A review of the management of dysphagia: a South African perspective.ABSTRACT
Dysphagia is an impairment of swallowing associated with neurological diseases, including stroke. Identification is vitally important but can be difficult because stroke patients with dysphagia rarely perceive that they have a swallowing problem. Assessments of swallowing are not consistently carried out by medical or nursing staff, and often, there are unclear lines of responsibility as to which patients should be referred to a speech-language pathologist. This study measured the prevalence, assessment, and management of dysphagia in three private rehabilitation clinics in South Africa. Findings indicated a prevalence of dysphagia in 56% of patients following stroke, a number far exceeding previously reported statistics. This number may have been inflated due to conservative swallowing assessments given the subjective measures commonly utilized in South Africa, a product of the often-limited availability of imaging technology. All three clinics evidenced a strong multidisciplinary approach in the care and management of dysphagia patients. These findings highlight the need for increased education of collaboration between speech-language pathologists and nursing staff and support the need for future research in the field of poststroke dysphagia.
Dysphagia is a condition in which the action of the swallow is difficult to perform or painful or one in which swallowed material is held up in its passage to the stomach (Thompson & Morgan, 1990). Related risks include airway obstruction, aspiration pneumonia, malnutrition, dehydration, and death (Kikawada, Iwamoto, & Takasaki, 2005; Perry & Love, 2001; Westergren, 2006). Nursing staff often lack a consistent approach to managing dysphagia, which increases the need for a multidisciplinary approach that incorporates specialized training (Werner, 2005). Patients who have experienced stroke should be screened and assessed for dysphagia because effective management is dependent on an accurate and early diagnosis (Carnaby, Hankey, & Pizzi, 2006; Leslie, Carding, & Wilson, 2003; Ramsey, Smithard, & Kalra, 2003; Westergren, 2006).
Poststroke dysphagia treatment in Africa may not be optimal because of insufficient resources, poor management of the minimal resources available, and lack of qualified and knowledgeable healthcare professionals (Canada and the World Backgrounder, 2000; Watt & Penn, 2000). Ogungbo et al. (2005) further accounted for the less-than-optimal services as due to the lack of dedicated stroke units and instrumentation, specifically the imaging facilities for the gold standard of modified barium swallow assessments. Although lack of resources, especially lack of qualified and experienced nurses, may not be a unique disadvantage found only in South Africa, Scribante and Bhagwanjee (2007) reported an acute shortage of nurses in a national audit of critical care resources in South Africa. The former health minister of 2008, Manto Tshabalala-Msimang, reported the shortage of nurses in South Africa to be nearly 40,000 in number (Naidoo, 2008), a statistic of frightening proportion.
The most interesting detail to emerge from the audit of Scribante and Bhagwanjee (2007) is that 50% of all nurses practicing in South Africa can be found in the private sector. Unfortunately, most South Africans cannot afford the services provided in the private sector; thus, a mismatch exists between the supply and demand of nurses available and patients in need. The superior resources of the privately owned hospitals and rehabilitation facilities in the urbanized areas in South Africa may lead to better care in such facilities and provide a framework for improved care in the public sector, in which most of the South African population seek care. However, there still remains a lack of research involving stroke patients with dysphagia who are recovering in rehabilitation clinics in South Africa (Canada and the World Backgrounder, 2000). As the knowledge of dysphagia management improves for South African healthcare providers, it is hoped that identification and management will improve. Research focused on accurate estimation of the prevalence of dysphagia and its increased risk for pulmonary consequences in the stroke population in South Africa will be critical to guide the design of future research (Martino et al., 2005).
Research developments in poststroke dysphagia have significant potential for measuring the effectiveness of existing identification and treatment techniques and identifying new assessment and intervention strategies for swallowing disorders caused by stroke (Chapey, 1994; Mulley, 1985). Furthermore, opening the lines of communication between stroke experts in the more developed worlds, such as the United States, and developing countries, such as in Africa, may improve the management of dysphagia the whole world over (Ogungbo et al., 2005). This review was designed to increase the awareness of dysphagia management in South Africa by highlighting the prevalence, management, and collaborative services found in three private rehabilitation clinics.
