Dysphagia screening in acute stroke care among non-consultant hospital doctors
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Acute stroke
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Comprehensive swallow screening assessments to identify dysphagia and make early eating and drinking recommendations can be used by trained nurses. This study aimed to validate the Dysphagia Trained Nurse Assessment (DTNAx) tool in acute stroke patients.Participants with diagnosed stroke were prospectively and consecutively recruited from an acute stroke unit. Following a baseline DTNAx on admission, participants underwent a speech and language therapist (SLT) bedside assessment of swallowing (speech and language therapist assessment [SLTAx]), videofluoroscopy (VFS) and a further DTNAx by the same or a different nurse.Forty-seven participants were recruited, of whom 22 had dysphagia. Compared to SLTAx in the identification of dysphagia, DTNAx had a sensitivity of 96.9% (95% confidence interval [CI] 83.8-99.9) and specificity of 89.5% (95% CI 75.2-97.1). Compared to VFS in the identification of aspiration, DTNAx had a sensitivity of 77.8% (95% CI 40.0-97.2) and a specificity of 81.6% (95% CI 65.7-92.3). Over 81% of the diet and fluid recommendations made by the dysphagia trained nurses were in absolute agreement compared to SLTAx. Both DTNAx and SLTAx had low diagnostic accuracy compared to the VFS-based definition of dysphagia.Nurses trained in DTNAx showed good diagnostic accuracy in identifying dysphagia compared to SLTAx and in identifying aspiration compared to VFS. They made appropriate diet and fluid recommendations in line with SLTs in the early management of dysphagia.
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Having worked as pharmacists at a long-term acute care hospital, we know that the concept of LTACH is widely misunderstood. Long-term acute care hospitals are not skilled-nursing facilities, acute rehab institutions, or short-term acute care hospitals. LTACHs offer different services from those of the other facilities, and clinical pharmacists who practice at LTACHs are required to have a high level of clinical and critical care skills.
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Background: Whether patients with acute stroke and large vessel occlusion (LVO) may benefit from prehospital identification and diversion by EMS to a center offering endovascular therapy (EST) is controversial. The accuracy of prehospital scales as predictors of LVO is only one feature of whether EMS can effectively identify patients suitable for EST. Other factors include accuracy of last known well time (LTKW) and identification of stroke mimics. We performed a population-based estimate of potential accuracy of field based identification of potential EST candidates in a large community setting. Methods: In Kaiser Permanente Northern California, all acute stroke patients arriving at its 19 primary stroke centers (PSC) between 7am and 12am were evaluated on arrival by stroke neurologists by video. We reviewed the teleneurology notes to determine the potential accuracy of EST selection based on NIHSS score > 7. Results: For 2016, there were 2546 total potential stroke alerts triaged by EMS as having potential acute strokes [Figure]. Of these, 1268 (50%) were not candidates for acute stroke treatment for various reasons including stroke mimics and inaccurate LTKW. Out of 1241 cases deemed candidates for acute stroke treatment, 638 (25.1%) had potential LVO based on NIHSS > 7. Of these, 116 (4.6% of total “potential strokes” and 18.2% of patients who had “severe” strokes) were diagnosed with LVO and treated with EST. Conclusions: Even if field based tools were as accurate as clinical scoring by stroke neurologists, less than 1 in 4 patients diverted to endovascular stroke centers and away from closer PSC would benefit by receiving EST. Given that 50% of patients triaged by EMS did not qualify for any acute stroke treatment, a lower percentage of patients would actually benefit from field based diversion. Stroke systems may be better served by focusing on rapid treatment, evaluation, and transfer to endovascular centers than field based diversion strategies.
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Introduction: Both the American Heart and American Stroke Associations recommend pre-notification of potential stroke patients to receiving facilities. Although Emergency Medical Services (EMS) may identify stroke symptoms in the field, initiation of the stroke code process is often postponed until after the patient arrives in the Emergency Department (ED). This could lead to unnecessary delays in assessment and intervention during an acute stroke. Hypothesis: We hypothesized that initiating a stroke code based on advanced notification of stroke symptoms via EMS and a Stroke Code Pit Stop (SCPS) would lead to decreased time of assessment, diagnosticssitics and IV tPA initiation. Methods: A pre- and post-intervention study of 733 patients presenting to 2 EDs in a 5 campus hospital system. Both EDs initiated a SCPS, with pre-notification of stroke symptoms via EMS and stroke code activation prior to patient arrival. Data were reviewed from January 2013-April 2014, comparing code stroke metrics pre- and post...
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Acute stroke patients with dysphagia are at risk of developing pulmonary infection, which increases the risk of death. Therefore, optimal management of dysphagia is essential; however, available evidence supporting the effectiveness of dysphagia treatments is limited. Surface electrical stimulation (e-stim) has been developed as a new treatment modality for dysphagia. In this study, we investigated the efficacy of surface sensory e-stim therapy in preventing pulmonary infection in 53 acute stroke patients with dysphagia. The risk of pulmonary infection was significantly decreased in the general dysphagia/surface e-stim combination therapy group. We considered that surface e-stim therapy can impact dysphagia treatment in acute stroke patients, particularly in preventing pulmonary infection. Future large and randomized studies are needed to evaluate the effects of surface sensory e-stim therapy on acute stroke patients.
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Fall-related sub-acute and non-acute care and rehabilitation-related acute care: what is the impact?
Background Falls are one of the leading causes of injury in older people. Rehabilitation services can assist individuals to improve mobility and function after sustaining a fall-related injury. However, the true impact of fall-related injuries resulting in hospitalisation are often underestimated because of failure to consider sub-acute and non-acute care provided following an acute care episode. Aim To examine fall-related sub-acute and non-acute care and to establish and project the burden of fall-related rehabilitation in acute care to 2020. Method Retrospective review of sub-acute and non-acute records linked to hospital admission and/or emergency department presentations during 2001–2002 to 2008–2009 in New South Wales (NSW), Australia. Analysis of temporal trends and projections to 2020 of rehabilitation-related (ICD-10-AM: Z47, Z48, Z50, Z75.1) acute hospital admissions. Results There were 4317 individuals with a fall-related injury who were admitted to hospital and later admitted for sub-acute and non-acute care; 84% of these were aged 65+ years; 70.4% were female; 27.2% had femur fractures. Total mean FIM scores significantly increased from 78.4 to 94.6 (p<0.0001) between admission and discharge. Fall-related acute rehabilitation episodes are increasing by 9.1% each year for individuals aged 65 years and older and are projected to rise from 18 300 in 2010–11 to 50 000 admissions by 2020. Significance This is the first study to provide a snap-shot of the epidemiological profile of individuals using sub-acute and non-acute care in NSW using linked data. This information can be used to inform resource implications for fall-related sub-acute and non-acute care and acute rehabilitation services.
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