Early Dysphagia Screening to Reduce Aspiration Pneumonia in Stroke Patients

Early Dysphagia Screening to Reduce Aspiration Pneumonia in Stroke Patients
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Table of Contents Project Overview.. 4 Project Description. 4 Project Rationale. 4 Personal/Professional Expectations. 5 Project Goals. 5 Analysis of the Literature. 6 Procedure. 7 Findings. 7 Introduction. 7 Purpose. 8 Significance. 9 Literature Review on Early Dysphagia Screening in Stroke Patients. 11 Main Findings from the Literature Review.. 12 What Counts as Early Dysphagia Screening. 12 Incidence of Dysphagia in Stroke Patients. 12 Predictors of Dysphagia and Dysphagia Screening. 13 Dysphagia and Stroke-Associated Pneumonia. 14 Effects of Early Dysphagia Screening. 15 Implementation of Dysphagia Screening. 17 Summary of the Literature. 18 Methods. 18 Design. 18 Setting. 19 Participants. 19 Data Collection Methods. 20 Interviews. 20 Survey. 21 Discussion of Findings. 21 Recommendations. 23 Conclusion. 24 References. 26 Appendices. 32 Appendix A: Interview Questions. 32 Appendix B: Survey Questions. 32 Project Overview
Project Description
The nursing practicum project, which took place at the Presbyterian hospital in New York, was about early dysphagia screening in stroke patients. The project aimed to establish whether dysphagia screening reduces the risk of aspiration pneumonia among stroke patients. The project utilized the water swallow screen for dysphagia detection.
Project Rationale
This project was important because it benefited patients and the nursing practice. First, I found it necessary to do a project on dysphagia screening because national and international guidelines recommend it for stroke patients 4-24 hours after being admitted to the hospital (Eltringham et al., 2018). Yet, there is a gap between recommendation and practice because dysphagia screening for stroke patients is not as routine practice as it should be (Sivertsen et al., 2017). Therefore, this was a necessary project that would first identify the effectiveness of dysphagia screening among stroke patients and then ensure that it becomes routine practice at the hospital.
This project benefited mostly stroke patients because it would ensure they receive optimum care, including dysphagia screening, at the time of stroke diagnosis. As Palli et al. (2017) indicate, dysphagia screening reduces aspiration pneumonia and the length of hospital stay among stroke patients. It would also improve nursing science and practice by contributing to nursing research and promoting the use of evidence-based practice in nursing.
Personal/Professional Expectations
As I established the project, I hoped I would become more competent in leadership, quality improvement, interprofessional collaboration, and clinical prevention, especially as I transition to a nurse with a mastery understanding of the nursing practice. I believe I would efficiently provide optimum care to my patients through improved competency in the areas mentioned earlier. I also hoped that the project would challenge my thinking, especially about the nursing profession, and allow me to apply critical thinking and decision-making in the real world as I interact with patients and other healthcare professionals.
I hoped that this project would allow me to identify my strengths and weaknesses, both at a personal and professional level. On a more personal level, I hoped that it would allow me to contribute to the world by changing the lives and experiences of the people I would interact with during the project.
Project Goals
This project's long-term goal was to facilitate process improvement through the use of early dysphagia screening to reduce aspiration pneumonia among stroke patients.
The short-term goals were:
* To train other team members about dysphagia screening through education sessions
According to Abu-Snieneh and Saleh (2018), healthcare professionals, such as nurses, provide direct primary care to stroke patients with dysphagia. As such, they should be competent in assessing and managing dysphagia. Training the team members about dysphagia screening would enhance their competency.
* To create a patient education program about dysphagia screening
According to Krekeler et al. (2018), stroke patients with dysphagia should be able to follow dysphagia recommendations even when there is no direct supervision from healthcare professionals. Their ability to adhere to the recommendations is supported by self-management and self-efficacy skills. This ability can only be achieved through patient education.
* To educate families about dysphagia screening
Families provide support to their loved ones, and as such, they need to also learn about dysphagia and dysphagia interventions to best support stroke patients.
Analysis of the Literature
Stroke patients are at significant risk of developing dysphagia and, consequently, aspiration pneumonia. However, early dysphagia screening reduces the risk of aspiration pneumonia among stroke patients, and as such, it should be standard practice (Eltringham et al., 2018; Palli et al., 2017). Also, dysphagia screening facilitates the identification of high-risk patients. This is because patients can either fail or pass dysphagia screening, and those who fail are more likely to aspire and experience stroke-related pneumonia and death (Ouyang et al., 2020; Joundi et al., 2017). As such, it is vital to perform dysphagia screening for early dysphagia identification. Yet, Sivertsen et al. (2017) reveal that there exists a gap between dysphagia screening recommendations and practice because many healthcare professionals have not incorporated dysphagia screening as a routine practice. This is an indication of the low integration of evidence into practice. I carried out the practicum project to support early dysphagia screening and provide additional evidence on the effect of dysphagia screening with the hope that this endeavor will enhance evidence-based practice.
