Streptococcus bovis - Gundersen Lutheran Health System

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outCoMeS froM A SCreeninG proCedure for orophArynGeAL dySphAGiA Pathway (ASCP)—for evaluating and treating acute stroke patients admitted to our medical center. Various stroke pathways have been described elsewhere 12,28 and have been found to be efficacious for caring for acute stroke patients. In conjunction with the ASCP and based upon previous literature concerning bedside screening examinations for oropharyngeal dysphagia, 3,5,13-15,18,19,21,22,28-42 3 of the authors developed a screening tool, Gundersen Lutheran Acute Dysphagia Screen (GLADS), for use by nurses. In brief, GLADS used a checklist that incorporated several observable risk factors (ie, Critical Criteria) relevant for both dysphagia and aspiration, and assessment tools for secretions, swallowing frequency, and water swallows. 26,31,33,40,41 Prior to using it with stroke patients, a select cadre of 20 registered nurses was trained by the 3 authors to administer GLADS. Through the ASCP, medically stable and adequately alert patients were screened a minimum of 3 times following admission and up to 48 hours prior to a consultation being generated for more comprehensive evaluation of swallowing function. Observations of (1) 1 or more critical criteria, (2) continuous intermittent coughing on secretions, (3) coughing with water swallow trials, 32,33 or (4) swallowing frequency fewer than 1 per minute or 4 per 5 minutes 40,41 denoted failure on GLADS, prompted a nothing by mouth order, and generated referral for further evaluation. If available in liquid form, necessary medications were given intravenously or intramuscularly. Results from a pilot study using GLADS for 118 acute stroke patients showed that none developed either pneumonia or malnutrition during hospitalization or at 3-month followup and suggested that trained nurses could effectively implement a screening procedure for dysphagia following stroke. 43,44 The purpose of the current retrospective investigation was to (1) determine the outcomes for pneumonia and nutrition for patients admitted through the ASCP between 1998 and 2006 and undergoing GLADS as part of the stroke protocol, (2) determine the effectiveness of GLADS as a screening procedure for dysphagia and aspiration, and (3) compare the neurological characteristics of patients who passed GLADS with those of patients who failed. MethodS Approval for retrospective review of patient medical records was obtained from Gundersen Lutheran Health System’s Research Committee and Institutional Review Board. All patients admitted through the ASCP between January 1998 and December 2006 were identified by service code and their medical records reviewed by the authors. Of these, the records of those patients who underwent screening using GLADS were reviewed for outcomes during hospitalization and at 35 days following discharge from hospital. A determination of pneumonia was made by reviewing the comments and diagnoses made by the primary service (typically internal medicine or neurology) or pulmonary medicine and the findings from chest radiographs. Nutritional status was determined by reviewing the nutritional assessment recommendations made by registered dieticians or the metabolic support team. General statistical associations and proportion comparisons with categorical variables were assessed with the χ 2 test. The Fisher exact test was used in place of the χ 2 test when at least 25% of the cells had counts less than 5. Univariate logistical models were used when predictive ability was tested. The cost and length-of-stay comparisons between groups were done with the Wilcoxon rank sum test of equal distributions. Exact confidence limits were calculated for the reported odds ratio. A P value < .05 was considered significant. Gundersen Lutheran Acute Dysphagia Screen (GLADS) reSuLtS Seven hundred fifty-three stroke patients, average age 74 years, had GLADS administered in conjunction with the ASCP between January 1998 and December 2006. Five hundred seventy-eight patients (77%) passed GLADS. Of these, 571 did not undergo further assessment for dysphagia prior to implementation of an oral diet; the remaining 