a b s t r a c t

Background: Dysphagia is a common problem for patients after an acute stroke which can lead to hospital ac- quired pneumonia (HAP) increasing morbidity and mortality. The Joint Commission has directed that stroke cer- tified hospitals perform a dysphagia screen at the time of initial presentation. We sought to evaluate if our ED dysphagia screen was correlated with lower rates of pneumonia in acute stroke patients.

Methods: We conducted a pre-post trial evaluating rates of pneumonia in patients with ischemic and hemor- rhagic stroke both before and after the use of our ED dysphagia screen. We defined HAP as a new infiltrate treated with antibiotics. Rates of HAP were compared using the ?² test. Any patients transferred out of our health system were excluded.

Results: We evaluated 419 and 469 preintervention hemorrhagic strokes and 1022 and 462 post screen ischemic strokes respectively. In the hemorrhagic groups rates of dysphagia were similar but rates of HAP decreased from 19% to 15% (P b 0.001) in the pre- post groups respectively. In the ischemic stroke groups rates of HAP decreased from 13.8% to 8% in the pre-post groups respectively, (P = 0.007). Rates of intubation were similar in the hem- orrhagic groups and were higher in the post screen ischemic stroke cohort.

Conclusion: The use of our ED dysphagia screen was associated with a significant reduction in the rates of HAP in both ischemic and hemorrhagic stroke patients. Given the high rates of dysphagia and significant comorbidity and complications for these stroke patients, the use of a screen is warranted.

(C) 2018

The use of an emergency department dysphagia screen is associ- ated with lower rates of pneumonia in both hemorrhagic and ische- mic strokes

Dysphagia is a frequent problem for patients suffering from both acute ischemic and hemorrhagic strokes. It is known that dysphagia in acute stroke leads to increased rates of hospital acquired pneumonia (HAP) due to aspiration, longer hospitalizations, and higher morbidity and mortality [1,2]. Rates of dysphagia in ischemic and hemorrhagic stroke have been estimated to be between 37 and 78% and 49%, respec- tively [3,4].

Given the high rates of dysphagia in these stroke populations the American Heart Association and the Joint Commission have directed

? This research was not supported by a grant or external funding.

* Corresponding author.

E-mail addresses: jschrock@metrohealth.org (J.W. Schrock), Lw14@case.edu (L. Lou), bab@case.edu (B.A.W. Ball), jkv@case.edu (J. Van Etten).

both primary stroke centers and comprehensive stroke centers to screen all stroke patients for dysphagia before allowing them to take any food or medication by mouth [5]. Use of a dysphagia screen has been shown to reduce subsequent HAP diagnoses when the screen is performed on a hospital floor and in an ICU setting [6,7].

Dysphagia screening is recommended prior to taking anything by

mouth including food and medications [8]. Currently dysphagia screen- ing is a performance metric that is measured by all certified stroke hos- pitals. Since most patients are treated with aspirin, if they are to begin Aspirin therapy in the ED, the screen should be performed prior to the medication being given.

Only a few ED dysphagia screens have been developed, tested, and described in a peer reviewed format [9-11]. No published studies have evaluated a single ED based screen to determine if the use of the screen lowers rates of subsequent HAP. The use of an ED dysphagia screen re- quires training and monitoring to ensure it is used correctly and consis- tently. If dysphagia screening in the ED proves effective in reducing dysphagia this would justify the expense of training staff to perform

https://doi.org/10.1016/j.ajem.2018.03.046

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it; if not, perhaps a Novel method would be needed to detect for dyspha- gia? Currently no study has evaluated the use of an ED dysphagia screen to determine if reduces rates of pneumonia and or mortality in acute stroke patients.

We developed the MetroHealth Dysphagia Screen to be performed on all acute stroke patients upon arrival to the ED and has been previ- ously described [11]. With this study we sought to determine if rates of HAP, a common complication of dysphagia after stroke, would change in patients after the screen was performed.

