Improving care for patients with dysphagia

Background: early diagnosis and effective management of dysphagia reduce the incidence of pneumonia and improve quality of care and outcome. Dysphagic stroke patients rarely perceive that they have a swallowing problem, and thus carers have to take responsibility for following the safe swallow recommendations made by the Speech and Language Therapist (SLT). Published work and observations in our own Trust indicated that patients with dysphagia may be fed in a manner which places them at significant risk of aspiration, despite SLT advice for safe swallowing. Objective: to determine compliance with swallowing recommendations in patients with dysphagia and to investigate the effectiveness of changes in practice in improving compliance. Design: sequential observational study before and after targeted intervention. Setting: an acute general and teaching hospital in an inner city area. Subjects: all patients with dysphagia on the caseload of the speech and language therapy department at the time of the study. Methods: observations were made on compliance with the recommendations of SLTs regarding consistency of fluids, dietary modifications, amount to be given at a single meal/drink, swallowing strategies, general safe swallow recommendations and whether supervision was required. A dysphagia link nurse programme was established, together with modification of an in-house training scheme, use of pre-thickened drinks and modification of swallowing advice sheets. The same observations were repeated after this intervention. Results: thirty-one patients were observed before and 54 after the intervention. There was improvement in compliance with the recommendations on consistency of fluids (48-64%, P < 0.05), amount given (35-69%, P < 0.05), adherence to safe swallow guidelines (51-90%, P < 0.01) and use of supervision (35-67%, P < 0.01). There were no significant differences in compliance with dietary modifications or swallowing strategies. Improvement in compliance was demonstrated in medical and geriatric wards and the stroke unit, but not in the surgical wards. Compliance with 'nil by mouth' instructions was 100% throughout. Conclusions: relatively simple and low-cost measures, including an educational programme tailored to the needs of individual disciplines, proved effective in improving the compliance with advice on swallowing in patients with dysphagia. It is suggested that this approach may produce widespread benefit to patients across the NHS.