Nurses' preferred items for dysphagia screening in acute stroke patients: A qualitative study

Background & Aim: Formal dysphagia screening protocols are not yet implemented in some hospitals although there is growing evidence that early dysphagia screening reduces pneumonia rates in stroke patients. Trained professionals are not often available outside weekdays working hours in stroke units, meaning that early screening is usually performed by nurses that use informal detection to screen dysphagia in acute stroke patients. The purpose of this study was to identify which items stroke nurses prioritize in their clinical practice to screen dysphagia in acute stroke patients. Methods & Materials: A qualitative study was developed using a focus group technique in five stroke units with a total of 20 stroke nurses selected by purposive sampling in march 2019. Qualitative Data Analysis Software Miner Lite 4.0 was used to assist in content analysis. Results: Two categories emerged: clinical data and swallowing and non-swallowing signs, each with a set of dimensions. In the category clinical data, relevance was noted for the dimension Glasgow Coma Scale and sex, identified as the most and least relevant, respectively, for dysphagia screening. In the category swallowing and non-swallowing signs no relevance evolved for preferred items. However, in this category, data suggest that nurses find less relevant in clinical practice speech disorders for dysphagia screening. Conclusions: Results reinforce the importance of a standardized approach through the use of valid and reliable dysphagia screening protocols, arguing the need for clear guidance in acute stroke clinical pathways on procedures for dysphagia screening.

Download Full-text

A qualitative study using the Theoretical Domains Framework to investigate why patients were or were not assessed for rehabilitation after stroke

Clinical Rehabilitation ◽

10.1177/0269215516658938 ◽

2016 ◽

Vol 31 (7) ◽

pp. 966-977 ◽

Cited By ~ 6

Author(s):

Elizabeth A Lynch ◽

Julie A Luker ◽

Dominique A Cadilhac ◽

Caroline E Fryer ◽

Susan L Hillier

Keyword(s):

Qualitative Study ◽

Acute Stroke ◽

Health Professionals ◽

Assessment Tool ◽

Theoretical Domains Framework ◽

Assessment Practices ◽

Stroke Units ◽

Changing Practice ◽

Referral Practices ◽

Rehabilitation Assessment

Objective: To explore the factors perceived to affect rehabilitation assessment and referral practices for patients with stroke. Design: Qualitative study using data from focus groups analysed thematically and then mapped to the Theoretical Domains Framework. Setting: Eight acute stroke units in two states of Australia. Subjects: Health professionals working in acute stroke units. Interventions: Health professionals at all sites had participated in interventions to improve rehabilitation assessment and referral practices, which included provision of copies of an evidence-based decision-making rehabilitation Assessment Tool and pathway. Results: Eight focus groups were conducted (32 total participants). Reported rehabilitation assessment and referral practices varied markedly between units. Continence and mood were not routinely assessed (4 units), and people with stroke symptoms were not consistently referred to rehabilitation (4 units). Key factors influencing practice were identified and included whether health professionals perceived that use of the Assessment Tool would improve rehabilitation assessment practices (theoretical domain ‘social and professional role’); beliefs about outcomes from changing practice such as increased equity for patients or conversely that changing rehabilitation referral patterns would not affect access to rehabilitation (‘belief about consequences’); the influence of the unit’s relationships with other groups including rehabilitation teams (‘social influences’ domain) and understanding within the acute stroke unit team of the purpose of changing assessment practices (‘knowledge’ domain). Conclusion: This study has identified that health professionals’ perceived roles, beliefs about consequences from changing practice and relationships with rehabilitation service providers were perceived to influence rehabilitation assessment and referral practices on Australian acute stroke units.

