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EPM.037
An investigation into current UK practice for screening adult patients with a tracheostomy tube for dysphagia

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An investigation into current UK practice for screening adult patients with a tracheostomy tube for dysphagia7

1. Background

•Patients with tracheostomy tubes are at risk of aspiration and swallowing disorders.1
 
•In the UK it is estimated that 12,000 tracheostomies are performed  annually.1
 
•Complications of swallow problems and aspiration in this population can be severe.2
 
•In the non-tracheostomised population, screening  to allow early identification of swallowing disorders can reduce associated complications significantly.3
 
•A UK audit (2014) found swallowing problems were the third most common complication in patients with tracheostomy.1. However the extent to which a tracheostomy tube causes swallowing problems is unclear.4
 
•Swallow screening by a range of healthcare professionals can identify patients at risk. Appropriate management plans can be implemented avoiding delays whilst waiting for speech and language therapy (SLT). Unnecessary involvement of SLT can therefore also be avoided.5
 
•Currently no standardised swallow screen for the tracheostomised population exists and there is no literature regarding current or best practice.
 

2. Aim

 To investigate current UK practice for screening adult patients with a tracheostomy tube for dysphagia and explore and describe participants’ perceptions of their current swallow screening process.

3. Study design

 •A mixed methods approach using an online questionnaire and telephone interviews.

 Participants and sampling

 •Practicing physiotherapists, speech and language therapists or nurses working with adults with tracheostomies in the UK.

 •Recruitment was via professional special interest groups, social media and snowball sampling. Interview participants were purposively sampled from questionnaire participants.

 Data analysis

 •Questionnaire  data was analysed using descriptive statistics.

 •Interviews were transcribed verbatim and analysed using thematic  analysis6 to identify key themes.

4. Results - Questionnaire

 •221 questionnaires completed

•28% of participants without a swallow screen indicated that all patients with a tracheostomy were seen by SLT
 
•28% of participants felt their swallow screen was effective at identifying patients at risk
 
•87% participants conducted 5 or fewer screens a month
 
•High risk diagnostic groups were referred directly to SLT
 

5. Results - Interviews

Thematic analysis revealed three themes; Processes, Safety and Wellbeing, Risk vs Resources and one integrative theme; MDT working.

Processes:

Varied approaches to conducting swallow screening:•Formal ‘protocol’ based screen in place •Informal methods •No swallow screening

Safety and Wellbeing:

•High risk patients always referred to SLT
•Reduces time patients wait to eat and drink
•Poor compliance with the screening amongst MDT
 
Risk vs Resources
•MDT doing the best they can with limited resources
•More resources for training
•Innovative ways of identifying patients at risk
 

MDT Working:

•Swallow screening enhances MDT working
•Reliant on long-term informal relationships
•SLT needs to be a visible presence on the ward
 
6. Conclusions
 
•Swallow screening varies across the UK and is not in-line with national guidelines
•The process is perceived as sub-optimal
•SLTs need to increase their presence in the MDT
•Managers and clinicians need to work together to improve MDT working
•Future research is needed to develop a swallow screening tool that is validated for this population and identifies barriers to MDT working.
 
References 1. National Confidential Enquiry Patient Outcome and Death. On the Right Trach? A review of the care received by patients who underwent a tracheostomy [Internet]. 2014 [cited 2014 July 15]. Available from: http://www.ncepod.org.uk/2014report1/downloads/On%20the%20Right%20Trach_FullReport.pdf. 2. Donzelli J, Brady S, Wesling M and Craney M. Simultaneous Modified Evan Blue Dye Procedure and Video Nasal Endoscopic Evaluation of the Swallow. Laryngoscope. 2001; 111 (10): 1746 – 1750. 3. Odderson IR, Keaton, JC and McKenna BS. Swallowing management in people on an acute stroke pathway: quality is cost effective. Arch Phys Med Rehabil. 1995; 76 (12): 1130 – 1133. 4. Leder SB, Ross DA, Confirmation of No Causal Relationship Between Tracheotomy and Aspiration Status: A Direct Replication Study. Dysphagia. 25 (1). 35 – 39.  5. Hinchey JA, Shephard T, Furie K, et al. Formal Dysphagia Screening Protocols Prevent Pneumonia. Stroke. 2005; 36 (9): 1972 – 1976. 6. Braun 2014. V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3 (2): 77 – 101. 7. Ginnelly A and Greenwood, N. Screening adult patients with a tracheostomy for dysphagia: a mixed methods study of practice in the united Kingdom. Int. J. Lang. Commun. Disord. 2016, 51 (3) 219 – 355..

 

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