Steve DaviesClinical Nurse Specialist in Nutrition Support

Gateshead Health Foundation NHS Truststeve.davies@ghnt.nhs.net

“Screening for Dysphagia After Stroke”

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.

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

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

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

Definitions:Level 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)

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

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

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)

Improving Stroke Services: a guide for commissioners (2006)

Small changes, big impact

–

safer swallowing screening and management

Small Change – Big Impact

New contacts 198 (35%)

Ongoing assessment/therapy 372 (65%)

Acute Care Settings 480 (84%)

Rehabilitation settings 77 (14%)

Community settings 13 (2%)

Table 1. DNS contacts during 39 week evaluation period

Small Change – Big Impact (2)

Year/Month Awaiting Initial Appt Longest Wait

1999 October PRE DNS

Dysphagia 20 pts 12 weeks

Language 15 pts 24 weeks

2002 October DNS IN POST

Dysphagia 8 pts 3 weeks

Language 10 pts 5 weeks

Table 3. Inpatient Caseload for DNS/SaLT Oct & Nov 2002

Month SaLT DNS New Referrals

October 13 (7 (35%) Language) 17

November 24 (15 (63%) Language) 15

Table 2. Impact upon SaLT Out Patient Waiting List

Next Step

• Should professions other than SaLT be involved in dysphagia management?

• If yes what levels of involvement?

• How do we decide?

Inter Professional Dysphagia Framework (IDF)

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.

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

• 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)

Patient PathwayKey: AW = Awareness AS = Assistant

F = Foundation S = Specialist

‘People should be having their swallow assessed in A&E, not waiting 7,8,9,10,hours on a trolley without a drink’

‘it was his second stroke wasn’t 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 can’t swallow, he’s 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’

‘she has quite a healthy cocktail of medication that she takes daily that she wouldn’t have any access to at all as some of it’s steroids, some of it’s Warfarin. I know she’d be going well off the boil by 48 hours because she’d 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, it’s only my mum, she’s not a person, she’s a patient.’

‘its actually quite frightening feeding somebody that’s coughing ……. and people avoid feeding people.

They lose weight you know , just because people are avoiding them.’

Executive Sumary:• They should receive an early multidisciplinary assessment, including

swallow screening, and have prompt access to a high-quality stroke unitMarkers 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

National Stroke Strategy

Thank you for listening

Any questions?