Stroke and Dysphagia Financial bid Stroke What is stroke? Stroke is a clinical event that results in cerebral damage, affecting brain function There are 2 types of stroke: Ischaemic Haemorrahagic Stroke is the third leading cause of death and disability At 75 years of age, 1 in 5 women and 1 in 6 men will have a stroke Consequences of stroke Approximately 1/3 of stroke survivors have communication difficulties, including: Aphasia Dysarthria Apraxia Other consequences can include: Dysphagia Physical disability Changes in mood and personality National Service Framework for Stroke Overall aim: reduce incidence of stroke and provide those who have had a stroke with prompt access to integrated stroke care services. Four main components: 1) Prevention 2) Immediate care 3) Early and continuing rehabilitation 4) Long-term support National Service Framework - for Older People (2002) pp. 70 SLT role within the care pathway SLTs are the only professionals qualified to diagnose, assess and provide a programme of care to address these communication and swallowing needs. SLTs play a vital role at all stages along the care pathway. SLTs are the core members of the team in the immediate care, and long-term rehabilitation of stroke survivors. SLTs have a role in training other clinical staff to develop their skills needed to understand the communication needs of stroke survivors. Dysphagia management Communication disability management Transfer of care to the community Rehabilitation within the community Completion of therapy and review National Stroke Strategy (2007) : Department of Health This was devised by six expert groups comprised of representatives from the wide range of professionals who support people with stroke, people who have had a stroke, carers and voluntary associations. It’s intended to ‘provide a quality framework to secure improvements to stroke services , to provide guidance and support to commissioners and strategic health authorities and social care, and inform the expectations of patients and their families by providing a guide to high quality health/social care services. Stroke Strategy Action Plan 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Awareness Preventing Stroke Involvement Acting on the warnings Stroke as a medical emergency Stroke unit quality Rehabilitation and community support Participation Workforce Service Improvement Voluntary sector The Stroke Association services can: Reduce hospital readmissions Shorten hospital stays Facilitate better integration of care Save other statutory expenditure Meet current government imperitives Meet the requirements of the national stroke strategies across the UK Voluntary Sector Connect works with individuals with aphasia and their families They aim to develop communication and rebuild confidence Access to Life services Voluntary Sector A clinical commissioner's guide to the voluntary sector (Girach, Hardisty & Massey, 2012) Clinical Commissioners Groups that engage with the voluntary sector can lead to: Better outcomes for people More cost effective use of NHS resources, generating value for money Widening of the local provider base NHS Annual Report The stroke pathway has developed significantly since 2010 In 2013, it was awarded with a Level 1 accreditation Introduced regional network to allow specialist stroke consultants to connect Thrombolysis available to suitable stroke patients 24 hours a day Top performer in accural targets out of 21 stroke sites Consistently maintain targets for inpatient stay Identified areas to target to streamline stroke pathway and reduce length of stay Aim for 2015 to implement improvements, allowing bed reductions by improving patient discharge into community and social care services as agreed and supported by the Right First Time Programme Dysphagia What is dysphagia? Dysphagia is the medical term describing difficulty in swallowing. Dysphagia can vary significantly in its severity and can affect individuals of all ages. It may occur as a congenital or acquired condition. Dysphagia can be a transient, persistent or deteriorating symptom according to the underlying pathology. Incidence/Prevalence of Dysphagia Dysphagia Framework The national framework for dysphagia suggests: Treatment and care must include Vigilant observation and early management of possible complications, such as chest infections, pneumonia A formal swallowing assessment and a plan for safe hydration, feeding and medication. Early and continuing rehabilitation including SLT for swallowing difficulties Specialist dysphagia services should provide training and advise to all professions and service providers for swallowing and nutritional needs SLT role within the care pathway Acute Setting SLT has key role in management of eating, drinking and swallowing in hours and days after stroke. SLT intervention reduces occurrence of respiratory infection and malnutrition whilst improving quality of life and functional outcomes e.g. returning to work. Transfer to Community – Swallowing difficulties persist in 11% of patients 6 months post-stroke. Pneumonia, pressure sores can be reduced with appropriate SLT intervention SLT role within the care pathway Rehab within community – SLT has role in continued management of patients with persisting dyspagia Able to prevent further health conditions, unnecessary readmission to hospital and reduce mortality rates. Recommendations – At least 1 SLT per 10 beds in every stroke unit (RCSLT, 2007) Staffing should be flexible and must address demographics of area accounting for physical geography Flexible working hours incl. weekends can reduce referral to treatment period (Sheffield Primary Care Trust) What research is telling us Key points from RCSLT resource manual for commissioning and planning services for SLCN (RCSLT, 2009) There is evidence that: Appropriate identification and management of dysphagia by SLTs reduces morbidity, mortality and improves quality of life. Interventions used by SLTs in treatment of dysphagia are effective. Appropriate management of dysphagia can reduce complications and length of hospital stays. What research is telling us Risk In 67% stroke patients, pneumonia manifests within 48hrs (Hassan et al, 2006) Impact Difficulty swallowing caused anxiety at meal times. (Costa Bandeira et al, 2008) Elderly patients with dysphagia had significantly more frequent chest pain, heart burn & regurgitation. (Tibbling & Gustafsson, 1991). Cost Length of stay in hospital longer for stroke patients with dysphagia; patients with dysphagia twice as likely to be discharged to nursing home. (Odderson et al, 1995). What research is telling us Supporting timely and effective intervention: Hospital comparison study (Lucas & Rogers, 1998) Found hospital with SLT dysphagia service for inpatients provided much higher standard of dysphagia treatment than hospital with no SLT service. Bedside assessment review (Ramsey, Smithard & Kalra, 2003) Conclusion – more refinement of assessments needed to improve accuracy Early swallow screen (Odderson, Keaton & McKenna, 1995) Completed within one day of admission, 39% patients failed and needed dietary intervention. Conclusion The SLT plays a vital role in the treatment of stroke and dysphagia, including assessment, management, intervention and training staff. The research supports the importance of early dysphagia intervention, with effective and early initial swallow screening reducing risk of aspiration pneumonia and consequently the length and cost of hospital stays. It is more cost effective to invest in quality care at the beginning of the pathway in order to obtain an early diagnosis and provide effective treatment, both reducing costs and improving patients’ quality of life. Thank you