Methods

We performed a pre-post trial evaluating all stroke patients present- ing to our emergency department. After approval from our institutional review board and receiving a waiver of informed consent, we found subjects based on ICD-9 codes for ischemic and hemorrhagic stroke. Charts were abstracted from our institution’s electronic medical record, Epic(TM) (Verona, WI) by trained abstracters blinded to the study out- come. Baseline demographic data was collected as well as the results of the dysphagia screen and subsequent rates of HAP. Pneumonia was pre-defined as a new infiltrate on chest radiogram that was treated with antibiotics. Other data collected included presenting NIH stroke scale, hospital length of stay and disposition status. For hemorrhagic strokes, we collected data in a 5-year period before and after the screen was started. For the acute ischemic stroke cohort, we collected data in a 4-year period before and after implementation of the dysphagia screen. With hemorrhagic strokes, additional data collected included intra- cranial hemorrhage (ICH) score and the Hunt-Hess score for subarach- noid hemorrhage. Rates of intubation in both groups were also col- lected. Patients were excluded if they were in the post screen cohort and did not have the dysphagia screen completed. Any patient that was transferred to another hospital system was also excluded. A diagno- sis of dysphagia was considered to have occurred if after speech pathol- ogy evaluation a dietary modification was made which could include; thickened, pureed, dysphagia mechanical soft, dental mechanical soft, liquid nectar, liquid honey, or nothing by mouth. Data were analyzed using STATA v.13 (College Station, TX) utilizing ?² testing for compari- son of rates of HAP. Other data are reported as frequencies or medians with interquartile ranges (IQR) where appropriate.

Results

In the ischemic stroke cohort, we evaluated 419 pre-screen patients and 1022 post-screen subjects. The baseline demographics were similar between the two groups and can be seen in Table 1. In both groups 50% were male and rates of thrombolytic use were 10% and 11% in the pre- and post-groups respectively. Rates of dysphagia during hospitalization

Table 1

Baseline demographics for the acute ischemic stroke cohort.

CVA = cerebrovascular disease, TIA = transient ischemic attack, CAD = coronary artery disease, NIHSS = National Institutes of Health Stroke Scale.

were 20% and 31% and rates of HAP were 13.8% and 8.0% P = 0.007 in the pre-post groups respectively. In the hemorrhagic stroke cohort, we evaluated 469 subjects in the preintervention group and 462 in the post-screen group. Both groups were 53% male and had similar demo- graphics which can be seen in Table 2. Rates of dysphagia for the hem- orrhagic group were similar 65% and 63% in the pre-post groups respectively. Rates of HAP were significantly lower in the post group 19% vs 13% P b 0.001.

The groups were similar in Severity of disease with some slight dif- ferences in rates of intubations. We found that for the hemorrhagic group the preintervention group had a higher percentage of subarach- noid hemorrhages, 194 (41%) compared with 135 (30%) respectfully, P

= 0.000. The rate of dysphagia based on hemorrhagic stroke type, ICH compared with SAH, showed similar rates of dysphagia between the two groups, 65% and 61% P = 0.30. For the hemorrhagic groups the rates of intubations were higher in the preintervention population, 22% vs 19% but this was not statistically significant when compared using the ?² test, P = 0.24. Likewise, the rates of in hospital death were higher for the preintervention hemorrhagic stroke patients which was close to statistical significance, 33% versus 27%, P = 0.055. Looking at the acute ischemic stroke population the percentage of deaths were higher in the post screen population when compared with the preintervention population, 5% and 3% respectfully. This differ- ence approached but did not reach statistical significance, P = 0.085. The rates of dysphagia in the hemorrhagic groups were similar but we found the post screen ischemic stroke group to have a higher rate of a dysphagia diagnosis, 20% for the preintervention group verses 30% for the post screen group, P = 0.000.

