McRae, J; (2018) Dysphagia following acute cervical spinal cord injury (DAISY): identification of current practice and development of a swallow screening tool. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

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.

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