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## Complete Summary

#### GUIDELINE TITLE

Management of patients with stroke: identification and management of
dysphagia. A national clinical guideline.

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). Management of
patients with stroke: identification and management of dysphagia. A
national clinical guideline. Edinburgh (Scotland): Scottish
Intercollegiate Guidelines Network (SIGN); 2004 Sep. 38 p. (SIGN
publication; no. 78). \[154 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

Any amendments to the guideline in the interim period will be noted on
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Dysphagia as a result of stroke

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Risk Assessment\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Geriatrics\
Internal Medicine\
Neurology\
Nursing\
Nutrition\
Otolaryngology\
Physical Medicine and Rehabilitation\
Speech-Language Pathology

#### INTENDED USERS

Dietitians\
Nurses\
Occupational Therapists\
Physicians\
Speech-Language Pathologists

#### GUIDELINE OBJECTIVE(S)

The aim of this guideline is to assist practitioners in reducing the
morbidity associated with dysphagia by early detection of swallowing
disorders in stroke patients and application of appropriate methods to
support food and fluid intake

#### TARGET POPULATION

Stroke patients throughout the care pathway from initial primary care
response, through hospital admission, on to continuing care in the
community. The emphasis is on patients in the acute setting.

**Note**: The guideline does not apply to people with neurological
conditions other than stroke or to people with subarachnoid haemorrhage.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation/Assessment**

1.  Initial clinical evaluation of swallowing and nutrition after
    stroke:

    -   Assessing risk of pneumonia (gag reflex, laryngopharyngeal
        sensory testing, water swallow test)

    -   Swallow screening

    -   Assessing risk of undernutrition

    -   Nutritional screening

2.  Assessment:

    -   Clinical bedside assessment (CBA)

    -   Instrumental assessment, including modified barium swallow (MBS)
        using videoflouroscopy and fibre optic endoscopic evaluation of
        swallowing (FEES) using a flexible nasendoscope

    -   Other assessments considered, but not recommended: cervical
        auscultation (CA) and pulse oximetry

3.  Provider training for screening and assessments

**Management/Prevention**

1.  Nutritional interventions:

    -   Oral nutritional supplementation (considered, but not
        recommended)

    -   Nasogastric (NG) tube feeding

    -   Percutaneous endoscopic gastrostomy (PEG) tube feeding

2.  Other management issues:

    -   Routine nutritional monitoring and interventions

    -   Diet modification

    -   Texture modification

    -   Delivery of oral hygiene

    -   Administration of medicines

    -   Assessment of communication, cognitive issues, and capacity for
        decision making

#### MAJOR OUTCOMES CONSIDERED

-   Morbidity associated with dysphagia (pneumonia, lower respiratory
    tract infections, weight changes, undernutrition or reduced
    nutritional status)

-   Risk of aspiration in stroke patients

-   Risk of undernutrition in stroke patients

-   Benefits, risks, and efficacy of interventions used to evaluate and
    manage dysphagia, and prevent complications

-   Quality of life

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence base for this guideline was synthesised in accordance with
Scottish Intercollegiate Guidelines Network (SIGN) methodology. A
systematic review of the literature was carried out using an explicit
search strategy devised by a SIGN Information Officer. Databases
searched include Medline, Embase, Healthstar, Cinahl, and the Cochrane
Library. The main part of the strategy was based on that used by the
Cochrane Library. The year range covered was 1980-2001. Internet
searches were carried out on various Web sites including the New Zealand
Guidelines Programme, the United Kingdom Health Technology Assessment
programme, and the United States National Guidelines Clearinghouse. The
Medline version of the main search strategies can be found on the [SIGN
Web site](http://www.sign.ac.uk/), in the section covering supplementary
guideline material. The main searches were supplemented by material
identified by individual members of the development group.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of randomised
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+**: Well conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1-**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort
studies; high quality case control or cohort studies with a very low
risk of confounding or bias and a high probability that the relationship
is causal

**2+**: Well conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Non-analytic studies (e.g., case reports, case series)

**4**: Expert opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

All selected papers were evaluated by two members of the group using
standard Scottish Intercollegiate Guidelines Network (SIGN)
methodological checklists before conclusions were considered as
evidence.