Download Full-text

Timing of Aspirin and Secondary Preventative Therapies in Acute Stroke: Support for Use of Stroke Units

Scottish Medical Journal ◽

10.1177/003693300505000209 ◽

2005 ◽

Vol 50 (2) ◽

pp. 69-72 ◽

Cited By ~ 1

Author(s):

J Reid ◽

M-J MacLeod ◽

D Williams

Keyword(s):

Acute Stroke ◽

Ct Scanning ◽

Medical Ward ◽

Stroke Patients ◽

Stroke Units ◽

General Medical Ward ◽

Brain Scans ◽

Angiotensin Ii Antagonist ◽

Acute Stroke Unit ◽

Ct Brain

Background: We aimed to study the timing of aspirin prescription in ischaemic stroke comparing patients admitted to an acute stroke unit (ASU) directly or via a general medical ward. We also analysed prescription of secondary preventive therapies in stroke patients in an ASU. Methods: Retrospective analysis was made of medical notes and prescription records of 69 patients admitted to an ASU over a three month period to establish timing of aspirin prescription with respect to onset of stroke symptoms, CT brain scan and route of admission to the ASU. Results: CT brain scans were obtained at a median of 2.1 days post stroke (IQ range 1.3–4.3). Patients directly admitted to the ASU received aspirin earlier post admission compared to those admitted via a medical ward (0.7 vs 2.2 days, p<0.01) and were also more likely to receive aspirin prior to CT scan being performed (57% vs 19%, p=0.02). 86% of stroke patients were discharged on an antiplatelet therapy, 79% on a statin, 37% on a thiazide diuretic and 32% on an ACE inhibitor or angiotensin II antagonist. Conclusion: Aspirin was given more promptly in acute stroke and more commonly prior to CT scanning in an ASU compared to a medical ward. Statin therapy is used extensively in stroke but there is a much lower rate of initiation of other secondary preventive therapies (e.g. anti-hypertensive therapy) in hospital. These findings demonstrate a hesitancy in early use of aspirin amongst general physicians and lends support for the use of stroke units.

Download Full-text

Abstract WP274: Improving Door to Ct Time by a Seven Item Stroke Screening Questionnaire for Patients Arriving to ER with Acute Stroke without Prior Notification

Stroke ◽

10.1161/str.48.suppl_1.wp274 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Roni Eichel ◽

Penina Ponger ◽

Nechama Kaufmann ◽

Natan M Bornstein

Keyword(s):

Acute Stroke ◽

Median Time ◽

Screening Method ◽

Triage Nurse ◽

Stroke Patients ◽

Early Screening ◽

Time Intervals ◽

Screening Questionnaire ◽

Prior Notification ◽

Suspected Stroke

Background: Arrival to the emergency room (ER) by ambulance services and prior notification have been identified as major factors for reducing Door to CT and Door to needle time with thrombolysis for patients with acute stroke. Unfortunately despite all efforts to increase the awareness of using ambulances, still 40-50% of patients arrive by private transportation without prior notification of the ER. Objective: We evaluated if a standardized seven item screening questionnaire, performed at the admission office of the ER, can reduce time to triage nurse evaluation and subsequently time of arrival to CT, for patients with acute stroke arriving to the ER without prenotification of the ER. Methods: Since April 2016 a standardized screening questionnaire was performed by the admission clerks at the ER arrival for any patient not referred by prior notification for stroke. This questionnaire included seven major stroke symptoms and time of onset of the symptoms. If one of these symptoms started less than 8 hours before the arrival to the ER the patient was urgently referred to the triage nurse which would then evaluate urgently and activate the a Stroke Code. Patient data was collected of all patients admitted to the ER with a suspected stroke between April-June 2015 and April-June 2016 and time intervals for Door to triage nurse and Door to CT were compared for patients admitted to the ER with suspected Stroke between the time period without questionnaire and with. Results: In the relevant time periods 143 stroke patients were admitted to our ER. Median time from arrival to triage nurse was 16 min (n=96) in 2016 compared to 28 min (n=47) in 2015 (p>0.0001). Patients arriving within 8 hours form symptom onset the median time for arrival to triage nurse was 15 min (n=49) and 28min (n=14) respectively (p=0.006). Median time from arrival to ER to CT brain was 29 min(n=18) for the group that was screened by an early seven point questionnaire at ER admission and stroke code activated versus 78 min(n=14)without early screening and stroke code activation(p=0.069). Conclusion: A standardized seven item stroke symptom questionnaire as an early ER admission screening method can reduce time intervals from arrival to CT for self-referral stroke patients without prior notification of the ER.

