Jijakli Amr, Skeels Katelyn, Zebelean Devin, Swanson Krista, LaChance Ashley, Dwyer Brigid, Savitz Ariel, Melkumova Emiliya, Leung Lester Y
Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA.
Neurol Clin Pract. 2024 Dec;14(6):e200352. doi: 10.1212/CPJ.0000000000200352. Epub 2024 Aug 16.
Decisions on enteral nutrition for patients with dysphagia after acute ischemic stroke (AIS) are often not evidence based. We sought to determine whether development of a nutritional support algorithm leveraging the Predictive Swallowing Score (PRESS) could improve process times without placement of unnecessary gastrostomies.
This is a quality improvement study conducted at an academic medical center comparing a 6-month cohort of adults with AIS and dysphagia prepathway (PRE, July 1, 2019-December 31, 2019) and a 6-month cohort postpathway (POST, January 1, 2020-June 30, 2020). Gastrostomy recommendation, time to gastrostomy decision (TTD), discharge with gastrostomy, discharge with a nasogastric tube (NGT), and length of stay (LOS) were compared between groups.
Among 121 patients with AIS and dysphagia, 58 (48%) were hospitalized prealgorithm and 63 (52%) postalgorithm. PRE TTD was longer than POST TTD (4.5 vs 1.5 days, = 0.004). Frequency of gastrostomy was similar between PRE and POST (12% vs 8%, = 0.58). LOS for patients recommended gastrostomy was longer in PRE (14.5 vs 6.5 days, = 0.03). Frequency of discharge with NGT was numerically higher in POST but not significantly different (0.7% vs 6%, = 0.4). Overall, LOS was the same in both groups (5 days).
Development of a structured nutritional support algorithm incorporating PRESS may help facilitate sooner gastrostomy placement without increasing gastrostomy placement frequency and encourage more discharges to inpatient rehabilitation facilities with NGTs.
急性缺血性卒中（AIS）后吞咽困难患者的肠内营养决策往往缺乏循证依据。我们试图确定利用预测吞咽评分（PRESS）制定营养支持算法是否能缩短流程时间，同时避免不必要的胃造口术。
这是一项在学术医疗中心进行的质量改进研究，比较了两组6个月队列的成年AIS伴吞咽困难患者，一组为路径前队列（PRE，2019年7月1日至2019年12月31日），另一组为路径后队列（POST，2020年1月1日至2020年6月30日）。比较两组间胃造口术建议、胃造口术决策时间（TTD）、带胃造口术出院、带鼻胃管（NGT）出院以及住院时间（LOS）。
121例AIS伴吞咽困难患者中，58例（48%）在算法制定前住院，63例（52%）在算法制定后住院。PRE组的TTD长于POST组（4.5天对1.5天，P = 0.004）。PRE组和POST组胃造口术的频率相似（12%对8%，P = 0.58）。建议行胃造口术患者的LOS在PRE组更长（14.5天对6.5天，P = 0.03）。POST组带NGT出院的频率在数值上更高，但差异无统计学意义（0.7%对6%，P = 0.4）。总体而言，两组的LOS相同（5天）。
纳入PRESS的结构化营养支持算法的制定可能有助于更快地进行胃造口术，而不增加胃造口术的频率，并鼓励更多患者通过NGT出院至住院康复机构。