Prevalence of Dysphagia
Literature often associates dysphagia with stroke. This association is important because it helps in the early identification and intervention of dysphagia and in the decrease of the occurrence of dysphagia-related morbidity and death (Martino et al., 2005). Groher and Bukatman (1986) reported that researchers in the United States found the occurrence of dysphagia following stroke to be approximately 30%. However, in their more recent studies done in Canada, Martino et al. (2005) found incidence rates to range between 37% and 45%. This increase may be due to improved methods of diagnosis for dysphagia but warrants increased education for the subsequent management of dysphagia across disciplines, specifically beyond the scope of speech pathology practice. Lee and Gaspar (2004) found that mortality rates related to dysphagia and dysphagia-related pneumonia vary greatly. In a country such as South Africa, where resources and funding for staff are often limited, it may be assumed, although not documented, that dysphagia mortality rates may be higher than those in developed countries. Pandian, Padma, Pamidimukkala, Sylaja, and Murthy (2007) reported that two thirds of global stroke occurs in low- and middle-income countries. Although not statistically supported in a review of current literature, this claim indicates a higher incidence of stroke in developing countries, which have the unfortunate imbalance between a greater incidence of stroke yet fewer resources available to maintain appropriate levels of care. Research detailing the occurrence of subsequent complications within South Africa is critical if we are to improve patient care and manage this potentially "silent killer."
Identification of Dysphagia
According to Dikeman and Kazandjian (1997), in-depth poststroke dysphagia assessments are usually conducted by a speech-language pathologist (SLP) and a physician. The first step in assessment is the clinical or "bedside" assessment and includes the following: observation of the patient's level of alertness, case history, oral motor structure and functioning, test swallows, observation during feeding, and stimulability for swallowing techniques and compensatory strategies (e.g., postural changes; Dikeman & Kazandjian, 1997). A good bedside evaluation should be simple, repeatable, and extremely sensitive to dysphagia risk (Hinds & Wiles, 1998). According to Perry and Love (2001), further development and validation of standardized screening methods are urgently required. In their study on the early assessment of dysphagia risk, Ramsey, Smithard, and Kalra (2003), who reviewed the outcomes of various assessment methods, concluded that, although screening was important, further refinements were needed to increase their accuracy.
Smith (2007) conducted a study in which 200 SLPs in the United States were surveyed on the assessment and management of aspiration in patients with dysphagia. Lack of significant differences was found with regard to their university training and clinical experience; however, there was variability in agreement with statements obtained from the medical literature with regard to aspiration and interventions. Some common recommendations made by SLPs were inconsistent with their reported knowledge base. These results indicate that SLPs are in need of continuing education in the field of dysphagia, a premise that is in line with the recommendation from Scotland's national clinical guideline for the management of stroke, which states that "there is an ongoing need for healthcare professionals to evaluate their practice in relation to outcomes and to consider carrying out audit and research in the field [of dysphagia]" (Scottish Intercollegiate Guidelines Network, 2004, p. 1). This is critical because evidence-based assessment and intervention are considered to be "best practice" when maintaining high levels of service delivery.
Following the clinical evaluation, if the SLP or physician feels that further assessment is necessary, instrumental assessment procedures can be performed, such as the standard barium swallow; modified barium swallow, also known as videofluoroscopic swallow study; and the fiber-optic endoscopic evaluation of swallowing. In addition, tests such as scintigraphy, also known as milkscan or technetium scan, cervical auscultation, ultrasound, pharyngeal manometry, surface electromyography, and pH probe can be performed (Langmore, 2001; Logemann, 1998; Murray, 2001).
In a study on the detection of dysphagia poststroke, Westergren (2006) reviewed literature discussing noninstrumental screening methods, and the results highlight the vital role of nursing staff in dysphagia assessments, ideally through the use of pulse oximetry. This dysphagia assessment tool, although not a commonly used measure, can be utilized in the midst of limited resources (Hill & Stoneham, 2000). Pulse oximetry measures the oxygenation in the patient's blood using a sensor that is attached to the index fingertip. It works by measuring oxygen levels before and after ingestion of food and liquids, with a spike indicating a possible presence of aspiration. Although not a precise measure of aspiration, this procedure can provide cautionary data in terms of patient oral intake in settings that have limited resources of video imaging.