Additional details can be found in the companion document titled \"SIGN
50: A Guideline Developers\' Handbook.\" (Edinburgh \[UK\]: Scottish
Intercollegiate Guidelines Network. \[SIGN publication; no. 50\]),
available from the [SIGN Web
site](http://www.sign.ac.uk/methodology/index.html).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The process for synthesizing the evidence base to form graded guideline
recommendations is illustrated in the companion document titled \"SIGN
50: A Guideline Developers\' Handbook.\" (Edinburgh \[UK\]: Scottish
Intercollegiate Guidelines Network. \[SIGN publication; no. 50\],
available from the [SIGN Web
site](http://www.sign.ac.uk/methodology/index.html).

Guideline recommendations are graded to differentiate between those
based on strong evidence and those based on weak evidence. This judgment
is made on the basis of an (objective) assessment of the design and
quality of each study and a (perhaps more subjective) judgment on the
consistency, clinical relevance and external validity of the whole body
of evidence. The aim is to produce a recommendation that is
evidence-based, but which is relevant to the way in which health care is
delivered in Scotland and is therefore implementable.

It is important to emphasise that the grading does not relate to the
importance of the recommendation, but to the strength of the supporting
evidence and, in particular, to the predictive power of the study
designs from which that data was obtained. Thus, the grading assigned to
a recommendation indicates to users the likelihood that, if that
recommendation is implemented, the predicted outcome will be achieved.

Evidence tables are compiled by SIGN executive staff based on the
quality assessments of individual studies provided by guideline
development group members. The tables summarise all the validated
studies identified from the systematic literature review relating to
each key question. They are presented in a standard format to make it
easier to compare results across studies, and will present separately
the evidence for each outcome measure used in the published studies.
These evidence tables form an essential part of the guideline
development record and ensure that the basis of the guideline
development group\'s recommendations is transparent

It is rare for the evidence to show clearly and unambiguously what
course of action should be recommended for any given question.
Consequently, it is not always clear to those who were not involved in
the decision making process how guideline developers were able to arrive
at their recommendations, given the evidence they had to base them on.
In order to address this problem, SIGN has introduced the concept of
considered judgment.

Under the heading of considered judgment, guideline development groups
summarise their view of the total body of evidence covered by each
evidence table. This summary view is expected to cover the following
aspects:

-   Quantity, quality, and consistency of evidence

-   Generalisability of study findings

-   Directness of application to the target population for the
    guideline.

-   Clinical impact (i.e. the extent of the impact on the target patient
    population, and the resources needed to treat them)

-   Implementability (i.e. how practical it would be for the NHS in
    Scotland to implement the recommendation)

Guideline development groups are provided with a pro forma in which to
record the main points from their considered judgement. Once they have
considered these issues, the group is asked to summarise their view of
the evidence and assign a level of evidence to it, before going on to
derive a graded recommendation.

On occasion, guideline development groups find that there is an
important practical point that they wish to emphasise but for which
there is not, nor is their likely to be, any research evidence. This
will typically be where some aspect of treatment is regarded as such
sound clinical practice that nobody is likely to question it. These are
marked in the guideline as Good Practice Points, and are indicated. It
must be emphasised that these are not an alternative to evidence- based
recommendations, and should only be used where there is no alternative
means of highlighting the issue.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendation**

**Note**: The grade of recommendation relates to the strength of the
evidence on which the recommendation is based. It does not reflect the
clinical importance of the recommendation.

