JCPSLP
Volume 16, Number 2 2014
91
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
dysphagia management in the acute phase post-
thrombolysis for clients with an ischaemic stroke.
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.
