NEED FOR IMMEDIATE SWALLOWING SCREENING IN POST STROKE PATIENTS
Stroke is the leading cause of severe neurological disability in adults and is allied with an array of complications. Dysphagia complicates acute ischemic strokes (AIS) in 42% cases and is more evident during the first week after ischemic stroke. Chest infection complicates AIS in 32% of the cases and 89% of these cases are due to dysphagia1 Pneumonia in stroke patients is often associated with aspiration. Swallowing assessment at time of admission in stroke patients can help in minimizing risk of pneumonia in stroke patients. A common perception is that Islamabad being the federal capital should be the model which should be replicated, however, despite its small size in both territorial and population terms although being endowed with adequate financial resources the provision of health services in the suburbs is not satisfactory. This situation is not unique to Islamabad; same situation is prevalent in all cities of Pakistan and other developing countries. Visits and interviews conducted in ICT indicated that currently no government or private hospital have any protocol for swallowing assessment at time of admission for stroke patients.
There is ample evidence that best practice in the care of patients with stroke is the early screening and identification of dysphagia as it allows for timely intervention resulting in reduced morbidity, length of stay, and health care expenditures. To ensure early detection of dysphagia, and to prevent dysphagia-related complications, screening of all stroke patients at time of admission for signs of swallowing issues is advisable. When a swallowing screening protocol is implemented, there is a decrease in morbidity over each year that the protocol is in place2. Implementation of strict swallowing screening protocol for patients with stroke, can improve clinicians’ adherence with screening swallowing before starting oral feed. American Heart Association/American Stroke Association (AHA/ASA) included screening of swallowing before starting oral feed , liquid, or medication in individuals presenting with stroke symptoms as part of their guidelines on the early management of adults with acute stroke. Completion of dysphagia screening prior to administration of oral intake was a Joint Commission (JC) required performance measure for Primary Stroke Center Certification until year 20103.
Many acute care facilities in developed countries have protocols according to which screening for dysphagia will be completed and documented on all ischemic /hemorrhagic stroke patients including warning strokes before food, fluids, or medication are started. Screening methods may include, but are not limited to, (a) water swallow tests, such as the Burke water swallow test or the 3 oz. Water swallow test (Suiter & Leder, 2008); (b) swallowing screening protocols including brief assessments of oral motor and sensory function as well as water swallow tests, such as the Toronto Bedside Swallowing Screening Test or the Simple Standardized Bedside Swallowing Assessment; or (c) clinical (bedside) Swallow examinations.4
Developing countries are still busy fighting communicable diseases and are unable to pay much attention to non communicable diseases such as stroke, although the number of stroke patients added to population increase the already existing BOD for these nations many fold. A study was conducted in India with aim to develop a bedside assessment protocol and grading scale for oro pharyngeal dysphagia. The Nair hospital bedside swallowing assessment (NHBSA) and Nair hospital swallowing ability scale (NHSAS) were developed after reviewing related literature. The NHBSA and NHSAS show high reliability and high face and content validity. Comparison with modified barium swallow revealed that the NHBSA appears to show potential in precisely identifying dysphagia and aspiration. 'Wet-gurgly voice quality,' 'cough after/during swallow ‘and’ weak/absent volitional cough' was the clinical indicators that appeared to properly discover presence of aspiration risk.
Guidelines and Pathways (protocols) are necessary to ensure quality care in health care facilities. The skills and competencies outlined in practice standard guide and protocols are important components in the provision of standardized quality health care. Patients tends to receive the greatest benefit when a number of health-care professionals team up, each bringing his/her own particular expertise to assessment and treatment of dysphagia. According to practice standards and guidelines for dysphagia intervention by speech- language pathologists given by College Of Audiologists And Speech Language Pathologists Of Ontario “Any regulated health professional trained in the clinical assessment of patients/clients (e.g. nurses, physicians, dietitians, physiotherapists, and occupational therapists) may conduct swallowing screening. Speech pathologists, however, can play a fundamental role in making dysphagia screening programs and educating those who conduct screening regarding the appropriate interpretation of findings.6
Keeping in view current health care services in our country, planning to have speech pathologist available at all emergency departments for swallowing screen appears to be almost impossible; we will need to train our allied health staff for initial dysphagia screening in emergency departments . All hospitals of Islamabad having emergency departments and catering stroke patients should make an effort to include dysphagia screening in their stroke care protocols at time of admission
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