Improving nursing practice with staff education: the challenges of dysphagia

A Review of Factors Contributing to Adults' Adherence to Dysphagia Dietary Recommendations Through an Ecological Lens

PURPOSE

The purpose of this review was to identify the factors affecting adherence to dysphagia dietary recommendations, a necessary contributor to the effectiveness of this compensatory strategy.

METHOD

A rapid review of two electronic databases was conducted in April 2021. Studies were included based on the following criteria: (a) were empirical studies published in English, (b) included data from the adult population, and (c) measured adherence to dietary recommendations. The ecological model and the health belief model were used as frameworks during the analysis process.

RESULTS

The literature search resulted in 930 unique abstracts, of which 14 articles were included based on the final criteria. Across the literature, multiple factors were identified as having an influence on adherence, classified according to three unique levels: the individual (e.g., dissatisfaction), the caregiver (e.g., knowledge), and the environment (e.g., institutional policies and values).

CONCLUSIONS

Improving adherence to dysphagia dietary recommendations is crucial for the effectiveness of those recommendations. As suggested by the current review, increased adherence will require careful attention to the multiple levels of factors that likely play a role, acknowledging the multifaceted nature of this complex behavior. Furthermore, characterizing the multilevel factors that influence adherence can contribute to future theoretical models, which could help guide speech-language pathologists in their clinical practices.

The Effectiveness of International Dysphagia Diet Standardization Initiative-Tailored Interventions on Staff Knowledge and Texture-Modified Diet Compliance in Aged Care Facilities: A Pre-Post Study

Background

The International Dysphagia Diet Standardization Initiative (IDDSI) has created global standardized definitions for texture-modified diets (TMDs) and thickened liquids to improve the safety and care for individuals with swallowing difficulties. The IDDSI framework guides health care facilities, such as aged care, to provide food to at-risk patients.

Objectives

This study aims to design, deliver, and evaluate a tailored intervention to facilitate IDDSI implementation in aged care.

Methods

Five aged care facilities received tailored interventions, which were guided by the Expert Recommendation for Implementing Change process and used the corresponding barriers identified in the previous study: 1) tailored material, delivery, and planning; 2) opinion leaders and professional input; 3) strategies to attract and involve staff; and 4) reflections and evaluations. Meal compliance against IDDSI standards and staff knowledge acquisition were the primary outcomes evaluating the impact of the intervention. Written consent was obtained from facility managers. Staff trainings were delivered by a dietitian, accompanied with electronic and printed materials. An audit was conducted on all items listed on the TMD daily menu (lunch, dinner, and midmeals). TMD IDDSI audits and staff self-administered surveys were conducted before and 6 mo after the intervention.

Results

Audits of 68 and 79 TMD meals/items were conducted pre- and postintervention, respectively. Significant improvement in meal compliance was found in all 3 levels of TMDs, including soft and bite-sized (50%; P = 0.0001), minced and moist (44%; P = 0.0024), and puréed (42%; P = 0.0024). The overall IDDSI compliance increased by 46% postintervention (P < 0.0001). Staff achieved higher scores in both dysphagia and IDDSI knowledge sections (P < 0.0001).

Conclusions

Tailored interventions facilitated IDDSI implementation in aged care evidenced by increased TMD compliance and staff knowledge, which remained at 6 mo postintervention.

Factors associated with swallowing assessment after oral endotracheal intubation and mechanical ventilation for acute lung injury

RATIONALE

Endotracheal intubation is associated with postextubation swallowing dysfunction, but no guidelines exist for postextubation swallowing assessments.

OBJECTIVES

We evaluated the prevalence, patient demographic and clinical factors, and intensive care unit (ICU) and hospital organizational factors associated with swallowing assessment after oral endotracheal intubation and mechanical ventilation in patients with acute lung injury (ALI).

METHODS

We performed a secondary analysis of a prospective cohort study in which investigators evaluated 178 eligible patients with ALI who were mechanically ventilated via oral endotracheal tube. The patients were recruited from 13 ICUs at four teaching hospitals in Baltimore, Maryland. Patient demographic and clinical factors, types of ICU, and hospital study sites were evaluated for their association with completion of a swallowing assessment both in the ICU and after the ICU stay before hospital discharge. Factors significantly associated with a swallow assessment were evaluated in a multivariable logistic regression model.

