NEED FOR IMMEDIATE SWALLOWING SCREENING IN POST STROKE PATIENTS IN PAKISTAN

Cerebrovascular accident (CVA) is one of the leading cause of neurological disability in adult population world wide. It is allied with an array of challenges. A common complication post stroke is swallowing difficulty , which results in complicating acute ischemic strokes (AIS) in 42% cases and is manifested immediately after ischemic stroke. Complications resulting from chest infections in patients of  AIS is 32%  and 89% of these infections  are secondary to dysphagia Pneumonia in stroke   patients is often associated with aspiration. (1) Swallowing assessment at time of admission in stroke patients can help in minimizing risk of pneumonia in stroke patients. A common perception is that Islamabad being the federal capital should be the model which should be replicated, however, despite its small size in both territorial and population terms although being endowed with adequate financial resources the provision of health services in the suburbs is not satisfactory. This situation is not unique to Islamabad; same situation is prevalent in all cities of Pakistan and other developing countries. Visits and interviews conducted in ICT indicated that currently no government or private hospital have any protocol for swallowing assessment at time of admission for stroke patients . There is ample evidence that it is ideal for patients with stroke to have early swallowing screening and identification of dysphagia as it will result in timely adoption of strategies which will  result in  reduced incidence of aspiration , duration of stay at hospital , and health care expenditures. To ensure best practice timely diagnosis of dysphagia, and adoption of strategies to prevent aspiration and other  complications associated with dysphagia, screening of all stroke patients at time of admission for signs of swallowing issues is advisable. Research evidence indicate that when stroke patients are immediately evaluated for swallowing efficacy following a screening protocol , there is a significant decrease in incidence of aspiration (2).  Implementation of strict swallowing screening protocol for patients with stroke, can improve clinicians’ adherence with screening swallowing before starting oral feed. American Heart Association/American Stroke Association (AHA/ASA) included swallowing assessment before starting anything orally including medication in patients with suspected stroke and it was made component of there early stroke management guidelines. Joint Commission (JC) certification until year 2010 for primary stroke centers required implementation of swallowing assessment protocol before starting anything orally in stroke patients (3). Many acute care facilities in developed countries have protocols according to which swallowing assessment to rule out dysphagia will be mandatory and findings will be documented on medical record files of all types of  stroke patients including warning strokes before food, fluids, or medication are started (for example all Joint Commission on the Accreditation of Health Care Organizations, 2004). Most commonly used swallowing screens are, water swallow tests and there modified versions, some protocols include brief assessments of oral motor and sensory function  and clinical (bedside) Swallow examinations.(4) Developing countries are still busy fighting communicable diseases and are unable to pay much attention to non communicable diseases such as stroke, although the number of stroke patients added to population increase the already existing BOD for these nations many fold. A study was conducted in India with aim to develop a protocol for bedside swallowing screening for oro pharyngeal dysphagia. The Nair hospital bedside swallowing assessment (NHBSA) and Nair hospital swallowing ability scale (NHSAS) were developed based on literature search and available practice patterns . The NHBSA and NHSAS showed highly significantly psychometric properties. A comparative study with current gold standard assessment technique modified barium swallow revealed that NHBSA have potential in precisely identifying swallowing difficulty and risk of aspiration.  Wet voice quality, post swallow cough, coughing between swallowing and absence or weakness of voluntary cough were found to be    warning signs that help in diagnosing  presence of aspiration risk. (5) Guidelines and Pathways (protocols) are necessary to ensure quality care in health care facilities. The skills and competencies outlined in practice standard guide and protocols are important components in the provision of standardized quality health care. Patients tends  to get maximum benefit when a number of related professionals team up for assessment and treatment of swallowing difficulty. According to guidelines and practice standards for dysphagia treatment by speech- language  pathologists given by College Of Audiologists And Speech Language Pathologists Of Ontario “Any  health professional trained in the clinical assessment of patients/clients (e.g. nurses, physicians, dietitians, physiotherapists, and occupational therapists) may conduct swallowing screening. However Speech pathologists play a key character in making assessment and  screening protocols for dysphagia  clients  and conducting training for those who at initial stage carry out screening and form opinion regarding efficacy of swallowing (6) Keeping in view current health care services in our country, planning to have speech pathologist available at all emergency departments for swallowing screen appears to be almost impossible. Adopting a more realistic approach we need to develop a simple and effective bed side swallow screen on base of available literature and train our allied health staff for initial dysphagia screening in emergency departments. All hospitals of Islamabad having emergency departments and catering stroke patients should make an effort to include dysphagia screening in their stroke care protocols at time of admission. Speech language pathologists must come forward to offer their expertise in this regard , this may seem difficult to implement initially but a combine effort and dedication can bring a positive change in existing system.

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