Dysphagia in adult stroke patients Incidence / Prevalence of ...

Dysphagia in adult stroke patients•Incidence / Prevalence of Dysphagia– >42% of acute patients admitted to hospital– 50% remain affected at day 7– Of those the recovery is at much slower rates– ’94 incidence in Canada for over 65 yr ~ 21,000Canadian Stroke Network - Confidential 1

Dysphagia in adult stroke patients‘Estimated’ recovery of dysphagia following stroke6050403020% Dysphagia +100Acute 1 mo 2 mo 3moCanadian Stroke Network - Confidential 2

Dysphagia in adult stroke patients• Significance of dysphagia in stroke• Malnutrition• Dehydration• Aspiration Pneumonia• LOS• MortalityCanadian Stroke Network - Confidential 3

Dysphagia screening in stroke patients• Does early detection alter healthoutcomes?• Do bedside screening maneuversaccurately detect dysphagia asdefined by videofluoroscopy?Martino, et al (2000) Dysphagia:15;19-30Canadian Stroke Network - Confidential 4

INCLUDEScreening for Dysphagia:Where We Are?EXCLUDEGood evidence forconsideration of thescreening maneuver.Fair evidence forconsideration of thescreening maneuver.ABDEGood evidence forexclusion of thescreening maneuver.Fair evidence forexclusion of thescreening maneuver.CPoor evidence for inclusion or exclusion, butrecommendations may be made on other grounds.Canadian Stroke Network - Confidential 5

TOR-BSST research• Objectives1 Dysphagia on screening (TOR-BSST) will positivelyrelate to AbN swallowing on VFS2 TOR-BSST will be reliable3 TOR-BSST can measure prevalence of dysphagiain stroke & mark its natural Hx across thecontinuum of careCanadian Stroke Network - Confidential 7

Does Detection and Treatment of Dysphagiain Stroke Patients Alter Their Outcome?Applyscreeningto strokepatientsDetecthighprobabilityofdysphagiaEarlierdiagnosticwork-upwith possibleVFSChange inchoice ortiming ofTreatmentChange inHealth O/C:• Pneumonia• Malnutrition• Dehydration• MortalityDetection Treatment OutcomeAdopted from Eddy, 1991Canadian Stroke Network - Confidential 8

As of Sept 2004……Target Jan 2005255 patients enrolled across 4 sites to dateRehab enrollment completedAcute enrollment behind target• Admits to general neuro (vs. stroke) units (16%)• Low NIH Scores (10%)• Hx of stroke that did not affect swallowing (16%)Canadian Stroke Network - Confidential 9

Heart and Stroke Foundation of Ontario & Ontario Ministry of HealthA Regional Approach to DysphagiaManagementParticipating Regions in Southern Ontario (2)Kitchener/WaterlooNiagara PeninsulaParticipating Institutions within these Regions (9)Canadian Stroke Network - Confidential 10

Best Practice Guidelines forManaging Dysphagia• Improving the management of dysphagia in stroke necessitates aninnovative use of regional resources• Ontario has a shortage of SLPs• With their specialized training, SLPs are key to recognize, assessand manage swallowing• Each hospital develops an interdisciplinary swallowing team (withMD, RN, OT, PT &/or RD) with support from a regional SLP• Swallowing team trained to provide screening of all acute strokepatients, therefore identifying dysphagia riskCanadian Stroke Network - Confidential 11

Dysphagia Screening Model: ARegional Pilot ProjectPhase ADevelopment and ImplementationPhase BAssessment within the Acute SettingPhase CFeasibility within the Acute & RehabCanadian Stroke Network - Confidential 12

Dysphagia Screening Model: ARegional Pilot ProjectResults√ Decreased variation in practice with new program√ Increased theoretical knowledge in those trained√ Increased satisfaction in those trained? Improved QOL in stroke patients? Improved satisfaction in stroke patientsCanadian Stroke Network - Confidential 13

Dysphagia Screening Model: ARegional Pilot ProjectThreats• SLPs concerned that new program might detract appropriatedysphagia referrals to SLP• SLPs concerned that trained professionals would not understand thedifference between screening and assessment• Facilities reluctant to abandon existing service delivery models• Large geographic distances between hospitals within the same regionlimited the frequency of on-site visits from the regional studycoordinatorCanadian Stroke Network - Confidential 14

The Overall Screening Question:Does Detection and Treatment of Dysphagiain Stroke Patients Alter Their Outcome?Applyscreeningto strokepatientsDetecthighprobabilityofdysphagiaEarlierdiagnosticwork-upwith possibleVFSChange inchoice ortiming ofTreatmentChange inHealth O/C:• pneumonia• malnutrition• dehydration• mortalityDirect Evidence : Evidence directly supports screening effects on healthoutcomes.In-Direct Evidence: Evidence for separate links in the chain suggest butare not confirmatory that screening improves healthoutcomes.Adopted from Eddy, 1991Canadian Stroke Network - Confidential 15