RESUMO
BACKGROUND: Early identification of dysphagia is associated with lower rates of pneumonia after acute stroke. The Barnes-Jewish Hospital Stroke Dysphagia Screen (BJH-SDS) was previously developed as a simple bedside screen performed by nurses for sensitive detection of dysphagia and was previously validated against the speech pathologist's clinical assessment for dysphagia. In this study, acute stroke patients were prospectively enrolled to assess the accuracy of the BJH-SDS when tested against the gold standard test for dysphagia, the videofluoroscopic swallow study (VFSS). METHODS: Acute stroke patients were prospectively enrolled at a large tertiary care inpatient stroke unit. The nurse performed the BJH-SDS at the bedside. After providing consent, patients then underwent VFSS for determination of dysphagia and aspiration. The VFSS was performed by a speech pathologist who was blinded to the results of the BJH-SDS. Sensitivity and specificity were calculated. Pneumonia rates were assessed across the 5-year period over which the BJH-SDS was introduced into the stroke unit. RESULTS: A total of 225 acute stroke patients were enrolled. Sensitivity and specificity of the screen to detect dysphagia were 94% and 66%, respectively. Sensitivity and specificity of the screen to detect aspiration were 95% and 50%, respectively. No increase in pneumonia was identified during implementation of the screen (P = .33). CONCLUSION: The BJH-SDS, validated against videofluoroscopy, is a simple bedside screen for sensitive identification of dysphagia and aspiration in the stroke population.
Assuntos
Transtornos de Deglutição/diagnóstico , Pneumonia Aspirativa/diagnóstico , Acidente Vascular Cerebral/complicações , Adulto , Idoso , Deglutição/fisiologia , Transtornos de Deglutição/etiologia , Etnicidade , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Aspirativa/etiologia , Sistemas Automatizados de Assistência Junto ao Leito , Reprodutibilidade dos Testes , Gravação em VídeoRESUMO
OBJECTIVES: (1) To examine clinician adherence to a standardized assessment battery across settings (acute hospital, inpatient rehabilitation facilities [IRFs], outpatient facility), professional disciplines (physical therapy [PT], occupational therapy, speech-language pathology), and time of assessment (admission, discharge/monthly), and (2) to evaluate how specific implementation events affected adherence. DESIGN: Retrospective cohort study. SETTING: Acute hospital, IRF, and outpatient facility with approximately 118 clinicians (physical therapists, occupational therapists, speech-language pathologists). PARTICIPANTS: Participants (N=2194) with stroke who were admitted to at least 1 of the above settings. All persons with stroke underwent standardized clinical assessments. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Adherence to Brain Recovery Core assessment battery across settings, professional disciplines, and time. Visual inspections of 17 months of time-series data were conducted to see if the events (eg, staff meetings) increased adherence ≥5% and if so, how long the increase lasted. RESULTS: Median adherence ranged from .52 to .88 across all settings and professional disciplines. Both the acute hospital and the IRF had higher adherence than the outpatient setting (P≤.001), with PT having the highest adherence across all 3 disciplines (P<.004). Of the 25 events conducted across the 17-month period to improve adherence, 10 (40%) resulted in a ≥5% increase in adherence the following month, with 6 services (60%) maintaining their increased level of adherence for at least 1 additional month. CONCLUSIONS: Actual adherence to a standardized assessment battery in clinical practice varied across settings, disciplines, and time. Specific events increased adherence 40% of the time with those gains maintained for >1 month 60% of the time.
Assuntos
Avaliação da Deficiência , Fidelidade a Diretrizes , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Ocupacional , Modalidades de Fisioterapia , Estudos Retrospectivos , Patologia da Fala e Linguagem , Estatísticas não ParamétricasRESUMO
This Special Interest article describes a multidisciplinary, interinstitutional effort to build an organized system of stroke rehabilitation and outcomes measurement across the continuum of care. This system is focused on a cohort of patients who are admitted with the diagnosis of stroke to our acute facility, are discharged to inpatient and/or outpatient rehabilitation at our free-standing facility, and are then discharged to the community. This article first briefly explains the justification, goals, and purpose of the Brain Recovery Core system. The next sections describe its development and implementation, with details on the aspects related to physical therapy. The article concludes with an assessment of how the Brain Recovery Core system has changed and improved delivery of rehabilitation services. It is hoped that the contents of this article will be useful in initiating discussions and potentially facilitating similar efforts among other centers.