Download Full-text

Stroke unities: the role of the occupational therapist and the perception of the multidisciplinary team

MOJ Gerontology & Geriatrics ◽

10.15406/mojgg.2021.06.00276 ◽

2021 ◽

Vol 4 (6) ◽

pp. 102-105

Author(s):

António Arsénio Duarte ◽

Ana Paula Martin ◽

Diana Santos ◽

Rafael Santos ◽

Rita Viegas

Keyword(s):

Acute Stroke ◽

Multidisciplinary Team ◽

Stroke Unit ◽

Occupational Therapist ◽

Medical Emergency ◽

Structured Interviews ◽

Stroke Patients ◽

Stroke Units ◽

The World

Every second a person in the world suffers from a stroke, not surprising, therefore, that stroke is the leading cause of death and morbidity in Portugal. Increasingly, acute stroke is considered a medical emergency. The evidence proves that the treatment of these patients in specialized units (stroke units) is effective in acute stroke. A stroke unit is a hospital area where professionals with specific, well-defined training work, who provide care to stroke patients who are already stabilized, but are still in an acute phase(DGS, 2001). The aim of this study is to understand the role of the occupational therapist in stroke units and to identify the perspective of the multidisciplinary team on their work, clarifying what are the advantages of this professional in the team. The study falls within the qualitative paradigm, exploratory and descriptive. Semi-structured interviews were performed to 39 health professionals. The technique used was the content analysis of interviews. Based on previously established categories, other categories emerged.

Download Full-text

The Preventive Effect of Dysphagia Screening on Pneumonia in Acute Stroke Patients: A Systematic Review and Meta-Analysis

Healthcare ◽

10.3390/healthcare9121764 ◽

2021 ◽

Vol 9 (12) ◽

pp. 1764

Author(s):

Seoyon Yang ◽

Yoo Jin Choo ◽

Min Cheol Chang

Keyword(s):

Acute Stroke ◽

Meta Analysis ◽

Cochrane Library ◽

Inclusion Criteria ◽

Preventive Effect ◽

Stroke Patients ◽

Early Screening ◽

Funnel Plot ◽

Significant Difference

(1) Background: Dysphagia is common in acute stroke patients and is a major risk factor for aspiration pneumonia. We investigated whether the early detection of dysphagia in stroke patients through screening could prevent the development of pneumonia and reduce mortality; (2) Methods: We searched the PubMed, Embase, Cochrane Library, and Scopus databases for relevant studies published up to November 2021. We included studies that performed dysphagia screening in acute stroke patients and evaluated whether it could prevent pneumonia and reduce mortality rates. The methodological quality of individual studies was evaluated using the Risk Of Bias In Non-randomized Studies of Interventions tool, and publication bias was evaluated by the funnel plot and Egger’s test; (3) Results: Of the 6593 identified studies, six studies met the inclusion criteria for analysis. The screening group had a significantly lower incidence of pneumonia than the nonscreening group did (odds ratio (OR), 0.60; 95% confidence interval (CI), 0.42 to 0.84; p = 0.003; I2, 66%). There was no significant difference in mortality rate between the two groups (OR, 0.61; 95% CI, 0.33 to 1.13; p = 0.11; I2, 93%); (4) Conclusions: Early screening for dysphagia in acute stroke patients can prevent the development of pneumonia.

Download Full-text

Swiss guidelines for the prehospital phase in suspected acute stroke

Clinical and Translational Neuroscience ◽

10.1177/2514183x21999230 ◽

2021 ◽

Vol 5 (1) ◽

pp. 2514183X2199923

Author(s):

Georg Kägi ◽

David Schurter ◽

Julien Niederhäuser ◽

Gian Marco De Marchis ◽

Stefan Engelter ◽

...

