MS.

MARIA SCHWARZ (Orcid ID : 0000-0001-9367-5696)

Accepted Article
Article type : Original Article

The impact of aspiration pneumonia and nasogastric feeding on clinical outcomes in stroke

patients: a retrospective cohort study.

Ms Maria SCHWARZ, Bachelor of Speech Pathology- Honours Class 1

Corner of Armstrong and Loganlea Roads, Meadowbrook Queensland, 4131.
Logan Hospital
Email: maria.schwarz@health.qld.gov.au
Phone: 3299 8299 Fax: 3299 8280

Mrs Anne COCCETTI, Bachelor of Speech Pathology- Honours Class 1

Corner of Armstrong and Loganlea Roads, Meadowbrook Queensland, 4131.
Logan Hospital
Email: anne.coccetti@health.qld.gov.au
Phone: 3299 8282

Ms Allison MURDOCH- Bachelor of Business- Health Information Management

Corner of Armstrong and Loganlea Roads, Meadowbrook Queensland, 4131.
Logan Hospital
Email: allison.murdoch@health.qld.gov.au
Phone: 3299 8986

Professor Elizabeth CARDELL, Master of Speech Pathology (research) -PhD

Building G40, Griffith University Gold Coast Campus 4222
Menzies Health Institute Queensland,
This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jocn.13922

This article is protected by copyright. All rights reserved.

 School of Allied Health Sciences, Griffith University
Email: e.cardell@griffith.edu.au
Phone: 5552 9570
Accepted Article
Conflict of interest: the authors report nil conflict of interest.

Funding: this project was supported by the Health Practitioners Research Grant Scheme,

2014/2015, Queensland Australia.

ABSTRACT

Aims and objectives: To determine presence of clinical complications related to dysphagia

and to explore their operational outcomes.

Background: Dysphagia is a common complication of stroke. The management of post stroke

dysphagia is multi-disciplinary with nurses playing a key role in screening for dysphagia risk,

monitoring tolerance of food and fluids and checking for the development of complications

such as fever, dehydration and change in medical status. Dysphagia often results in further

complications including aspiration pneumonia and the need for nasogastric feeding.

Dysphagia related complications have been shown to have a significant impact on morbidity

and mortality, length of stay and cost of admission.

Design: In a retrospective cohort study,

Methods: A total of 110 patients presenting with an ischemic stroke, were chart audited.

Results: Aspiration pneumonia post stroke was noted to be significantly associated with

increased overall length of stay; poorer functional outcomes post stroke as well as being

associated with a high risk of mortality. The presence of a nasogastric tube was also

associated with reduced functional outcomes post stroke and increased risk of death.

Conclusion: High prevalence and cost of complications associated with stroke highlights the

complexity of providing nursing and allied health care to this patient population. This

provides a snap shot of dysphagia related complications experienced by stroke patients.

This article is protected by copyright. All rights reserved.

 Relevance to clinical practice: This paper highlights that post stroke complications can

significantly impact on patient outcomes and operational factors such as cost of admission,
Accepted Article
therefore post stroke care requires a multi-disciplinary approach to management.

Furthermore, preventing and managing complications post stroke is a key element of nursing

care and has the potential to significantly reduce incidence of mortality, length of stay and

cost of hospital admission.

Key words: stroke, dysphagia, aspiration, nasogastric feeding

What does this paper contribute to the wider global clinical community?

 Dysphagia (swallowing problem) is common following stroke and requires a multi-

disciplinary approach to management.

 Post stroke complications such as dysphagia, aspiration pneumonia and the need for

nasogastric feeding have a significant impact on patient outcomes such as mortality,

length of hospital stay and admission cost.

 Preventing and managing complications post stroke is a key element of nursing care

and has the potential to significantly reduce incidence of mortality, length of stay and

cost of hospital admission.

