National guidelines recommend dysphagia screening (DS) before any oral intake in hospitalized stroke patients to reduce the risk of hospital-acquired pneumonia (HAP). We examined the relationship between DS and HAP in acute ischemic stroke patients in the Get With the Guidelines-Stroke (GWTG-S) program.
Methods:
Data from 1251 GWTG-S hospitals from 04/01/2003 to 03/01/2009 were analyzed. GWTG-S defines HAP as a clinical diagnosis of pneumonia requiring antibiotics. Use of a bedside, evidence-based swallow screen prior to any oral intake qualified as a DS. Univariate analyses (chi-square for categorical variables or Wilcoxon for continuous variables) and multivariate logistic regression analyses were performed to examine the relationship between DS and HAP, adjusting for patient and hospital characteristics
Results:
Among 365,726 ischemic stroke patients, 213097 (59.83%) underwent DS, and 25,166 (6.88%) developed HAP. When compared to patients without pneumonia (
Table 1
), patients with HAP were older and more frequently had CAD/MI, diabetes, prior stroke/TIA, dyslipidemia, atrial fibrillation. They, underwent DS less often, and had increased length of stay, morbidity and in-hospital mortality. Among the subgroup who had NIHSS recorded (n=160,837, 44%), HAP patients had higher median NIHSS (13 vs. 5). Among patients with NIHSS<2, 3.3% developed HAP. In multivariate analysis, factors independently associated with a lower risk of HAP were DS (OR 0.86 [0.83-0.90]), female (OR 0.83 [0.81-0.85]), dyslipidemia (OR 0.84 [0.82-0.86]), and hypertension (OR 0.96 [0.94-0.98]).
Discussion:
Our data suggests that dysphagia screening is associated with a lower likelihood of HAP, but screening rates remain low. Strategies that increase the rate of dysphagia screening among all stroke patients, even those with mild strokes, should be more broadly implemented. Prospective validation of these findings is warranted.
Table 1.
Unadjusted associations between patient and hospital characteristics and clinical outcomes
Overall(% or value)
HAP(% or value)
No HAP(% or value)
Study Population
365726 (100%)
25166(6.9%)
340560(93.1%)
Age (years) Median (IQR)
73(61, 82)
77(66, 85)
73(61,82)
Female
52.5
49.2
52.8
Dysphagia Screen Performed
59.8
54.8
60.2
In Hospital Death
5.7
18.1
4.8
P-values are <.0001 for all comparisons and are based on Chi-square test (for dichotomous and nominal factors) or Wilcoxon test (for ordinal and continuous factors)
Infections Present on Admission Compared with Hospital-Acquired Infections in Acute Ischemic Stroke Patients