Procedure
After settling on dysphagia screening among stroke patients as my practicum project, I created the project’s objectives to guide my work. I also identified the current best evidence to support my practicum project. It is through this process of evidence identification that I decided to use water swallow screening for dysphagia in stroke patients. This type of swallow screen is the most common and is easy to use (Mulheren & Gonzalez-Fernandez, 2019). It is also the least invasive and can facilitate early detection of dysphagia, therefore promoting patient safety. I engaged the relevant stakeholders about the swallow screen and provided the necessary educational resources to encourage the implementation of dysphagia screening. I also performed the test on patients to establish the effectiveness of dysphagia screening among stroke patients.
Findings
The results of the project revealed that most of the patients who passed the water test did not experience aspiration. This demonstrates that dysphagia screening can reduce the risk of aspiration pneumonia among stroke patients. The stakeholders were satisfied with the results, and all agreed that the test was easy to take and less time-consuming (it only took one minute), and as such, it can be easily incorporated into routine practice.
Introduction
Stroke patients may experience stroke-related complications that threaten their health and quality of life. One of the significant stroke-related complications is pneumonia. Eltringham et al. (2020) reveal that about 14% of stroke patients develop stroke-related pneumonia. According to Grossmann et al. (2021), stroke-related pneumonia is caused by aspiration resulting from weak swallowing reflexes. In addition, one of the risk factors for stroke-related pneumonia is dysphagia. In fact, Feng et al. (2019) indicate that about 30-65% of stroke patients experience dysphagia, which is associated with more extended hospitalization due to aspiration pneumonia and malnutrition, increased risk of morbidity and mortality, and a significant burden on the healthcare system. As such, it is important to identify patients at risk of developing stroke-related pneumonia early enough so that effective prevention interventions can be applied. Sivertsen et al. (2017) reveal that if aspiration pneumonia can be detected early, the risk of developing pulmonary complications can be significantly reduced. Also, the risk of death from stroke-related pneumonia can be avoided. Eltringham et al. (2020) recommend that the risk of stroke-related pneumonia can be reduced through improved swallowing assessment. Healthcare professionals are responsible for applying evidence-based interventions to improve the health outcomes of stroke patients, especially by reducing aspiration pneumonia.
Purpose
This project aimed to establish whether early dysphagia screening is effective in reducing aspiration pneumonia among stroke patients. According to Joundi et al. (2017) and Sivertsen et al. (2017), evidence-based guidelines recommend that all patients with acute stroke should undergo dysphagia screening within the first few hours after hospital admission. Grossmann et al. (2021) also reveal that patients who receive an early dysphagia diagnosis within the first 24 hours of admission were less likely to develop aspiration pneumonia than those who did not receive an early dysphagia diagnosis. Yet, in practice, the implementation of early dysphagia screening is not at par with the guidelines recommended (Sivertsen et al., 2017). The first purpose of this project was to understand the effectiveness of early dysphagia screening in reducing aspiration pneumonia among stroke patients. The second purpose was to promote the implementation of early dysphagia screening to improve stroke patients' health outcomes. The project focused on patients who have been diagnosed with acute stroke and are at risk of developing stroke-associated pneumonia. For this project, stroke-related pneumonia was defined as a range of pulmonary infections that develop in patients within seven days after a stroke diagnosis (Chen et al., 2021). The results of the study will provide evidence that is significant to nursing practice.
Significance
The nursing profession is responsible for improving the quality of patient care and patient outcomes. According to Bridges et al. (2020), nurses are only able to improve patient care if they draw from evidence that supports the best nursing care practices. This project facilitated good nursing care practices when it comes to stroke patients by providing evidence on the effectiveness of dysphagia screening in reducing aspiration pneumonia in stroke patients. Although there are guidelines that recommend early dysphagia screening, there exists a gap between practice and recommendation (Sivertsen et al., 2017). This project will help in closing that gap by providing evidence to support early dysphagia screening. This might increase adherence to recommendations and, as a result, reduce the risk of aspiration pneumonia in stroke patients. The findings of this project also have the potential of being incorporated into a quality improvement program for a healthcare institution where dysphagia screening has not yet been implemented.
In addition, this project will also investigate dysphagia as an intervention in aspiration pneumonia. This investigation might make it clear why nurses are not implementing early dysphagia screening despite the recommended guidelines. Is it because early dysphagia screening will be an additional practice in their already heavy workload? Is it because they are not able to translate research into practice? According to Bridges et al. (2020), research that investigates interventions informs policy. It also identifies areas of practice improvement so that nurses can provide quality and safe care. By examining early dysphagia screening as an intervention for reducing stroke-related pneumonia, this project will identify areas of practice improvement and inform healthcare policy.
