Policy and practice
90
JCPSLP
Volume 16, Number 2 2014
Journal of Clinical Practice in Speech-Language Pathology
KEYWORDS
THROMBOLYSIS
DYSPHAGIA
CLINICAL
PROTOCOL
RISK
MANAGEMENT
GUIDELINES
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
Management of dysphagia
in thrombolysed stroke
patients
Development of a preliminary clinical practice protocol
Jennifer Davis, Elizabeth Cardell and Anne Coccetti
Heyland, Morrison & Sibbald, 2004). For example,
adherence to formalised dysphagia screening protocols has
been found to reduce the incidence of pneumonia in acute
stroke (Hinchley et al., 2005; Odderson, Keaton, &
McKenna, 1995).
Thrombolysis, which is the dissolving of blood clots
through pharmacological means, is increasingly being used
in metropolitan and regional hospitals in the hours following
acute ischaemic stroke (Sung, Ong, Wu, Hsu, & Su, 2010),
with RCTs suggesting improved outcomes and reduced
disability at 3 months post-stroke (Simpson, Dewey &
Parsons, 2010). However, this intervention is not without its
risks. Following thrombolysis, patients have heightened risk
of catastrophic outcomes such as intracranial haemorrhage
(Wardlaw, Murray, Berge, & del Zoppo, 2009, 2010;
Wardlaw et al., 2012) and systemic bleeding (Wardlaw,
Koumellis, & Liu, 2013). Importantly, a correlation has
been found between thrombolysis protocol violations and
increased mortality (Ahmed et al., 2009).
Dysphagia is a well-recognised consequence of stroke,
with a prevalence rate of 47% cited in the most recent
national stroke audit (National Stroke Foundation, 2009),
and an incidence of 44% cited by Flowers, Silver, Fang,
Rochon, and Martino (2013). Medical complications
associated with dysphagia include chest infection,
dehydration, reduced dietary intake, malnutrition, aspiration,
asphyxiation and increased mortality (e.g., Chouinard,
Lavigne, & Villeneuve, 1998; Foley, Martin, & Salter, 2009;
Low, Wyles, Wilkinson, & Saisbury, 2001; Martino et al.,
2005; Perry & Love, 2001; Smithard et al., 1996; Whelan,
2001). Aspiration has been reported in 19.5% to 42% of
people within the first 5 days post-stroke (Kidd, Lawson,
Nesbitt, & McMahon, 1995; Marik & Kaplan, 2003). These
complications have been found to contribute to increased
length of stay and patient costs (Odderson et al., 1995), as
well as to an increased risk of discharge to institutional care
(Smithard et al., 1996).
A review of the literature reveals significant health costs
related to the impact of dysphagia, for example, around
$547 million annually in the acute hospital setting (Altman,
Yu, & Schaeffer, 2010). Aspiration pneumonia results in a
three-fold increased risk of death within 30 days post-
diagnosis (Cabre, Serra-Orat, & Palomera, 2010) and
is expensive, with a mean cost of $17,000 per episode
of treatment in Ontario (Sutherland, Hamm, & Hatcher,
2010). A decrease in annual cost for chest infection
treatment in hospital has been found when there is speech
The use of thrombolysis in specified patient
presentations is supported in the acute phase
following ischaemic stroke by stroke clinical
guidelines. However, thrombolysis is
associated with a number of complications
and risks. Further, thrombolysis protocol
violations have been associated with
increased patient mortality. Although the
risks associated with thrombolysis and
non-compliance with protocols are
recognised, a review of literature and
benchmarking suggested that no specific
protocols existed to guide speech
pathologists through dysphagia management
during the critical time period directly post-
thrombolysis. As a result, Logan Hospital
Speech Pathology Department sought to
develop an evidence-based clinical practice
protocol to standardise dysphagia service
delivery and limit patient and staff risk. This
paper presents a review of literature in this
area and details regarding the development
of The Logan Hospital Dysphagia Clinical
Protocol for Thrombolysed Patients.
Background
Ongoing improvements to services via operational changes
are central for ensuring the optimisation of clinical care. The
standardisation of clinical processes through the
development of clinical practice protocols has been found
to be an effective strategy to reduce variations and to
minimise the probability of clinical errors and enhance client
outcomes (Kohn, Corrigan, & Donaldson, 2000).
Furthermore, clinical protocols have been shown to be a
useful medium for ensuring maintenance of quality of
clinical care across a range of clinical areas in the current
cost-conscious environment (Owen et al., 2006; Panella,
Moran, & Di Stanislao, 1997; Pearson, Goulart-Fisher, &
Lee, 1995; Wentworth & Atkinson, 1997). Specifically, the
implementation of clinical protocols has been shown to
positively impact on clinical costing via decreased length of
stay, improved efficiency of staff, waste reduction, and
reducing complications (Korpiel 1995; Martin, Doig,
Jennifer Davis
(top), Elizabeth
Cardell (centre)
and Anne
Coccetti
