Identification and nursing management of dysphagia in individuals with acute neurological impairment (update)

A comparison of Knowledge, attitude and practice (KAP) of nurses on nursing Post-stroke dysphagia patients between iii-A and ii-A hospitals in China: a propensity score-matched analysis

Background

Whether knowledge, attitude and practice of nurses on nursing post-stroke dysphagia patients varies between different ranking hospitals is still unknown. This study aimed to compare the knowledge, attitude and practice level of nurses on nursing post-stroke dysphagia patients between iii-A and ii-A hospitals in China.

Design

A cross-sectional study design was used.

Methods

Data were collected from eighteen hospitals in Wuhan, Hubei in May–July 2020, and a total of 824 nurses were recruited by convenient sampling. After propensity score matching, 205 participants in iii-A hospitals were matched with 205 participants in ii-A hospitals.

Results

There were no statistically differences in the socio-demographic characteristics between two groups after propensity score matching. Before matching, the regression coefficients between hospital ranking and knowledge, attitude, practice were -0.415, -0.718 and -1.855, respectively. After matching, the coefficients changed to -0.394, -0.824 and -1.278. Nurses from iii-A hospitals had higher knowledge and attitude scores than nurses from ii-A hospitals, but no significant practice scores difference was observed between various rankings of hospitals.

Conclusions

The KAP of nurses on nursing post-stroke dysphagia patients were different in iii-A and ii-A hospitals. Administrators should strengthen management, provide more learning resources and trainings to meet nurses’ needs about methods to deal with and recognize dysphagia, so as to further improve the quality of post-stroke dysphagia management.

Training for Caregivers and Compliance with Dysphagia Recommendations in a Tertiary Multiple Sclerosis Rehabilitation Center

Background

Dysphagia is common in persons with multiple sclerosis (MS). Speech and language therapists give dysphagia recommendations to persons with MS and caregivers. Nonadherence to these recommendations can increase the risk of aspiration. We investigated current compliance with dysphagia recommendations among caregivers and kitchen staff and assessed improvement in compliance by increasing knowledge through tailored training.

Methods

An observational cohort study was conducted over 4 weeks during which the compliance of the caregivers and kitchen staff in a rehabilitation center was monitored. A questionnaire was used to assess reasons for noncompliance. A 2-hour training session was provided for all caregivers and kitchen staff to improve their knowledge and skills. The compliance rate was observed again 1 and 6 months after the training. Compliance was defined by whether recommendations were followed.

Results

Results showed a significant improvement after training for overall compliance by caregivers (from 58% to >81%, P < .001). This improvement was still observed 6 months later (80%). After training, significant differences were found in compliance with the following recommendations (P ≤ .001): consistency of soup, consistency of liquids, food preparation, alertness, speed, amount, posture, and supervision. Recommendation for utensils did not improve (P = .44). Compliance with diet modifications made by the kitchen staff improved significantly (from 74% to >86%, P = .002), and even more during follow-up (to >95%, P = .009).

Conclusions

Dysphagia training tailored to the needs of caregivers to improve knowledge significantly improves compliance with dysphagia recommendations and the quality of care.

Knowledge and Perception of Registered Nurses Regarding the Scope of Practice of Speech-Language Pathologists

Objective: To assess the knowledge and perception of registered nurses regarding the scope of practice of speech-language pathologists (SLP) in Saudi Arabia. Background: Interdisciplinary collaboration is vital between the SLP and nurses due to the complex care needed by patients with speech problems. Methods: A total of 294 registered nurses were surveyed utilizing the Knowledge and Perception of Speech-Language Pathologists questionnaire. Descriptive statistics and tests for differences and relationships were performed. Results: The findings revealed that nursing respondents had an overall good understanding of the value and scope of practice of the SLP. However, they frequently and wrongly responded to scenarios concerning patients who suffered from Alzheimer’s dementia, laryngeal cancer, traumatic brain injury, and stroke. Conclusions: It is vital for nurses to understand the value, role, and scope of practice of the SLP. Further educational nursing interventions and training are necessary for effective interprofessional collaboration and teamwork.