**Grade A**: At least one meta-analysis, systematic review of randomized
controlled trials (RCTs), or RCT rated as 1++ and directly applicable to
the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**Grade B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**Grade C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**Grade D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

**Good Practice Points**: Recommended best practice based on the
clinical experience of the guideline development group

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A national open meeting is the main consultative phase of Scottish
Intercollegiate Guidelines Network (SIGN) guideline development, at
which the guideline development group presents its draft recommendations
for the first time. The national open meeting for this guideline was
held on 16 May 2002 and was attended by 100 representatives of all the
key specialties relevant to the guideline. The draft guideline was also
available on the SIGN Web site for a limited period at this stage to
allow those unable to attend the meeting to contribute to the
development of the guideline.

The guideline was also reviewed in draft form by a panel of independent
expert referees, who were asked to comment primarily on the
comprehensiveness and accuracy of interpretation of the evidence base
supporting the recommendations in the guideline.

As a final quality control check, the guideline is reviewed by an
Editorial Group comprising the relevant specialty representatives on
SIGN Council to ensure that the peer reviewers\' comments have been
addressed adequately and that any risk of bias in the guideline
development process as a whole has been minimised.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*Note from the Scottish Intercollegiate Guidelines Network (SIGN) and
National Guideline Clearinghouse (NGC): In addition to these
evidence-based recommendations, the guideline development group also
identifies points of best clinical practice in the full-text guideline
document.*

The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-,
2++, 2+, 2-, 3, 4) are defined at the end of the \"Major
Recommendations\" field.

**[Initial Clinical Evaluation of Swallowing and Nutrition after
Stroke]{.underline}**:

**C**: All stroke patients should be screened for dysphagia before being
given food or drink.

**Assessing Risk of Pneumonia**

**B**: The water swallow test should be used as a part of the screening
for aspiration risk in stroke patients.

**C**: Clinical history taking should take into account comorbidities
and other risk factors (e.g., smoking or respiratory disease) to
identify increased risk of developing aspiration pneumonia.

**Swallow Screening**

**D**: Patients with dysphagia should be monitored daily in the first
week to identify rapid recovery. Observations should be recorded as part
of the care plan.

**B**: A typical swallow screening procedure should include:

-   Initial observations of the patient\'s consciousness level

-   Observations of the degree of postural control

If the patient is able to actively cooperate and is able to be supported
in an upright position the procedure should also include:

-   Observations of oral hygiene

-   Observations of control of oral secretions

-   If appropriate, a water swallow test

**Nutritional Screening**

**D**: Patients\' nutritional risk should be established using a valid
and reliable screening procedure suitable for stroke patients.
Nutritional screening should be repeated at regular interval throughout
the episode of care.

**D**: Nutritional screening should focus on the effects of the stroke
on nutritional status (e.g., presence of dysphagia and ability to eat)
rather than previous nutritional status.

**D**: Nutritional risk should be established within 48 hours of
admission to hospital.

**D**: Results from the nutritional screening process should guide
appropriate referral to a dietitian for assessment and management.

**D**: Nutritional screening should cover:

-   Body mass index (BMI)

-   Ability to eat

-   Appetite

-   Physical condition

-   Mental condition

**[Assessment]{.underline}**:

**Clinical Bedside Assessment**

**B**: A standardised clinical bedside assessment (CBA) should be used
by a professional skilled in the management of dysphagia (currently
speech and language therapists).

**B**: The clinical bedside assessment developed and tested by Logemann,
or a similar tool, is recommended.

**Instrumental Assessment**

**C**: The modified barium swallow test and fibre optic endoscopic
evaluation of swallow are both valid methods for assessing dysphagia.
The clinician should consider which is the most appropriate for
different patients in different settings.

**[Training for Screening and Assessments]{.underline}**:

**Screening**

**D**: A training package for nurses should include:

-   Risk factors for dysphagia

-   Early signs of dysphagia

-   Observation of eating and drinking habits

-   Water swallow test

-   Monitoring of hydration

-   Monitoring weight and nutritional risk

**Assessment**

**D**: All staff involved in the detection and management of dysphagia
should be trained according to the recommendations of the relevant
professional body.

**D**: Standard criteria should be established for the interpretation of
the results of radiological and fibre optic assessments.

