against Aboriginal cultural responsiveness and wellbeing frameworks and collaboratively and iteratively reflected upon throughout This article brings together Aboriginal wisdom strengths based healing informed approaches grounded in holistic and integrated support and Western wisdom biomedicine and therapeutic models in relation to FASD From a place of still awareness Dadirri both forms of wisdom were drawn upon to create Australia s first FASD Indigenous Framework a new practice in the assessment and diagnosis of FASD which offers immense benefit to equity justice support and healing for Aboriginal families with a lived experience of FAS

Optimising care for patients with cognitive impairment and dementia following hip fracture

The global shift in demographics towards aging populations is leading to a commensurate increase in age-related disease and frailty. It is essential to optimise health services to meet current needs and prepare for anticipated future demands. This paper explores issues impacting on people living with cognitive impairment and/or dementia who experience a hip fracture and are cared for in acute settings. This is important given the high mortality and morbidity associated with this population. Given the current insufficiency of clear evidence on optimum rehabilitation of this patient group, this paper explored three key themes namely: recognition of cognitive impairment, response by way of training and education of staff to optimise care for this patient group and review of the importance of outcomes measures. Whilst there is currently insufficient evidence to draw conclusions about the optimal ways of caring for patients living with dementia following hip fracture, this paper concludes that future research should improve understanding of healthcare staff education to improve the outcomes for this important group of patients

Differential Responses of Calcifying and Non-Calcifying Epibionts of a Brown Macroalga to Present-Day and Future Upwelling pCO2

Seaweeds are key species of the Baltic Sea benthic ecosystems. They are the substratum of numerous fouling epibionts like bryozoans and tubeworms. Several of these epibionts bear calcified structures and could be impacted by the high pCO2 events of the late summer upwellings in the Baltic nearshores. Those events are expected to increase in strength and duration with global change and ocean acidification. If calcifying epibionts are impacted by transient acidification as driven by upwelling events, their increasing prevalence could cause a shift of the fouling communities toward fleshy species. The aim of the present study was to test the sensitivity of selected seaweed macrofoulers to transient elevation of pCO2 in their natural microenvironment, i.e. the boundary layer covering the thallus surface of brown seaweeds. Fragments of the macroalga Fucus serratus bearing an epibiotic community composed of the calcifiers Spirorbis spirorbis (Annelida) and Electra pilosa (Bryozoa) and the non-calcifier Alcyonidium hirsutum (Bryozoa) were maintained for 30 days under three pCO2 conditions: natural 460±59 µatm, present-day upwelling1193±166 µatm and future upwelling 3150±446 µatm. Only the highest pCO2 caused a significant reduction of growth rates and settlement of S. spirorbis individuals. Additionally, S. spirorbis settled juveniles exhibited enhanced calcification of 40% during daylight hours compared to dark hours, possibly reflecting a day-night alternation of an acidification-modulating effect by algal photosynthesis as opposed to an acidification-enhancing effect of algal respiration. E. pilosa colonies showed significantly increased growth rates at intermediate pCO2 (1193 µatm) but no response to higher pCO2. No effect of acidification on A. hirsutum colonies growth rates was observed. The results suggest a remarkable resistance of the algal macro-epibionts to levels of acidification occurring at present day upwellings in the Baltic. Only extreme future upwelling conditions impacted the tubeworm S. spirorbis, but not the bryozoans

Current videofluoroscopy practice in the United Kingdom: A survey of imaging professionals

Introduction Videofluoroscopy (VFSS) is a frequently used radiological investigation for dysphagia and is conducted within a radiology setting by speech and language therapists (SLTs) working alongside imaging personnel (radiologists and/or radiographers). Previous surveys of SLT practice have reported variability in VFSS protocols and procedures. The aim of this study was to explore current clinical practice for VFSS from the perspective of imaging personnel engaged in VFSS within the United Kingdom. Methods A comprehensive online survey enabled exploration of current practices of imaging professionals. Target participants were diagnostic imaging personnel (radiographers and radiologists) with experience of working in VFSS clinics. Descriptive statistics describe and summarise the data alongside inferential statistics where appropriate. Results 54 survey participants represented 40 unique acute healthcare organisations in the UK, in addition to two respondents from the Republic of Ireland. The survey demonstrated high variance in clinical practice across all stages of the VFSS procedure. Clinicians were not always compliant with current UK guidelines and the roles and responsibilities of different professionals working within the clinics were often not clearly defined. Conclusion Further research is required to develop new international, interprofessional VFSS guidelines to standardise service delivery for VFSS, improving diagnostic accuracy, efficiency and patient experience. Implications for practice In the absence of VFSS guidelines for imaging personnel, practitioners should familiarise themselves with the UK Royal College of Speech and Language Therapists VFSS Position paper; IR (ME)R guidelines and DRLs for the client groups with which they work to guide clinics and improve practice. Clinicians should revisit protocols and clinical governance regarding safe practice in order to improve the quality of care within the VFSS clinic

Accuracy and clinical utility of comprehensive dysphagia screening assessments in acute stroke: A systematic review and meta‐analysis