Knowledge and Practice of Health Professionals in the Management of Dysphagia

The aim of this study was to determine healthcare providers' knowledge and practices about dysphagia. A descriptive cross-sectional study was carried out based on a self-administered and anonymous questionnaire addressed to healthcare providers in Spain. A total of 396 healthcare providers participated in the study. Of these, 62.3% knew the definition of dysphagia as a swallowing disorder. In addition, up to 39.2% of the participants reported that they did not know whether the EatingAssessmentTool (EAT-10) dysphagia screening test was usedin their own clinical settings. Similarly, up to 49.1% of them did not know the ClinicalExaminationVolume-Viscosity (MECV-V) method. Nearly all participants (98.8%) reported that thickeners must be used forall liquids administered to patients. A higher percentage of respondents based the choice of texture on patient's tolerance (78.2%) rather than on the MECV-V result (17.3%). In addition,76.4% of the professionals had witnessed a bronchoaspiration; after it, 44.4% (n = 175) of them reported the appearance of pneumonia, and 14.5% (n = 57) the death of the patient (p = 0.005). The participants revealeda moderate/low knowledge ofthe definition, diagnosis, and clinical management of liquid dysphagia, which indicates some room for improvements.

Protocol of nursing care in hospitalized dysphagic patients

PURPOSE

To investigate nursing care for patients hospitalized with oropharyngeal dysphagia.

METHOD

This is a descriptive study of a qualitative approach, developed during the year 2017, in a Public hospital in Rio de Janeiro that offers a nursing residency program. The sample consisted of 17 nursing residents who work in the care of dysphagic patients. Data collection was realized by applying the problem-based learning methodology and data were analyzed according to the content analysis technique.

RESULTS

The data analysis allowed for the identification of the main aspects of nursing care in the patient hospitalized with oropharyngeal dysphagia and the elaboration of a nursing care protocol for the patient, based on a discussion of thematic categories.

CONCLUSION

This study allowed for the identification of the relevant nursing care for the patient hospitalized with oropharyngeal dysphagia, which could provide assistance for nurses, thereby improving the quality of care and safety of the service provided for hospitalized patients.

Post-stroke dysphagia: An exploration of initial identification and management performed by nurses and doctors

BACKGROUND

South African speech-language therapists are the only health professionals charged with dysphagia rehabilitation. However, registered nurses and doctors are often initial healthcare contact points for post-stroke dysphagia. Notwithstanding service concerns, they do indeed identify and manage post-stroke dysphagia. However, little is known about specifically what they do during these initial clinical encounters.

OBJECTIVE

To explore how doctors and registered nurses, on initial clinical contact, identify and manage post-stroke dysphagia.

METHOD

A quantitative descriptive survey design, with non-probability, purposive sampling, was used. Twenty-one registered nurses and four doctors at a private South African hospital self-administered a questionnaire. Univariate analyses were completed by calculating frequency distributions of nurses' and doctors' identification and management practices.

RESULTS

Most (86%) did not use a formal screening tool. Indicators screened informally included: presence of drooling (84%) or gag reflex (76%), level of alertness (80%) and spontaneous saliva swallow (80%). Participants neglected important indicators like voluntary cough and vocal quality. Management provided included head of bed elevation (96%), speech-language therapist referrals (92%), nasogastric tube insertions (88%), intravenous fluids (84%) and positional adjustments (76%). Alternative management included total parenteral nutrition (52%), syringe feeding (48%), swallow muscle strengthening exercises (56%) and swallow manoeuvres (52%).

CONCLUSION

Results indicated that doctors and registered nurses under-utilised important dysphagia indicators and used potentially harmful management practices like syringe feeding. Management practices further included out-of-scope methods like dysphagia rehabilitation exercises or manoeuvres. Recommendations include peer dysphagia screening training using formal tools and basic dysphagia management methods to better equip doctors and registered nurses when they clinically engage post-stroke patients.

