Dysphagia is one of the most common reasons for a gastrostomy tube (GT) placement as a means of chronic nutrition as the patient transitions to rehabilitation. Discussion regarding artificial nutrition is one of the reasons palliative care service becomes involved in the care of an ischemic stroke patient. Recent recommendations state that palliative care involvement should be promoted as part of patient- and family- centered care. To provide timely palliative care involvement, dysphagia evaluations by speech and language pathologists (SLPs), GT placement in the in-patient setting, a Dysphagia-Gastrostomy-Palliative care (DG-Pal) multidisciplinary algorithm was created.
Hypothesis: The authors hypothesize that the use of the DG-Pal algorithm will increase palliative care involvement, shorten the time to SLP dysphagia evaluation, and the time for GT placement without increase in in-patient mortality.
Methods: The DG-Pal algorithm was created by a Stroke Gastrostomy Task Force of the University of Mississippi Medical Center Stroke. The patients admitted with acute ischemic strokes were grouped into “Before DG-Pal (June 2015) versus After DG-Pal (January 2016)”. Primary outcome included palliative care involvement and timing. Secondary outcome include time to first SLP dysphagia evaluation, GT placement, and in-hospital mortality rate.
Results: A total of 78 patients were included for analysis. There were 45 (58%) patients included in the “before DG-Pal” cohort. Palliative care involvement was significantly higher in the “after DG-Pal” cohort (36% vs 4.5%, p=.001). The timing of palliative care involvement and time to first SLP dysphagia evaluation were similar in both groups. GTs were placed only among the “after DG-Pal” cohort (3, [9%]). In-hospital mortality rate was comparable between “before DG-Pal” and “after DG-Pal” groups respectively (2.3% vs 6.1%).
Conclusions: This is the first report of the use of a multi-disciplinary Dysphagia-Gastrostomy-Palliative care (DG-Pal) algorithm to improve palliative care involvement and the coordination of care for ischemic stroke patients. Further prospective studies are needed to further analyze the effect on patient and family outcomes.