**[Nutritional Interventions]{.underline}**:

**Tube Feeding**

**D**: Patients in the early recovery phase should be reviewed weekly by
the multidisciplinary team to ascertain if longer term (\>4 weeks)
feeding is required.

**B**: Feeding via percutaneous endoscopic gastrostomy (PEG) is the
recommended feeding route for long-term (\>4 weeks) enteral feeding.
Patients requiring long-term tube feeding should be reviewed regularly.

**D**: Patient\'s and carer\'s perceptions and expectations of PEG
feeding should be taken into account and the benefits, risks and burden
of care fully explained before initiating feeding.

**[Other Management Issues]{.underline}**:

**Effect of Regular Review on Patient Outcome**

**D**: Patients with persistent dysphagia should be reviewed regularly,
at a frequency related to their individual swallowing function and
dietary intake, by a professional skilled in the management of
dysphagia.

**Effect of Therapy on Patient Outcome**

**D**: Advice on diet modification and compensatory techniques (postures
and manoeuvres) should be given following full swallowing assessment.

**D**: Texture modified food should be attractively presented and
appetising. Patients should have a choice of dishes.

**Other Considerations**

**D**: Good oral hygiene should be maintained in patients with
dysphagia, particularly in those with PEG or nasogastric (NG) tubes, in
order to promote oral health and patient comfort.

**D**: Hospital and community pharmacists or medicines information
centres should be consulted by the professional managing the patient\'s
dysphagia on the most appropriate method of administering medication.

**Care of Patients with Dysphagia**

**D**: Staff, carers and, patients should be trained in feeding
techniques. This training should include:

-   Modifications of positioning and diet

-   Food placement

-   Management of behavioural and environmental factors

-   Delivery of oral care

-   Management of choking

**The Effect of Communicative or Cognitive Impairment on the Management
of Dysphagia Patients**

**D**: Communication, cognitive function, and the capacity for decision
making should be routinely assessed in patients with dysphagia.

**[Definitions]{.underline}**:

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of randomised
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+**: Well conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1 -**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort
studies; high quality case control or cohort studies with a very low
risk of confounding or bias and a high probability that the relationship
is causal

**2+**: Well conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Non-analytic studies (e.g., case reports, case series)

**4**: Expert opinion

**Grades of Recommendation**

**Note**: The grade of recommendation relates to the strength of the
evidence on which the recommendation is based. It does not reflect the
clinical importance of the recommendation.

**A**: At least one meta-analysis, systematic review of RCTs, or RCT
rated as 1++ and directly applicable to the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

**Good Practice Points**: Recommended best practice based on the
clinical experience of the guideline development group

#### CLINICAL ALGORITHM(S)

Algorithms are provided in the original guideline document for:

-   Swallow screening procedure

-   Clinical bedside assessment

-   Oral care

-   Assessment of patient suitability for a percutaneous endoscopic
    gastrostomy (PEG) tube

-   Postdischarge monitoring for patients on home enteral tube feeding

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Implementation of a systematic programme of diagnosis and management
    of dysphagia within an acute stroke management plan can reduce the
    occurrence of pneumonia.

-   Starting tube feeding early may reduce case fatality and that unless
    there are strong practical reasons why a percutaneous endoscopic
    gastrostomy (PEG) tube should be used, early tube feeding should be
    via a nasogastric (NG) tube.

-   Routine nutritional monitoring and interventions (i.e., regular
    weighing, nutritional analysis, staff attention to swallowing,
    texture modified diets, and tube feeds) contribute to improvements
    in nutrition and ensure that dysphagia is not associated with
    undernutrition in patients surviving beyond one month.

-   Diet modification and use of postures or manoeuvres have been shown
    to be effective in specific individuals using videofluoroscopy and
    are standard management of dysphagia following stroke.

-   Good oral hygiene can prevent oral and dental disease and reduce the
    risk of aspiration pneumonia.