Keyword(s):

Acute Stroke ◽

Arterial Occlusion ◽

Intravenous Thrombolysis ◽

Current Guideline ◽

Stroke Patients ◽

Stroke Units ◽

Stroke Treatment ◽

Prehospital Phase ◽

Acute Stroke Treatment ◽

The Right

Acute stroke treatment has advanced substantially over the last years. Important milestones constitute intravenous thrombolysis, endovascular therapy (EVT), and treatment of stroke patients in dedicated units (stroke units). At present in Switzerland there are 13 certified stroke units and 10 certified EVT-capable stroke centers. Emerging challenges for the prehospital pathways are that (i) acute stroke treatment remains very time sensitive, (ii) the time window for acute stroke treatment has opened up to 24 h in selected cases, and (iii) EVT is only available in stroke centers. The goal of the current guideline is to standardize the prehospital phase of patients with acute stroke for them to receive the optimal treatment without unnecessary delays. Different prehospital models exist. For patients with large vessel occlusion (LVO), the Drip and Ship model is the most commonly used in Switzerland. This model is challenged by the Mothership model where stroke patients with suspected LVO are directly transferred to the stroke center. This latter model is only effective if there is an accurate triage by paramedics, hence the patient may benefit from the right treatment in the right place, without loss of time. Although the Cincinnati Prehospital Stroke Scale is a well-established scale to detect acute stroke in the prehospital setting, it neglects nonmotor symptoms like visual impairment or severe vertigo. Therefore we suggest “acute occurrence of a focal neurological deficit” as the trigger to enter the acute stroke pathway. For the triage whether a patient has a LVO (yes/no), there are a number of scores published. Accuracy of these scores is borderline. Nevertheless, applying the Rapid Arterial Occlusion Evaluation score or a comparable score to recognize patients with LVO may help to speed up and triage prehospital pathways. Ultimately, the decision of which model to use in which stroke network will depend on local (e.g. geographical) characteristics.

Download Full-text

Actigraphic measurement of the upper limbs movements in acute stroke patients

Journal of NeuroEngineering and Rehabilitation ◽

10.1186/s12984-019-0603-z ◽

2019 ◽

Vol 16 (1) ◽

Cited By ~ 1

Author(s):

Chiara Iacovelli ◽

Pietro Caliandro ◽

Marco Rabuffetti ◽

Luca Padua ◽

Chiara Simbolotti ◽

...

Keyword(s):

Standard Deviation ◽

Motor Activity ◽

Acute Stroke ◽

Motor Performance ◽

Activity Index ◽

Clinical Severity ◽

Upper Limbs ◽

Stroke Patients ◽

Stroke Units ◽

Phi Coefficient

Abstract Background Stroke units provide patients with a multiparametric monitoring of vital functions, while no instruments are actually available for a continuous monitoring of patients motor performance. Our aim was to develop an actigraphic index able both to identify the paretic limb and continuously monitor the motor performance of stroke patients in the stroke unit environment. Methods Twenty consecutive acute stroke patients (mean age 69.2 years SD 10.1, 8 males and 12 females) and 17 bed-restrained patients (mean age 70.5 years SD 7.3, 7 males and 10 females) hospitalized for orthopedic diseases of the lower limbs, but not experiencing neurological symptoms, were enrolled. This last group represented our control group. The motor activity of arms was recorded for 24 h using two programmable actigraphic systems showing off as wrist-worn watches. The firmware segmented the acquisition in epochs of 1 minute and for each epoch calculates two motor activity indices: MAe1 (Epoch-related Motor Activity index) and MAe2 (Epoch-related Motor Activity index 2). MAe1 is defined as the standard deviation of the acceleration module and MAe2 as the module of the standard deviation of acceleration components. To describe the 24 h motor performance of each limb, we calculated the mean value of MAe1 and MAe2 (respectively MA1_24h and MA2_24h). Then we obtained two Asymmetry Rate Indices: AR1_24h and AR2_24h to show the motor activity prevalence. AR1_24h refers to the asymmetry index between the values of MAe1 of both arms and AR2_24h to MAe2 values. The stroke patients were clinically evaluated by NIHSS at the beginning (NIHSST0) and at the end (NIHSST1) of the 24 h actigraphic recordings. Results Both MA1_24h and MA2_24h indices were smaller in the paretic than in the unaffected arm (respectively p = 0.004 and p = 0.004). AR2_24h showed a better capability (95% of paretic arms correctly identified, Phi Coefficient: 0.903) to discriminate the laterality of the clinical deficit than AR1_24h (85% of paretic arms correctly identified, Phi Coefficient: 0,698). We also found that AR1_24h did not differ between the two groups of patients while AR2_24h was greater in stroke patients than in controls and positively correlated with NIHSS total scores (r: 0.714, p < 0.001 for NIHSS, IC95%: 0.42–0.90) and with the sub-score relative to the paretic upper limb (r: 0.812, p < 0.001, IC95%: 0.62–0.96). Conclusions Our data show that actigraphic monitoring of upper limbs can detect the laterality of the motor deficit and measure the clinical severity. These findings suggest that the above described actigraphic system could implement the existing multiparametric monitoring in stroke units.