Nursing staff could provide critical support for dysphagia management during and immediately following patient mealtimes by monitoring for both pulse oximetry and any overt signs of dysphagia. Such support could include attention to the swallow reflex during feeding, being aware of factors such as positioning during eating or drinking, coughing or choking after eating or drinking, complaints of a feeling of obstruction, frequent throat clearing, unexplained temperature spikes, food avoidance, heartburn, change in respiration pattern after swallowing, and prolonged mealtimes (Westergren, 2006). Increasing the knowledge of nursing staff on the detection of swallowing difficulties could have a direct impact on patient outcomes.
Lees, Shame, and Edwards (2006) conducted a study involving nurse-led dysphagia screening in acute stroke patients. They investigated the outcomes of a systematic approach to training nurses who conduct dysphagia assessments. An improvement was noted in the time patients waited for dysphagia screening, from 35 hours to less than 1 hour, with the time patients spent in hospital being inappropriately designated as nil per oral, a term used to prohibit oral feeding. These results confirm the effectiveness of dysphagia education being provided for all nursing staff.
Hinds and Wiles (1998) investigated the assessment of swallowing and referral of poststroke dysphagia patients by SLPs. They investigated the effectiveness of structured assessments and a timed water swallowing test to screen for dysphagia in acute stroke patients. The timed water swallowing test assesses the patient's ability to drink a specified volume of water over a period. Poor results on the timed water swallowing test were associated with increased risks of mortality, pneumonia, and dietary modification. Given these results, Hinds and Wiles reported the timed water swallowing test as being a useful screening source and referral source, once again, another preassessment tool that could be supported by nursing staff.
Management of Dysphagia
Dikeman and Kazandjian (1997) stated that poststroke dysphagia is best treated through a systematic management plan. Following identification of dysphagia or dysphagia risk, the patient is ideally referred to an SLP and a dietician who work together to clarify the patient's nutrition and feeding requirements (Rosenvinge & Starke, 2005). Together, they typically establish dietary recommendations (e.g., the thickening of liquids) to achieve normal nutrition and hydration while minimizing the risks of choking or aspiration. Clinical evaluations should be performed on a daily basis, and, when necessary, instrumental assessments can be used to monitor the patient's progress.
In severe cases of dysphagia in which rehabilitative behavioral interventions are not an option, a nasogastric (NG) feeding tube, a percutaneous endoscopic gastrostomy (PEG) tube, or a gastrostomy tube may need to be inserted as a means of compensatory nonoral feeding (Huckabee & Pelletier, 1999).
Ideally, the client's dysphagia management team, which usually includes a doctor, nursing staff, an SLR a dietician, and family members, decides whether the patient will be fed orally (e.g., via a special consistency diet) or nonorally (e.g., via a PEG tube; Finestone & Greene-Finestone, 2003). An oral approach can be a difficult task to monitor, given the number of people often involved in the feeding process. A thickened or "pureed" diet may not be a patient's first choice psychologically, despite reducing aspiration risk. Family members may require a high level of education to see the benefit of compliance in the face of patient morale. Another challenge for this approach comes from the limitation of SLP staffing to monitor all patients at all mealtimes. For these reasons, nursing staff can play a critical role in supporting both the family education and the supervision of meals to ensure appropriate dysphagia management.
Modi (1999) investigated the practices, training, and concerns of hospital-based SLPs in South Africa. Results indicated that most of the SLPs were involved in assessing and treating dysphagia patients. Limited staff, large caseloads, restricted access to supervision, and poor knowledge demonstrated by other health personnel of their role in dysphagia were highlighted as being problems. This study implies that there is a need to increase the knowledge of all health personnel and endorse continued professional development of those practicing in this area.