#### POTENTIAL HARMS

-   Limitations of *modified barium swallow* (MBS) include potential
    difficulty in transporting stroke patients to a radiology
    department, exposure to radiation, and the limitations of basing
    management recommendations on a \"snapshot\" view of swallowing
    function.

-   *Nasogastric (NG) tubes*: inadvertent placement into the lungs can
    be a problem, and if unrecognised has serious consequences.
    Oesophagitis and upper gastrointestinal ulceration may also occur.

-   *Percutaneous endoscopic gastrostomy (PEG) tubes*: Minor
    complications, such as tube displacement, minor skin infection, tube
    obstruction and leakage are relatively common with a reported rate
    of 13 to 62%. Major complications, such as gastric haemorrhage,
    serious abdominal wall infection, peritonitis and gastric fistula
    are reported in between 3 to 19% of patients. The procedure related
    mortality is 0 to 2.5%. Long term mortality following PEG placement
    is high, presumably reflecting the seriousness of the underlying
    stroke. Mortality rates at 30 days, 6 months, and 12 months are in
    the range of 20%, 40%, and 50% respectively.

-   Both *NG and PEG tubes*: with both types of tube feeding gastric
    intolerance can occur and may limit adequate delivery of nutrition.
    Gastro-oesophageal reflux and aspiration are common and neither type
    of tube feeding reduces the risk of aspiration after stroke.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline is not intended to be construed or to serve as a standard
of care. Standards of care are determined on the basis of all clinical
data available for an individual case and are subject to change as
scientific knowledge and technology advance and patterns of care evolve.
Adherence to guideline recommendations will not ensure a successful
outcome in every case, nor should they be construed as including all
proper methods of care or excluding other acceptable methods of care
aimed at the same results. The ultimate judgment regarding a particular
clinical procedure or management plan must be made by the appropriate
healthcare professional(s), following discussion of the options with the
patient, in light of the diagnostic and treatment choices available. It
is advised, however, that significant departures from the national
guideline or any local guidelines derived from it should be fully
documented in the patient\'s case notes at the time the relevant
decision is taken.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Implementation of national clinical guidelines is the responsibility of
each National Health Service (NHS) Health Board and is an essential part
of clinical governance. It is acknowledged that every Health Board
cannot implement every guideline immediately on publication, but
mechanisms should be in place to ensure that the care provided is
reviewed against the guideline recommendations and the reasons for any
differences assessed and, where appropriate, addressed. These
discussions should involve both clinical staff and management. Local
arrangements may then be made to implement the national guideline in
individual hospitals, units and practices, and to monitor adherence.
This may be done by a variety of means including patient-specific
reminders, continuing education and training, and clinical audit.

**Key Points for Audit**

Data should be collected to confirm that:

-   Comorbidities and correctable risk factors are assessed on admission

-   Nutritional risk is assessed within 48 hours of admission

-   Screening for dysphagia takes place before any food/drink is given

-   Screening for dysphagia in inpatients is repeated daily for a
    minimum of one week after initial assessment

-   Criteria are in place to highlight the need for referral to a
    dietitian or speech and language therapist (SLT) and referral
    procedures are in place

-   Documentation of nutritional management of the patient (including
    justification of the decision not to feed, consistency of modified
    diets and monitoring of food and fluid intake) is available

-   Non-compliance of patients on modified oral intake does not reflect
    lack of appropriate care

-   The patient has received the modified diet and drinks that have been
    recommended

-   A pharmacist is involved/consulted at an early stage

-   Multidisciplinary training programmes are in place

-   The timing, institution, and complications of tube feeding
    (nasogastric \[NG\] and percutaneous endoscopic gastrostomy \[PEG\])
    are recorded

-   Named professional in charge of patients discharged with NG or PEG
    has been identified

-   An oral care protocol is in place

-   Patients with persistent dysphagia are reviewed

-   The relevant information has been imparted to the patient and
    family/carer in an appropriate format

-   Professionals, patients and carers are aware of the forthcoming
    Clinical Standards for Stroke Services published by NHS Quality
    Improvement Scotland

