JCPSLP July 2014_Vol16_no2

pathology involvement (Marsh, Bertanou, Souminen, & Ventankachalam, 2010). Adherence to formalised dysphagia screening protocols has been found to reduce the incidence of pneumonia in acute stroke patients (Hinchley et al., 2005; Odderson et al., 1995). In light of the evidence, early dysphagia assessment for people following a stroke is essential to minimise the medical complications that can arise and to reduce the burden on the health care system (Hinchley et al., 2005; Odderson et al., 1995). Currently, in Australia, The National Stroke Foundation Clinical Guidelines for Stroke Management (2010) recommend dysphagia screening within 24 hours of admission to hospital. However, thrombolysed clients represent a vulnerable clinical subgroup. Intracranial haemorrhage is the most significant clinical risk (Wardlaw et al., 2009, 2010; Wardlaw et al., 2012), and medical protocols for management of patients post-thrombolysis have been developed to reduce this and other risks. When assessing a thrombolysed patient for dysphagia, these inherent risks and limitations need to be considered and accounted for. Potential additional risks associated with thrombolysis are significant. A recent review of decision-making tools used within thrombolytic stroke management has indicated that current tools to support decision-making are insufficiently developed (Flynn et al., 2013). Thus, although risks have been identified, clinical protocols for risk minimisation and streamlining operational services are still in their infancy. Speech pathologists must operate within a clear set of guidelines that detail specific risks associated with this population, and then adhere consistently to time-limited or excluded options for patient care. The absence of such guidelines is a significant clinical and operational risk to both patients and staff, as the timing of initial swallowing evaluation for thrombolysed patients necessarily becomes dependent on the clinical protocol surrounding the administration of the thrombolytic agent. Hence, there is a need for the development of a clinical practice protocol for managing thrombolised patients with dysphagia. In the following sections, we outline the process of developing such a protocol at the Logan Hospital Speech Pathology Department. Protocol development Logan Hospital in Queensland is a 328-bed facility located 20 minutes from the local tertiary facility, the Princess Alexandra Hospital in Brisbane. Results from an internal audit indicated that thrombolysis had been implemented for ischaemic stroke management at Logan Hospital since 2011, with a frequency of 13% in 2011 (206 patients with admission diagnosis of stroke, 122 confirmed ischaemic strokes, 11 patients underwent thrombolysis). In 2012, 9 patients underwent thrombolysis out of a total of 155 patients with an admission diagnosis of stroke (excluding confirmed haemorrhagic strokes). The National Stroke Foundation (NSF) recommends a target rate of 20% of ischaemic stroke patients undergoing thrombolysis (NSF, 2012). This figure suggests that the number of thrombolysed patients will increase as facilities aim to achieve the NSF recommendations regarding thrombolysis rates. Aims The primary purpose of developing a protocol was to review and implement the current evidence base for acute

management of dysphagia for speech pathology services to stroke patients undergoing thrombolysis within the Emergency Department and Intensive Care Unit of the Logan Hospital. It aimed to ensure evidence-based practice informed clinical practice to limit patient risk as well as clinician risk. It was hypothesised that the introduction of a clinical protocol would be valuable to the organisation by increasing cost-saving through increased efficiency, reduced length of stay, and reduced incidence of complications. The development of The Logan Hospital Dysphagia Clinical Protocol for Thrombolysed Patients (PTP) included a review of current evidence and best practices, stakeholder engagement, and incorporation of existing risk-mitigation strategies. Literature and practice review and findings A project officer was appointed at 0.2FTE for 6 weeks to oversee the development of the protocol. Initially, a database search of Pubmed, Cochrane and Medline was conducted in March 2012, using the search terms “thrombolysis”, “dysphagia”, “stroke”, “speech pathology”, “swallowing”, “protocol” and “pathway”. This literature review revealed no specific clinical protocols at any facility within Australia or overseas that specifically addressed Furthermore, telephone and email contact with speech pathologists at over 20 local and interstate tertiary institutions revealed no published or informal existing protocols specific to dysphagia management in use. Dysphagia was reported in the literature as a common consequence of stroke within the acute phase of care (e.g., Flowers et al., 2013; Mann, Hankey, & Cameron, 2000; NSF, 2010; Odderson et al., 1995). Dysphagia assessment was referenced within local thrombolysis pathways (Lysis Protocol, Acute Ischaemic Stroke, Clinician Management, Logan Hospital; Lysis Protocol, Acute Ischaemic Stroke, Nursing Management, Logan Hospital) but did not specify clear timeframes and limitations based on clinical timing of assessment. Despite the absence of clinical practice protocols, the literature highlighted a number of risk factors and associated management correlates that required consideration post-thrombolysis. These risk factors and management strategies as per the local thrombolysis pathways (Lysis Protocol, Acute Ischaemic Stroke, Clinician Management, Logan Hospital; Lysis Protocol, Acute Ischaemic Stroke, Nursing Management, Logan Hospital) included that the patient: 1. not to be sat upright within 2 hours; 2. only to be sat upright within 4 hours for urgent assessments; 3. not to brush teeth within 24 hours; 4. not for insertion of catheters/lines within 24 hours; 5. not for mobilising within 6 hours; and 6. swallowing screening/assessment to be completed before administration of oral medications. The above risks and management strategies have been recommended in the literature (e.g., Ahmed et al., 2009; Butcher et al., 2010; Graham, 2003; Ramsey, Smithard & Kalra, 2003) and have implications for speech pathology practice in managing dysphagia in this population. As such, these formed the foundations for the development of the clinical protocol for thrombolysed patients. dysphagia management in the acute phase post- thrombolysis for clients with an ischaemic stroke.

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JCPSLP Volume 16, Number 2 2014

www.speechpathologyaustralia.org.au