Construcción, implementación y evaluación de una vía clínica de la disfagia en una unidad de ictus agudo

Abstract

Introduction: clinical pathways (CPWs) are tools that develop activities to avoid the appearance of problems and are applied to a predictable clinic, facilitate multidisciplinary care for patients, where they describe activities, sequences and duration of any care process, intervening in coordination between health workers. Stroke is a health problem of the first order and its neurological assistance is urgent. Good practice dictates that should be treated in stroke units with continuous monitoring and specific care. One of the most important symptoms in stroke is dysphagia, which affects the patient on multiple levels, assuming the first cause of aspirations and respiratory complications, making it necessary to identify it in order to give timely treatment. Objectives: to assess the quality of care for dysphagia, to analyze the results of the implementation of a pathway to improve its identification and management, unify criteria for daily nursing action, map the processes of detection and treatment of dysphagia, define indicators to measure the quality of the care process, and identify opportunities for improvement in the processes of dysphagia care in stroke patients. Material and methods: this project constituted the design and implementation of a CPW. It included a cross-sectional descriptive observational study for the validation of indicators. In addition, for its implementation and evaluation, a quasi-experimental design was developed with an improvement cycle methodology. It was developed in the stroke unit of the Hospital Clinic Universitary Virgen of the Arrixaca, with a sample of 43 patients for evaluations, and the entire sample size for indicators of low casuistry. All patients admitted to the stroke unit between March-July 2021 were included for the 1st measurement, and from January to March 2022 for the 2nd measurement. The work was developed thanks to the support of a multidisciplinary working group. Results: through the process of elaboration of the CPW, the quality of care for dysphagia in the stroke unit was assessed. Criteria for action in nursing practice included in the CPW were unified, which is composed of documents such as the final activity matrix, dysphagia detection flowchart, variation sheet, information sheet for relatives/patients, and quick guide on dysphagia after a stroke. To evaluate the implementation of the CPW, 7 indicators were selected, extracted from a search of articles, and 2 indicators were created that were considered useful for the evaluation, having a total of 9 indicators (process n=7 and results n=2). The results of 5 of the indicators demonstrated perfect reliability, only two of them moderate reliability, No. 3 "Register of the type of test used in the detection of dysphagia" with a kappa value of 0.47, and indicator No. 6 "ITC to nutrition/endocrine in the patient with NGS", with a kappa value of 0.50. The three indicators with the highest non-compliance with the 1st measurement were: No. 3 "Register of the test used to detect dysphagia" (95% CI 0-10.90), No. 4 "Register of respiratory complications" (95% CI 3.60-24.30), and indicator No. 1 "Performance of the dysphagia test" (95% CI 24.90-54.10). The improvements achieved in the 3 main indicators after CPW implantation were: No. 7 "ITC to RHB dysphagia in the patient with dysphagia at discharge" MR=100% and MA=38%, No. 4 "Register of respiratory complications" MR=94% MA=81%, and No. 6 "ITC to nutrition/endocrine in the patient with SNG" MR=76% MA=38. The indicator that did not improve, but did not worsen either, was No. 2 "Register of types of dysphagia" since it had the same compliance both in the first and in the second measurement. Conclusions: the design of the CPW has managed to unify some criteria among professionals so that patients benefit from multidisciplinary care in the detection of dysphagia. The inclusion of the volumen viscosity swallow test as a dysphagia detection test in the stroke unit will allow all hospital units to work homogeneously with the same test. Process mapping allows the trajectory of the functions carried out by the healthcare workers to be recognized graphically. Nine feasible and reliable indicators have been piloted when measuring the quality of care for dysphagia in patients with stroke. Interconsultations to nutrition/endocrine, dysphagia rehabilitation, and interconsultations to Otorhinolaryngology, glycemia and electrocardiogram protocols were corrected.