Saudi Stroke Standards

Swallow screening Purpose The purpose of dysphagia screening is to identify patients potentially at risk of aspiration. Delays in screening for and assessing dysphagia after stroke, are associated with higher risk of stroke-associated aspiration pneumonia. Swallow screening may help identify dysphagia early, thereby ensuring timely referrals to speech and language therapy and dietetics, thereby minimising the impact on the patient. Since stroke-associated aspiration pneumonia is one of the main causes of mortality after acute stroke, an early dysphagia assessment may contribute to preventing deaths from acute stroke and could be implemented even in settings without access to high-technology specialist stroke care.8 Rationale Dysphagia is a common consequence of stroke, affecting approximately 37% to 78% of patients with acute stroke and is associated with increased risk of aspiration, pneumonia, prolonged hospital stay, disability, and death  Evidence supports that early identification of dysphagia reduces the risk for aspiration pneumonia, and there is also emerging evidence of an association between a failed screening and severe disability, discharge to long-term care, and 1- year mortality. Stroke patients with dysphagia therefore may experience a combination of these possible negative health complications. Accurate and early identification of dysphagia is critical and can facilitate a better recovery. 8 Bray, B. D., Smith, C. J., Cloud, G. C., Enderby, P., James, M., Paley, L., ... & Rudd, A. G. (2017). The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia. J Neurol Neurosurg Psychiatry, 88(1), 25-30.  Patients with dysphagia often do not receive sufficient caloric intake, which may result in poorer outcomes as a result of malnutrition. Standards 1) All acute stroke patients should be nil per oral until swallow screening is completed. 2) All acute stroke patients should have a swallow screen test within 4 hours by an appropriately trained clinician (typically a trained nurse). 3) Patients should be screened for swallowing deficits as soon as they are alert and ready for trialing oral intake, using a valid screening tool, by an appropriately trained professional. 4) Patients who fail the swallowing screening should be kept nil per oral (NPO) and referred to a speech pathologist for a comprehensive assessment. 5) Comprehensive assessment by a speech language pathologist should be done within 72 hours of referral. An instrumental evaluation is required to verify the presence/absence of aspiration and to determine the biomechanical swallowing function to guide the treatment plan.9 6) The choice of instrumental evaluation may be based on instrument availability or other considerations (i.e. fibreoptic endoscopic evaluation of swallowing, video fluoroscopy.10 7) For stroke survivors with swallowing difficulties, behavioral approaches such as swallowing exercises, environmental modifications, safe swallowing advice, and appropriate dietary modifications should be used early. 8) Until a safe swallowing method is established for oral intake, patients with dysphagia should have their nutrition and hydration managed with early consideration of alternative non-oral routes. 9) Swallow screening may be repeated if medical status changes. QM