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). Management of
patients with stroke: identification and management of dysphagia. A
national clinical guideline. Edinburgh (Scotland): Scottish
Intercollegiate Guidelines Network (SIGN); 2004 Sep. 38 p. (SIGN
publication; no. 78). \[154 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Sep

#### GUIDELINE DEVELOPER(S)

Scottish Intercollegiate Guidelines Network - National Government Agency
\[Non-U.S.\]

#### SOURCE(S) OF FUNDING

Scottish Executive Health Department

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Guideline Development Group*: Ms Iris Clarke (*Chair*), Speech and
Language Therapist, Raigmore Hospital, Inverness; Mrs Catherine Dunnet
(*Secretary*), Head of Speech and Language Therapy Service, Glasgow
Royal Infirmary; Ms Jane Camp, Clinical Governance Practice Development
Nurse, Gartnavel Royal Hospital, Glasgow; Dr David Campbell, General
Practitioner, Irvine; Ms Francesca Chappell, Information Officer, SIGN;
Dr Ali El-Ghorr, Programme Manager, SIGN; Sister Hazel Fraser, Stroke
Coordinator, Queen Margaret Hospital, Dunfermline; Dr Julian Guse,
Consultant Radiologist, Monklands Hospital, Airdrie; Dr Ray Holden,
Consultant Gastroenterologist, Monklands Hospital, Airdrie; Dr Romana
Hunter, Clinical Lecturer, Dundee Dental School; Dr Roberta James,
Programme Manager, SIGN; Mrs Morag Ogilvie, Senior Dietitian, St Johnís
Hospital, Livingston; Dr Brian Pentland, Consultant Physician, Astley
Ainslie Hospital, Edinburgh; Ms Fiona Small, Physiotherapist, Western
General Hospital, Edinburgh; Professor David Stott, Consultant in
Geriatric Medicine, Glasgow Royal Infirmary; Ms Fiona Strachan, Senior
Dietitian, Woodend Hospital, Aberdeen; Ms Gillian Wilson, Speech and
Language Therapist, Victoria Infirmary, Glasgow; Mrs Kathryn Wood,
Principal Pharmacist, Tayside Primary Care Trust

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Declarations of interests were made by all members of the guideline
development group. Further details are available from the Scottish
Intercollegiate Guidelines Network (SIGN) Executive.

#### GUIDELINE STATUS

This is the current release of the guideline.

Any amendments to the guideline in the interim period will be noted on
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/pdf/sign78.pdf).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Quick reference guide: Management of patients with stroke:
    identification and management of dysphagia. Scottish Intercollegiate
    Guidelines Network, 2004 Sep. 2 p. Available in Portable Document
    Format (PDF) from the [Scottish Intercollegiate Guidelines Network
    (SIGN) Web site](http://www.sign.ac.uk/pdf/qrg78.pdf).

-   SIGN 50: A guideline developer\'s handbook. Edinburgh (Scotland):
    Scottish Intercollegiate Guidelines Network. (SIGN publication; no.
    50). Available from the [SIGN Web
    site](http://www.sign.ac.uk/methodology/index.html).

-   Appraising the quality of clinical guidelines. The SIGN guide to the
    AGREE (Appraisal of Guidelines Research & Evaluation) guideline
    appraisal instrument.  Edinburgh (Scotland): Scottish
    Intercollegiate Guidelines Network, 2001. Available from the [SIGN
    Web site](http://www.sign.ac.uk/methodology/agreeguide/index.html).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on October 22, 2004. The
information was verified by the guideline developer on January 26, 2005.

#### COPYRIGHT STATEMENT

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audit.

Users wishing to use, reproduce, or republish SIGN material for
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medium. To do this, please contact <sara.twaddle@nhs.net>.

Additional copyright information is available on the [SIGN Web
site](http://www.sign.ac.uk/guidelines/published/copyright.html).

### DISCLAIMER

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Date Modified: 11/3/2008