How do care processes affect pneumonia after stroke?
Research type
Research Study
Full title
How do care processes impact on development of stroke-associated pneumonia?
IRAS ID
317182
Contact name
Sabrina Eltringham
Contact email
Sponsor organisation
Sheffield Teaching Hospitals NHS Foundation Trust
Duration of Study in the UK
0 years, 6 months, 8 days
Research summary
Research Summary
Preventing pneumonia after a stroke is a key challenge of hospital care. Patients with swallowing difficulties (dysphagia) are vulnerable to getting pneumonia in the first few days after a stroke. A range of other factors are also linked with risk of pneumonia and different groups of professionals work together to manage a person’s swallowing. This complex mix of factors makes it difficult to unpack which clinical processes affect the chances of stroke patients getting pneumonia. This research builds on a previous study that looked at the differences between hospitals in the way a person’s swallow was assessed and managed and whether how it was done made a difference to the chances of getting pneumonia. This study will dig deeper and explore what happens at a patient level on a hyper acute stroke unit. The aim is to better understand the barriers and facilitators to reducing pneumonia to build knowledge at a broader level. The researcher will observe the mealtimes of 10 stroke patients with dysphagia who have had a specialist swallowing assessment. The observations will happen during the first 72 hours of person’s admission to hospital. Observations will include implementation of the recommendations from the specialist swallow assessment, positioning of the patient when feeding and oral care. Medical records will be monitored for possible development of pneumonia and mouth care interventions. The results of the observations will be analysed and patterns searched for to help us understand which care processes and staff behaviours may impact on development of pneumonia. This information will then be used to help guide what happens in the future to reduce the chances of getting pneumonia.Summary of Results
Background
Stroke survivors are susceptible to developing pneumonia. Swallowing problems (dysphagia) and how these are managed may affect the chances of developing a chest infection. Trying to unpack which aspects of a stroke survivor's swallowing management are linked to getting pneumonia is challenging because many care processes overlap and different professionals are involved. This research aimed to unpack what factors may impact on stroke patients getting pneumonia by carrying out mealtime observations during the first few days of hospital admission on the stroke unit.What we did
Mealtime care processes of ten stroke survivors who had a swallowing assessment and management plan were observed. Observations included the carrying out of the person's swallowing advice (such as changes to diet, thickening drinks, pacing, positioning) and oral care. Two observations took place for each patient at different times and days. Medical records were looked at to monitor possible development of pneumonia and oral care. The International Classification of Functioning, Disability and Health model was used to analyse the observations and a separate group of people affected by stroke were involved in the analysis process. Together, we generated themes and implications for clinical practice.
What we found
There were four overarching themes:
1. Communication - The swallow management plan included a lot of information which needs to be communicated simply to the stroke survivor, their family and different staff groups. Any changes need to be communicated to all parties promptly. There were examples of staff using 'hands on' learning opportunities about oral care, positioning, pacing, suitable food options and thickened fluids with less experienced staff.
2. Variation - This involved variability in staffing resource to support patients at mealtimes, particularly in the evenings and with oral care, availability of eating utensils and types of drinking cups. There was variation in understanding of the dysphagia diet and fluid consistencies and not all aspects of the swallow management plan were followed consistently.
3. Patient preparation - This involved 'setting up' the stroke survivor for mealtimes, medications and oral care. Examples of practice to minimise risk of pneumonia were patients being sat out in a chair or adjusting the bed in a more upright position, checking the swallowing notices behind the bed, and providing furniture and cutlery to help the person function independently. There were instances where patients were not set up due to staffing pressures and family members assisted or patients did not have what they needed. 4. Swallowing and oral care is everyone's business - Different professionals demonstrated their specialist knowledge around mealtimes and oral care. For example, physiotherapy integrating mealtime preparation as part of their assessment and therapy staff recommending strategies about teeth brushing in a stroke survivor with cognitive difficulties. Family members assisted with mealtime preparation. Carryover of swallowing and oral care into different places, for example a kitchen assessment or the therapy gym, highlighted the need to check the person's swallowing management plan.
How does this research benefit stroke survivors and their families?
This research identifies areas for improving the consistency of providing information to patients and their families about what to expect after having a swallowing assessment and how relatives can support people with swallowing difficulties and advice about mouth care after stroke.
What are the implications for clinical practice?
* The swallowing management plan needs to be comprehensive, simple, and memorable.
* Staff to check the swallowing management plan and act on all the information in the plan. * Staff education to address differences in staff awareness of dysphagia management.
* Providing information for patients and their families about managing swallowing problems and oral care after stroke.
* Maximise opportunities for integration of mealtime preparation and mouthcare as part of therapy activities and interventions.
* Finding ways to alleviate staffing pressures to help set up patients for mealtimes and mouthcare particularly during evening and weekend service.
* Improve access and use of appropriate resources to support implementation of the management plan and mouthcare.
REC name
Wales REC 4
REC reference
22/WA/0246
Date of REC Opinion
15 Sep 2022
REC opinion
Favourable Opinion