1. Stroke and Dysphagia
Financial bid

2. Stroke

3. 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
Fran
A stroke is a clinical event resulting in cerebral damage, and as you can see by the statistics, its prevalence issignificant

4. 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
Fran
Around a third of stroke survivors have communication difficulties, which can affect speech, language or both. Stroke has a huge impact on people’s lives, affecting their eating and drinking, mobility and even their mood and personality.

5. 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:
Prevention
Immediate care
Early and continuing rehabilitation
Long-term support
Standard five of the National Service Framework for Older People is for stroke.
The overall aim is to reduce incidence of stroke in the population and provide those who have had a stroke with prompt access to integrated stroke care services.
There are four main components for the development of integrated stroke services:
Prevention reducing the risk factors for stroke across the population as well as those at relatively greater risk of stroke. The risk factors for each patient at risk or recovering from stroke should be identified and advice, support and treatment provided as appropriate.
Immediate care  Patients should be treated by specialist stroke teams within designated stroke units.
Early and continuing rehabilitation Evidence indicates early, expert and intensive rehabilitation in a hospital stroke unit improves the long-term outcome for patients. Rehabilitation will vary according to needs e.g. SLT for patients with communication or swallowing difficulties. Although treatment is initiated in hospital, the primary care team must make arrangements for support packages and treatment to be continued after discharge into the community setting.
Long-term support  Rehabilitation should continue until it is clear maximum recovery has been achieved.

6. National Service Framework - for Older People (2002) pp. 70
This diagram is the stroke care pathway recommended by the National Service Framework for stroke. It provides a care pathway for patients identified at risk of stroke, patients suspected of having had transient ischaemic attack, and patients who have had a suspected stroke.
National Service Framework - for Older People (2002) pp. 70

7. 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

8. 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.

9. Stroke Strategy Action Plan
Awareness
Preventing Stroke
Involvement
Acting on the warnings
Stroke as a medical emergency
Stroke unit quality
Rehabilitation and community support
Participation
Workforce
Service Improvement

10. 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
Fran –
The Stroke Association is a national charity, carrying out research into stroke, and providing support to stroke survivors during recovery and life after stroke.
The Stroke Association offers local support, for example the Sheffield Communication Support Service, which provides stroke survivors in Sheffield with communication support groups, with the aim to build confidence and help achieve the best possible recovery.

11. Voluntary Sector
Connect works with individuals with aphasia and their families
They aim to develop communication and rebuild confidence
Access to Life services
Fran –
Connect is another charity that works with stroke survivors. They work with both the individuals and their families to support communication between loved ones and rebuild confidence. They also train healthcare professionals who work with individuals with aphasia, which enhances stroke services.
Connect was involved in the development of the National Stroke Strategy in 2007, by helping people with aphasia and their carers to provide feedback on the strategy. Connect played a significant role in informing key decision makers about aphasia, and therefore influence policy making.

12. 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
Fran –
In a document written by NHS commissioners themselves, they highlighted the key role the voluntary sector plays in providing effective services.. The voluntary sector takes a person-centred approach, therefore they understand the needs of service users.
The commissioners also recognised how the voluntary sector can lead to better outcomes and more cost effective use of NHS resources.
Parliament has passed legislation that requires commissioners to consider ‘social value’ in public services, therefore, commissioners should view the voluntary sector as an obvious partner when procuring services, so the presence of such well-established charities like the Stroke Association and Connect, should be seen as a motive to provide funding to this client group, .

13. 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
Liv

14. Dysphagia

15. 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.
Danielle

16. Incidence/Prevalence of Dysphagia
Danielle

17. 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
Liv

18. 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
Sarah –
In the acute stage, SLT’s have important role in training other professionals to carry out initial dysphagia screening e.g. bedside assessment – SIGN recommends that this must be done before any food or drink given in hospital. Following the screen the SLT must undertake a risk assessment where they determine the safety of food trials.
SLT intervention at this stage can shorten the patient length of hospital stay from 6.7% to 0%, reducing the hospital stay by up to 5.5 days by collaborating with the dietician to manage nutritional uptake. SLT management can also reduce patient morbidity as a a result of aspiration pneumonia.
When transferring patients to the community team, early supported discharge from the stroke ward should be accompanied by timely SLT dysphagia management. This reduces the likelihood of patients being readmitted to hospital with pneumonia or other respiratory infections.

19. 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)
Sarah –
Persisting dysphagia is higher in those who have severe strokes and therefore patients that are more likely to be living in residential homes. Benefits of SLT intervention at this stage in the care pathway can prevent further health complications, unnecessary readmission to hospital and reduce mortality rates. Within all stages of the care pathway it is important for the SLT’s to work in close partnership with other agencies e.g. voluntary organisations, adult education groups to support health-related QOL and maintain independence within the community.
Other SLT dysphagia recommendations address the staffing levels and suggest that, although they are unable to give a recommended SLT ratio per population, the number of SLT’s should reflect the population demographics. A recent Sheffield study trialled providing SLT intervention on Saturday morning and reduced the referral to treatment period by 5% during this time. SLT’s also felt that there was a positive effect on duration of nil by mouth episodes, hence improving QOL.

20. 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.
Helen

21. 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).
Helen -
Hassan et al carried out a study on stroke patients and found that, of those patients who developed pneumonia, 67% was within 48 hours and this is almost invariably caused by swallowing disorders.
Costa Bandeira et al looked at the impact of swallowing disorders on mealtimes, they found that anxiety was caused either by individuals being frightened to eat alone for fear of choking or feeling embarrassed by slow or unusual eating behaviour.
Another negative effect of swallowing difficulties was found by Tibbling and Gustaffson, who found that older patients with dysphagia suffered much more frequently from chest pain, heart burn and regurgitation.
In terms of the cost of dysphagia, Odderson et al found that, on average, the length of hospital stay is much longer for those patients with dysphagia, compared to those without. Patients with dysphagia were also twice as likely to be discharged to a nursing home than those without.
This research highlights not only the discomfort and poor quality of life experienced by patients with dysphagia, but also the impact on the hospitals caring for them and the cost of doing so – it is therefore in our interest to carry out effective assessments and intervention to provide cost-effective dysphagia care.

22. 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.
Helen -
Lucas and Rogers carried out a comparison study on two hospitals in the UK, looking at dysphagia management service. Hospital A had a SLT inpatient service for stroke patients, while hospital B had extra-contractual referral for dysphagia assessment by SLTs from another hospital. Results showed that hospital A had better identification of dysphagia, more complete documentation of nutrition and hydration management, less risky dysphagia management and less need for chest physiotherapy compared to hospital B – indicates importance of SLT as integral part of dysphagia service.
Ramsey, Smithard and Kalra reviewed bedside assessments and concluded that more reliable bed side tests would allow swallow screening to take place earlier before SLT contact which would reduce the number of underfed/inappropriately fed patients whilst awaiting dysphagia assessment, thus reducing the risk of malnutrition and aspiration pneumonia and longer more expensive hospital stays.
Odderson, Keaton and McKenna carried out study where early swallow screen was completed within one day of admission and before any oral intake by patient. Their results showed that 39% of patients failed the early swallow screen and needed early dietary intervention, preventing them from being fed inappropriately and risk developing aspiration pneumonia. Interestingly they also found that no patients developed pneumonia, supporting their conclusion that an early swallow screen and dysphagia management in acute stroke patients reduces the risk of aspiration pneumonia, is cost affective and assures quality care with optimal outcome.

23. 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.
Helen

24. Thank you