The Dysphagia in Stroke Protocol Reduces Aspiration Pneumonia in Patients with Dysphagia Following Acute Stroke: a Clinical Audit

Abstract

Cough reflex testing has been evaluated as a component of the clinical swallowing assessment as a means of identifying patients at risk of aspiration during swallowing. A previous study by our research group found good sensitivity and specificity of the cough reflex test for identifying patients at risk of aspiration post-stroke, yet its use did not decrease pneumonia rates, contrary to previous reports. The aim of this study was to expand on our earlier work by implementing a clinical management protocol incorporating cough reflex testing within the same healthcare setting and compare patient outcomes to those from the original study and to evaluate clinical outcomes in patients with acute stroke who were managed using the Dysphagia in Stroke Protocol (DiSP). Secondarily, to compare those outcomes to historical data prior to implementation of the DiSP. This clinical audit measured outcomes from 284 patients with acute stroke managed per the DiSP, which guides use of videofluoroscopic swallowing study and patient management based on clinical exam with cough reflex testing. Data from our previous trial were included for comparison of pre- and post-DiSP patient outcomes. Data collection took place between November 2012 and April 2016 at four urban hospitals within New Zealand. Following implementation of the DiSP, the rate of aspiration pneumonia (10%) was substantially lower than the pre-DiSP rate (28%), with no pneumonia readmissions within 3 months. Pneumonia-related mortality was unchanged. By 3 months, 81% of the patients were on a normal diet and 67% had returned home, compared to pre-DiSP outcomes of 55% and 55% respectively. Previous work has suggested that simply implementing cough reflex testing in dysphagia management may not be sufficient to improve patient outcomes. The present study adds to this picture by suggesting that the true variable of influence may be the way in which the results of the test are applied to patient care. There is a strong case to support the use of a structured protocol if cough reflex testing is to be implemented in clinical practice.

Impact of the systematic use of the Gugging Swallowing Screen in patients with acute ischaemic stroke

“…SAP occurred in 13.6% of patients [95% confidence interval (CI), 8. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18].9%] at a median time of 3 days after stroke (IQR, 2-4) and there was no difference in its occurrence between the pre-GUSS and GUSS periods (12.5% vs. 15.1%, P = 0.490). The characteristics of patients according to the occurrence of SAP are described in Table S1.…”

“…Among the final population of patients (n = 344), 204 were admitted during the pre-GUSS period and 140 during the GUSS period. Median age was 71 years (IQR, 59-79), 178 were male (51.7%) and median National Institutes of Health Stroke Scale score was 11 (IQR, [6][7][8][9][10][11][12][13][14][15][16][17][18]. Baseline characteristics of the study population according to the inclusion period are detailed in Table 1.…”

“…In a small prospective register-based study of consecutive patients with acute stroke admitted to an intensive care unit, the systematic administration of a dysphagia screen resulted in a non-significant borderline reduction of pneumonia and did not change inhospital mortality when compared with a period when patients did not receive a dysphagia screen [14]. Another prospective study of patients with acute stroke showed that, after incorporation of a dysphagia management protocol that included the cough reflex test, swallowing trials and instrumental assessment of swallowing with videofluoroscopy, the frequency of aspiration pneumonia reduced to 10% compared with 28% in the historical control group of patients whose management was not protocol-based; however, these results were not adjusted for stroke severity [15]. It may be difficult to discern the real clinical impact of the implementation of a dysphagia screening test, specifically in a setting where it integrates a complex and multidomain protocol of management of patients with stroke, which is already in place in ASUs with medium and high patient volumes.…”

Cough reflex testing in acute stroke: A survey of current UK service provision and speech and language therapist perceptions

“…Citric acid solution is classed as an unlicensed medicine, and issues with procurement and availability of alternative concentrations may have led to the widespread use of this concentration, despite more recent studies demonstrating potential for improved patient outcomes (lower aspiration pneumonia rates, readmissions, shorter hospital stays and return to a normal diet) at higher concentrations (Perry et al . 2019), although it should be acknowledged that the changes in patient outcomes in this study were felt to be due to the use of a standardized dysphagia management protocol that guided clinical interpretation of CRT results rather than as a result of inclusion of CRT per se.…”

“…Early management has potential to reduce morbidity, rates of pneumonia, length of hospitalization and medical costs (Perry et al . 2019).…”