Additional challenges faced by South African healthcare providers include the many cultural and economic differences in the population. In a country with 11 official languages, it is not uncommon to encounter English barriers, in addition to many patients who demonstrate a preference for alternative medicine provided by the local sangoma or Izinyanga, the traditional healers found in many African communities. Morris (2001) reported traditional healers to be of value to 80% of Africans across the continent, with their numbers outnumbering Western doctors by at least 10 to 1. Puckree, Mkhize, Mgobhozi, and Lin (2002) reported that 70% of 300 patients interviewed in the province of Kwa-Zulu Natal in South Africa preferred to consult with a traditional healer before seeking Westernized care. Given these statistics, improved management of dysphagia in South Africa would need not only to address the improved collaboration with nursing staff but also to integrate the role of the traditional healer in the collaboration of care.
In addition to these cultural differences, the weakened currency of the Rand in South Africa puts salaries at risk in a time of international economic crisis. According to the Democratic Nursing Organisation of South Africa, South African nurses can expect to earn between $13,000 and $18,000 annually, depending on experience, compared with the international estimate of earnings between $22,500 and $45,000 (Naidoo, 2008). As of 1998, the South African government began to require a 1-year commitment of community service of special skilled professions following academic qualification. This group included doctors, dentists, and pharmacists, with physiotherapists, occupational therapists, SLPs, clinical psychologists, dieticians, radiographers, and environmental health officers joining in as of 2003 (Reid, 2002). In 2007, this community service year was extended to include nurses having completed a 4-year degree or diploma. This year serves not only to retain health professional services in the face of possible immigration for improved salaries but also to provide such services in rural areas that may not attract individuals by choice. Such challenges impact not only patient care but also the experiences of the community as a whole.
A study on the experiences and perceptions of caregivers of stroke patients, conducted by Flemengas (2005), highlights the poor support structures available to stroke patients and their families living in South Africa. This study also addresses the challenges of staff and limited resources commonly experienced. SLPs in South Africa comprise a small percentage of practicing healthcare professionals and often find themselves trying to service large caseloads in a country that has minimal resources and several dilemmas related to the provision of healthcare, education, housing, and nutrition (Canada and the World Backgrounder, 2000; Watt & Penn, 2000). Flemengas' results also reveal that caregiver experiences were worsened by inadequate support structures available in South Africa. The lack of poststroke education provided to caregivers was noted as being an issue of great concern. In addition, this study highlights the need for SLPs and nursing staff to take the initiative and educate themselves on the topic of dysphagia despite a lack of support, resources, or available funding.
The purpose of this research study was to measure the prevalence and review the assessment and management strategies related to dysphagia in three private rehabilitation clinics in South Africa. This research was designed as a preliminary investigation into current practice in a private, and thus advantaged, rehabilitative setting in the hopes of improving services across all settings. By presenting the results to an international audience, a further aim was to bridge the gaps between developed and developing countries to increase awareness and share current practice strategies to improve overall management of dysphagia.
Three private rehabilitation clinics in Gauteng, South Africa, were thus invited to participate in this review. To respect the privacy of the three rehabilitation clinics, each will remain anonymous. Thirty records from each clinic, 90 records in total, were randomly selected from the stroke patient records dated January 1,2006, to December 31,2006, to provide current results. The sample size was a sufficient number for this preliminary study; however, a larger sample size would be recommended for future research. Informal interviews with the resident SLPs were conducted when necessary (e.g., when the researcher felt that the patient records were missing information or when information within the files appeared unclear).
The medical records from both men and women were reviewed for this study. In the past, statistics have shown a higher incidence of strokes occurring in men versus women (Groher & Bukatman, 1986); however, recent literature suggests that both genders display an equal chance of having a stroke (Williams, 2004). Although it was deemed valuable to investigate if dysphagia is more common in one gender versus the other within this random sample, a larger sample size would be needed to obtain an accurate gender breakdown. Due to the observation of a large number of the stoke patients being younger than 70 years, it was decided that patient age should be included in the data collection findings rather than be one of the selection criteria.
