The Provision of Dysphagia Assessment Following Acute Stroke in Non-metropolitan

378 Pages·2010·4.88 MB·English

The Provision of Dysphagia
Assessment Following Acute Stroke
in Non-metropolitan
New South Wales and Victoria.

Michelle Smith-Tamaray

A thesis submitted in fulfilment
of the requirements for the degree of
Doctor of Philosophy

School of Community Health
Charles Sturt University
March, 2010
TABLE OF CONTENTS

List of Tables ................................................................................................................. ix
List of Figures ................................................................................................................ xi
Certificate of Authorship ............................................................................................. xii
Ethical Approval .......................................................................................................... xiv
Dedication ..................................................................................................................... xv
Acknowledgements ...................................................................................................... xvi
Presentations and Publications Arising from this Thesis .......................................... xviii
Abstract ......................................................................................................................... xx

PART ONE: INTRODUCTION

CHAPTER 1 AN INTRODUCTION TO THIS STUDY ................. 2
1.1 BACKGROUND TO THIS STUDY FROM THE
RESEARCHER’S PERSPECTIVE .................................................................... 2
1.2 PURPOSE AND SCOPE OF THIS STUDY ....................................................... 3
1.3 AN OVERVIEW OF THE THESIS ................................................................... 4
CHAPTER 2 ASSESSMENT OF DYSPHAGIA FOLLOWING
STROKE ....................................................................... 6
2.1 STROKE AND DYSPHAGIA ............................................................................ 7
2.1.1 Defining Stroke .......................................................................................... 7
2.1.2 Defining Dysphagia ................................................................................... 7
2.1.3 Dysphagia Following Stroke...................................................................... 8
2.1.3.1 Patterns of Recovery in Dysphagia Following Stroke ...................... 9
2.1.3.2 Consequences of Dysphagia Following Stroke................................. 10
2.1.4 Best Practice in Stroke and Dysphagia: The Multidisciplinary Team ..... 12
2.1.5 Timeliness and Universal Assessment of Dysphagia
Following Stroke ...................................................................................... 15
2.1.6 Do Dysphagia Programs Work? .............................................................. 16

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2.2 THE ASSESSEMENT OF DYSPHAGIA.......................................................... 18
2.2.1 Non-instrumental Assessment of Dysphagia ........................................... 19
2.2.1.1 Screening Tools ................................................................................ 19
2.2.1.2 Clinical Bedside Assessment ............................................................. 22
2.2.2 Adjuncts to the Clinical Assessment of Dysphagia ............................... 26
2.2.2.1 Cervical Auscultation ...................................................................... 26
2.2.2.2 Pulse oximetry .................................................................................. 28
2.2.3 Instrumental Assessment of Dysphagia ................................................. 30
2.2.3.1 Videofluoroscopy ............................................................................ 30
2.2.3.2 Fiberoptic Endoscopic Evaluation of Swallowing (FEES) ............... 34
2.2.3.3 Other Forms of Instrumental Assessment ........................................ 37
2.3 SUMMARY AND IMPLICATIONS FOR THE CLINICAL
SETTING ........................................................................................................... 37
CHAPTER 3 EQUITY, THE NON-METROPOLITAN
CONTEXT AND SPEECH PATHOLOGY ............ 40
3.1 EQUITY IN THE CONTEXT OF HEALTH CARE ......................................... 41
3.1.1 Accessibility and Access to Health Services ........................................... 42
3.1.1.1 Financial Considerations for Health Services in Australia .............. 43
3.1.1.2 Availability of Health Services and Speech Pathology Services
in Australia ........................................................................................ 45
3.1.2 Quality of Care as a Factor to Consider in Equity .................................. 60
3.1.2.1 What Constitutes Quality .................................................................. 61
3.1.2.2 Use of the Evidence Base and Guidelines to Achieve
Quality of Care ................................................................................ 61
3.1.2.3 Quality of Care: An Outcome of a Unified Approach ..................... 63
3.2 CONCLUSION AND IMPLICATIONS OF THE LITERATURE
FOR THE CURRENT RESEARCH ................................................................. 64
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PART TWO: METHODOLOGY

