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outCoMeS froM A SCreeninG proCedure for orophArynGeAL dySphAGiA patients who passed GLADS, these patients’ strokes were likely ischemic. Like those patients passing GLADS, those who failed had normal or minimally impaired speech, language, or cognitive function (78 patients, 45%). For those patients with impairment, a motor speech disorder was most common (44 patients, 25%), and a focal language disorder (aphasia) was least common (19 patients, 11%). Thirty-four patients had dementia. We found no significant association between these deficits and pneumonia (P = .61), nor, as for those patients passing GLADS, were they good predictors of a patient’s ability to maintain a safe oral diet after stroke (P = .89). Median length of stay for patients failing GLADS was 5 days (range 1-62 days), significantly higher than for those patients who passed (3 days, P < .0001). Median cost of hospitalization for these patients was $11,703, which was also significantly higher than for those who passed (P < .0001). For the 14 patients who failed GLADS and developed pneumonia during hospitalization, the median length of stay was 7 days, and the median cost $19,933. Moreover, if odds ratios are considered, the 175 patients failing GLADS were 4 times more likely to develop pneumonia during hospitalization than were the 578 who passed (95% CI, 1.86- 9.04). Table 2 summarizes the findings for the 175 patients failing GLADS. diSCuSSion Results of the current investigation suggest that GLADS is an effective screening measure for oropharyngeal dysphagia following acute stroke when administered by carefully trained nurses in conjunction with an ASCP. Barring unrelated stroke complications, over 90% of patients passing GLADS were able to maintain a safe and nutritionally sound oral diet without pneumonia or further comprehensive evaluation for dysphagia during hospitalization. They were also less likely than patients who failed GLADS to develop pneumonia during their hospitalization or after discharge. We found that neither site of lesion nor communicative or cognitive deficits was a predictor of who would develop pneumonia. We also found that prior stroke—even with related comorbidities including dysphagia or speech or cognitive deficits—was not a good predictor of a patient’s ability to maintain a safe oral diet following a new stroke. Not surprisingly, cost of hospitalization and length of stay were reduced when stroke was not complicated by pneumonia. One might argue that the 175 patients who failed GLADS had more devastating strokes that resulted in a complicated course with protracted hospitalization, increased expense, and a higher death rate than those who passed GLADS. Interestingly, however, with time and dysphagia therapy, almost half of these patients went on to become functional and safe oral feeders during their hospitalization. This finding could also represent the influence of the comprehensiveness and intensity of the ASCP itself. The importance of a swallowing screen as a component of an ASCP has been stressed by others. 42 Using a speech pathologist or certified nurse to screen for dysphagia, they found that 48 of 124 patients (39%) failed the initial screen and required dietary texture change, as well as direct dysphagia therapy. Whereas in our study patients who failed GLADS were referred for further evaluation prior to initiation of an oral diet, their patients apparently did not undergo further workup for dysphagia or aspiration prior table 2. Demographic and Clinical Characteristics of 175 Patients Failing 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 Comfort measures Lost to follow-up Stroke location Left cerebral hemisphere Right cerebral hemisphere Brainstem Bihemispheric Undetermined Stroke type Ischemic Hemorrhagic Undetermined Communicative / cognitive deficit Dysarthria / dyspraxia Aphasia Dementia None to initiating an oral diet. However, none of their patients were reported to have developed aspiration pneumonia. Using a water swallow screening test for 100 consecutive acute stroke patients, Nilsson et all have reported a pneumonia rate of 14% (2 of 14 dysphagic patients). 46 Apparently neither of the patients who developed pneumonia received direct swallowing therapy. In our study, 14 of 175 patients failing GLADS developed pneumonia during hospitalization, which—if odds ratios are considered—is 4 times the likelihood of the 578 patients who passed. Aspiration pneumonia following stroke has a reported incidence rate of 13%. 47 Moreover, the incidence of pneumonia increases with age, particularly over 65 years. 48 Hinchey et al 12 found from a prospective multicenter study that institutions that had formal dysphagia screening protocols for acute stroke had Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009 11 88 87 69 106 13 0 0 82 14 7 2 16 32 55 11 3 1 65 68 14 4 24 106 7 62 44 19 34 78 (50) (50) (39) (61) (7) (0) (0) (47) (8) (50) (1) (9) (18) (31) (34) (2) (.5) (37) (39) (8) (2) (14) (61) (4) (35) (25) (11) (19) (45)
