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IMPROVEMENT OF MORTALITY AND ASPIRATION PNEUMONIA RATE IN STROKE UNIT AFTER IMPLANTATION OF DYSPHAGIA ASSESMENT PROTOCOL

Authors:

Abstract

Introduction: The acute stroke (IA) is the most common cause of oropharyngeal dysphagia (OD) and aspiration pneumonia (AP). We want to compare the incidence of AP before and after the implementation of a protocol for the integrated management of OD in the stroke unit (SU) of the Hospital Universitario Rey Juan Carlos (HURJC) in Mostoles (Madrid). Methods: We have established three study periods: preimplantation period (PiP: September 2013 - February 2014), before Dysphagia Unit Protocol in SU; Initiation period (InP: March 2014 - June 2014) take off of protocol and consolidation period (CP: June 2014 - March 2015). We divide patients admitted to the SU in two groups. The first group are patients with low risk of OD (TIA or mild stroke) in which the screening is done through an adaptation of NOD step-wise protocol of Ickenstein, performed by SU nursing. The second group are patients with moderate or high OD risk (moderate / severe or vertebrobasilar stroke), where the screening is performed by a trained nurse of Dysphagia Unit. She asses patients with bedside evaluation and Volume-viscosity test. This same nurse establishes the need for further invasive tests for the assesment of dysphagia (FESST and / or VFSS). She also adapts the consistency of individual diets and even provides indications of dysphagia rehabilitation. Results: 420 patients with stroke (PiP: 78 patients, InP: 100 patients and CP: 242 patients) were included. The groups were comparable in clínics AND epidemiology OD have some degree of 37.7% in the PiP, 36% on InP and 32% for CP. We found that AP prevalence was 32% in the PIP, 10% on InP (OR = 4.2; p = 0.0002) and 7% in the CPs (OR 6.6, p = 0.0001). Mortality rate was 16.6% in the PiP, 10% in the INP (p = 0.09) and 8.6 in CPs (p=0.001). Conclusions: In our hospital, the implementation of a protocol for the integrated manegement of dysphagia has reduced the mortality and aspiration pneumonia rate in patients of Stroke Unit.
IMPROVEMENT*OF*MORTALITY*AND*ASPIRATION*PNEUMONIA*RATE*IN*
STROKE*UNIT*AFTER*IMPLANTATION*OF*DYSPHAGIA*ASSESMENT*PROTOCOL
GUTIÉRREZ FONSECA, R*.; FERNANDEZ FERRO, J.**; GARCÍA BOTRAN, B*.; GUILLAN RODRIGUEZ, M.**; GRANELL
NAVARRO, J.*; PARDO MORENO, J.**; MILLAS GOMEZ, T.*; SAMBRANO, L***.; ABUIN FLORES, M.**
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PURPOSE:
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PROTOCOL:*METHODS
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N:#420#
PreP:#78#
PostP:#100#
Consolid.#
(242)#
#
Age#(Mean+#SD)#
72,9#+/B14#
73,1+/B13#
73,5+/B14#
Sex#Female#
51,3%#(40)#
55%(55)#
49,5%(120)#
Ischemic#Stroke#
86%(67)#
89%(89)#
85%(206)#
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RESULTS:
We compare*the results of*three next time*periods,*with 420*patients.
QSerie*1:*Previous Period (control).*Stroke patients before protocol dysphagia (78*patients).*
(Sept.2013QFeb.*2014)
QSerie*2:*PostQProtocol Period (implementation)*(100*patients)*Initial implementation of*the protocol.*
(Feb.2014QJun.2014)
QSerie*3:*Period of*consolidation (242*patients).*Consolidated Protocol.*(Jun*2014QMarch*2015)
We note*that all groups are*homogeneus in*epidemiologic dates.
We achieve significant reduction in*mortality rate and*the rate of*pneumonia,*even in*the
implementation phase is appreciated and*that becomes more*striking in*the consolidation phase
with statistical significance.
It is noted in*the implementation phase some increase in*stay just better when it comes*to the
consolidation phase.
CONCLUSIONS
QSystematic evaluation of*swallowing in*patients with stroke can*improve
mortality rate and*reduce*pneumonia.
QSequential interdisciplinary evaluation to redistribute resources and*workload
and*classify patients according to their risk.
QThe existence of*a*dedicated nurse*for swallowing problems can*improve health
outcomes of*patients with stroke
Conflict of)interest The authors have no)conflicts of)interest or financial ties to disclose.
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Article