Implementation of hospital wide dysphagia screening in a large acute tertiary teaching hospital

Purpose: There are no examples in the literature of successful long-term hospital-wide implementation of nurse-led dysphagia screening. This article aims to describe strategies used to implement hospital-wide dysphagia screening in a large acute tertiary teaching hospital in Australia. It reports on compliance, accuracy and nursing staff satisfaction using the validated Royal Brisbane and Women's Hospital Dysphagia Screening Tool (RBWH DST).Method: A retrospective observational study of audit data was conducted to examine hospital-wide compliance and accuracy of dysphagia screen completion. A nursing staff survey measured staff satisfaction. Implementation included: (1) utilisation of validated tool (RBWH DST); (2) key stakeholder engagement and strong governance; (3) policy development; (4) education; and (5) review and monitoring processes.Result: Audits conducted over a 9-year period (n = 3726) showed an average hospital-wide compliance rate of 74% and an accuracy rate of 82%. A nurse satisfaction survey (n = 109) showed high levels of satisfaction associated with using the RBWH DST.Conclusion: The RBWH DST was implemented in a large acute tertiary teaching hospital with acceptable compliance and accuracy rates and favourable nursing staff satisfaction. Further study is required to objectively evaluate patient health and cost benefits associated with using the RBWH DST.

Evaluation of the Chinese version of the swallowing screen in stroke patients with dysphagia

Objective:

The purpose of this study was to validate a Chinese version of the modified Standardized Swallowing Assessment (SSA) instrument used by nurses in stroke patients with dysphagia and explore the feasibility of the simplified instrument.

Materials and Methods:

This study involved a cross-sectional design. Nurses independently applied the modified SSA to 127 patients with stroke before a complete dysphagia evaluation conducted by a speech–language pathologist. Factor analysis of eight dysphagia variables in the modified SSA was performed to evaluate construct validity. The accuracy of the screening instrument was assessed through receiver operating characteristic (ROC) analysis.

Results:

The comprehensive swallowing assessment revealed that 49.6% of the stroke patients had dysphagia. The modified SSA had an acceptable internal consistency coefficient. The inter-rater agreement between nurses using the modified SSA showed a Kappa coefficient of 0.509. All items had a communality loading of >0.5, and two factors accounted for 73.89% of the response variance. The area under the ROC curve was 0.79 (95% confidence interval: 0.71–0.87). The sensitivity and specificity derived for dysphagia detection were satisfactory according to the results obtained from the original 8-item and simplified 6-item scales (sensitivities = 82.50% and 81.00% and specificities = 59.40% and 64.10%, respectively; accuracy = 70.87% and 72.44%, respectively).

Conclusion:

This preliminary study suggests that the modified SSA is a potentially reliable and valid nurse-administered screening instrument for dysphagia detection in patients with stroke.

Project SITUP: An Interdisciplinary Quality Improvement Initiative to Reduce Aspiration Pneumonia

The purpose of this quality improvement initiative was to improve oropharyngeal dysphagia screening and reduce aspiration pneumonia rates on 3 inpatient hospital medical units. Guided by a Plan-Do-Study-Act methodology, an interdisciplinary health team developed and implemented a systematic process for oropharyngeal dysphagia screening and management. As a result, use of the screening protocol increased, timely initiation of speech language pathology consultations increased, and aspiration pneumonia rates decreased.

Nursing interventions in adult patients with oropharyngeal dysphagia: a systematic review

BACKGROUND

Oropharyngeal dysphagia is a geriatric syndrome of high prevalence. It requires screening, diagnosis and specific care to avoid possible complications. The objective of this study is to perform a systematic review of the literature to know what interventions are performed by nursing professionals in the care of adult patients with OD.

METHODS

A systematic literature review was conducted, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration guideline. Included are observational and analytical scientific studies on the interventions nurses made in the assessment and screening of OD secondary to age and/or neurodegenerative diseases, as well as nursing interventions in patient's care and diagnosis in the electronic databases of Medline, SCOPUS and CINALH.

RESULTS

A total of 51 articles were included: 10 observational studies, 29 experimental studies and 12 systematic reviews. 66.7% studies talked about the interventions to patients with OD secondary to ICTUS. 82.05% was performed in a hospital setting. In 49.01% of the articles, nurses are mentioned as participants in the interventions.

CONCLUSION

Screening and clinical assessment of OD for an early diagnosis are the interventions performed by the most prevalent nursing professionals found in the literature, mainly in the OD, due to ICTUS and in the hospital setting. Further research on interventions by nursing professionals is needed in this area.

The impact of aspiration pneumonia and nasogastric feeding on clinical outcomes in stroke patients: A retrospective cohort study

AIMS AND OBJECTIVES

To determine presence of clinical complications related to dysphagia and to explore their operational outcomes.

