Identification and nursing management of dysphagia in individuals with acute neurological impairment (update)

Background Dysphagia, or difficulty in swallowing, is a serious and life threatening medical condition that affects a significant number of individuals with neurological impairment. Nurses, who are available to patients 24 hours a day, are in the ideal position to identify individuals with swallowing difficulties and initiate interventions that may prevent further complications until a formal assessment can be undertaken1. Appropriate assessment of swallowing function is essential to the accurate identification and diagnosis of deficits in swallowing and to the effective management of dysphagia. Objectives What is the nursing role in the recognition and management of dysphagia in adults with neurological impairment? Is there evidence on the effectiveness of nursing interventions in the recognition and management of dysphagia? Inclusion criteria Types of participants- Adult patients over the age of 18 years with neurogenic dysphagia secondary to acute neurological impairment were the chief population of interest; studies of nurses caring for these patients were also included. Types of interventions- This review included studies which used various interventions which focussed on the nursing role in recognition and nursing management of dysphagia; any formal observation of ability to swallow undertaken / documented by nurses; Clinical / Bedside Swallowing Assessment undertaken by nurses; and/or pulse oximetry monitoring. Types of outcomes- Early recognition by nurses of those with difficulty swallowing Clinical screening by nurses of any patient with suspected swallowing difficulties Timely referral by nurses to speech language pathology for formal assessment Any outcome measures from interventions that aimed to prevent aspiration, choking episodes and/or associated morbidity were of interest. Time spent prior to the initiation of appropriate nutrition and hydration by patients with neurological impairment Types of studies- Original quantitative research studies with a range of study designs such as randomised controlled trials, quasi-randomised trials, observational and descriptive studies. Exclusion criteria Studies focussing solely on diagnostic procedures ordered or undertaken by either medical professionals or speech-language pathologist (such as videofluoroscopy/VFSS) were not of interest to this review. Search strategy A comprehensive search of a wide variety of published and unpublished sources was undertaken for the period between January 1998 and January 2008 using as main keywords: dysphagia (text word and MH) or gag reflex or swallow or "deglutition disorder" (text word and MH); problem or impair or difficult; neurological and impair or stroke or bedside swallowing assessment; MH "Brain Diseases+" or neurological and impair* or disorder* disease* or malfunction. Methodological quality Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer. Data extraction The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Due to significant variability in study methodology, populations and interventions, no statistical meta-analysis was possible. Results are presented in narrative and tabular form instead. Results Forty-two quantitative studies were retrieved and, of these, 17 met the inclusion and quality criteria, representing a wide range of quantitative research methodologies. Conclusions The evidence from this updated review indicates that nurses are well-placed to conduct dysphagia assessments and that there are several tools available that may be suitable for them to use. It is important that formal dysphagia screening protocols are in place and that nurses are trained to use them. If nurses screen patients with an acute neurological impairment within 24 hours of admission, it may reduce the time that patients spend without appropriate methods of nutrition and hydration and improve clinical outcomes. Dysphagia screening by nurses does not replace assessment by other health professionals; instead it enhances the provision of care to patients at risk allowing for early recognition and intervention to occur.