INTRODUCTION

Swallowing difficulties and complications such as aspiration pneumonia and the need for

nasogastric feeding are common following stroke. There is a paucity of literature regarding

the impact of post-stroke complications on patient outcomes and operational context, which

this paper aims to address. A greater understanding of the impact of post stroke complications

will support improvement management and monitoring of patients. In addition, the high risk

of post stroke complications highlights the need for clear policies and practice guidelines to

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 monitor for and manage complications. Nursing staff should therefore have a thorough

knowledge of post stroke complications and be able to monitor for and manage these
Accepted Article
complications in clinical practice.

BACKGROUND

The stroke population is known to be at high risk of physiological changes associated with

complications which require close nursing monitoring to decrease patient risk of developing

complications (Jones et al., 2007). Nursing staff are no longer simply responsible for

supportive cares, their role in stroke management has grown to include the prevention of

complications and initiation of rehabilitation goals, as well as education and support for

patients and family members (Alexandrov, 2010). Qualitative analysis of 35 reflections

identified the nursing role in stroke care as fitting into 3 distinct categories- as a care

provider, a facilitator of personal recovery and as the manager or central contact point for

multi-disciplinary care (Burton, 2000).

Dysphagia is a common complication following stroke with reported incidences around 20-

78% however varying greatly in the literature, depending on assessment process (Arnold et

al., 2016, Flowers et al., 2013, National Stroke Foundation., 2010, Martino et al., 2012,

Martino et al., 2005). The management of post stroke dysphagia is multi-disciplinary with

nurses playing a key role in screening for dysphagia risk, monitoring tolerance of food and

fluids and providing feedback regarding current status to other team members (McFarlane et

al., 2014, Hines et al., 2011, Bird, 2001, Cichero et al., 2009, Daniels et al., 2012, Kertscher

et al., 2014, Smithard, 2016, Speyer, 2013, Trapl et al., 2007). Despite the efforts of the

multi-disciplinary team, dysphagia following stroke is often associated with a number of

clinical complications including aspiration pneumonia, dehydration, malnutrition and

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 subsequently the need for non-oral feeding (Dziewas et al., 2004, Foley et al., 2009, Arnold

et al., 2016).
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Aspiration pneumonia is a common complication following stroke (Dziewas et al., 2004,

Foley et al., 2009). Incidence rates post stroke are estimated between 11% and 50% (Brogan

et al., 2014, Hannawi et al., 2013, Sørensen et al., 2013). Similar to dysphagia, pneumonia

has been found to be an independent risk factor for negative clinical outcomes and death

(Westendorp et al., 2011), with an incidence of mortality reported at 20% in patients

diagnosed with pneumonia (Wilson, 2012). Often, patients with aspiration pneumonia, as a

consequence of dysphagia, receive nasogastric feeding.

Nasogastric feeding is a common method of providing nutrition and hydration when patients’

are unable to meet nutritional requirements (Brogan et al., 2014). However, it is important to

note that the presence of a nasogastric tube has been found to be significantly related to the

development of respiratory complications with an incidence of pneumonia of 38% reported in

patients fed with a nasogastric tube (Brogan et al., 2014). Similarly, in a study by Dziewas

and colleagues (2004), 44% of patients who had a nasogastric tube placed insitu developed

pneumonia.

Nursing management of dysphagia, aspiration pneumonia and nasogastric feeding is therefore

interrelated and relatively commonplace. The need for ‘skilled nursing care’ is known to be a

key factor in the success of stroke unit care in reducing post stroke morbidity and mortality

(Burton et al., 2009, Langhorne and Pollock, 2002). Nursing staff have a particular role in

advocating for patients who have signs of risk factors of dysphagia to be seen by appropriate

multi-disciplinary team members (such as the speech pathologist and medical officer)

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 (Fedder, 2017). The provision of nursing care for stroke patients, particularly those with

dysphagia is likely to be time consuming and require specialist training. A structured

Accepted Article
observation of 100 morning care sessions identified that nurses spent on average 21 minutes

of contact time with each stroke patient (ranging between 1 and 43 minutes) (Booth et al.,

2005), highlighting a significant demand on nursing resources and workload for all stroke

patients (as those with complications were not specifically highlighted in this studies data

analysis). However, there is a paucity of literature which describes the increased demands of

nursing care for patients with post stroke complications such as aspiration pneumonia or

nasogastric feeding. Anecdotally nursing staff report that patients with dysphagia and the

associated complications have increased care needs thus increasing pressure on nursing

resources. This increase in demands on nursing staff may be reflected in operational

outcomes such as cost and hospital length of stay. Complications of dysphagia have a

significant operational effect such as increases in on overall admission costs and length of

stay (Guyomard et al., 2009, Altman et al., 2010). Indeed presence of dysphagia has an

estimated cost at around $547 million in an acute hospital setting (Altman et al., 2010), with

an additional cost of pneumonia of $1700 per episode of care in the Canada (Sutherland et

al., 2010).

