Ishmail Sillah, DNP, MS RN, MPH
Nominated From: Indiana University
Research Site: Moi University
Research Area: Stroke Care Quality Improvement
Primary Mentor: Dr. Megan McHenry
Research Project
Exploring effective implementation strategies to improve Post Stroke Dysphagia Screening in a developing country.
Post Stroke Dysphagia Screening (PSDS) supports timely assessment, documentation, and communication of strategies to prevent poor stroke outcomes. These poor outcomes include aspiration pneumonia, malnutrition, dehydration, prolonged hospitalization, functional status decline, depression, and premature death. Evidence based bedside PSDS tools require minimal resources to reduce these risks. Thus, stroke care guidelines recommend early PSDS before administering food, fluids, or medication orally. Unfortunately, a knowledge translation gap exists between these expert recommendations and practices in developing African countries where post stroke dysphagia case fatality is up to 79.84% and the mean survival time is as early as 12 days. At Moi Teaching and Referral Hospital (MTRH), in western Kenya, formal PSDS tools are underutilized. Only 3% of patients with stroke received PSDS before oral intake; and assessment of knowledge on stroke care revealed that 73.4% of sampled clinicians did not routinely perform or order PSDS. This prompted the question on how to create a locally adapted PSDS strategy that is acceptable, feasible, and appropriate to use in a setting with limited stroke care resources? Methods: This mixed method study aims to answer this question by: 1. Exploring multidisciplinary leadership perceptions on PSDS determinants at MTRH. 2. Selecting an acceptable, feasible, and appropriate PSDS tool for this setting via expert input. 3. Evaluating face validity of the selected tool via cognitive interviews with local clinicians. Results: Aim 1: Multidisciplinary leaders will identify PSDS determinants via interviews guided with the pragmatic Context Assessment Tool (quantitative) and Think-Aloud Method (qualitative). Aim 2: Acceptability, feasibility, and appropriateness validation of dysphagia screening tools will occur via a series of recorded stroke care expert polling workshop (quantitative-qualitative). Aim 3: Face validity assessment of a stroke care expert selected screening tool will occur via cognitive interviews with End User Judges such as local nurses, physicians, and therapists at MTRH (qualitative). Conclusion: Study findings will reveal PSDS determinants and a systematic process of selecting a PSDS tool that is acceptable, feasible, and appropriate to use in a setting with limited stroke care resources. We believe this work will provide a rigorous and contextualized perspective on strategies to help reduce poor outcomes from post stroke dysphagia at MTRH and settings with similar resource limitations globally.
Research Significance
This is the first study to explore effective implementation strategies to overcome the knowledge translational gap that exists between PSDS guideline recommendations proven to reduce poor stroke outcomes and the underutilization of these strategies in a public hospital within western Kenya. Our literature review revealed that, despite bedside PSDS tools being a cost-effective and low risk strategy to reduce the risk for aspiration pneumonia, mechanical ventilation, and prolonged hospitalization among patients with stroke, these services are severely underutilized in settings with stroke care resource limitations such as MTRH. As such, the timely and scientifically rigorous performance of this study will help reduce the risk of post stroke dysphagia complications at MTRH via the development of a PSDS strategy that is acceptable, feasible, and appropriate for this setting. This study also aims to highlight how effective implementation strategies can be used understand organizational readiness challenges to general supportive stroke care quality improvement. This understanding can then be applied to support stroke care efforts that go beyond PSDS to address other preventable stroke related complications in a resource conservative manner. It is our hope that successful completion of this project will stimulate the curiosity to utilize more implementation strategies to address supportive stroke care quality improvement needs not only in Kenya but also in other settings with limited stroke care resources across the globe.
Mentors