7 patients had normal VFSS test results and were started on an oral diet subsequent to study. However, 4 of these patients had inadequate oral intake and were given enteral feedings, as well. One hundred seventy-five patients (23%) failed GLADS and went on for further evaluation (ie,VFSS, fiberoptic study of swallow, 29,45 or both) and treatment. Of the patients passing GLADS, 287 were men and 291 were women. By report, 10 patients had premorbid dysphagia, although its nature was unclear. Although 1 patient was described as having aspiration premorbidly, no patients were diagnosed with pneumonia at the point of admission through the ASCP. Five hundred twentyfour patients (91%) maintained an oral diet and were free from pneumonia during their hospitalization and within 35 days of Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009 9 ID Stamp: Reason for Admission/Primary Diagnosis:____________________________________________ Date of Admission:_____________ Attending Staff:__________________________________ House Staff:___________________________ RN Completing Index:_____________________ Dates:________________________________________________________________________ Trials Critical Criteria* Check if Present Check if Present Check if Present Decreased volitional cough _____ _____ _____ Wet hoarseness _____ _____ _____ Audible oropharyngeal pooling of secretions _____ _____ _____ Decreased mental status _____ _____ _____ Tracheostomy _____ _____ _____ Tube feedings, NG or gastrostomy _____ _____ _____ Assessment* Coughs on secretions _____ _____ _____ Coughs on 3-ounce H2O trials _____ _____ _____ Swallowing frequency (4 or < in 5’) _____ _____ _____ This screen should be administered a minimum of three times within 24-48 hours of admission. If patient demonstrates one or more of the critical criteria, coughs on secretions, has failed H2O swallowing trials, or swallows four times or less in a five minute time period, then status should be NPO including medications unless they can only be given orally) until the screen is passed or formal evaluation of deglutitory function has been completed.
discharge. Twelve patients (2%) developed pneumonia during their hospitalization, 6 of whom were diagnosed with aspiration pneumonia by clinical examination and chest radiograph. Neither prior stroke nor premorbid dysphagia were good predictors of a patient’s ability to maintain a safe oral diet (P = .34; P = .26). Six patients (1%) developed pneumonia after discharge from hospital and subsequent placement in an extended care facility. Thirty-two patients (6%) died during the course of the study, 3 of whom had pneumonia, although it was not determined if pneumonia was the cause of death. Three patients were lost to followup. Of the 578 patients who passed GLADS, 222 experienced a left cerebral hemisphere stroke, 190 had a right hemisphere stroke, 25 had a brainstem stroke, and 21 had bihemispheric cerebral strokes, based upon clinical examination, radiographic study, or table 1. Demographic and Clinical Characteristics of 578 Patients Passing GLADS Characteristic n (%) Sex Men Women Prior stroke Yes No Premorbid conditions Dysphagia Pneumonia Aspiration Nutritional / pneumonia outcomes Adequate oral diet, no pneumonia Pneumonia during hospital stay Aspiration pneumonia Pneumonia after discharge Total pneumonias Supplemental nutrition Deaths Deaths with concurrent pneumonia Lost to follow-up Stroke location Left cerebral hemisphere Right cerebral hemisphere Brainstem Bihemispheric Undetermined Stroke type Ischemic Hemorrhagic Ischemic / hemorrhagic Undetermined Communicative / cognitive deficit Dysarthria / dyspraxia Aphasia Dementia None 287 291 201 377 10 0 1 524 12 6 6 18 4 32 3 3 222 190 25 21 120 334 12 4 228 124 82 99 273 (50) (50) (35) (65) (2) (0) (0) (91) (2) (50) (1) (3) (1) (6) (9) (1) (38) (33) (4) (4) (21) (58) (2) (1) (39) (21) (14) (17) (47) both. Site of lesion could not be determined from neuroimaging for the remaining 120 patients. We found no significant association between site of lesion and pneumonia (P = .24). Three hundred thirty-four patients (58%) experienced an ischemic stroke with the current admission, 12 hemorrhagic, and 4 with features of both ischemic and