JCPSLP July 2014_Vol16_no2

Although early contraindications and limitations to swallow assessments were evident in literature regarding the management of thrombolysed patients, clinical stroke guidelines supported the need for dysphagia assessment within the first 24 hours of admission and prior to any oral intake or administration of oral medications to reduce further complications (NSF, 2010). The early provision of adequate nutrition and hydration is well documented as being critical for optimising functional outcomes for patients. Dehydration has been associated with poorer patient outcomes, including increased complications and mortality (NSF, 2010; Yamaguchi, Minematsu, & Hasegawa, 1997), and may predispose a patient to recurring stroke (Yasaka et al., 1993) or exacerbate the ischaemia of stroke (Harrison, 1989). Hence, timely dysphagia management was deemed to be critical. Consultation Having identified potential clinical risks and strategies that would impact on dysphagia management within the thrombolysed patient group, input from key stakeholders was sought. Internal stakeholders including medical staff, nursing staff, speech pathologists and dieticians were consulted through face-to-face discussions and the project garnered much support across the disciplines. A deadline was given for feedback about the protocol and all feedback was considered and actioned as necessary. Stakeholder engagement ensured a holistic, team-centred approach to meet the clinical and organisational goals for this protocol. The speech pathology representatives led the protocol development, overseen by the project officer. Several key stakeholders within this group had been involved in the development of local medical and nursing clinical protocols for managing thrombolysed patients and therefore were very familiar with the challenges faced when providing acute services to this patient group. Agreed timeframes for dysphagia management adhered to local thrombolysis management pathways for medical and nursing staff. The protocol for thrombolysed patients From the literature and practice reviews and the consultation process, two key documents that identified critical time periods post-administration of thrombolysis were developed, namely, (a) a clinical protocol document, and (b) a decision tree to visually depict the clinical protocol. The decision to use a visual decision tree has since been supported in the literature, with a review of decision-making tools used within thrombolysis published since the implementation of this pathway recommending that methods such as evidenced-based graphical displays be employed to improve interpretability of textual information (Flynn et al., 2013). It is important to state that neurosurgery is not undertaken at Logan Hospital; therefore, haemorrhagic stroke patients deemed eligible for active or surgical management are transferred to the local tertiary facility. Although these patients are, at times, only briefly located within the Logan Hospital prior to transfer, a management stream for these patients was seen as clinically necessary and was included in the visual decision-making tree. Stakeholder feedback was sought following the completion of draft documents. Two recommendations that emerged included the inclusion of a text table regarding use of nasogastric tubes within 24 hours and a clear statement

that patients must remain nil by mouth (NBM) until the Dysphagia Screening Tool (DST) has been passed. Revision and final approval from the executive director of allied health was achieved following this consultation and the protocol was published on local information management systems to ensure 24 hour all-of-hospital access. Figure 1 details the visual decision-making tree for the Logan Hospital PTP, For more explanation and guidelines relating to this tree, see the Appendix. Implementation On introduction of this protocol to the Emergency Department, a series of educational seminars were provided to speech pathology, medical, and nursing staff likely to be involved. These multidisciplinary seminars presented information about thrombolysis and dysphagia assessment, and an elaboration of the new management pathway. Currently, all new speech pathology staff members are given written information and have a face-to-face orientation session to this pathway. The Logan Hospital PTP was first implemented in July 2012. Since that time, over a dozen patients have undergone thrombolysis and have been managed using this clinical protocol. Evaluation To determine the usability and utility of the clinical protocol, a number of evaluation processes have been undertaken. Staff members using the protocol have been interviewed informally regarding pathway utilisation and adherence to recommendations. Anecdotal feedback revealed high use and adherence of the protocol, specifically within the Emergency Department, along with perceptions of improved patient care and reduced risk to staff in terms of non-maleficence. In addition, the Speech Pathology Department is in the process of collecting ongoing data relating to this protocol via clinical chart audit. In recognition that clinical protocols can contribute to organisational cost saving through reducing complications, increasing efficiency, and decreasing length of stay, data including patient length of stay, complications, timing of initial swallow assessment, appropriate use of the clinical pathway, discharge destination, staff feedback and incident reports will be considered. Following completion of this planned evaluation phase, it is possible that some minor modifications to the protocol may be required, in line with standard quality improvement frameworks. Summary and conclusion It is recognised that as the use of thrombolysis post-stroke increases, operational guidelines and clinical protocols to guide the management of patients in the acute phase will be needed to decrease clinical risk and increase operational effectiveness. The present protocol represents a starting point for speech pathology and the management of patients with dysphagia post-thrombolysis. However, the effectiveness and efficiency of services, once such protocols are implemented, need to be thoroughly evaluated. Currently, plans for more formal and rigorous evaluation of this new clinical protocol are underway, and to assist this data collection and analysis, funding has been sought from grant agencies. It is hoped that future formalised evaluation of the Logan Hospital PTP will demonstrate improved services and outcomes for this vulnerable and growing group of patients

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JCPSLP Volume 16, Number 2 2014

Journal of Clinical Practice in Speech-Language Pathology