The review followed both an analytic and a descriptive approach in terms of research design. Following ethical clearance, the selected records were retrospectively reviewed using a data collection form generated by the primary author to access relevant information (the data collection form is available online, as Supplemental Digital Content 1, http://links.lww. com/JNN/A1). The data extracted were analyzed and averaged into tables according to the study's aims. Incidence levels were recorded as percentages using mean scores and included standard deviations. Content analysis, which incorporated both qualitative and quantitative purposes, allowed for a thematic approach to determine similarities and differences regarding the diagnostic methods and intervention strategies of the three private rehabilitation clinics. All identifying patient information was kept confidential throughout data collection and subsequent analysis.
Results and Discussion
Prevalence of Dysphagia, Dysphagia Management, and Dysphagia-Related Complications
The prevalence levels of dysphagia within this sample were 56%, which is significantly higher than the levels described by Martino et al. (2005; see Table 1). This suggests a possible increase in the occurrence of poststroke dysphagia or a high level of efficient dysphagia screening and assessment methods within this sample. Specifically, of the 90 records reviewed, 50 patients received poststroke dysphagia intervention, 12 patients received poststroke intervention without having been diagnosed as having dysphagia, 26 patients were reported as not in need of dysphagia intervention (e.g., modified diets and compensatory strategies), and only 2 patients were reported as deceased prior to discharge. These findings can be further viewed as percentages of the 90 patient files that were reviewed (see Figure 1).
The prevalence of poststroke dysphagia intervention without diagnosis was surprisingly high. This may be due to the fact that in 13% of the patient files, the SLPs within this sample had written "monitor swallowing" as part of their overall intervention plan, even when dysphagia had not been officially diagnosed. This management exemplifies efficient dysphagia assessment (Dikeman & Kazandjian, 1997) and demonstrates the opportunity nursing staff could have to support the patient with potential dysphagia.
Mortality levels were found to be particularly low within this sample, with 88 of the 90 patients being discharged from the rehabilitation facilities. This positive finding once again highlights the high level of early and effective care that was provided by these three rehabilitation facilities during the year of 2006. Such effective care is essential when working with patients at risk for dysphagia, especially considering the previously mentioned findings of Johnson, McKenzie, and Sievers (1993), who reported that 50% of patients in the United States diagnosed with severe dysphagia develop pneumonia, and aspiration pneumonia has been listed as a possible cause of death in stroke patients (Daniels, Schroeder, McClain, Corey, & Foundas, 2006).
[FIGURE 1 OMITTED]
Certain commonalities within this sample of acute stroke patients were noted. Of the 90 patient files, 50 were male patients and 40 were female patients (see Table 2). The type of strokes reported consisted of 41 right cerebral hemisphere, 41 left cerebral hemisphere, 1 cerebellar, 2 brainstem, 2 global, and 3 "other." The category other included type of strokes occurring elsewhere in the central nervous system (e.g., a stroke in the basal ganglia).
Severity of stroke was subjectively recorded using the clinical judgment of SLPs, and results indicated that of the 90 patient records, 16 were classified as mild, 47 were classified as moderate, and 27 were classified as severe. A majority of the stroke patients therefore experienced "moderately severe" cerebral strokes; however, it must be noted that the level of severity was a subjective measure because, other than site of lesion (e.g., cerebral, cerebellar, or brainstem), there appeared to be no standard, objective descriptions of the severity or scope of lesion available in the patient files. A review of each patient's current level of performance on initial assessments was used to help determine the severity of stroke.
Length of stay at the rehabilitation facility was calculated from a smaller sample size due to limited information available in 20 of the 90 patient files. Of the 70 files reviewed, an average length of stay of 5 1/2 weeks was found. Although the length of stay for each patient will vary depending on multiple health and recovery factors, attention to the efficient diagnosis and management of dysphagia has the potential to reduce further health complications, thereby reducing overall length of stay. This is critical when considering that patients with dysphagia have been reported to experience longer hospital stays than do those patients without (Teasell, Foley, Fisher, & Finestone, 2002).