Download Full-text

Five Years of Acute Stroke Unit Care: Comparing ASU and Non-ASU Admissions and Allied Health Involvement

Stroke Research and Treatment ◽

10.1155/2014/798258 ◽

2014 ◽

Vol 2014 ◽

pp. 1-5

Author(s):

Isobel J. Hubbard ◽

Malcolm Evans ◽

Sarah McMullen-Roach ◽

Jodie Marquez ◽

Mark W. Parsons

Keyword(s):

Length Of Stay ◽

Acute Stroke ◽

Stroke Unit ◽

Allied Health ◽

Stroke Patients ◽

Stroke Units ◽

John Hunter ◽

Acute Stroke Unit ◽

Allied Healthcare ◽

Over Time

Background.Evidence indicates that Stroke Units decrease mortality and morbidity. An Acute Stroke Unit (ASU) provides specialised, hyperacute care and thrombolysis. John Hunter Hospital, Australia, admits 500 stroke patients each year and has a 4-bed ASU.Aims.This study investigated hospital admissions over a 5-year period of all strokes patients and of all patients admitted to the 4-bed ASU and the involvement of allied health professionals.Methods.The study retrospectively audited 5-year data from all stroke patients admitted to John Hunter Hospital(n=2525)and from nonstroke patients admitted to the ASU(n=826). The study’s primary outcomes were admission rates, length of stay (days), and allied health involvement.Results.Over 5 years, 47% of stroke patients were admitted to the ASU. More male stroke patients were admitted to the ASU (chi2=5.81;P=0.016). There was a trend over time towards parity between the number of stroke and nonstroke patients admitted to the ASU. When compared to those admitted elsewhere, ASU stroke patients had a longer length of stay (z=−8.233;P=0.0000) and were more likely to receive allied healthcare.Conclusion.This is the first study to report 5 years of ASU admissions. Acute Stroke Units may benefit from a review of the healthcare provided to all stroke patients. The trends over time with respect to the utilisation of the John Hunter Hospitall’s ASU have resulted in a review of the hospitall’s Stroke Unit and allied healthcare.

Download Full-text

Abstract TP255: The Emergency Department Dysphagia Screen is Associated With Lower Rates of Pneumonia in Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.47.suppl_1.tp255 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Jon W Schrock ◽

