Standards of care

I've been looking over the standards of care we are required to achieve by our commissioners, heres the key points:

Standards of care for a stroke unit

Current NHS London staffing standards for SLT = 0.081 SLT per stroke bed (HfL SU Standard 13)

24 stroke beds = 1.95 SLTs

Service standards

·   All newly admitted patients to be seen by SLT within 72 hours of admission to SU (NICE Stroke Quality Standard 2010, Standard #5)

• All referrals for swallow ax seen within 24 hours (preferably) and not longer than 72 hours (RCP Clinical Guidelines for Stroke 2008, CQ3 – within 2 working days for high risk ax)

• Attend both MDMs every week (HfL SU standard 17)

·   Set goals within 5 days of admission to stroke unit (NICE Stroke Quality Standard 2010, Standard #5).

• All patients with communication difficulties to be seen for 45 mins of therapy per day, unless unable to tolerate (NICE Stroke Quality Standard 2010, Standard #7). Our practice uses communication, breakfast, newspaper, stroke education and counselling group to help us meet this target (an SLT or SLTA attends all of these groups).

Royal College of Physicians Clinical Guidelines for Stroke 2008

• All patients with any impairment at 24 hours should receive a full multidisciplinary assessment using an agreed procedure or protocol within five working days, and this should be documented in the notes.

Dysphagia:

If the admission screen indicates problems with swallowing, the person should have a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours afterwards.

• Until a safe swallowing method has been established, all patients with identified swallowing difficulties should:
• receive hydration (and nutrition after 24–48 hours) by alternative means
• be given their medication by the most appropriate route and in an appropriate form
• have a comprehensive assessment of their swallowing function undertaken by a speech and language therapist or other appropriately trained professional with specialism in dysphagia
• be considered for nasogastric tube feeding
• have written guidance for all staff/carers to use when feeding or providing liquid.
• Patients with difficulties in swallowing should be assessed by a speech and language therapist or other appropriately trained professional with specialism in dysphagia for active management of oral feeding by:
• sensory modification, such as altering taste and temperature of foods or carbonation of fluids
• texture modification of solids and/or liquids.
• Every patient who requires food or fluid of a modified consistency should:
• be referred to a dietician or multidisciplinary nutrition team
• have texture of modified food or liquids described using national agreed descriptors
• have both fluid balance and nutrition monitored.
• Patients with difficulties in self-feeding should be assessed and provided with the appropriate equipment to enable them to feed independently and safely.
• Gastrostomy feeding should be considered for patients who:
• need but are unable to tolerate nasogastric tube feeding within the first four weeks
• are unable to swallow adequate amounts of food and fluid orally at four weeks
• are at long-term high risk of malnutrition.
• Instrumental direct investigation of oropharyngeal swallowing mechanisms (eg by videofluoroscopy or flexible endoscopic evaluation of swallowing) should only be undertaken:
• in conjunction with a speech and language therapist with specialism in dysphagia
• if needed to direct an active treatment/rehabilitation technique for their swallowing difficulties, or
• to investigate the nature and causes of aspiration.
• Any patient unable to swallow food safely at one week after stroke should be considered for an oropharyngeal swallowing rehabilitation programme designed and monitored by a speech and language therapist with specialism in dysphagia. This should include one or more of:
• compensatory strategies such as postural changes (eg chin tuck) or different swallowing manoeuvres (eg supraglottic swallow)
• restorative strategies to improve oropharyngeal motor function (eg Shaker head lifting exercises)
• Any patient discharged from specialist care services with continuing problems with swallowing food or liquid safely should:
• be trained, or have carers trained, in the identification and management of swallowing difficulties
• receive planned follow-up and reassessment of the swallowing difficulty.

Aphasia:

• Any patient found to have aphasia on screening or suspected to have it on clinical grounds should have a full formal assessment of language and communication by a speech and language therapist.
• When a patient has been found to have aphasia, a speech and language therapist should:
• explain the nature of the impairment to the patient, family and treating team
• establish the most appropriate method of communication and then inform (and if necessary train) the family and treating team
• re-assess the nature and severity of the loss at appropriate intervals.
• Any patient with aphasia persisting for more than two weeks should:
• be given treatment aimed at reducing identified specific language impairments while continuing to progress towards goals
• be considered for early intensive (2–8 hours/week) speech and language therapy if they can tolerate it
• be assessed for alternative means of communication (eg gesture, drawing, writing, use of communication aids) and taught how to use any that are effective.
• While a patient has difficulties with communication:
• all people interacting regularly with a person who has aphasia should be taught the most effective communication techniques for that person.
• their mood should be assessed using whatever method seems most appropriate (eg direct questioning using adapted techniques, behavioural observation).
• Any patient with aphasia persisting at six months should
• be considered for and if appropriate referred for a further episode of specific treatment (in a group setting or one-to-one)
• have their need and the need of their family for social support and stimulation assessed formally, and met if possible (eg by referral to voluntary sector groups)

Dysarthria:

• Any patient whose speech is unclear or unintelligible so that communication is limited or unreliable should be assessed by a speech and language therapist to determine the nature and cause of the speech impairment.
• Any person who has dysarthria following stroke sufficiently severe to limit communication should:
• be taught techniques to improve the clarity of their speech
• be assessed for compensatory alternative and augmentative communication techniques (eg letter board, communication aids) if speech remains unintelligible.
• The communication partners (eg family, staff) of a person with severe dysarthria should be taught how to assist the person in their communication. (RCP 2008)

Dyspraxia:

o   Any patient who has marked difficulty articulating words should be formally assessed for apraxia of speech and treated to maximise intelligibility.

• Any patient with severe communication difficulties but reasonable cognition and language function should be assessed for and provided with appropriate alternative or augmentative communication aids.