While evidence supports the increased risk of morbidity and mortality which result from post

stroke dysphagia, there is limited data which describes the extent of these post stroke

complications and their impact on patient outcomes and operational context. This presents a

unique opportunity to investigate the incidence and prevalence of dysphagia-related

complications, while considering the effects of these complications on operational factors

such as the impact on the nursing workforce, cost and length of stay.

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 THE STUDY

Aims
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To determine the impact of the dysphagia related clinical complications of aspiration

pneumonia and nasogastric feeding on patient outcomes, cost and length of stay.

Design

In this retrospective cohort study, a review of the medical notes of patients admitted for

ischemic stroke a secondary hospital in South East Queensland, Australia (thrombolysed and

non-thrombolysed) between January 2011 and December 2014 was undertaken using

Diagnosis-Related Group coding (DRG).

Participants

The in-hospital clinical records of 110 patients selected based on Diagnosis-Related Group

coding (DRG), using purposive sampling. Inclusion criteria were adult patients (over 18 year

of age) admitted with a diagnosis of stroke as documented by the treating medical team.

Participants were excluded if they were transferred to another facility during their Emergency

Department admission or if considered palliative during their Emergency Department

admission. As the site at which data was collected does not provide neurosurgical care

patients, with documented haemorrhagic stroke and documented transient ischemic attack

were also excluded.

Data collection

The data was sourced retrospectively from the medical record. Data was collected from

January 2011 to December 2014 (a total of 48 months). This period was chosen to

incorporate changes in hospital policy relating to thrombolysis of acute stroke patients.

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 Purposive sampling was conducted to include both thrombolysed and non thrombolysed

stroke patients. The first author conducted data collection for all participants using a self
Accepted Article
designed screening tool for the following outcomes (1) patient demographics (age, gender),

(2) stroke information (single or multiple infarct, ischaemic or haemorrhagic stroke, Bamford

classification of stroke, presence of stroke risk factors) (3) measure of function (4)

information on hospital admission (length of stay, discharge destination, adverse

events/complications and cost of admission).

Ethical considerations

As data was collected retrospectively, and all patients were de-identified through being

assigned a code, individual consent was not required. Ethical clearance was obtained from the

appropriate human research ethics committee, in addition to a successful Public Health Act

application, which allowed retrospective auditing without direct patient consent

Data analysis

An exploratory approach to analysis was utilised in this study. Descriptive statistics included

calculation of frequencies with percentages, means, medians and standard deviation using

IBM SPSS version 22 statistical analysis software (Corp, 2013). Additional analysis was

completed using parametric and non parametric statistical methods, this included two group

mean comparisons (ANOVA) for cost and length of stay, percent frequency for

complications, cross tabulations with Pearson’s Chi-Square and relative risk calculations to

investigate relationships between categorical outcomes such as complications and death. In

addition, comparison on medians using Bootstrap sampling technique with 95% confidence

intervals was completed for comparison of cost and length of stay by complications.

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 Validity, reliability and rigour

The current study involved a retrospective chart review, no formalised or standardised

Accepted Article
assessment tools were used. Validity and reliability of results is likely to be impacted on by

the relatively small sample size and the limitations of retrospective chart auditing,

additionally auditing was performed only by the first author.

RESULTS

The clinical record review revealed a total of 110 ischemic stroke patients. Demographic and

assessment information is listed in Table 1.