Prevalence and Variation of Patients' Feeding Status
Despite the minority of the sample being within the mild severity category of type of stroke, a high percentage of patients were able to feed independently, were being fed orally, and were eating a soft consistency diet (see Table 3). Of the 90 patient files reviewed, 42 out of 90 were able to feed independently, 77 were on an oral diet, and 13 were on a nonoral diet (e.g., being fed via a PEG tube). In terms of the varying stages of diets, 8 were on a PEG tube diet, 5 were on an NG tube diet, 5 were on a pureed diet, 39 were on a soft diet, and 33 were on a full ward diet. The high prevalence of oral feeding, despite less than half of the patients being dependent for feeding, exemplifies the high level of care from the three clinics, which is in effect lowering the level of additional risks that accompany nonoral feeding methods discussed by Williams (2004).
Dysphagia Diagnostic Methods Utilized by the Rehabilitation Facilities
An informal interview with one of the rehabilitation clinic's SLPs revealed that the SLPs and dieticians at one of the sites aimed to assess every new stroke patient for dysphagia. A very low percentage of patients from the overall sample were assessed via radiographic evaluations; however, a high percentage of patients were diagnosed as being dysphagic (see Table 4). This supports the effectiveness of clinical evaluations performed by SLPs and confirms a statement made by Hinds and Wiles (1998) that a good bedside evaluation is one that is extremely sensitive to dysphagia identification. Once again, the limited staffing of both nurses and SLPs in the South African context impacts the ability to ensure that all patients at risk for dysphagia have access to the diligent care demonstrated in this review. However, an increase in the collaboration of all health professionals in the public sector may help achieve equal standards, as seen in these three rehabilitation clinics.
Dysphagia Intervention Techniques Utilized by the Rehabilitation Facilities
Although selected files did not always include dietician reports and feedback, informal interviews with the resident SLPs revealed that intervention from a dietician was given to every patient who may have been in need of an individualized diet. Therefore, dietician intervention levels presented in Table 5 may only be used as a guide as to how many patient files reported having intervention from a dietician.
As shown in Table 5, out of the 90 patient files, 62 had their swallowing monitored by an SLP, 51 received dietary modifications by an SLP, 39 received oral sensorimotor and behavioral intervention from an SLP, 49 received dietary modifications by a dietician, 57 received nutritional modification (e.g., low-cholesterol diet) from a dietician, 43 received counseling from a dietician, 11 were placed on an NG tube, and 8 were placed on a PEG tube. During informal interviews with the SLPs, it was also noted that a dietary modification was not made by an SLP without consulting a dietician because modifying the consistency of a diet could in turn modify its nutritional contents.
On the basis of the findings of this research project, specific management techniques that may help support hospital-based SLPs the most are monitoring the patients' swallowing ability on a daily basis and modifying the patients' diet appropriately. The intervention techniques described at these three sites proved to be successful in avoiding the additional risks associated with feeding tubes by providing alternative forms of intervention.
A blind review of the selected files was conducted, utilizing an SLP with a master of arts in communicative disorders, currently employed in the university setting teaching dysphagia as a reliability coder. Specifically, this individual reviewed a random sample of 10% of the selected medical records using the same data-gathering form as the researcher. Findings were correlated using Cohen's kappa. In addition, percentage agreement was also determined for reliability purposes when Cohen's kappa scores were not satisfactory or less than .7 (Fleming & Nellis, 2000; Murphy & Davidshafer, 2001).
Cohen's kappa results revealed a score of 1, or a perfect agreement, between coders' findings within the categories of age, gender, average length of stay, type of stroke, feeding status (i.e., oral versus nonoral diet), the use of videofluoroscopic diagnostic methods, the use of a PEG tube as an intervention technique, and cognitive comorbidities. The results were satisfactory for stage of diet and dysphagia prevalence levels; therefore, there was a strong agreement between the researcher's and reliability coder's reviews.
