Approximately 78% of persons who have a stroke have post-stroke dysphagia during the acute stroke hospitalization. While many of these patients spontaneously recover their swallowing function, approximately 33% have dysphagia three months post-stroke. The consequences of dysphagia to the patient can include severe morbidity or mortality, as pneumonia is a main cause of death in persons who have had strokes. Dysphagia can also have a serious impact on the healthcare system costs due to readmissions and increased length of stay related to, largely preventable, pneumonia, malnutrition, and dehydration.

In this session, we will highlight three specific areas where we now have research-based guidance related to in-hospital dysphagia care. Namely, 1) the importance of instrumental examinations for dysphagia, 2) timing of G-tube placements, and 3) discharge planning and referrals.

Imaging via instrumental examinations is critical either via Modified Barium Swallow Studies (MBSSs) (aka Videofluoroscopic Swallow Studies (VFSSs)) or Flexible Endoscopic Examinations of Swallowing (FEES). The two main reasons these instrumental assessments are critical in the acute hospitalization are 1) many patients with post-stroke dysphagia silently aspirate, and 2) access to instrumental assessments is greatly limited outside of the acute care hospital. These exams, specifically the fluoroscopic evaluation of swallowing function, are used not only to diagnose dysphagia but also to identify physiological impairments that lead to specific, targeted treatments to address the impaired function. In addition, in the recent years there has been a large amount of work accomplished to improve the rigor of these exams with standardized protocols now existing that have been proven to be reliable and valid.

While approximately 33% of patients with post-stroke dysphagia have sustained swallowing problems, the other 66% of patients with post-stroke dysphagia have temporary dysphagia that resolves within the first 3 to 6 months after stroke. In the U.S. placement of G-tubes is earlier than clinical guidelines suggest, and follow-up for continuing swallow-related care after a g-tube is placed is inconsistent. These practices lead to patients being discharged on a G-tube who have recovery of swallow functions but are not re-evaluated and never eat by mouth again. In fact, recent evidence revealed that 61% of patients with a G-tube in skilled nursing facilities did not have evidence of dysphagia upon instrumental assessment.

There is a broken feedback loop whereby the inpatient, acute care clinical team does not see the outcomes of stroke patients after acute hospitalization discharge. This results in practices in the inpatient acute care setting that greatly impact access to care post-acute hospitalization (lack of continuity of care). These manifest in a number of patient and healthcare system issues including readmission, aspiration pneumonia, morbidity/mortality, lack of access to care, costs, etc.). More than ever before, the access to post-discharge care is now greatly dependent on patients being discharged from the acute hospitalization with a diagnosis of dysphagia. Due to the Patient-Driven Payment Model (PDPM), the diagnoses that a patient is admitted to a skilled nursing facility (SNF) with determine the payment the SNF receives to care for that patient, and often the care that the patient has access to.

Thus, we propose a session with four talks:

Speaker 1. Importance of post-stroke dysphagia.
The goal of this talk is to convey the importance of post-stroke dysphagia and provoke advocacy in clinical care.

Speaker 2. Swallowing imaging is critical.
The goal of this talk is to inform the non-SLP audience of the importance of swallowing imaging, disseminate recent evidence regarding the validity and reliability of these assessments, and encourage advocacy for swallowing imaging in the acute care of stroke patients.

Speaker 3. G-tube placement should wait two weeks.
The goal of this talk is to highlight issues related to early placement of g-tubes, disseminate recent evidence regarding g-tube placements, discuss funding changes that relate to a lack of follow-up, and encourage changes to clinical practices.

Speaker 4. Access to care and lost to follow-up: what can the acute care team do to help?
The goal of this talk is to highlight issues caused by the lack of a feedback loop (to the acute stroke team), disseminate recent data indicating the existence of these care issues, and advocate for changes in acute care practice related to continuity of care for post-stroke dysphagia.

Salman Ikramuddin

University of Texas Health Sciences

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