MEASUREMENTS AND MAIN RESULTS

Before hospital discharge, 79 (44%) patients completed a swallowing assessment, among whom 59 (75%) had their assessments initiated in ICU and 20 (25%) had their assessments initiated on the hospital ward. Female sex (odds ratio [OR] = 2.01; 95% confidence interval [95% CI] = 1.03-3.97), orotracheal intubation duration (OR = 1.13 per day; 95% CI = 1.05-1.22), and hospital study site (Site 3: OR = 2.41; 95% CI = 1.00-5.78) were independently associated with swallowing assessment. Although Site 3 had a twofold increase in swallowing assessments in the ICU, there was no significant difference between hospitals in the frequency of swallowing assessments completed after ICU discharge (P = 0.287) or in the proportion of patients who failed a swallowing assessment conducted in the ICU (P = 0.468) or on the ward (P = 0.746).

CONCLUSIONS

In this multisite prospective study, female sex, intubation duration, and hospital site were associated with postextubation swallowing assessment. These results demonstrate variability in practice patterns between institutions and highlight the need to determine the appropriate timing and indications for swallowing assessment and to more fully understand swallowing dysfunction after intubation.

Time and time-frequency characterization of dual-axis swallowing accelerometry signals

Single-axis swallowing accelerometry has shown potential as a non-invasive clinical swallowing assessment tool. Previous swallowing accelerometry research has focused exclusively on the anterior-posterior vibration detected on the surface of the neck. However, hyolaryngeal motion during pharyngeal swallowing occurs in both the anterior-posterior and superior-inferior directions, suggesting that dual-axis accelerometry may be worthy of investigation. With this motivation, the present paper provides a characterization of dual-axis swallowing accelerometry signals from healthy adults in the time and time-frequency domains. Time-domain analysis revealed that signals in the two axes exhibited different probability density functions, and minimal cross-correlation and mutual information. Time-frequency analysis highlighted inter-axis dissimilarities in the scalograms, pseudo-spectra and temporal evolution of low- and high-frequency content. Therefore, it was concluded that the two axes contain different information about swallowing and that the superior-inferior axis should be further investigated in future swallowing accelerometry studies.

A radial basis classifier for the automatic detection of aspiration in children with dysphagia

Background

Silent aspiration or the inhalation of foodstuffs without overt physiological signs presents a serious health issue for children with dysphagia. To date, there are no reliable means of detecting aspiration in the home or community. An assistive technology that performs in these environments could inform caregivers of adverse events and potentially reduce the morbidity and anxiety of the feeding experience for the child and caregiver, respectively. This paper proposes a classifier for automatic classification of aspiration and swallow vibration signals non-invasively recorded on the neck of children with dysphagia.

Methods

Vibration signals associated with safe swallows and aspirations, both identified via videofluoroscopy, were collected from over 100 children with neurologically-based dysphagia using a single-axis accelerometer. Five potentially discriminatory mathematical features were extracted from the accelerometry signals. All possible combinations of the five features were investigated in the design of radial basis function classifiers. Performance of different classifiers was compared and the best feature sets were identified.

Results

Optimal feature combinations for two, three and four features resulted in statistically comparable adjusted accuracies with a radial basis classifier. In particular, the feature pairing of dispersion ratio and normality achieved an adjusted accuracy of 79.8 ± 7.3%, a sensitivity of 79.4 ± 11.7% and specificity of 80.3 ± 12.8% for aspiration detection. Addition of a third feature, namely energy, increased adjusted accuracy to 81.3 ± 8.5% but the change was not statistically significant. A closer look at normality and dispersion ratio features suggest leptokurticity and the frequency and magnitude of atypical values as distinguishing characteristics between swallows and aspirations. The achieved accuracies are 30% higher than those reported for bedside cervical auscultation.

Conclusion

The proposed aspiration classification algorithm provides promising accuracy for aspiration detection in children. The classifier is conducive to hardware implementation as a non-invasive, portable "aspirometer". Future research should focus on further enhancement of accuracy rates by considering other signal features, classifier methods, or an augmented variety of training samples. The present study is an important first step towards the eventual development of wearable intelligent intervention systems for the diagnosis and management of aspiration.