Dysphagia Outcomes for Patients with Feeding Tubes Undergoing Inpatient Rehabilitation: Follow-Up

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1 Dysphagia Outcomes for Patients with Feeding Tubes Undergoing Inpatient Rehabilitation: Follow-Up R. Jordan Stewart, MEd, CCC-SLP, BRS-S Susan Brady, MS, CCC-SLP, BRS-S Cari Manypenny, MS, CCC-SLP Richard Krieger, MD Andrea Quill, MA, CCC-SLP Karen Ng, MS, CCC-SLP Julie VeSota, MA, CCC-SLP

2 Disclosures I have no relevant financial or nonfinancial relationships in the products or services described, reviewed, evaluated or compared in this presentation.

3 Introduction Swallowing difficulties that require the placement of an enteral feeding tube (FT) in order for the patient to safely maintain adequate nutrition and hydration and administer medications are common, especially following a severe stroke or brain injury. 1-3 Several medical complications are known to be associated with FT placement and it has been reported that outcomes are not always improved as a result of the FT placement. 4,5 Placement of a FT following a severe stroke for the management of dysphagia can be a stressful decision for the patients, their families, and the entire healthcare team. 6,7

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5 Previous Research Krieger et al., 2010 Investigated patients with a stroke with a FT & NPO upon admission to Marianjoy. 8 65% (93/143) were able to resume some type of oral feedings 46.9% (67/143) were able to return to 3 meals by IPR discharge Mean days post stroke until returning to 3 meals daily= days Length of Stay 26.9 days for those eating 3 meals daily days for those eating <3 meals daily Only 20% (30/143) who were able to return to 3 meals daily had their FT removed prior to discharge. Factors associated with removal of tube: Longer LOS at Marianjoy Higher admission FIM score Patients more likely to be discharged to home

6 Current Study - Objectives 1) Identify the incidence of FT placement in patients at Marianjoy with either a diagnosis of stroke or BI. 2) Identify % of patients with a FT that are able to return to 3 meals daily while still at Marianjoy. 3) Identify the duration from insertion of FT until patient returns to 3 meals daily. 4) Identify % of patients with a FT placement who are able to have their FT removed prior to discharge. 5) Identify the rationale for patients with a FT who are not able to have their FT removed prior to discharge. 6) Identify the impact the presence of a FT may have upon: Length of stay Discharge destination

7 Method - Subjects Subjects: All patients admitted to Marianjoy inpatient from April 1, 2010 until September 31, 2011 with a FT placement secondary to neurogenic dysphagia following a stroke or BI. Exclusion Criteria: Pediatric patients, FT for nutrition purposes only (no dysphagia), chronic FT placement (not as a result of current illness) Subject Assignment: Group 1: Subjects who are receiving 3 meals daily during IPR Group 2: Subjects who are NOT receiving 3 meals daily during IPR

8 Methods - Procedure Medical chart reviews were completed by inpatient SLPs on each respective service Diet levels coded as: NPO Tube Feeding Supplements Modified dysphagia diet (3 meals) Regular diet (3 meals) Demographics: Age, diagnosis, gender, discharge destination, VFSS results for aspiration & penetration

9 Method - Procedure FT Status At Discharge: 1) Patient still NPO 2) Patient receiving PO feedings but requires supplemental feedings for medication, nutrition, and/or hydration 3) Patient discharged before tube matured (e.g. tube inserted less than 6 weeks) 4) Physician s preference for possible future medical procedure / condition 5) Patient maintaining all nutritional needs (only receiving water flushes to keep tube patent) but tube in place pending removal by GI surgeon after discharge. 6) Other (specify)

10 This data was NOT collected during our study!

11 Results (N=64) Group 1, n=43, subjects (67%) receiving 3 meals per day Group 2, n=21, subjects (33%) NOT receiving 3 meals per day Mean Length of Rehabilitation Length of Stay 23.5 days (±8.9 days) 90.6% (58/64) patients discharged with FT still in place

12 Results Subject Demographics (N=64) Mean Age Standard Deviation Age Range Gender years ± years years 40 males 24 females RIC n % Stroke (RIC 01) % Brain Injury (RIC 02, 03, 18) % Other Neuro (RIC 04, 06, 20) 6 9.4%