Aspiration pneumonia

While only 11.8% (n=13) of patients developed aspiration pneumonia, 58.33% of these

patients who developed aspiration pneumonia died (n=7 from 12 patients who died)

(p<0.0001). Therefore, the relative risk of a patient dying following aspiration pneumonia

was 10.45 (CI 95%, OR 21.47). Patients who developed aspiration pneumonia were more

likely to have a more severe Modified Rankins Score (MRS) (Rankin, 1957) on discharge

(p<0.0001). The average MRS (Rankin, 1957) for a patient who developed aspiration

pneumonia was 5.23 (SD 1.17) compared to only 2.91 (SD 1.46) in patients who did not

develop aspiration pneumonia.

Nasogastric feeding

Nasogastric tube (NGT) insertion was also considered as a complication of stroke. A NGT

was inserted in 20.9% of patients in this study. The presence of a NGT was noted to correlate

significantly with death (p<0.0001) with 39.13% (n=9) of patients with a NGT died

compared to only 3.44% (n=3) of patients who died without a NGT insitu. The relative risk

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 of death following NGT insertion was 11.35 (CI 95%, OR 18.00). The presence of an NGT

significantly increased the risk of developing aspiration pneumonia (p<0.0001) with a

Accepted Article
relative risk of risk of 12.609 (CI 95%, OR 21.54). NGT insertion also correlated

significantly with more severe MRS (Rankin, 1957) on discharge (p<0.0001). The average

MRS (Rankin, 1957) on discharge for a patient with an NGT was 4.83 (SD 1.19) compared to

a score of 2.75 (SD 1.53) in patients who did not require an NGT during admission.

Cost and Length of Stay

Information regarding cost analysis can be found in Table 2. In addition to an average cost

increase of $9,100.28 if aspiration pneumonia occurred during admission, the mean length of

stay for patients who developed aspiration pneumonia was 24.92 days (median 17, 95% CI

6.5-48), which is significantly longer than the 9.43 days (median 6, 95% CI 5-8) for patients

who did not develop aspiration pneumonia during admission (p<0.0001) (see Figure 1).

Similarly the presence of a nasogastric tube demonstrated an average cost increase of

$8099.42 (p<0.0001). The mean length of hospital stay was significantly increased for

patients requiring an NGT, with a mean length of stay of 19.04 days (median of 16, 95% CI

9.51-21) compared to a mean of 9.21 days (median 5, 95% CI 4-8) without NGT insertion

(see figure 2).

DISCUSSION

The aims of this project were to investigate the impact of dysphagia related complications,

specifically aspiration pneumonia and nasogastric feeding, on patient outcomes and service

changes including cost and length of stay. The results support and further clarify the

significant extent to which post stroke complications impact on patient and operational

outcomes. Thus highlighting the importance of high quality nursing care, including patient

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 monitoring and established processes to prevent secondary complications (Evans et al.,

2001).
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Dysphagia has been shown to be a significant predictor of pulmonary complications and

mortality (Arnold et al., 2016, Guyomard et al., 2009). The incidence of aspiration

pneumonia varies greatly in the stroke literature with incidence rates between 7-33% being

reported in a systematic review (Martino et al., 2005). The incidence rate of aspiration

pneumonia (12%) within this study concurred with the ranges reported in the current

literature, which notably vary greatly between 6% and 22% (Katzan et al., 2003, Langhorne

et al., 2000). Similar to previous studies, this study also identified a significant increase in

mortality in patients who developed aspiration pneumonia during their admission. However,

the incidence of death (58%) in patients who developed aspiration pneumonia was noted to

be significantly higher than the 20% reported by (Wilson, 2012) and the 5% reported by

(Chang et al., 2013). This higher rate of death in the present study may potentially be

accounted for either by the inclusion of patients who had undergone thrombolysis, the

exclusion of haemorrhagic stroke patients or may be the result of increased stroke severity

within the current population (supported by the significant increase in modified Rankins

scores (Rankin, 1957). Further, the relatively small number of patients in current study may

have also affected the current results. Regardless, the high rate of aspiration pneumonia,

particularly the high risk of mortality in this population lends support to the importance of the

nursing role in dysphagia screening, monitoring patients during meals and referring to

appropriate team members (such as speech pathologists) when concerns arise (Nakazora et

al., 2017, Evans et al., 2001). Appropriate management protocols and escalation procedures

also are recommended in clinical practice to ensure consistent care provision.