Discussion

In this pre-post cohort study, we found that the use of an ED dyspha- gia screen was associated with decreased rates of HAP during hospital admission. Each group had a rate of decrease in HAP of approximately 6% making this the first study to show a statistically significant decline in the rate of HAP after the use of an ED dysphagia screen in patients presenting with acute stroke. This is significant because the Joint Com- mission, which certifies the majority of Primary and Comprehensive Stroke Centers, recommends that hospitals use validated and evidence based tools when providing stroke care. This study supports the use of ED dysphagia screening in reducing the rates of aspiration HAP in pa- tients with acute stroke. Given the high rates of dysphagia in the groups, the use of a screen early in the hospital course is warranted.

Prior research by Lakshminarayan et al. has shown that HAP rates were higher in patients who did not receive a dysphagia screen com- pared to those who were screened, particularly those who were screened and passed [12]. This study did not control for how patients were screened and allowed for multiple types of screens. Our study is

Table 2

Demographic data for patients with intracranial hemorrhage.

CVA = cerebrovascular disease, CAD = coronary artery disease, SAH = subarachnoid hemorrhage.

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unique in that each group underwent the same ED dysphagia screen and should bolster confidence in those institutions who wish to use it. Another study performed by Titsworth et al. showed decreased rates of HAP after the use of a hospital based dysphagia screening protocol [7]. Our study is unique as it performed the screen only in the ED, at the time of first contact for the patient and the hospital system. It is however reassuring to see that various screens used throughout the hospital sys- tem each resulted in lower rates of HAP for patients with acute ischemic

stroke.

There were some differences in the baseline characteristics in our groups. The hemorrhagic groups had higher rates of deaths and intuba- tions, however these differences did not reach statistical significance. The baseline difference of an increased number of SAH likely did not in- fluence the results as the rates of dysphagia were similar between the two types of hemorrhagic stroke.

For the ischemic stroke group, we found slightly higher rates of intu- bations, however similar rates of death. There was a marked increase in the diagnosis of dysphagia in the pre- and post-stroke which may have been influenced by a Hawthorne effect since as a hospital system we were more closely looking for symptoms of dysphagia in our acute stroke population. Even if this was an effect of the ED dysphagia screen we would welcome it as any effort to identify dysphagia earlier in the hospital course should provide benefit.

While it is well known that strokes complicated by dysphagia can in-

crease mortality and length of stay, we do not know if earlier diagnosis changes this outcome [13,14]. It still seems prudent to identify and manage dysphagia in the acute stroke setting as early as possible. The use of a screen is a low-cost and standardized method, particularly once the initial investment of training personnel has been implemented. With the release of the new American Heart Association (AHA) 2018 Stroke guidelines and an accompanying systematic review on dysphagia in stroke the AHA stated that the use of a dysphagia screen does not change the risk of death or dependency but could reduce pneumonia [8,15]. They gave this recommendation of classification strength of IIa with a Level of evidence of C with limited data. The AHA still recom- mends dysphagia screen in acute stroke but stated the dysphagia screen’s main utility was on prevention of pneumonia and not on mor-

tality in acute stroke patients [8].

Limitations

Some limitations in the study include the ability to show association but not definitive causation based on study design. We only explored dysphagia in the ED at the initial hospitalization for acute stroke so can- not infer these results beyond that time. As mentioned in the results section we had some slight differences in the rates of intubations how- ever we feel these differences had minimal influence on the rates of sub- sequent HAP.

This study was conducted at a large Urban academic medical center, results with other populations may show different outcomes. We can- not assure that using a different ED screen would result in the same outcomes.

Conclusion

The use of this ED dysphagia screen is associated with a reduction in the rates of HAP in patients with both acute ischemic stroke and hemor- rhagic stroke. We did not see changes in mortality with the use of the dysphagia screen. Larger studies would need to performed to see if out- comes such as length of stay or death are reduced with the use of an ED dysphagia screen. With the high rates of dysphagia in these patient pop- ulations the use of a screen is justified.

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