The nursing profession and practice rely significantly on existing knowledge. This project will add to the existing literature on dysphagia screening. Other nurses and healthcare professionals can synthesize information from this project and use it to advance nursing practice. It will also be a source of evidence that can be applied to nursing practice. As Chien (2019) indicates, there is a link between research and nursing practice because the former provides knowledge, and the latter relies on this knowledge to establish the best evidence for nursing practice. In addition, nursing research is not limited to discovery; it also encompasses the translation of evidence into practice, which is what this project will accomplish.
Also, nurses and other healthcare professionals have a responsibility to provide preventative services that protect patients from health complications and improve population health. This project will provide evidence on the effectiveness of dysphagia screening in reducing the risk of aspiration pneumonia. Since evidence-based guidelines recommend early dysphagia screening for stroke patients (Joundi et al., 2017; Sivertsen et al., 2017), it is essential to facilitate the implementation of dysphagia screening as a preventative approach. This project will support the utilization of evidence-based preventative strategies such as dysphagia screening to reduce the risk of stroke-related pneumonia and its associated health complications.
Further, this project will facilitate communication among healthcare professionals. The management of dysphagia requires an interprofessional approach to ensure that patients receive the best services (McGinnis et al., 2018). In dysphagia screening and management, an interprofessional team of nurses, speech and language pathologists, dietitians/nutritionists, and physicians, among others, must work together to provide effective and safe care. Since this project will investigate the effectiveness of dysphagia screening among stroke patients, it will indirectly promote interprofessional communication when it is implemented in healthcare facilities based on the project's recommendation. To properly work together, healthcare professionals from multiple disciplines must communicate effectively. This project will also promote communication among professionals in the field because it will contribute to the discussion about the effectiveness of dysphagia screening. The information from the results of this project will be used by professionals to support their argument for and against dysphagia screening if any, because it is a source of best evidence. The different professionals can also learn from this project and consult with each other on how to improve the implementation of dysphagia screening to make it a routine practice in the management of stroke patients.
Literature Review on Early Dysphagia Screening in Stroke Patients
To establish what is already known about dysphagia screening in stroke patients and identify an information gap, if any, an electronic search was conducted. Cochrane Library, PubMed Central, and Google Scholar databases were used to search for articles that were no older than five years. The search terms ‘dysphagia in stroke patients,’ ‘dysphagia screening in stroke patients,’’ dysphagia and stroke-associated pneumonia,’ and ‘aspiration pneumonia in stroke patients’ were used. About thirty articles on the topic of dysphagia and pneumonia in stroke patients were yielded and are the focus of this literature review. The goal is to understand what is known about the topic in terms of what counts as early dysphagia screening, dysphagia incidence, predictors of dysphagia and dysphagia screening, as well as the effects of dysphagia screening on stroke patients.
Main Findings from the Literature Review
What Counts as Early Dysphagia Screening
In their article on delays in dysphagia screening after acute stroke, Bray et al. (2017) stipulate that there is a lack of strong evidence on how quickly dysphagia screening should be done to yield the required results. To fill this gap in information, they conducted a study on 63,650 patients with acute stroke. They established that in the first 24 hours, the risk of stroke-associated pneumonia increased by 3% and after 24 hours, the risk increased by an additional 4% (Bray et al., 2017). Indeed, the risk of developing stroke-associated pneumonia rises as the patient delays in receiving dysphagia screening. Grossmann et al. (2021) support this finding that the first few hours of admission are crucial for the detection of dysphagia and the prevention of stroke-associated pneumonia. Also, Eltringham et al. (2018) indicate that it is recommended for dysphagia screening to be done within 4-24 hours after hospital admission. It is unclear from the literature why dysphagia screening needs to wait for at least those 4 hours before it can be initiated. However, it is clear that dysphagia screening should occur within the first 24 hours after hospital admission. Any screening that occurs after 24 hours should not be considered an early intervention for stroke-associated pneumonia because the risks of developing pneumonia increase significantly after the first 24 hours.
Incidence of Dysphagia in Stroke Patients
Dysphagia is a common complication experienced by stroke patients and contributes to the risk of stroke-associated pneumonia. In a prospective clinical trial conducted at a university hospital in Belgium, De Cock et al. (2020) established that the incidence of dysphagia among 151 stroke patients with first ischemic stroke was 23%. However, this incidence was lower than what has been reported previously in other clinical trials. It is unclear why the incidence was lower in this particular study. De Cock et al. (2020) claim that the incidence rate in their study was significantly lower can be substantiated by findings from other studies. For instance, Rofes et al. (2018) conducted an observational cohort study that established that the incidence of oropharyngeal dysphagia was 45%. Kim et al. (2020) indicate that the incidence of dysphagia varies from 50% to 80%. However, it is unclear whether this prevalence rate is at a local, national, or global level. In a systematic review, Pacheco-Castilho et al. (2019) found that the incidence rate of dysphagia in Brazil was 59% to 76%. Oliveira et al. (2019) also reveal that the incidence varies from 8% to 80% depending on the methodology, assessment, and the time that has passed between admission and assessment. Jones et al. (2020) add that the varying incidence rates of dysphagia are a result of varying definitions of dysphagia which can be defined in terms of diet modifications or the scores after a dysphagia screening among others. What this does is confirm that dysphagia among stroke patients is significantly high and requires interventions that facilitate early detection.