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 From an operational perspective the relationship between cost and aspiration pneumonia was

found to be highly significant, with a cost of admission increase of $9100.29 for patients who
Accepted Article
developed aspiration pneumonia during admission. In the current context of cost efficient

health service provision, a saving of this magnitude on each stroke admission can have a

positive impact on health service cost efficiency. In addition, the current study confirmed that

the length of patient stay was significantly increased by the presence of aspiration

pneumonia, with the average hospital admission of 9.24 days extended by 15 days for those

patients who developed aspiration pneumonia during their admission. This significantly

increased length of stay clearly has a marked impact on bed availability, hospital through put

and the health service, more broadly. It is known that the potential to avoid aspiration

pneumonia by appropriate/effective dysphagia management can also reduce length of stay

and assist with maximising inpatient hospital bed access (Guyomard et al., 2009, Richardson

and Mountain, 2009). Further, nursing workloads are likely to be impacted by the increased

nursing needs of the patient with aspiration pneumonia, for example the demand for

intravenous anti-biotic, closer monitoring and increased preparation requirements for clinical

assessments (such as chest x-rays), thus supporting the need for appropriate dysphagia

management to minimise complications.

The incidence of nasogastric feeding in this study was found to be slightly lower than

incidences of 44% reported by (Dziewas et al., 2004). However, similar to previous literature,

the insertion of a NGT was found to be significantly related to poorer functional outcomes on

discharge and increased risk of death (Brogan et al., 2014, Ding and Logemann, 2000,

Dziewas et al., 2004). The impact of NGT insertion on cost and length of stay was also noted

to be highly significant, with a cost of admission increase of $8099.42. This increase in cost

per admission represents a significant cost burden on the health care system when NGT

This article is protected by copyright. All rights reserved.

 feeding was required. Clinically, the need for nasogastric feeding is also likely to increase

demands on nursing staff as the tube position must be regularly checked, feeds and flushes
Accepted Article
need to be administered as per regime, medications will need to be crushed and the patient

must be monitored for complications and distress caused by the nasogastric tube (Curtis,

2013).

The present study has supported and extended findings from earlier studies and has identified

that the post stoke dysphagia-related complications of aspiration pneumonia and nasogastric

feeding result in increased mortality rates, increased disability/stroke severity, significantly

increased hospital length of stay and increased overall cost of admission (Chang et al., 2002,

Falsetti et al., 2009, Saxena et al., 2006, Altman et al., 2010, Guyomard et al., 2009). The

high prevalence and significant risks associated with dysphagia-related post stroke

complications such as aspiration pneumonia and nasogastric feeding, spotlight the importance

of nursing staff as ‘care providers’ by maintaining safety and ensuring basic needs (such as

nutrition and hydration) are met (Burton, 2000). It is suggested that ‘skilled nursing care’ in

the form of screening, risk identification, continuous monitoring and management of

physiological changes, as well as appropriate multi-disciplinary referrals in stroke patients

could prevent secondary complications (Burton et al., 2009, Evans et al., 2001, Jones et al.,

2007, Langhorne and Pollock, 2002). Thus, appropriate multi-disciplinary dysphagia

management, combined with nursing care which effectively prevents secondary

complications will assist in reducing patient morbidity and mortality rates, reduce patient

length of stay, reduce cost of admission and reduce nursing burden, all of which optimises

health care and patient outcomes.

This article is protected by copyright. All rights reserved.

 Limitations

The limitations of this study are its relatively small sample size which reduced the statistical
Accepted Article
power of several important findings. Similarly collecting data retrospectively via chart

auditing may be flawed or affected due to poor documentation or errors occurring during data

collection. Patient satisfaction surveys also were not completed, which may have offered

useful information regarding the patient’s experience of dysphagia and quality of life

measures. Finally, data collected regarding nursing staffing levels, workload demands and the

perceptions of nursing staff may have added insight regarding nursing workload and the

potential to reduce adverse outcomes. The adoption of a more robust study design with

greater participant numbers would improve the statistical strength of these findings.