BACKGROUND

Dysphagia is a common complication of stroke. The management of poststroke dysphagia is multidisciplinary with nurses playing a key role in screening for dysphagia risk, monitoring tolerance of food and fluids and checking for the development of complications such as fever, dehydration and change in medical status. Dysphagia often results in further complications including aspiration pneumonia and the need for nasogastric feeding. Dysphagia-related complications have been shown to have a significant impact on morbidity and mortality, length of stay and cost of admission.

DESIGN

Retrospective cohort study.

METHODS

A total of 110 patients presenting with an ischaemic stroke were chart-audited.

RESULTS

Aspiration pneumonia poststroke was found to be significantly associated with increased overall length of stay, poorer functional outcomes poststroke as well as being associated with a high risk of mortality. The presence of a nasogastric tube was also associated with reduced functional outcomes poststroke and increased risk of death.

CONCLUSION

High prevalence and cost of complications associated with stroke highlight the complexity of providing nursing and allied health care to this patient population. This provides a snapshot of dysphagia-related complications experienced by stroke patients.

RELEVANCE TO CLINICAL PRACTICE

This paper highlights that poststroke complications can significantly impact on patient outcomes and operational factors such as cost of admission; therefore, poststroke care requires a multidisciplinary approach to management. Furthermore, preventing and managing complications poststroke is a key element of nursing care and has the potential to significantly reduce incidence of mortality, length of stay and cost of hospital admission.

Validity and reliability of swallowing screening tools used by nurses for dysphagia: A systematic review

Dysphagia following neurological impairment increases the risk of dehydration, malnutrition, aspiration pneumonia, and even death. Screening for dysphagia has been reported to change negative outcomes. This review evaluated the validity and reliability of measurement tools for screening dysphagia in patients with neurological disorders to identify a feasible tool that can be used by nurses. Electronic databases were searched for studies from 1992 to 2015 related to dysphagia screening measurements. The search was applied to the Pubmed, CINAHL, Cochrane, Medline, EBSCO host, and CEPS + CETD databases. A checklist was used to evaluate the psychometric quality. The tools were evaluated for their feasibility for incorporation into routine care by nurses in hospitals. A total of 104 papers were retrieved, and eight articles finally met the inclusion criteria. The sensitivity and specificity of the screening tools ranged from 29% to 100% and from 65% to 100%, respectively. The interrater reliability ranged from good to excellent agreement. On the basis of quality evaluations, all the included studies had a risk of bias because of inadequate methodological characteristics. The Standardized Swallowing Assessment is the most suitable tool for detecting dysphagia because its psychometric properties and feasibility are higher than those of other screening tools that can be administered by nurses.

Screening Accuracy for Aspiration Using Bedside Water Swallow Tests: A Systematic Review and Meta-Analysis

BACKGROUND

Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration.

METHODS

Sixteen online databases, Google Scholar, and known content experts through May 2015 were searched. Only prospective studies with patients ≥ 18 years of age given WST screenings validated against nasoendoscopy or videofluoroscopy were included. Data extraction used dual masked extraction and quality assessment following Meta-analysis of Observational Studies in Epidemiology guidelines.

RESULTS

Airway response (eg, coughing/choking) with or without voice changes (eg, wet/gurgly voice quality) was used to identify aspiration during three different bedside WSTs. Pooled estimates for single sip volumes (1-5 mL) were 71% sensitive (95% CI, 63%-78%) and 90% specific (95% CI, 86%-93%). Consecutive sips of 90 to 100 mL trials were 91% sensitive (95% CI, 89%-93%) and 53% specific (95% CI, 51%-55%). Trials of progressively increasing volumes of water were 86% sensitive (95% CI, 76%-93%) and 65% specific (95% CI, 57%-73%). Airway response with voice change improved overall accuracy in identifying aspiration.

CONCLUSIONS

Currently used bedside WSTs offer sufficient, although not ideal, utility in screening for aspiration. Consecutive sips with large volumes in patients who did not present with overt airway responses or voice changes appropriately ruled out risk of aspiration. Small volumes with single sips appropriately ruled in aspiration when clinical signs were present. Combining these bedside approaches may offer improved screening accuracy, but further research is warranted.