Dysphagia screening and hospital-acquired pneumonia in patients with acute ischemic stroke: findings from Get with the Guidelines--Stroke

Background: National guidelines recommend dysphagia screening (DS) before oral intake in stroke patients to reduce hospital-acquired pneumonia (HAP). We examined the relationship between DS and HAP after ischemic stroke.

Methods: Get with the Guidelines-Stroke defines HAP as postadmission diagnosis of pneumonia requiring antibiotics, and DS as the use of bedside swallow screening prior to oral intake. Univariable and multivariable analyses examined the relationship between DS and HAP.

Results: Among 314,007 ischemic stroke patients at 1244 Get with the Guidelines-Stroke hospitals from 2003-2009 who were eligible for DS and had completed HAP data, a total of 216,372 (68.9%) underwent DS and a total of 17,906 (5.7%) developed HAP. When compared with patients without HAP, patients with HAP were older, had admission National Institutes of Health Stroke Scale (NIHSS) score (median NIHSS score: 10 versus 4), were more likely to undergo DS (75.5% versus 68.5%), and had increased length of stay and in-hospital mortality (12.4% versus 2.3%). In multivariable analyses, factors independently associated with a lower risk of HAP were female gender (odds ratio [OR] 0.84), dyslipidemia (OR 0.84), and hypertension (OR 0.94). DS was associated with a higher adjusted OR for HAP (OR 1.40), but the OR was greatly attenuated after adding NIHSS score to the model (OR 1.10).

Conclusions: HAP occurs in 1 of 17 hospitalized stroke patients and is associated with a greater than 5-fold increase in mortality. DS did not occur in 31.1% of eligible patients, with increased screening among those with more severe strokes and those who developed HAP. The attenuation of the relationship between DS and HAP risk when controlling for NIHSS score suggests the association between screening and pneumonia is confounded by severity. Controlled trials are needed to determine DS effectiveness.