1. Ensuring optimal nutrition in acute stroke units
Development of an evidence-based national practice guideline
Migle Karaliute1, Margrethe T. Børvik2, Hugo Nilssen3, Ida Rasmussen3, Bjarte Skille4, Margitta T. Kampman5
1Dept. of Neurology, 2Dept. of Therapeutic Services, 3Dept. of Clinical Nutrition, 4Dept. of Geriatrics, 5Centre for Clinical Research and Education, University Hospital North Norway, Tromsø
RATIONALE
Studies in different patient populations indicate that up to half of the patients admitted to hospital with acute stroke may be malnourished, and that probably as many initially present with dysphagia. Malnutrition may develop as a consequence of dysphagia if nutritional intake is substantially reduced.
Most stroke patients with dysphagia regain normal swallowing function within few weeks, whereas the proportion of patients with malnutrition has been show to increase during the hospital stay. Undernutrition in patients with acute stroke is an independent risk factor for poorer functional outcomes that is potentially modifiable.
Identifying patients at nutritional risk and patients with dysphagia as soon as possible after admission to an acute stroke unit is likely to reduce complications, prolonged hospital stay, poor functional outcomes, and mortality.
METHODS
A team consisting of clinical nutritionists, a speech and language pathologist, stroke nurses and physicians developed these guidelines following the Appraisal of Guidelines, Research and Evaluation (AGREE) framework. We identified and critically reviewed existing guidelines and conducted systematic literature searches to provide the evidence base for our recommendations.
Flow diagram showing measures for prevention of malnutrition in patiens with acute stroke
Prevention of malnutrition in patients with acute stroke
Feeding by nasogastric tube is initiated within 24 h in patients who are unable to take adequate nutrition and fluids orally, as recommended by the Norwegian guidelines for the treatment of stroke (grade A recommendation).
Nutritional support should be initiated in patients with no dysphagia who are malnourished or at risk of malnutrition (grade B recommendation) but not in patients who are well nourished at admission to the hospital. Food intake should be registered in patients who are malnourished or at risk of malnutrition, followed by referral to a dietician for nutritional assessment and individualised dietary advice if required . Guidelines and reviews contain useful suggestions for optimising nutritional management that have not been evaluated in clinical studies.
Dysphagia management in patients with acute stroke
Patients with abnormal swallowing test are referred to a speech and language pathologist to assess the need for:
Modification of consistency/texture of foods and fluids
Applying swallowing compensation techniques (postures and manoeuvres)
Rehabilitative swallowing therapy (restorative exercises)
Videofluoroscopy (usually not indicated during the first two weeks after a stroke)
Electronical tool in the patient record to assist calculation of the nutritional risk score
Electronical tool to document swallowing test results in the electronical patiens record
RESULTS
Formal evaluation of 6 guidelines, 1 systematic review and reports of 18 individual studies provides the evidence base for these guidelines.
RECOMMENDATIONS
Screening for undernutrition and nutritional risk in patients with acute stroke (Grade A)
Undernutrition in patients with acute stroke is an independent risk factor for poorer functional outcomes.
No specific tool for nutritional risk screening has been developed for or recommended in stroke patients. NRS 2002 was developed for in hospital use and is the only validated instrument that includes both age and severity of disease. In a comparison of the best documented tools, NRS had the highest sensitivity, specificity, and positive and negative predictive values. It is also the preferred tool for in hospital use in the Norwegian guidelines for prevention and treatment of malnutrition .
NRS 2002 should be repeated weekly because undernutrition may develop or worsen during hospitalisation.
Screening for dysphagia before offering food or drink to patients with acute stroke (Grade A)
Dysphagia carries a high risk of aspiration, which in turn predisposes for pulmonary infection. Structured reviews and recently published studies provide consistent evidence to support the assumption that formally screening for dysphagia before offering food or drink reduces the risk of pneumonia.
Our searches identified more than 10 protocols for dysphagia screening by trained nurses. With few exceptions, a water swallow test is the central item in dysphagia screening. The swallowing screen that is part of the Norwegian guideline for treatment of stroke contains a water swallow test that offers a teaspoon full of water three times before the patients tries to drink 50 ml of water.
PILOT IMPLIMENTATION OF THE NRS TOOL AND SWALLOWING SCREEN
Nurses learned how to perform a swallowing screen and how to use the electronic nutritional status screening tool in an educational session on 1 June Use of these instruments during the month of June was evaluated:
Pilot 18 patients consecutively admitted in June 2012
CONCLUSIONS
We recommend that
nutritional risk screening with NRS 2002 be performed within 24 h from admission (grade A).
a screening test of swallowing function be performed by a trained nurse shortly after admission and before the patient is offered food or drink (grade A), followed by a comprehensive dysphagia assessment by a speech pathologist for patients with abnormal swallowing screen.
feeding by nasogastric tube is initiated within 24 h in patients who are unable to take adequate nutrition and fluids orally (grade A).
Nutritional support be initiated in individuals at risk of malnutrition (grade B)
We have developed an electronic tool in the patient record to assist calculation of the nutritional risk score and an electronic form to document swallowing test results in the electronic patient record, both of which were easily implemented.