pneumonia rates of 2.4%, versus 5.4% for those that did not. Although the specific nature of the protocols was not fully described, and randomization was an issue, their results led them to conclude that “A formal dysphagia screen prevented pneumonia even after adjusting for stroke severity.” 12(p1973) Outcomes from the current and previous studies incorporating a screening procedure for dysphagia in acute stroke in conjunction with an acute care pathway 12,42 may be a reflection of the propensity of dysphagia following stroke to improve or resolve within 6 months of onset, 3,9 the nature of acute stroke pathways, which are inherently designed to provide the most comprehensive and efficacious treatment for the patient and to prevent complications from acute stroke, or a combination of these factors. Other than diet modification and regular observation by the medical and nursing team for signs of change in status related to oral feedings, none of the 578 patients who passed GLADS received formal dysphagia therapy. Thus, it could be concluded that their dysphagia, if present, was mild and not disabling. Median length of hospital stay and cost of hospitalization were lower for those patients whose stroke was not complicated by pneumonia. Similar trends have been noted previously. 12,28,49 Like others, 13 we believe that screening procedures like GLADS do not delineate the specific nature of dysphagia, only whether the patient is having or may be at risk for swallowing difficulties. Nonetheless, based upon the results of the current investigation as well as the work of others, 42 we conclude that nursing staff can be trained to administer a screening tool for dysphagia following acute stroke that will allow implementation of oral feedings with minimal or no complications, even though the nature of the swallowing disorder may not have been fully delineated. We believe GLADS was effective not only because it was administered by trained nursing staff, but also because of elements included in the screening tool itself and how they were used, rather than individual screening measures that have been used previously for dysphagia, for example, the 3-oz water swallow test, 32,33 swallowing frequency, or a timed test of swallowing. 40,41 The importance of co-occuring risk factors (Critical Criteria) has been stressed by others as well. 5,7,18,34,50 If a screening tool alone, such as GLADS, is effective for implementing an uncomplicated oral feeding regimen following acute stroke, what, then, is the role of VFSS and videoendoscopic swallowing evaluation? We propose, as implemented at our institution and suggested elsewhere, 23 that these procedures be reserved for patients who fail a comprehensive screening procedure or who have inconclusive screening results, who have unstable medical conditions that can potentially affect deglutitory function and subsequent respiration, or who require radiographic or photographic documentation of swallowing function prior to and following an invasive or surgical procedure. Finally, we believe that we have taken a step in meeting 1 of the recommendations concerning the need for further development of efficacious screening procedures and best practice strategies for dysphagia. 21-23 Although it proved difficult logistically to incorporate into this retrospective study, a measure of interrater reliability for nurses administering GLADS should be included in future prospective investigations. Given today’s healthcare environment, more research is both needed and recommended to develop safe, reliable, and costeffective screening tools for dysphagia following stroke. ACknoWLedGMentS The authors thank Gundersen Lutheran Medical Foundation for sponsoring Melissa Hunter’s summer research fellowship. We also wish to thank Cathy Lazarus, PhD, BRS-S, New York University School of Medicine, for her insightful and critical comments, and Gundersen Lutheran Health System and Gundersen Lutheran Medical Foundation for their ongoing support for research. referenCeS 1. National Stroke Association. National Stroke Association’s Complete Guide to Stroke. 1999, pp 3. National Stroke Association Web site. http://www. stroke.org/site/DocServer/NSA_ complete_guide.pdf?docID =341. Accessed December 10, 2007. 2. American Heart Association. Heart & Stroke Facts: 1996 Statistical Supplement. New York: American Heart Association; 1996. 3. Barer DH. The natural history and functional consequences of dysphagia after hemispheric stroke. J Neurol Neurosurg Psychiatry. 1989;52(2):236- 241. 4. Veis SL, Logemann JA. Swallowing disorders in persons with cerebrovascular accident. Arch Phys Med Rehabil. 1985;66(6):372-375. 5. Horner J, Massey EW, Riski JE, Lathrop DL, Chase KN. Aspiration following stroke: clinical correlates and outcome. Neurology. 1988;38(9):1359-1362. 6. Groher ME, Bukatman R. The prevalence of swallowing disorders in two teaching hospitals. Dysphagia. 1986;1(1):3-6. 7. Horner J, Massey EW. Silent aspiration following stroke. Neurology. 1988;38(2): 317-319. 8. Linden P, Siebens AA. Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehabil. 1983;64(6):281-284. 9. Smithard DG, O’Neill PA, England RE, et al. The natural history of dysphagia following a stroke. Dysphagia. 1997;12(4):188-193. 10. Schmidt J, Holas M, Halvorson K, Reding M. Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia. 1994;9(1):7-11. 11. Swigert NB. NPO until dysphagia screen. Presented at: American Heart Association Telephone Conference; July 4, 2007. 12. Hinchey JA, Shephard T, Furie K, et al. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36(9):1972-1976. 13. Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia. 1999;14(1):44-51. 14. Logemann JA. Evaluation and Treatment of Swallowing Disorders. San Diego, CA: College-Hill Press; 1983:249. 15. Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G. Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil. 1988;69(8):637-640. 12 Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009
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