CHAPTER 4 RESEARCH APPROACH AND
DATA COLLECTION ............................................... 67
4.1 AN OVERVIEW AND RATIONALE OF THE STUDY .................................. 67
4.2 RESEARCH QUESTIONS ................................................................................ 69
4.3 RESEARCH APPROACH ................................................................................. 72
4.3.1 Why Pragmatism? .................................................................................... 72
4.3.2 The Use of Mixed Methods Research Design in
Approaching This Work ........................................................................... 74
4.4 COLLECTION OF DATA ................................................................................. 75
4.4.1 Phase One: Telephone Survey ................................................................. 75
4.4.1.1 Informants ......................................................................................... 75
4.4.1.2 Procedure .......................................................................................... 76
4.4.2 Phase Two: Semi-structured Interviews .................................................. 78
4.4.2.1 Informants ......................................................................................... 79
4.4.2.2 Procedure .......................................................................................... 80
4.4.3 Phase Three: Focus Groups ..................................................................... 82
4.4.3.1 Informants ......................................................................................... 83
4.4.3.2 Procedure .......................................................................................... 85
CHAPTER 5 UNDERSTANDING THE DATA.............................. 88
5.1 ANALYSIS OF QUANTITATIVE DATA ........................................................ 88
5.2 ANALYSIS OF QUALITATIVE DATA ........................................................... 90
5.2.1 Data From Open Ended Questions of the Telephone Survey .................. 91
5.2.2 Data From Semi-structured Interviews and Focus Groups ...................... 92
5.3 WRITING AS THE FINAL STAGE OF DATA INTERPRETATION ........... 95
5.4 ENSURING RIGOUR IN THE PROCESS OF THIS RESEARCH ................. 95
5.5 ETHICAL CONDUCT OF THIS RESEARCH ................................................ 97
5.6 READING THE FINDINGS CHAPTERS OF THIS THESIS ......................... 98
5.7 CONCLUSION .................................................................................................. 99
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PART THREE: NOT ALL SERVICES ARE CREATED
EQUAL: PHASE ONE RESULTS AND DISCUSSION

CHAPTER 6 DEVELOPMENT OF A CLASSIFICATION
SYSTEM FOR ADULT SPEECH PATHOLOGY
SERVICES IN NON-METROPOLITAN AREAS 101
6.1 DEFINITIONS OF TERMINOLOGY USED IN THE
CLASSIFICATION SYSTEM ........................................................................ 101
6.2 A DESCRIPTION OF THE CLASSIFCIATION SYSTEM............................ 104
6.2.1 Service Type 1 ....................................................................................... 104
6.2.2 Service Type 2 ....................................................................................... 105
6.2.3 Service Type 3 ....................................................................................... 106
6.2.4 Service Type 4 ....................................................................................... 107
6.2.5 Service Type 5 ....................................................................................... 108
6.2.6 Summary of the main distinctions between the service types ............... 109
6.3 GEOGRAPHICAL DISTRIBUTION OF THE SERVICE TYPES ................. 110
6.4 FREQUENCY OF SPEECH PATHOLOGY SERVICES TO
ACUTE HOSPITALS IN NON-METROPOLITAN NEW
SOUTH WALES AND VICTORIA ................................................................. 112
CHAPTER 7 ISSUES UNDERLYING PROVISION OF
ACUTE DYSPHAGIA SERVICES IN
NON-METROPOLITAN AREAS .......................... 117
7.1 CASELOAD DISTRIBUTION AND MANAGEMENT ................................. 117
7.2 DISTANCE AND SERVICING OUTLYING HOSPITALS........................... 120
7.3 SKILLS AND SUPPORT ................................................................................. 124
7.4 UNMET NEED ................................................................................................. 128
7.5 SUMMARY OF IMPLICATIONS OF THE CLASSIFICATION
SYSTEM AND THE UNDERLYING ISSUES ............................................... 130

