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JCPSLP
Volume 16, Number 2 2014
Journal of Clinical Practice in Speech-Language Pathology
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
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