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Objectives: Dysphagia occurs in approximately 51%-78% of patients with acute stroke. The incidence of pneumonia caused by aspiration in dysphagic patients increases both mortality and the need for hospitalization. The aim of this study was to investigate whether the incidence of aspiration pneumonia could be reduced in such patients by an early screening for dysphagia and intensified oral hygiene. Material and methods: In this controlled trial, 146 hospitalized acute stroke patients with moderate or severe dysphagia were included in three groups: an intervention group (n = 58), one internal control group (n = 58, retrospectively selected from same clinic), and one external control group (n = 30) from a comparable stroke unit in a neighboring hospital. The intervention consisted of early screening with a clinical method of dysphagia screening, the Gugging Swallowing Screen, and intensified oral hygiene. Results: The incidence of x-ray verified pneumonia was 4 of 58 (7%) in the intervention group compared with 16 of 58 (28%) in the internal control group (p < .01) and with 8 of 30 (27%) in the external control group (p < .05). Conclusions: Early and systematic dysphagia screening by the Gugging Swallowing Screen method and intensified oral hygiene reduced the incidence of x-ray verified pneumonia.
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Background: Oropharyngeal dysphagia (OD) is a major complaint among many patients with neurological diseases and in the elderly, but is often underdiagnosed. The volume-viscosity swallow test (V-VST) is a bedside method to screen patients for dysphagia. Methods: The V-VST was designed to identify clinical signs of impaired efficacy (labial seal, oral and pharyngeal residue, and piecemeal deglutition) and impaired safety of swallow (voice changes, cough and decrease in oxygen saturation ≥3%). It starts with nectar viscosity and increasing bolus volume, then liquid and finally pudding viscosity in a progression of increasing difficulty to protect patients from aspiration. Results: The V-VST allows quick, safe and accurate screening for OD in hospitalized and independently living patients with multiple etiologies. The V-VST presents a sensitivity of 88.2% and a specificity of 64.7% to detect clinical signs of impaired safety of swallow (aspiration or penetration). The test takes 5-10 min to complete. Discussion and conclusion: The V-VST is an excellent tool to screen patients for OD. It combines good psychometric properties, a detailed and easy protocol designed to protect safety of patients, and valid end points to evaluate safety and efficacy of swallowing and detect silent aspirations.
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To determine the accuracy of the bedside volume-viscosity swallow test (V-VST) for clinical screening of impaired safety and efficacy of deglutition. We studied 85 patients with dysphagia and 12 healthy subjects. Series of 5-20 mL nectar (295.02 mPa.s), liquid (21.61 mPa.s) and pudding (3682.21 mPa.s) bolus were administered during the V-VST and videofluoroscopy. Cough, fall in oxygen saturation > or =3%, and voice changes were considered signs of impaired safety, and piecemeal deglutition and oropharyngeal residue, signs of impaired efficacy. Videofluoroscopy showed patients had prolonged swallow response (> or =1064 ms); 52.1% had safe swallow at nectar, 32.9%, at liquid (p<0.05), and 80.6% at pudding viscosity (p<0.05); 29.4% had aspirations, and 45.8% oropharyngeal residue. The V-VST showed 83.7% sensitivity and 64.7% specificity for bolus penetration into the larynx and 100% sensitivity and 28.8% specificity for aspiration. Sensitivity of V-VST was 69.2% for residue, 88.4% for piecemeal deglutition, and 84.6% for identifying patients whose deglutition improved by enhancing bolus viscosity. Specificity was 80.6%, 87.5%, and 73.7%, respectively. The V-VST is a sensitive clinical method to identify patients with dysphagia at risk for respiratory and nutritional complications, and patients whose deglutition could be improved by enhancing bolus viscosity. Patients with a positive test should undergo videofluoroscopy.
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To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature. Databases were searched (1966 through May 2005) using terms "cerebrovascular disorders," "deglutition disorders," and limited to "humans" for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration. Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77). The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.
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  • P Clavé
  • P Garcia Peris
Clavé, P. Garcia Peris, P. Guia de Diagnóstico y tratamiento nutricional y rehabilitador de la disfagia orofaringea Ed Glosa.