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CHAPTER 8 DEPARTMENTAL RESOURCING OF ACUTE
SPEECH PATHOLOGY SERVICES .................... 132
8.1 PROVISION OF DYSPHAGIA SERVICES BY A SPEECH
PATHOLOGIST ............................................................................................... 132
8.1.1 Policies and Procedures in the Clinical Setting ..................................... 132
8.1.2 Response Times and Timeliness of Assessment .................................... 134
8.1.3 Use of Non-instrumental Assessment Tools .......................................... 137
8.1.4 Use of Instrumental Assessment Tools .................................................. 140
8.1.4.1 Restrictions in the Access of Videofluoroscopy for
Acute Patients .................................................................................. 142
8.2 PROVISION OF DYSPHAGIA SERVICES IN THE
ABSENCE OF A SPEECH PATHOLOGIST .................................................. 154
8.2.1 Policies and Procedures for Management of Dysphagia
in the Absence of a Speech Pathologist ................................................. 154
8.2.2 Summary ................................................................................................ 160
CHAPTER 9 DISCUSSION OF RESULTS FROM PHASE ONE 162
9.1 HYPOTHETICAL CASES BASED ON THE RESULTS
FROM PHASE ONE ....................................................................................... 162
9.1.1 Scenario A: Mrs Smith........................................................................... 162
9.1.2 Scenario B: Mrs Smith ........................................................................... 165
9.2 SUMMARY OF RESULTS PRESENTED IN PART THREE ....................... 167

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PART FOUR: THE PROVISION OF DYSPHAGIA
ASSESSMENT FOLLOWING ACUTE STROKE: PHASES
TWO AND THREE FINDINGS AND DISCUSSION

CHAPTER 10 THE CONTEXT OF A NON-METROPOLITAN
SPEECH PATHOLOGY SERVICE .................... 170
10.1 CHALLENGING THE STATUS QUO: THE ROLE OF
DEPARTMENTAL HISTORY AND RECRUITMENT AND
RETENTION .................................................................................................... 170
10.1.1 Recruitment and Retention Issues ........................................................ 170
10.1.2 The Impact of Previous Personnel & Making Changes
Within the Department ......................................................................... 172
10.2 THE SPORADIC NATURE OF ACUTE SERVICES .................................... 174
10.3 SUMMARY ...................................................................................................... 175
CHAPTER 11 WHAT HAPPENS WHEN THE SPEECH
PATHOLOGIST IS PRESENT? ............................................... 176
11.1 REFERRAL TO SPEECH PATHOLOGY ..................................................... 178
11.2 PRIORITISATION AND RESPONSE TO A REFERRAL ............................ 184
11.2.1 Prioritisation ......................................................................................... 184
11.2.2 Response Times ................................................................................... 187
11.3 THE CLINICAL BEDSIDE ASSESSMENT ................................................... 189
11.3.1 Undertaking the Clinical Bedside Assessment ..................................... 190
11.3.2 Use of Cervical Auscultation and Pulse Oximetry
within the Clinical Assessment ............................................................ 192
11.3.3 The Role of Previous Experience in the Clinical Assessment .............. 193
11.3.4 Clinical Assessment: “It’s not me, it’s them.” ...................................... 194
11.4 VIDEOFLUOROSCOPY ................................................................................. 195
11.4.1 How Videofluoroscopy is Used in Clinical Practice ............................ 201
11.4.1.1 How often is videofluoroscopy used? ........................................... 202
11.4.1.2 Rationale for undertaking videofluoroscopy ................................ 203
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11.4.1.3 Does access to videofluoroscopy have an impact
on how clinicians manage patients with acute dysphagia? ........... 205
11.5 COMMUNICATION OF RECOMMENDATIONS ....................................... 207
11.6 MANAGEMENT, REVIEW AND DISCHARGE.......................................... 210
11.7 SUMMARY ..................................................................................................... 211
CHAPTER 12 WHAT HAPPENS WHEN THE SPEECH
PATHOLOGIST IS NOT PRESENT? ................. 213
12.1 PROCESSES OF ASSESSMENT IN THE ABSENCE OF A
SPEECH PATHOLOGIST ............................................................................. 213
12.1.1 Variations on Nil by Mouth Till Speech Pathology
Assessment and Ad Hoc Medical Assessment .............................................. 214
12.1.2 Variations on Telephone Consultation........................................................... 221
12.1.3 The Weekend Speech Pathology Service ...................................................... 226
12.1.4 The Use of Screening Tools by Other Professionals ..................................... 227
12.2 CONSIDERATIONS IN ESTABLISHING GUIDELINES
FOR ASSESSMENT IN THE ABSENCE OF A
SPEECH PATHOLOGIST ............................................................................. 232
12.3 DISCUSSION ................................................................................................. 236
12.4 SUMMARY OF RESULTS PRESENTED IN PART FOUR ........................ 240
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PART FIVE: THEMES UNDERLYING THE PROVISION
OF DYSPHAGIA ASSESSMENT SERVICES