Assuntos
Avaliação de Resultados em Cuidados de Saúde , Equipe de Assistência ao Paciente/organização & administração , Centros de Reabilitação/organização & administração , Reabilitação do Acidente Vascular Cerebral , Humanos , Recuperação de Função Fisiológica/fisiologiaAssuntos
Transtornos de Deglutição/diagnóstico , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/enfermagem , Acidente Vascular Cerebral/terapia , Técnicas de Apoio para a Decisão , Humanos , Louisiana , Programas de Rastreamento/enfermagem , Desenvolvimento de Programas , Qualidade da Assistência à Saúde , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Use of standardized assessments in acute rehabilitation is continuing to grow, a key objective being to assist clinicians in determining services needed postdischarge. OBJECTIVE: The purpose of this study was to examine how standardized assessment scores from initial acute care physical therapist and occupational therapist evaluations contribute to discharge recommendations for poststroke rehabilitation services. DESIGN: A descriptive analysis was conducted. METHODS: A total of 2,738 records of patients admitted to an acute care hospital with a diagnosis of stroke or transient ischemic attack were identified. Participants received an initial physical therapist and occupational therapist evaluation with standardized assessments and a discharge recommendation of home with no services, home with services, inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF). A K-means clustering algorithm determined if it was feasible to categorize participants into the 4 groups based on their assessment scores. These results were compared with the physical therapist and occupational therapist discharge recommendations to determine if assessment scores guided postacute care recommendations. RESULTS: Participants could be separated into 4 clusters (A, B, C, and D) based on assessment scores. Cluster A was the least impaired, followed by clusters B, C, and D. In cluster A, 50% of the participants were recommended for discharge to home without services, whereas 1% were recommended for discharge to an SNF. Clusters B, C, and D each had a large proportion of individuals recommended for discharge to an IRF (74%-80%). There was a difference in percentage of recommendations across the clusters that was largely driven by the differences between cluster A and clusters B, C, and D. LIMITATIONS: Additional unknown factors may have influenced the discharge recommendations. CONCLUSIONS: Participants poststroke can be classified into meaningful groups based on assessment scores from their initial physical therapist and occupational therapist evaluations. These assessment scores, in part, guide poststroke acute care discharge recommendations.
Assuntos
Avaliação da Deficiência , Ataque Isquêmico Transitório/reabilitação , Avaliação de Resultados em Cuidados de Saúde/normas , Reabilitação do Acidente Vascular Cerebral , Atividades Cotidianas , Idoso , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Ocupacional , Alta do Paciente , Modalidades de Fisioterapia , Recuperação de Função Fisiológica , Centros de Reabilitação , Instituições de Cuidados Especializados de EnfermagemRESUMO
BACKGROUND: Although many dysphagia screening tools exist, none has high sensitivity and reliability or can be administered quickly with minimal training. OBJECTIVE: To design and validate a swallowing screening tool to be used by health care professionals who are not speech language pathologists to identify dysphagia and aspiration risk in acute stroke patients. METHODS: In a prospective study of 300 patients admitted to the stroke service at an urban tertiary care hospital, interrater and test-retest reliabilities of a new tool (the Acute Stroke Dysphagia Screen) were established. The tool was administered by nursing staff when patients were admitted to the stroke unit. A speech language pathologist blinded to the results with the new tool administered the Mann Assessment of Swallowing Ability, a clinical bedside evaluation, with dysphagia operationally defined by a score less than 178. RESULTS: The mean time from admission to screening with the new tool was 8 hours. The mean time between administration of the new tool and the clinical bedside evaluation was 32 hours. For the new tool, interrater reliability was 93.6% and test-retest reliability was 92.5%. The new tool had a sensitivity of 91% and a specificity of 74% for detecting dysphagia and a sensitivity of 95% and a specificity of 68% for detecting aspiration risk. CONCLUSIONS: The Acute Stroke Dysphagia Screen is an easily administered and reliable tool that has sufficient sensitivity to detect both dysphagia and aspiration risk in acute stroke patients.