CONCLUSION

Post stroke dysphagia-related complications such as aspiration pneumonia and the need for

nasogastric feeding demonstrated a significant association with mortality and were associated

with poor functional patient outcomes. In addition, these complications were associated with

increased clinical cost of patient care and patient’s length of hospital stay, and added

complexity and time to nurses’ work load. Therefore, early identification of dysphagia,

timely assessment and management, and careful patient monitoring by the multidisciplinary

team, is paramount to minimise complications which can arise from dysphagia.

RELEVANCE TO CLINICAL PRACTICE

This paper highlights that post stroke complications can significantly impact on patient

outcomes and operational factors such as cost of admission, therefore post stroke care

requires a multi-disciplinary approach to management. Furthermore, preventing and

This article is protected by copyright. All rights reserved.

 managing complications post stroke is a key element of nursing care and has the potential to

significantly reduce incidence of mortality, length of stay and cost of hospital admission.
Accepted Article
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Science, 13, 65-73.

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 WESTENDORP, W. F., NEDERKOORN, P. J., VERMEIJ, J.-D., DIJKGRAAF, M. G. &

VAN DE BEEK, D. 2011. Post-stroke infection: a systematic review and meta-

Accepted Article
analysis. BMC neurology, 11, 110.

WILSON, R. D. 2012. Mortality and cost of pneumonia after stroke for different risk groups.

Journal of Stroke and Cerebrovascular Diseases, 21, 61-67.

Table 1: Demographic information

Demographic Information Patients (n=110)

Sex Male = 50

Female= 60

Age at time of stroke (years) Average age = 69.87

Range = 28-94

Initial stroke (%) 87 (79.1%)

Bamford classification (%) a

PACI 49 (44.5%)

TACI 18 (16.4%)

POCI 14 (12.7%)

LACI 29 (26.4%)

Presence of stroke risk factors

94 (85.5%)
b
(present)(%)

Received thrombolysis (%)

40 (36.3%)

Modified Rankin Score (Rankin, 1957)

prior to event (score of 0 on admission)(%) c 74 (67.3%)

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 Modified Rankins Score (Rankin, 1957) on

discharge (score of 0 on discharge) 8 (7.3%)

Accepted Article
a
Bamford Classification (PACI- partial anterior circulation infarct, TACI-total anterior

circulation infract, POCI- posterior circulation infarct, LACI- lacunar infract)

b
Stroke risk factors defined by National Stroke Foundation Guidelines (2010) (current

smoker, obesity, high intake of alcohol, high blood pressure, high cholesterol, diabetes)

c
Modified Rankin Score (Rankin, 1957) is a measure of disability (a score of 0 - no

symptoms, 1- no significant disability despite symptoms, 2- slight disability, 3- moderate

disability, 4- moderately severe disability, 5- severe disability, 6- dead).

The percent reported in this table reflects the percentage of participants who scored a MRS of

0 on admission and discharge.

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 Table 2: Clinical Outcomes and Cost Comparison

Complication Cost with Cost without Significance

Accepted Article
(percent incidence) complication complication

Aspiration pneumonia Mean $20,829.54 Mean $11,729.26 p<0.0001

(11.8%) Median $17,662 Median $9,036

95% CI 95% CI

$10,009.5- $27,748 $9,036 - $12,515

Nasogastric feeding Mean $19,210.65 Mean $11,111.23 p<0.0001

(20.9%) Median $17,662 Median $9,036

95% CI 95% CI

$16,222 - $25,116 $9,036 - $10,639

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 Figure 1. Mean Cost of Admission – Aspiration Pneumonia

Mean Cost of Admission- Aspiration

Accepted Article
Pneumonia
$25,000.00
$20,000.00
$15,000.00
$10,000.00 Mean cost
$5,000.00 Standard deviation
$0.00
Aspiration Aspiration Total
pneumonia pneumonia
present absent

Figure 2. Mean Cost of Admission- NGT

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