Identification and nursing management of dysphagia in individuals with acute neurological impairment: a systematic review (new update)

Abstract

Background: Dysphagia, or difficulty swallowing, is a serious and life-threatening medical condition that affects a significant number of individuals with acute neurological impairment, largely from stroke. Objectives: To find the best available evidence regarding: • The nursing role in the recognition and management of dysphagia in adults with acute neurological impairment. • The evidence on the effectiveness of nursing interventions in the recognition and management of dysphagia. Inclusion criteria: This review considered any quantitative studies that evaluated interventions which focused on the nursing role in the recognition and screening for dysphagia in adults over the age of 18 years with neurogenic dysphagia. Other interventions concerned with the nursing management of dysphagia were also of interest to the review. Outcomes of interest were: • 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 pathologists for formal assessment Search strategy: The databases searched included CINAHL, MEDLINE, Cochrane CENTRAL, Web of Science, Embase and Mednar. The search for unpublished studies included OpenSIGLE, New York Academy of Medicine Library, Gray Literature Report and Dissertations Abstracts International. Methodological quality: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data collection: Data were extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI. Data synthesis: Quantitative data was, where possible, pooled in statistical meta-analysis using RevMan 5.0. Effect sizes are expressed as odds ratios (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis. Heterogeneity was assessed statistically using the standard Chi-square and I-squared tests. Where statistical pooling was not possible, the findings are presented in narrative form including tables and figures to aid in data presentation where appropriate. Results: Four new studies were added by this update; data from which enabled a number of new analyses providing stronger evidence that dysphagia screening by nurses significantly reduces the number of chest infections in patients with stroke (OR 0.45, 95% CI 0.33-0.62, p<0.00001). The presence of formal dysphagia care guidelines including nurse-initiated dysphagia screening is effective for reducing inpatient death (OR 0.60, 95% CI 0.43-0.84, p=0.003) and for reducing chest infections (OR 0.68, 95% CI 0.51-0.90, p=0.008). Formal dysphagia guidelines also increased the number of screens conducted and the number of screens completed within 24 hours of admission. Conclusions: It is important that formal dysphagia screening guidelines are in place in healthcare organizations and that the guidelines include recommendations that patients are screened for dysphagia with a validated tool within 24 hours of admission. Dysphagia screening may reduce the rates of death, chest infections and days spent nil by mouth; however the latter requires more evidence.