How does variation in assessment and management of dysphagia in acute stroke affect the development of stroke-associated pneumonia (SAP)?

Eltringham, Sabrina Arabel (2022) How does variation in assessment and management of dysphagia in acute stroke affect the development of stroke-associated pneumonia (SAP)? Doctoral thesis (PhD), Manchester Metropolitan University.

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Abstract

Background: Patients with dysphagia are at increased risk of stroke-associated pneumonia (SAP). Preventing SAP is therefore one of the key challenges of stroke unit care. This study investigated how variation in assessment and management of dysphagia in acute stroke affects the risk of stroke patients developing SAP. Methods: Two systematic reviews identified the methods of dysphagia assessment and management in acute stroke that influence the risk of SAP, and other interventions and care process that may contribute to that risk. A mixed methods study was used to develop a national survey of organisational practice about dysphagia assessment and management in acute stroke. The quantitative method was a review of stroke patient records (N=30). Qualitative methods included interviews with hospital staff (N=15) and patients and carers (N=6). Four topic areas were identified for exploration: (a) dysphagia screening, (b) specialist swallowing assessments and management, (c) NGT feeding, and (d) oral care processes. Speech and Language Therapists from 166 stroke units in England and Wales were surveyed. Survey data were linked to the Sentinel Stroke National Audit Programme (SSNAP) data to estimate risk of SAP. Results: Survey completion rate was 68% (N=113). There was variation in dysphagia screening protocols (DSPs), oral care and NGT placement. Patterns of consistency occurred in the specialist swallow assessment. Multivariable analyses showed no evidence of association in incidence of SAP when using DSPs that used water only compared to multiple consistencies; when using written guidelines for the specialist swallowing assessment compared to not using written guidelines; when teams inserted NGTs overnight compared to teams that did not; and when teams had a written oral care protocol compared to those that did not. Discussion The multifactorial pathophysiology of SAP and inter dependency of dysphagia care processes make it difficult to unpack which components of dysphagia assessment and management are associated with risk of SAP. Future empirical research and large clinical trials that allow evaluation of multiple interventions to determine what are most effective at minimising risk of SAP are needed.