Improving the identification and management of aspiration after stroke

Abstract

Dysphagia, a common clinical corollary following stroke, may contribute to aspiration pneumonia, malnutrition, and dehydration which may significantly impair patient rehabilitation.
Survey
Aim: Establish current clinical practice regarding nurse dysphagia screening.
Method: A cross-sectional regional postal survey was undertaken with 60 nurses and 45 Speech and Language Therapists.
Results: Nurses were taught to use water swallow screening tools but, in reality, used a variety of testing materials.
Conclusion: This demonstrated the need for a clinically useful bedside swallow screening tool.
Pilot Study
Aim: Develop and evaluate the diagnostic accuracy of a new BEdside Swallow Screening Tool (BESST), for use by nurses with acute stroke patients.
Method: A literature search was undertaken to inform the BESST. Face validity was established using an iterative process of semi-structured interviews with eight specialist SLTs and eight nurses. The tool was piloted on 12 purposefully selected stroke patients by comparing the management options chosen by two nurses using the BESST with those of the Specialist SLT using their bedside assessment (gold standard).
Results: The BESST demonstrated excellent sensitivity (100%) but specificity demonstrated by both nurses was poor (< 45% for both).
Conclusion: A larger validation study of a modified BEEST would be appropriate.
Main Study
Aim: Establish the diagnostic accuracy and utility of the BESST.
Method: Ratings by nurses using the BESST were compared with experienced SLT bedside assessment in 124 consecutively admitted stroke patients.
Results: The BESST demonstrated good agreement between nurses (81%) and within nurses (87% nurse 1, 86% nurse 2), 93% sensitivity, 82% specificity; 71% positive
iii
predictive value, 95% negative predictive value; and overall efficiency was 84%. The BESST dictated the same management as the SLT in 75% of cases, and safely allowed 92% of patients modified oral intake when compared to the water swallow screening tool.
Conclusion: The BESST has potential use in clinical practice, but further research is needed.