IntroductionNurses and other nonspecialists in dysphagia are often trained to screen swallowing poststroke. There are many basic tools that test water only, they are usually conservative, and patients that fail the test remain nil by mouth until a speech and language therapy assessment. More comprehensive tests also allow nonspecialists to recommend modified oral intake. Little is known about the accuracy, clinical utility and cost‐effectiveness of these tests.MethodsFollowing PRISMA guidelines, a systematic review was conducted to describe comprehensive swallowing tests that are available for use in acute stroke by nurses or other nonspecialists in dysphagia. A meta‐analysis was performed to evaluate accuracy and the clinical utility of the tests was considered. Searches and analyses, conducted by two reviewers, included MEDLINE, Embase, trial registries and grey literature up to December 2018. Validated studies were assessed for quality and risk of bias using QUADAS‐2.ResultsTwenty studies were included, describing five different tests, three of which had undergone validation. The tests varied in content, recommendations and use. There was no test superior in accuracy and clinical utility. Three studies validating the Gugging Swallow Screen provided sufficient data for meta‐analysis, demonstrating high sensitivity; 96% (95% CI 0.90–0.99), but low specificity, 65% (95% CI 0.47–0.79), in line with many water swallow tests. Results should be interpreted with caution as study quality and applicability to the acute stroke population was poor.ConclusionsThere is no comprehensive nurse dysphagia assessment tool that has robustly demonstrated good accuracy, clinical utility and cost‐effectiveness in acute stroke.Relevance to Clinical PracticeNurses and other clinicians can develop competencies in screening swallowing and assessing for safe oral intake in those with poststroke dysphagia. It is important to use a validated assessment tool that demonstrates good accuracy, clinical utility and cost‐effectiveness

Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data

OBJECTIVES: To investigate whether further centralisation of acute stroke services in Greater Manchester in 2015 was associated with changes in outcomes and whether the effects of centralisation of acute stroke services in London in 2010 were sustained. DESIGN: Retrospective analyses of patient level data from the Hospital Episode Statistics (HES) database linked to mortality data from the Office for National Statistics, and the Sentinel Stroke National Audit Programme (SSNAP). SETTING: Acute stroke services in Greater Manchester and London, England. PARTICIPANTS: 509 182 stroke patients in HES living in urban areas admitted between January 2008 and March 2016; 218 120 stroke patients in SSNAP between April 2013 and March 2016. INTERVENTIONS: Hub and spoke models for acute stroke care. MAIN OUTCOME MEASURES: Mortality at 90 days after hospital admission; length of acute hospital stay; treatment in a hyperacute stroke unit; 19 evidence based clinical interventions. RESULTS: In Greater Manchester, borderline evidence suggested that risk adjusted mortality at 90 days declined overall; a significant decline in mortality was seen among patients treated at a hyperacute stroke unit (difference-in-differences -1.8% (95% confidence interval -3.4 to -0.2)), indicating 69 fewer deaths per year. A significant decline was seen in risk adjusted length of acute hospital stay overall (-1.5 (-2.5 to -0.4) days; P0.05), length of hospital stay declined (P<0.01), and more than 90% of patients were treated in a hyperacute stroke unit. Achievement of evidence based clinical interventions generally remained constant or improved in both areas. CONCLUSIONS: Centralised models of acute stroke care, in which all stroke patients receive hyperacute care, can reduce mortality and length of acute hospital stay and improve provision of evidence based clinical interventions. Effects can be sustained over time

Digital methods to enhance the usefulness of patient experience data in services for long-term conditions: the DEPEND mixed-methods study

Background Collecting NHS patient experience data is critical to ensure the delivery of high-quality services. Data are obtained from multiple sources, including service-specific surveys and widely used generic surveys. There are concerns about the timeliness of feedback, that some groups of patients and carers do not give feedback and that free-text feedback may be useful but is difficult to analyse. Objective To understand how to improve the collection and usefulness of patient experience data in services for people with long-term conditions using digital data capture and improved analysis of comments. Design The DEPEND study is a mixed-methods study with four parts: qualitative research to explore the perspectives of patients, carers and staff; use of computer science text-analytics methods to analyse comments; co-design of new tools to improve data collection and usefulness; and implementation and process evaluation to assess use of the tools and any impacts. Setting Services for people with severe mental illness and musculoskeletal conditions at four sites as exemplars to reflect both mental health and physical long-terms conditions: an acute trust (site A), a mental health trust (site B) and two general practices (sites C1 and C2). Participants A total of 100 staff members with diverse roles in patient experience management, clinical practice and information technology; 59 patients and 21 carers participated in the qualitative research components. Interventions The tools comprised a digital survey completed using a tablet device (kiosk) or a pen and paper/online version; guidance and information for patients, carers and staff; text-mining programs; reporting templates; and a process for eliciting and recording verbal feedback in community mental health services. Results We found a lack of understanding and experience of the process of giving feedback. People wanted more meaningful and informal feedback to suit local contexts. Text mining enabled systematic analysis, although challenges remained, and qualitative analysis provided additional insights. All sites managed to collect feedback digitally; however, there was a perceived need for additional resources, and engagement varied. Observation indicated that patients were apprehensive about using kiosks but often would participate with support. The process for collecting and recording verbal feedback in mental health services made sense to participants, but was not successfully adopted, with staff workload and technical problems often highlighted as barriers. Staff thought that new methods were insightful, but observation did not reveal changes in services during the testing period. Conclusions The use of digital methods can produce some improvements in the collection and usefulness of feedback. Context and flexibility are important, and digital methods need to be complemented with alternative methods. Text mining can provide useful analysis for reporting on large data sets within large organisations, but qualitative analysis may be more useful for small data sets and in small organisations. Limitations New practices need time and support to be adopted and this study had limited resources and a limited testing time. Future work Further research is needed to improve text-analysis methods for routine use in services and to evaluate the impact of methods (digital and non-digital) on service improvement in varied contexts and among diverse patients and carers. Funding This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 28. See the NIHR Journals Library website for further project information