Cervical spinal cord injury (CSCI) patients have complex needs, often requiring tracheostomy, ventilation and surgery. These multiple factors have been linked to the development of oropharyngeal dysphagia with reported incidences of 8-80%. Resulting complications include respiratory impairment, increased morbidity and prolonged length of stay in an intensive care unit (ICU). This delays transfer to specialised units for on-going rehabilitation. Currently there is no clinical guidance for the effective identification and management of oropharyngeal dysphagia following CSCI. The aim of the DAISY project was to develop a screening tool to improve the recognition of oropharyngeal dysphagia risks. In turn this would lead to earlier intervention and improved outcomes. The two studies in the first part of the thesis investigated variations in clinical practice between specialised and non-specialised units and across professional groups through the perspective of staff and patients. A multi-disciplinary staff survey revealed significant differences in oropharyngeal dysphagia care, tracheostomy management and ventilatory weaning that were likely to affect outcomes. Interviews with CSCI patients and their carers about their experience of care across multiple settings identified a number of themes reflecting the process of adjustment and transition post- injury. Many reported a long wait for the ‘golden opportunity’ to transfer to a spinal unit for rehabilitation before recovery could take place. Variable management of eating and communication problems had a long-lasting impact. In the second part of the thesis, the literature review and study findings generated 85 statements for a Delphi consensus process on oropharyngeal dysphagia risk factors and management. An international expert panel achieved consensus on 73% of statements after two rounds, although methods of screening and assessing oropharyngeal dysphagia remained unclear. Based on these results, the DAISY swallow screening tool was developed and a final study evaluated usability of the tool in two non-specialised units. A pragmatic observational approach was employed to permit the tool to embed in current practice, however staff engagement and participant recruitment was limited making the value of the tool inconclusive tool. Further multi-site research is needed to evaluate the validity and utility of the DAISY screening tool. Prospective outcome data is required to verify variations in clinical management across units and the contribution of specialist guidance to improve clinical practices.

Dysphagia following acute cervical spinal cord injury (DAISY): identification of current practice and development of a swallow screening tool

BACKGROUND:Current medical scores have limited efficiency and safety profiles to enable assignment to the most appropriate treatment site in patients with lower respiratory tract infections (LRTIs). We describe our current triage practice and assess the potential of a combination of CURB65 with proadrenomedullin (ProADM) levels for triage decisions.METHODS:Consecutive patients with LRTIs presenting to our emergency department were prospectively followed and retrospectively classified according to CURB65 and ProADM levels (CURB65-A). Low medical risk patients were further subgrouped according to biopsychosocial and functional risks. We compared the proportion of patients virtually allocated to triage sites with actual triage decisions and assessed the added impact of ProADM in a subgroup.RESULTS:Overall, 93% of 146 patients were hospitalised. Among the 138 patients with available CURB65-A, 17.4% had a low medical risk indicating possible treatment in an outpatient or non-acute medical setting; 34.1% had an intermediate medical risk (short-hospitalisation); and 48.6% had a high medical risk (hospitalisation). Fewer patients were in a low CURB65-A class (I) than a low CURB65 class (0,1) (17.4% vs. 46.3%, p <0.001). Mean length of hospitalisation was 9.8 days including 3.6 days after reaching medical stability. In 60.3% of patients, hospitalisation was prolonged after medical stability mainly for medical reasons.CONCLUSIONS:Current rates of hospitalisation are high in patients with LRTI and length of stay frequently extended beyond time of medical stabilization. The lower proportion of patients reclassified as low risk by adding ProADM to the CURB65 score might improve confidence in the triage algorithm.

Optimized Patient Transfer Using an Innovative Multidisciplinary Assessment in the Kanton Aargau (OPTIMA I): an Observational Survey in Lower Respiratory Tract Infections

Enteral nutrition in cervical cord injury—A retrospective cohort study

The aim of this study was to assess the adequacy of nutrition provision to mechanically ventilated patients in the acute phase after cervical cord injury. High spinal cord injury is associated with reduced gastric emptying due to excessive sympathetic activity from the isolated thoracolumbar cord [1], which is believed to compromise nasogastric delivery of nutrition and worsen clinical outcomes. However, the success of feeding early after high spinal cord injury has not been formally evaluated.

/pdf/enteral-nutrition-in-mechanically-ventilated-patients-with-1iqtxj5zbn.pdf

Enteral nutrition in mechanically ventilated patients with cervical spinal cord injury

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Enteral nutrition in cervical cord injury—A retrospective cohort study

Enteral nutrition in mechanically ventilated patients with cervical spinal cord injury