13 Results- Diet Level Change Noted changes from admit to discharge diet level NPO patients: 84.78% (39/46) were able to advance to some type of oral feedings by time of d/c from IPR Diet Level Admit Diet Discharge Diet NPO 46 (71.9%) 7 (10.9%) Tx Feeds 4 (6.3%) 14 (21.9%) 3 meals/day 14 (21.9%) 43 (67.2%)

14 Feeding Tube Status at Discharge FEEDING TUBE STATUS N= 64 % FT Removed 6 9.4% Still NPO TF Required 6 9.4% Supplemental TF Required % Immature FT % Future Medical Procedure 2 3.1% FT Requires Removal by GI Surgeon 6 9.4%

15 Results Discharge Destination Discharge Destination n % Subacute % Home % Acute Care 4 6.3% Assisted Living 1 1.6% Expired 2 3.1%

16 Discussion Compared to previous research by Krieger et al. (2010): Only NPO patients with FTs were reviewed Current study looked at patients with FT regardless of PO status Only stroke patients were reviewed Current study looked at patients on Stroke and BI units Sample size difference

17 Discussion Previous Study Patients discharged to home were more likely to have their FT removed during IPR Onset of illness to IPR admit: days Marianjoy LOS = 22.9 days 61.5% males 65% returned to some type of oral feedings 46.9% returned to 3 meals daily 20% had FT removed during IPR Current Study Majority of patients were discharged with FT in place to subacute facility Onset of illness to IPR admit: days Marianjoy LOS = 23.5 days 62.5% males 89% receiving some type of oral feedings 67% receiving 3 meals per day 9.4% had FT removed during IPR

18 Translation to Clinical Practice Current study revealed majority of patients were discharged with FT in place to subacute facility Majority of patients with FT admitted to IPR will return to some PO feeds with about half of population returning to 3 meals/day Majority of patients will be discharged from IPR with their FT still present Current study provides additional clarification for rationale as to why FT remains in place even when 3 meals per day has resumed

19 Study Limitations Need to further evaluate the predictive factors for FT removal across different diagnoses and admit levels to assist with decision making for patients and families Need to further evaluate reasoning for fewer FT being removed vs. previous study (9.4% vs. 20%) and if differences may be explained by different patient population

20 Conclusion This study reveals a significant majority of brain injury or stroke patients with a FT secondary to dysphagia returned to 3 meals/day during their inpatient stay, despite the majority being discharged to subacute facilities with their FT still present.

21 References 1. Norton B, Homer-Ward M, Donnelly MT, Long RG, Holmes GKT. A randomized prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute stroke. BMJ. 1996; 312: Wirth R, Volkert D, Bauer JM, et al. PEG tube placement in German geriatric wards a retrospective data-base analysis. Z Gerontol Geriatr. 2007; 40: Callahan CM, Haag KM, Weinberger M, Tierney WM, Buchanan NN, Stump TE, Nisi R. Outcomes of percutaneous endoscopic gastrostomy among older adults in a community sessing. J Am Geriatr Soc. 2000; 48: Attanasio A, Bedin M, Stocco S, Negrin V. Biancon A, Cecchetto G, Tagliapietra M. Clinical outcomes and complications of enteral nutrition among older adults. Miverva Med. 2009; 100: Calver J, McCaul KA, Burmas M, Horner BJ, Flicker L. Use of gastrostomy tubes in older Western Australians: a population based study of frequency, indications and outcomes. Med J Aust. 2009; 190: Bell C, Somogyi-Zauld E, Masaki K, Fortaleza-Dawson T, Blanchette PL. Factors associated with physicians decision-making in starting tube feedings. J Palliat Med. 2008; 11: Mitchell SL, Lawson FME. Decision-making for long-term tube-feeding in cognitively impaired elderly people. CMAJ. 1999; 160: Krieger RR, Brady S, Stewart RJ, Terry A, Brady JJ. Predictors of returning to oral feedings after feeding tube placement for patients Poststroke during inpatient rehabilitation. Top Stroke Rehabil 2010: 17:

22 Questions?

23 Thank You Thank You R. Jordan Stewart, MEd, CCC-SLP, BRS-S Board Recognized Specialist in Swallowing and Swallowing Disorders