Systematic dysphagia screening and dietary modifications to reduce stroke-associated pneumonia rates in a stroke-unit.

BACKGROUND AND PURPOSE: While formal screening for dysphagia following acute stroke is strongly recommended, there is little evidence on how multi-consistency screening and dietary modifications affect the rate of stroke-associated pneumonia (SAP). This observational study reports which factors affect formal screening on a stroke-unit and how dietary recommendations relate to SAP. METHOD: Analyses from a database including 1394 patients admitted with acute stroke at our stroke-unit in Austria between 2012 and 2014. Dietary modifications were performed following the recommendations from the Gugging Swallowing Screen (GUSS). Patients evaluated with GUSS were compared to the unscreened patients. RESULTS: Overall, 993 (71.2%) patients were screened with GUSS; of these 50 (5.0%) developed SAP. In the 401 unscreened patients, the SAP rate was similar: 22 (5.5%). Multivariable analysis showed that either mild to very mild strokes or very severe strokes were less likely to undergo formal screening. Older age, pre-existing disability, history of hypertension, atrial fibrillation, stroke severity, cardiological and neurological complications, nasogastric tubes, and intubation were significant markers for SAP. Out of 216 patients, 30 (13.9%) developed SAP in spite of receiving nil per mouth (NPO). CONCLUSION: The routine use of GUSS is less often applied in either mild strokes or very severe strokes. While most patients with high risk of SAP were identified by GUSS and assigned to NPO, dietary modifications could not prevent SAP in 1 of 7 cases. Other causes of SAP such as silent aspiration, bacteraemia or central breathing disturbances should be considered.

Development of a modified swallowing screening tool to manage post-extubation dysphagia.

Post-extubation dysphagia is a condition that is becoming a growing concern. The condition occurs in 3-62% of extubated patients and can be related to mixed aetiologies, such as neuromuscular impairment, critical illness and laryngeal damage. The risk factors for developing dysphagia in critically ill patients are under-diagnosed and perhaps underestimated. Recent studies recommend the implementation of a standardized swallowing screen to prevent aspiration and decrease pneumonia rate and mortality. The aim of this quality improvement initiative was the development of a bedside swallowing screening tool to assess effective swallowing post-endotracheal extubation. Post-extubation dysphagia can result in a delay in re-feeding, with the potential for malnutrition as well as overt and covert aspiration if swallowing is not effectively screened. It is apparent that ICU nurses commence the initial screen for swallowing in the absence of an evidence base of care. A review of current local and international practice guidelines excludes the process of an effective swallowing screen of the extubated patient. Previously, a referral to speech and language therapists would be required to assess swallowing only after an initial review by the ICU medical team. This often leads to delays if the referral is made outside normal working practice, such as weekends or evenings. The initial development of a swallowing screening tool is the first step to promoting a nurse-led/-initiated bedside swallow screening tool that will enhance patient care and patient safety. There is growing body of evidence regarding the incidence of post-extubation dysphagia. Currently, there are very few recognized bedside swallowing screening tools to identify patients at risk. The most serious complication associated with post-extubation dysphagia is aspiration pneumonia, which is the leading cause of nosocomial infection in the critically ill patient.

Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen.

BACKGROUND AND PURPOSE: Acute-onset dysphagia after stroke is frequently associated with an increased risk of aspiration pneumonia. Because most screening tools are complex and biased toward fluid swallowing, we developed a simple, stepwise bedside screen that allows a graded rating with separate evaluations for nonfluid and fluid nutrition starting with nonfluid textures. The Gugging Swallowing Screen (GUSS) aims at reducing the risk of aspiration during the test to a minimum; it assesses the severity of aspiration risk and recommends a special diet accordingly. METHODS: Fifty acute-stroke patients were assessed prospectively. The validity of the GUSS was established by fiberoptic endoscopic evaluation of swallowing. For interrater reliability, 2 independent therapists evaluated 20 patients within a 2-hour period. For external validity, another group of 30 patients was tested by stroke nurses. For content validity, the liquid score of the fiberoptic endoscopic evaluation of swallowing was compared with the semisolid score. RESULTS: Interrater reliability yielded excellent agreement between both raters (kappa=0.835, P<0.001). In both groups, GUSS predicted aspiration risk well (area under the curve=0.77; 95% CI, 0.53 to 1.02 in the 20-patient sample; area under the curve=0.933; 95% CI, 0.833 to 1.033 in the 30-patient sample). The cutoff value of 14 points resulted in 100% sensitivity, 50% specificity, and a negative predictive value of 100% in the 20-patient sample and of 100%, 69%, and 100%, respectively, in the 30-patient sample. Content validity showed a significantly higher aspiration risk with liquids compared with semisolid textures (P=0.001), therefore confirming the subtest sequence of GUSS. CONCLUSIONS: The GUSS offers a quick and reliable method to identify stroke patients with dysphagia and aspiration risk. Such a graded assessment considers the pathophysiology of voluntary swallowing in a more differentiated fashion and provides less discomfort for those patients who can continue with their oral feeding routine for semisolid food while refraining from drinking fluids.

[Early recognition of speech and speech-associated disorders after acute stroke]. / Früherkennung von sprachlichen und sprachassoziierten Störungen nach akutem Schlaganfall.

In the course of increasing demands in acute stroke care in stroke units, criteria for efficient speech diagnosis, which can be applied in the first hours of acute stroke are necessary. In this study we investigated early recognition of speech and speech-associated disorders in acute stroke, and compared the neurologists' clinical diagnoses at admission with the results of a test battery (KAP--Kurze Aphasieprüfung). 90 of 104 consecutively recruited patients could be tested within the first three days. 53.8% (n = 49/N = 91) of the patients presented with language disorders in the clinical neurological examination at admission compared to 63.7% (n = 58/N = 91) that were found to have language disorders according to KAP. Syndrome classification in the group of aphasias showed a frequent occurrence of global aphasia, unclassified aphasia, anomic aphasia and agraphia. Speech apraxia and alexia were always accompanied by aphasia. A large amount of patients are affected by a variety of speech disorders. This study could show that a portion of these disorders could not be diagnosed in the acute situation without using a standardized test battery. Therefore clinical examination should be supplemented by standardized tests in routine diagnosis of speech disorders in acute stroke units in order to treat every patient adequately as soon as possible.