hemorrhagic stroke. For 228 (39%) patients, medical records failed to indicate if stroke was ischemic or hemorrhagic. However, all patients had at least 1 neuroimaging study, so a hemorrhagic lesion, if present, likely would have been identified. Thus, it could be argued that these strokes were ischemic. Two hundred seventy-three patients (47%) had normal or minimally affected speech, language, and/or cognition. One hundred twenty-four patients had distinct focal speech deficits, that is, dysarthria or dyspraxia of speech. Eightytwo patients had aphasia, and 99 patients had findings consistent with dementia. There was no significant association between these findings and pneumonia (P = .15). Moreover, having either a communicative or cognitive deficit was not a good predictor of a patient’s ability to maintain a safe oral diet after stroke (P = .89). The median length of stay for patients passing GLADS was 3 days (range 1-38 days), and the median cost of hospitalization was $7,967. For the 12 patients who passed GLADS but developed pneumonia during hospitalization, the median length of stay was 6.5 days, and the median cost was $20,099. Table 1 summarizes the findings for the 578 patients passing GLADS. Of the 175 patients failing GLADS, 88 were men and 87 were women. Sixty-nine patients (39%) had a history of prior stroke. Thirteen patients reportedly had pre-existing dysphagia, the nature of which was unclear. Neither prior stroke nor preexisting dysphagia was a good predictor of a patient’s ability to safely tolerate an oral diet (P = .92, P = .28). With behavioral therapy for their dysphagia, 84 patients (48%) maintained an oral diet and 82 remained free from pneumonia within the study period. Fourteen patients developed pneumonia during their hospitalization—7 presumably due to aspiration—and 2 developed pneumonia after discharge, for an overall pneumonia rate of 9%, a rate significantly higher than that of the patients who passed GLADS, both during hospitalization and after discharge (P = .0002; P = .0008). Thirty-two patients (18%) required enteral nutritional support in conjunction with their dysphagia therapy. Fifty-five patients (31%) died during the study period, 11 possibly due to pneumonia. Three patients were placed on comfort care, and 1 patient was lost to follow-up. The death rate was significantly higher for patients who failed GLADS than for those who passed (31% vs 5.5%, odds ratio 7.8; range 4.9-12.6; P < .0001). Sixtyfive patients experienced a left hemispheric and 68 patients a right hemispheric stroke. Fourteen patients had brainstem and 4 patients had bihemispheric stroke, while site of lesion was undetermined from neuroimaging for 24 patients. Like those who passed, patients who failed GLADS exhibited no significant association between the site of lesion and pneumonia (P = .75). Like those patients who passed GLADS, most patients who failed had experienced an ischemic stroke (106 patients, 61%). Seven patients had experienced a hemorrhagic stroke, while for 62 patients (35%), medical records failed to indicate if the stroke was ischemic or hemorrhagic. However, as previously posited for those 10 Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009
Page 1 and 2: Th e Gundersen Lu T h e r a n M e d
Page 3 and 4: editor David E. Hartman, PhD, BC-AN
Page 5 and 6: through our online Scholarly Activi
Page 7 and 8: competition practice of each subjec
Page 9 and 10: effect. These data suggest that the
Page 11: Authors: David E. Hartman, PhD, BC-
Page 15 and 16: pneumonia rates of 2.4%, versus 5.4
Page 17 and 18: Authors: Alexander D. Wade, MD Depa
Page 19 and 20: Since that report, other authors ha
Page 21 and 22: Authors: Abhishek Tandon, MD Depart
Page 23 and 24: cancer, duodenal ulcers, inflammato
Page 25 and 26: figure 1. Radiograph depicting a 4-
Page 27 and 28: Authors: Meghana Raghavendra, MB, B
Page 29 and 30: Authors: Ines H. Berger, MD, PhD De
Page 31 and 32: and nerve root avulsion. Simmel, in
Page 33 and 34: Authors: Brian E. Udermann, PhD, AT
Page 35 and 36: figure 2. Longtime LEHP member Don
Page 37 and 38: Summer Splendor Kelly Hodgson Kline

Streptococcus bovis - Gundersen Lutheran Health System

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