Predictors of Dysphagia and Dysphagia Screening
After examining dysphagia screening among stroke patients in China, Liang et al. (2022) found that the main predictors of dysphagia and dysphagia screening were admission to stroke units and the lack of past stroke history. Patients admitted to non-stroke units, those with a history of stroke, and those with a high score based on the National Institute of Health Stroke Scale (NIHSS) were less likely to be screened for dysphagia. Liang et al. (2022) attributed the lack of screening to the probability that in severe stroke, dysphagia might not be a care priority. Yet, Joundi et al. (2017) found that the main predictor of dysphagia and dysphagia screening was the severity of stroke. They established that compared to patients with severe strokes, patients with mild strokes were less likely to be screened for dysphagia. This differs from Liang et al. (2022), who found that patients with high NIHSS scores (severe stroke) were less likely to be screened for dysphagia. Rofes et al. (2018) further reveal that in addition to past stroke history and high NIHSS scores, other predictors of dysphagia necessitating dysphagia screening were old age and high stroke lesion volume. The location of the lesion also predicts and influences the development of dysphagia in stroke patients (Fernandez-Pombo et al., 2019).
Other predictors include male gender (Henke et al., 2017), speech deficit, and admission to an intensive care unit (ICU), step-down unit, or a stroke unit (Joundi et al., 2017). The findings of Joundi et al. (2017) differ from those of Liang et al. (2022) because Joundi et al. (2017) found that admission to other non-stroke units also warrants a dysphagia screening. However, Jones et al. (2020) reveal that there are quite a number of predictors of dysphagia, and the less commonly mentioned ones in the literature include higher Glasgow Coma Scale on admission, facial palsy, hemorrhagic vs. ischemic stroke, malnutrition/low BMI at admission, brainstem involvement, and presence of dysarthria, among others. This reveals that dysphagia screening is driven by many factors, which can vary from patient to patient.
Dysphagia and Stroke-Associated Pneumonia
The risk of developing stroke-associated pneumonia is highly associated with dysphagia (Eltringham et al., 2020). According to a systematic review by Pacheco-Castilho et al. (2019), the prevalence of developing stroke-associated pneumonia when a patient has dysphagia is 22%, while the prevalence when a patent has no dysphagia is 2%. Further, in a study by Feng et al. (2019), where stroke patients were classified into dysphagia and non-dysphagia groups, the results revealed that compared to the non-dysphagia group, patients in the dysphagia group were approximately four times more likely to develop stroke-associated pneumonia. This was within a period of one year. Also, the rate of mortality was higher in the dysphagia group. Chang et al. (2022), through a systematic review, also found that the incidence of stroke-associated pneumonia was higher in the dysphagia group when compared to the non-dysphagia group. However, unlike Feng et al. (2019), Chang et al. (2022) found no significant difference in the rate of mortality between the dysphagia and non-dysphagia groups.
However, Phan et al. (2019) and Liang et al. (2022) reveal that stroke-associated pneumonia is caused by more than just dysphagia; it is also caused by the severity of the stroke, older age, and comorbidity, which are also predictors of dysphagia. In addition, whether a patient receives dysphagia screening or not determines whether they will develop stroke-associated pneumonia (Liang et al., 2022). Patients who receive dysphagia screening early are less likely to develop pneumonia. Verma (2019) adds that one of the significant risk factors for stroke-associated pneumonia is dysphagia and related aspiration. As such, one of the interventions that can help reduce this risk is early detection of dysphagia, which can be achieved through early screening. The literature reveals that there is a strong relationship between dysphagia and aspiration pneumonia and that early screening can be beneficial to stroke patients.
Effects of Early Dysphagia Screening
Early dysphagia screening is recommended, especially before any medication or food is given orally, because it is associated with a reduction in the rate of pneumonia (Sivertsen et al., 2017). As Schrock et al. (2017) reveal in their study, the rate of hospital-acquired pneumonia among stroke patients was reduced by approximately 6% after dysphagia screening in the emergency department (ED) was implemented. This decline shows that when dysphagia screening is done as soon as stroke patients get to the ED and before they are admitted to various units, their chances of developing stroke-associated pneumonia are significantly lowered. Melgaard et al. (2020) conducted a study to establish the feasibility as well as outcomes ...