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Evidence base Dysphagia is common in hospitalised stroke patients and can adversely affect outcome. FOOD trial showed early Naso-Gastric Tube (NGT), late Percutaneous Endoscopic Gastrostomy (PEG) insertion in dysphagic stroke on NBM was beneficial. NICE Guidelines CG68 recommends initiating tube feeding within 24hours for Stroke patients on NBM. Dislodgement of NGT is frequent, leads to interruption of food and medications administration. Nasal bridle (NB) with NGT has been shown to reduce frequency of NGT dislodgement.
Change strategy First cycle of audit carried out on 20 consecutive acute stroke admitted to ASU showed frequent dislodgement of NGT without the use of NB.
Average age of patients -82 (range: 50 to 92), Male: Female - 8:12. Dysphagic stroke = 11/ 20 (55%), Dysphagic stroke on NBM = 7/11 (60%), Number with NGT insertion = 7/ 7 (100%), average NGT insertion/patient = 9.2 (range: 4–17)
Strategy for improvement: Proposal submitted to the hospital management committee for the purchase of NB and training of staff for NB insertion after a presentation of the results of cycle 1 audit and raising awareness of the fact that introduction of NB will reduce the cost, make care of stroke patients safer. Proposal was accepted, training of staff completed, NB insertion introduced and 2nd cycle audit completed after 8 weeks of introduction of NB into practice. All MDT members of ASU team were involved right from the beginning of the project.
Change effects Cycle 2: audit of 21 consecutive stroke patients admitted to ASU with dysphagia on NBM showed reduction of average NGT insertion to 1.2 (range 1–4 ) compared to cycle 1 (pre-Nasal Bridle introduction audit), average NGT insertion 9/patient (range 4-17). Average age, age range, male/female distribution was similar to Cycle 1 audit. Patients in the audit cycle 2 had no complications from NB with NGT insertion except dislodgement in 3/21(14%)
Conclusion NGT insertion with NB reduced average insertion significantly (average 1.2, cycle 2 compared to average insertion of 9, cycle 1) and help maintain continuous nutrition, hydration and medication administration, thereby improving quality and safety of stroke care while reducing the overall cost from multiple insertions, reduced X-rays.
Other stroke units can use our experience to improve safety, quality while reducing cost of care in this group of stroke patients.