CHAPTER 13 “YOU’VE GOT TO MAKE AN IMPACT”:
INFLUENCING THE CULTURE OF ACUTE
STROKE MANAGEMENT IN
NON-METROPOLITAN AREAS ......................... 242
13.1 “YOU’VE REALLY GOT TO PROVE YOUR WORTH”:
BEING RECOGNISED AS A TEAM MEMBER ......................................... 244
13.2 “OUT OF SIGHT, OUT OF MIND”: THE IMPORTANCE
OF BEING PRESENT .................................................................................... 248
13.3 “ITS ALWAYS BETTER TO HAVE THAT RAPPORT”:
THE IMPORTANCE OF DEVELOPING RELATIONSHIPS
WITH OTHER STAFF ................................................................................... 252
13.4 THE ROLE OF EDUCATION AND KNOWLEDGE ................................... 254
13.5 IMPACT OF SERVICE TYPE ON BEING PART OF THE
ACUTE TEAM ............................................................................................... 257
13.6 CONSEQUENCES OF BREAKDOWN IN
IMPLEMENTATION OF RECOMMENDATIONS ..................................... 260
CHAPTER 14 SOMETHING’S GOT TO GIVE: THE
CHALLENGE OF RESOURCE ALLOCATION
FOR PROVISION OF DYSPHAGIA
SERVICES FOLLOWING ACUTE STROKE .... 263
14.1 OTHER CLIENTS MISSED OUT ................................................................. 264
14.2 UNMET NEED MISSED OUT ...................................................................... 267
14.3 THE SPEECH PATHOLOGIST MISSED OUT ........................................... 269
14.4 THE PATIENT WITH DYSPHAGIA MISSED OUT ................................... 271
14.5 WHY SOMEONE OR SOMETHING HAD TO MISS OUT ........................ 278
14.6 CONCLUSION ............................................................................................... 279
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PART SIX: CONCLUSION

CHAPTER 15 SUMMARY, CONTRIBUTIONS AND
FUTURE DIRECTIONS ....................................... 282
15.1 UNIQUE CONRIBUTIONS OF THIS RESEARCH..................................... 282
15.2 SUMMARY OF FINDINGS OF THIS STUDY ............................................ 282
15.3 LIMITATIONS OF THIS RESEARCH ......................................................... 284
15.4 IMPLICATIONS OF THIS RESEARCH ...................................................... 286
15.5 FUTURE DIRECTIONS ................................................................................ 289
15.6 FINAL REMARKS ........................................................................................ 291

REFERENCES ...................................................................................... 293
APPENDICES ....................................................................................... 325

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