Severity of stroke, ability to feed independently, dysphagia treatment prevalence levels, a clinical evaluation as a diagnostic method, and all treatment techniques excluding PEG tube placement all revealed nonsatisfactory agreement between the researcher and reliability coder when utilizing Cohen's kappa. However, percentage agreement scores revealed more satisfactory results, including 74% reliability for severity of stroke, 61% reliability for ability to feed independently, 87% reliability for dysphagia treatment incidence levels, 96% reliability for bedside evaluation as a diagnostic method, 78% reliability for an SLP monitoring swallowing status, 65% reliability for an SLP modifying the patients' diet, 78% reliability for an SLP practicing swallowing techniques, 65% reliability for a dietician modifying the patients' diet, 28% reliability for the dietician providing nutritional modifications, 43% reliability for the dietician providing patient and family counseling, and 91% reliability for the use of a NG tube as treatment.
This study was designed to initiate discussion of dysphagia prevalence, assessment, management, and complications. The increased awareness of dysphagia will hopefully improve the care provided to patients not only in private rehabilitation clinics and hospitals but also in public-funded institutions as well.
Although resources may be limited in some facilities in South Africa (Canada and the World Backgrounder, 2000; Watt & Penn, 2000), this study highlights some key strategies currently being implemented in three private rehabilitation clinics that could be incorporated in most, if not all, other facilities with minimal additional resources or staffing demands.
In terms of assessment for dysphagia, SLPs should conduct a clinical assessment that is sensitive and repeatable enough to reliably identify the condition (Dikeman & Kazandjian, 1997; Hinds & Wiles, 1998). Following the initial clinical evaluation, if the SLP or physician feels that further assessment is necessary in determining the client's risk for dysphagia, instrumental procedures such as modified barium swallow (videofluoroscopic swallow study) should be performed (Chapey, 1994; Dikeman & Kazandjian, 1997; Logemann, 1998). In addition, other staff members, specifically nursing staff involved in the care of poststroke patients, could help identify the presence of dysphagia, by increasing awareness when it comes to the assistance of improved patient monitoring. Increasing the knowledge of nursing staff could have a direct impact on patient outcomes (Westergren, 2006).
In terms of management, the SLPs and dieticians working at the three clinics involved in this review combined their intervention techniques for those patients who were at risk for having dysphagia and in return received a high percentage of positive outcomes. The primary aim of their intervention was to achieve normal nutrition and hydration while minimizing the risks of choking or aspiration. Clinical assessments were performed on a daily basis, and, when necessary, radiographic studies were used to monitor patients' progress. More common techniques of intervention at the three clinics included the modification of patient diet consistencies by both SLPs and dieticians, the monitoring of swallowing ability by SLPs, oral sensorimotor and behavioral intervention by SLPs, modification of nutritional status by dieticians, and nutritional counseling by dieticians. NG and PEG feeding tubes were only used as a last resort, and therefore the additional risks associated with these nonoral methods of feeding were avoided.
Current nursing training in South Africa falls within a 4-year diploma or a 4-year degree for general nursing, midwifery, psychiatry, or community health nursing at nursing colleges, universities, and technikons (Geyer, Naude, & Sithole, 2002). There is a diploma in clinical nursing science, health assessment, treatment, and care, which constitutes the post-basic preparation for nurse practitioners. This diploma focuses on the development of assessment skills, knowledge of pathology, and epidemiology of common diseases in South Africa, diagnosis and treatment of health and diseases of all age groups, multidisciplinary referrals, counseling, medicolegal and ethical decisions, leadership, management, and research development (Geyer et al., 2002). Given the wide range of skills expected of nurses in many of the underdeveloped areas of South Africa, it is not uncommon to encounter nursing staff unfamiliar with the diagnosis and referral process of dysphagia. Increasing the knowledge of nursing staff on how to monitor swallowing, ensure diet consistencies are correct, follow diet recommendations made by SLPs and dieticians strictly, perform oral sensorimotor intervention, and feed dependent patients appropriately could lead to improved patient outcomes and reduced costs of hospital or clinic intervention.
