JCPSLP July 2014_Vol16_no2

Policy and practice

Management of dysphagia in thrombolysed stroke patients Development of a preliminary clinical practice protocol Jennifer Davis, Elizabeth Cardell and Anne Coccetti

The use of thrombolysis in specified patient presentations is supported in the acute phase following ischaemic stroke by stroke clinical guidelines. However, thrombolysis is associated with a number of complications and risks. Further, thrombolysis protocol violations have been associated with increased patient mortality. Although the risks associated with thrombolysis and non-compliance with protocols are recognised, a review of literature and benchmarking suggested that no specific protocols existed to guide speech pathologists through dysphagia management during the critical time period directly post- thrombolysis. As a result, Logan Hospital Speech Pathology Department sought to develop an evidence-based clinical practice protocol to standardise dysphagia service delivery and limit patient and staff risk. This paper presents a review of literature in this area and details regarding the development of The Logan Hospital Dysphagia Clinical Protocol for Thrombolysed Patients. Background Ongoing improvements to services via operational changes are central for ensuring the optimisation of clinical care. The standardisation of clinical processes through the development of clinical practice protocols has been found to be an effective strategy to reduce variations and to minimise the probability of clinical errors and enhance client outcomes (Kohn, Corrigan, & Donaldson, 2000). Furthermore, clinical protocols have been shown to be a useful medium for ensuring maintenance of quality of clinical care across a range of clinical areas in the current cost-conscious environment (Owen et al., 2006; Panella, Moran, & Di Stanislao, 1997; Pearson, Goulart-Fisher, & Lee, 1995; Wentworth & Atkinson, 1997). Specifically, the implementation of clinical protocols has been shown to positively impact on clinical costing via decreased length of stay, improved efficiency of staff, waste reduction, and reducing complications (Korpiel 1995; Martin, Doig,

Heyland, Morrison & Sibbald, 2004). For example, adherence to formalised dysphagia screening protocols has been found to reduce the incidence of pneumonia in acute stroke (Hinchley et al., 2005; Odderson, Keaton, & McKenna, 1995). Thrombolysis, which is the dissolving of blood clots through pharmacological means, is increasingly being used in metropolitan and regional hospitals in the hours following acute ischaemic stroke (Sung, Ong, Wu, Hsu, & Su, 2010), with RCTs suggesting improved outcomes and reduced disability at 3 months post-stroke (Simpson, Dewey & Parsons, 2010). However, this intervention is not without its risks. Following thrombolysis, patients have heightened risk of catastrophic outcomes such as intracranial haemorrhage (Wardlaw, Murray, Berge, & del Zoppo, 2009, 2010; Wardlaw et al., 2012) and systemic bleeding (Wardlaw, Koumellis, & Liu, 2013). Importantly, a correlation has been found between thrombolysis protocol violations and increased mortality (Ahmed et al., 2009). Dysphagia is a well-recognised consequence of stroke, with a prevalence rate of 47% cited in the most recent national stroke audit (National Stroke Foundation, 2009), and an incidence of 44% cited by Flowers, Silver, Fang, Rochon, and Martino (2013). Medical complications associated with dysphagia include chest infection, dehydration, reduced dietary intake, malnutrition, aspiration, asphyxiation and increased mortality (e.g., Chouinard, Lavigne, & Villeneuve, 1998; Foley, Martin, & Salter, 2009; Low, Wyles, Wilkinson, & Saisbury, 2001; Martino et al., 2005; Perry & Love, 2001; Smithard et al., 1996; Whelan, 2001). Aspiration has been reported in 19.5% to 42% of people within the first 5 days post-stroke (Kidd, Lawson, Nesbitt, & McMahon, 1995; Marik & Kaplan, 2003). These complications have been found to contribute to increased length of stay and patient costs (Odderson et al., 1995), as well as to an increased risk of discharge to institutional care (Smithard et al., 1996). A review of the literature reveals significant health costs related to the impact of dysphagia, for example, around $547 million annually in the acute hospital setting (Altman, Yu, & Schaeffer, 2010). Aspiration pneumonia results in a three-fold increased risk of death within 30 days post- diagnosis (Cabre, Serra-Orat, & Palomera, 2010) and is expensive, with a mean cost of $17,000 per episode of treatment in Ontario (Sutherland, Hamm, & Hatcher, 2010). A decrease in annual cost for chest infection treatment in hospital has been found when there is speech

KEYWORDS THROMBOLYSIS DYSPHAGIA CLINICAL PROTOCOL RISK MANAGEMENT GUIDELINES THIS ARTICLE HAS BEEN PEER- REVIEWED

Jennifer Davis (top), Elizabeth Cardell (centre) and Anne Coccetti

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JCPSLP Volume 16, Number 2 2014

Journal of Clinical Practice in Speech-Language Pathology