Optimising Medicines Administration for Patients with Dysphagia in Hospital: Medical or Nursing Responsibility?

Abstract

Dysphagia is common—not only associated with stroke, dementia, Parkinson’s but also in many non-neurological medical problems—and is increasingly prevalent in ageing patients, where malnutrition is common and pneumonia is frequently the main cause of death. To improve the care of people with dysphagia (PWD) and minimise risk of aspiration and choking, the textures of food and drinks are frequently modified. Whilst medicines are usually concurrently prescribed for PWD, their texture is frequently not considered and therefore any minimisation of risk with respect to food and drink may be being negated when such medicines are administered. Furthermore, evidence is starting to emerge that mixing thickeners with medicines can, in certain circumstances, significantly affect drug bioavailability and therefore amending the texture of a medicine may not be straightforward. Research across a number of hospital trusts demonstrated that PWD are three times more likely to experience medication administration errors than those without dysphagia located on the same ward. Errors more commonly seen in PWD were missed doses, wrong formulation and wrong preparation through medicines alteration. Researchers also found that the same patient with dysphagia would be given their medicines in entirely different ways depending on the person administering the medicine. The alteration of medicines prior to administration has potential for patient harm, particularly if the medicine has been designed to release medicines at a pre-defined rate or within a pre-defined location. Alteration of medicines can have significant legal implications and these are frequently overlooked. Dispersing, crushing or mixing medicines can be part of, or misconstrued as, covert administration, thus introducing a further raft of legislation. Guidance within the UK recommends that following identification of dysphagia, the ongoing need for the medicine should be considered, as should the most appropriate route and formulation, with medicines alteration used as a last resort. The patient should be at the centre of any decision making. Evidence suggests that in the UK this guidance is not being followed. This article considers the clinical and legal issues surrounding administration of medicines to PWD from a UK perspective and debates whether medicines optimisation should be the primary responsibility of the prescriber when initiating therapy on the ward or the nurse who administers the medicine.

Dysphagia Screening Protocol for Acute Stroke Patient: A Literature Review

“…There is no consensus on the method of screening for dysphagia between hospitals, so the use of protocols or instruments still varies (24). The oldest and most frequently used method is the Water Swallowing Test (WST) (6). The test by giving water varies depending on the perception of the nurse, ranging from 3 ml to 60 ml.…”

“…Stroke is a leading cause of disability and death worldwide (1). The priority of nursing intervention are to maintain nutrition and ensure that stoke patient could swallow safely without aspiration (1,6). Stroke may lead to mild, moderate or severe swallowing difficulties.…”

“…Stroke may lead to mild, moderate or severe swallowing difficulties. Several recent studies highlight the impact of dysphagia on dehydration, malnutrition, and aspiration pneumonia (6). Aspiration pneumonia was associated with prolonged hospital stay; worsening stroke patient outcome, and increased mortality (6).…”

“…Dysphagia defined as difficulty in food or liquid passing from the mouth, through the pharynx to the esophagus and onwards to the stomach (6). Approximately 65-90% of dysphagia patients experience disturbances in the oropharyngeal phase, changes in lung function, risk of aspiration, nutrition, and quality of life (5).…”

<p>Unlicensed “Special” Medicines: Understanding the Community Pharmacist Perspective</p>

“…This license ensures a medicine has passed through clinical trials and has met the MHRA's standards of safety and efficacy. 2 However, sometimes there is no licensed product available to treat a patient's specific clinical needs, for example, those in paediatric and elderly populations, as medicines are rarely tested and licensed for use within these age groups; 3 those with rare diseases; 4,5 those physically unable to take a licensed medicine, such as patients with dysphagia, 6 or in times of drug shortages. 7 When no suitable licensed product is available, unlicensed medicines, often known as 'specials' are supplied.…”