How does dysphagia assessment in acute stroke affect pneumonia?
Research type
Research Study
Full title
How does variation in assessment and management of dysphagia in acute stroke affect the development of stroke-associated pneumonia?
IRAS ID
222255
Contact name
Sabrina Eltringham
Contact email
Sponsor organisation
Sheffield Hallam University
Clinicaltrials.gov Identifier
TSA_ PGF_2017, Stroke Association Postgraduate Fellowship
Duration of Study in the UK
5 years, 0 months, 1 days
Research summary
Summary of Research
After a stroke some people have difficulty swallowing. Food and drink can go down the wrong way into the lungs instead of the stomach. This can cause a serious chest infection. When a person first comes into hospital, a specially trained nurse tests their swallow to see if the person has a swallowing problem. If the nurse thinks the person's swallow is unsafe, a speech and language therapist completes a more thorough assessment and will make recommendations on how they can eat and drink more safely or suggest different ways the person can get the nutrition they need. There are many swallowing tests a trained nurse might use. This project will find out whether there are tests which are better at reducing the chances of getting a chest infection and whether or not it makes a difference when your swallow is tested and how it is done. It will investigate what is already known about this, review patient notes to find out what happens in the first few days and interview people who either carry out the tests or experience them. This information will be used to make a questionnaire, which will be sent out to all hospitals in England and Wales to find out how different hospitals assess and manage patients in the first 72 hours from admission. Finally, the answers from the questionnaire will be cross-referenced with information collected by the Sentinel Stroke National Audit Programme (provided by most hospitals in England and Wales). By linking hospital data with the register, we can search for patterns to see if there are other reasons why you are more likely to develop a chest infection. We will then use this information to help guide what happens in the future to reduce the risk of getting a chest infection.Summary of Results
Swallowing problems (dysphagia) are common after stroke and if not identified early and managed properly can lead to serious problems. This research aimed to understand how we test and manage a person’s swallow after a stroke and whether the way we manage that makes a difference to them getting a chest infection (pneumonia). The research started by looking at 2 different things: firstly, what has been written about these tests; and secondly, how we care for patients with swallowing problems during the first few days in hospital. The results were published in two articles. In the first we reported that lots of different tests were used and that no specific test could be recommended. However, having your swallow tested early by a trained nurse and being seen by a specialist (a speech and language therapist) significantly reduces the risk of getting pneumonia. In the second we looked at the way we care for patients with swallowing problems and whether some of the things we do and ways we care for people, are linked with pneumonia. We found a range of medical interventions, and that how we care for patients may impact on patients with swallowing problems getting pneumonia. However, we needed to be cautious in how we interpreted the findings because of the size of some of the studies, the different study types and the way they the results were reported.Next, 30 patients’ medical notes were looked at to understand better what happens during a patient’s first few days in hospital. Not everyone had their swallow tested as early as the guidelines recommend and possible reasons for why there was a delay were identified. Some staff did not know what the guidelines recommend about testing a person’s swallow and so did not always follow the correct way of doing things. Fifteen staff from 5 hospitals were also interviewed to get a better understanding of what happens from the clinical perspective and to find out whether things are done differently across hospitals. The staff talked about reasons for delays in care. There were differences between hospitals in three areas: the way a person’s swallowing is tested; the care patients receive; and in the resources available to the staff to help patients. Five interviews were also carried out with patients from one hospital who had swallowing problems in the early days after their stroke to get a better understanding of the patients' experience and how they felt about having their swallow tested. A separate group of people affected by stroke helped read and think through what messages came out of the patient interviews and to help identify what was most relevant to stroke survivors. Working with those stroke survivors has improved the quality of the research because it helped to confirm the messages the researcher found, and it helped find additional messages that may have been overlooked. Communication to patients and their families and following recommended guidelines were 2 new themes that the group identified. The results of the staff interviews and patient interviews were published in two articles.
The information that was learnt was used to make a survey, which was sent out to all hospitals in England and Wales. This survey helped find out how different hospitals test a person’s swallow and other types of care during the first few days of them arriving in hospital. The answers from the survey were cross-referenced with information collected by the Sentinel Stroke National Audit Programme (provided by most hospitals in England and Wales). By linking hospital data with the audit data, patterns were searched for to see if there are other reasons why a person affected by stroke is more likely to develop a chest infection. Four care processes that might be linked to pneumonia were explored (a) using a water only swallow test compared to a test that uses different consistencies of fluid and food, (b) using written information compared to not using written information to guide the first swallowing assessment, (c) inserting nasogastric tubes overnight or not (d) if there was written guidance or not for oral care. We found no evidence for a link between these care processes and the risk of getting a chest infection. However, the sample size of the survey may have been too small to detect an effect. An article about the survey has been published.
In summary this research revealed there are differences between hospitals in the way a person’s swallow is tested and managed in the first few days after stroke but no link was found between the care processes examined and getting a chest infection. However, because this research did not find a link does not necessarily mean one does not exist. Trying to unpack which aspects of swallowing assessment and management are linked to risk of getting a chest infection is challenging because of the range of factors that may be involved and that many of the care processes overlap and different professionals are involved. The findings of this research have been published. Future larger studies can build on them. Observational studies are also needed to try and unpack what factors impact on patients getting pneumonia.
Future implications of this work include all stroke patients should have their swallow tested as soon as they are admitted to hospital using either a water only or a test that includes different consistencies of food and drink. If swallowing difficulties are identified a speech and language therapist or equivalent trained professional should assess the person as soon as possible and if clinically indicated a person should be considered for a Xray of their swallow or an investigation that involves a camera to look inside their throat when the person is swallowing. Tackling the reasons for delays in having a swallow test may minimise the chance of the person developing a chest infection. More evidence is needed to determine how best to provide mouth care in patients with swallowing problems.
REC name
London - Bromley Research Ethics Committee
REC reference
18/LO/0096
Date of REC Opinion
31 Jan 2018
REC opinion
Further Information Favourable Opinion