Linda Lou

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Data ◽

Pulmonary Infiltrate ◽

T Test ◽

Stroke Severity ◽

Stroke Patients ◽

Early Screening

Introduction: Dysphagia is a common problem in acute ischemic stroke (AIS) patients predisposing them to pneumonia and leading to worse outcomes. The Joint Commission mandated that dysphagia screening be performed at hospital presentation which for most patients with AIS, is the Emergency Department (ED). No evidence exists to demonstrate if the use of an ED dysphagia screen is associated with lower rates of pneumonia. Hypothesis: We assessed the hypothesis that the use of our ED dysphagia screen would not be associated with lower rates of pneumonia in AIS patients. Methods: We performed a pre-post cohort study evaluating the rates of pneumonia in AIS patients presenting to our ED. Our pre group were AIS patients presenting from 2005-2009 and our post group from 2011-2015. The presence of pneumonia was pre-defined as new pulmonary infiltrate treated with antibiotics. We collected demographic and clinical data including rates of dysphagia and stroke severity. Data are presented as frequencies and medians with interquartile ranges (IQR) where appropriate. Rates of pneumonia were compared using the t-test. Results: We evaluated 419 pre screen and 1022 post screen AIS patients. Both groups were 50% female. The use of thombolytics in the pre group was 10% and post group was 11%. The median ages and ED NIHSS scores for the pre and post population were 63 years (IQR 53-73), 6 (IQR 3-10) and 64 years (IQR 56-76), 4 (IQR 2-8). Rates of dysphagia during hospitalization were 20% and 31% for the pre-post groups respectively. Rates of pneumonia for the pre-post groups were 13.8% and 8.0% respectively which was significantly different P=0.0007. Conclusion: The use of an ED dysphagia screen is associated with a lower rate of pneumonia in AIS patients. This study was not designed to prove causation so other factors also may have influenced the lower rate of pneumonia including possibly slightly less severe strokes. The rates of diagnosed dysphagia were higher in the post group suggesting ED screening may heighten awareness resulting in increased diagnoses of dysphagia. Given the rates of dysphagia and pneumonia early screening of AIS patients in the ED seems prudent.

Download Full-text

Distance Neurological Supervision Using Telestroke Does Not Increase Door-to-Needle Time in Acute Ischemic Stroke Management: The Experience of Two Regional Stroke Units

Frontiers in Neurology ◽

10.3389/fneur.2021.616620 ◽

2021 ◽

Vol 12 ◽

Author(s):

Radhika Sood ◽

Jean-Marie Annoni ◽

Andrea M. Humm ◽

Ettore Accolla ◽

Olivier Bill ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Information ◽

Working Hours ◽

Recombinant Tissue Plasminogen Activator ◽

Systematic Evaluation ◽

Stroke Patients ◽

Stroke Units ◽

Admission Time ◽

Baseline Characteristics

Background and Aims: Timely administration of recombinant tissue plasminogen activator (r-tPA) improves clinical outcomes in acute ischemic stroke patients. This study aims to explore the influence of the systematic presence on site of a neurologist compared with telestroke management on door-to-needle time in acute ischemic stroke outside of working hours (OWH).Methods: This retrospective cohort study included all r-tPA-treated patients in the emergency rooms of two Swiss stroke units, Nyon Hospital [Groupement Hospitalier de l'Ouest Lémanique (GHOL)] and Fribourg Hospital [Hôpital de Fribourg (HFR)], between February 2014 and September 2018. Door-to-needle time was analyzed for patients admitted during working hours (WH' weekdays 08:00–18:00) and OWH (weekdays 18:00–08:00, weekends, and public holidays). The latter was compared between centers; OWH, every patient was evaluated prior to thrombolysis by a neurologist on site in GHOL, while HFR adopted distance neurological supervision with teleradiology, performed by telephone evaluation of relevant clinical information with online real-time access to brain imaging.Results: Data were analyzed for 157 patients in HFR and 101 patients in GHOL. No statistically significant differences in baseline characteristics were found for the 258 r-tPA-treated acute ischemic stroke patients, in terms of age, gender, cardiovascular risk factors (hypertension, diabetes, and atrial fibrillation), and pre-Modified Rankin Scale (pre-mRs) between centers, with the exception of smoking and anticoagulation status. Patients in HFR presented with more severe strokes {median National Institutes of Health Stroke Scale (NIHSS) [6 (SD 6.88) (GHOL), 8 (SD 6.98) (HFR), p = 0.005]}. No significant differences in baseline characteristics were found as per admission time independently of the center. Door-to-needle time was significantly longer in the HFR cohort when compared with GHOL, irrespective of admission time. Both centers demonstrated significantly longer median door-to-needle time OWH. However, analysis of the door-to-needle time differences between WH and OWH showed no significant interaction using robust ANCOVA WRS2 analysis (p = 0.952) and a Bayesian model (BF01 = 3.97).Conclusions: On-site systematic evaluation by a neurologist did not appear to influence door-to-needle time OWH, suggesting distance supervision may be time-efficient in thrombolysis. This supports existing prospective studies in hyperacute telestroke management. The relevance lies in optimizing resource use considering the increasing demand for emergency neurological management.

Download Full-text