The primary limitation to this study was that the record review represented a particular sample from private rehabilitation clinics or hospitals and so may not have been representative of the greater South African context. As previously mentioned, publicly funded hospitals and clinics provide services for most South Africans due to the costs involved in being treated at a private rehabilitation facility and the accessibility to private facilities in rural areas. It is therefore important to note that further research is required to measure the prevalence, incidence, and management of dysphagia in other hospitals and the possible discrepancy between the levels of care. Additional limitations included patient information being documented incorrectly or insufficiently in the medical files or the differences noted between the researcher's record review and the volunteer's blind review due to subjective coding, such as in the case of severity of stroke. Data correlations were therefore calculated to analyze the differences and ensure validity.
It is felt that this study may initiate further research into effective management of dysphagia in South Africa. Accurate measures of the incidence of dysphagia and its complications within the stroke population will help guide future research to assess the benefits of varying dysphagia interventions (Martino et al., 2005). Further research is urgently required to compare this study's results with larger sample sizes and within the public sector in South Africa and beyond to ensure the best possible research-based practice for all patients with dysphagia.
This study underscores the need for improved clinical practice to improve patient management in terms of health and overall costs to all parties involved (e.g., patients, families, and hospitals). The review of 90 records from three private rehabilitation clinics in South Africa indicated that exemplary care with regard to dysphagia is being provided to patients following stroke. Other rehabilitation facilities that may not have access to the equivalent resources should use these three clinics as examples in striving toward reaching a satisfactory level of healthcare.
The findings from this project aim to validate and support current intervention strategies for clients with dysphagia, used in private and highly established rehabilitation hospitals. In addition, these findings aim to increase the awareness of the SLPs' role in dysphagia identification and intervention and help support all staff (e.g., dieticians and nurses) in such management and to highlight the role of the nursing staff in successful management. It is hoped that with improved knowledge and access to information regarding dysphagia, the identification and management of this "silent killer" will become more effective and more accessible to all socioeconomic populations.
The authors express their gratitude to the three rehabilitation facilities that participated in this study. Their willingness to accommodate the authors is much appreciated.
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Zara Blackwell, BA, is at The University of Witwatersrand, Johannesburg, South Africa.
Question or comments about this article may be directed to Penelope Littlejohns, MA SLP-CCC, at penelope.littlejohns@ wits.ac.za. She is working at the Department of Speech Pathology & Audiology, The University of the Witwatersrand, Johannesburg, South Africa.
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TABLE 1. Incidence Levels of Dysphagia, Dysphagia Intervention, and Mortality Incidence Type n % Incidence of poststroke dysphagia 50 56 intervention with diagnosis Incidence of poststroke dysphagia 12 13 intervention without diagnosis Incidence of patients who did not 26 29 require dysphagia intervention Incidence of mortality 2 2 TABLE 2. Characteristics of the Sample Characteristic n % Age at onset M = 62 years SD = 14 years Gender Male 50 56 Female 40 44 Average length of stay M = 5.5 weeks (out of 70 samples) SD = 5.3 weeks Type of stroke Cerebral: 41 46 right hemisphere Cerebral: 41 46 left hemisphere Cerebellar 1 1 Brainstem 2 2 Global 2 2 Other 3 3 Severity of stroke Mild 16 18 Moderate 47 52 Severe 27 30 TABLE 3. Incidence and Variation of Patients' Feeding Status Characteristic n % Able to feed 42 47 independently Diet Oral 77 86 Nonoral 13 14 Stage of diet Percutaneous endoscopic 8 9 gastrostomy tube Nasogastric tube 5 6 Pureed diet 5 6 Soft diet 39 43 Full ward diet 33 37 TABLE 4. Diagnostic Assessment Methods Diagnostic Assessment Type n % Clinical assessment by a 88 98 speech-language pathologist Videofluoroscopic swallow study 9 10 TABLE 5. Dysphagia Intervention Techniques Dysphagia Intervention Type n % SLP: Monitor swallowing 62 69 SLP: Dietary modifications 51 57 SLP: Swallowing techniques 39 43 Dietician: Dietary modifications 49 54 Dietician: Nutritional modifications 57 63 Dietician: Counseling 43 48 NG tube 11 12 PEG tube 8 9 Note. SLP = speech-language pathologist; NG = nasogastric; PEG = percutaneous endoscopic gastrostomy.