Simple test can prevent pneumonia after a stroke

Aspiration is main pneumonia risk in stroke victims

Millions of dollars and several hundred thousand lives could be saved if more hospitals followed a simple best practice — the swallow test — for stroke victims, assert researchers in a new study in the journal Neurology.1 Aspiration, note medical experts, is the main pneumonia risk in stroke patients.

A research team from MetroHealth and Case Western Reserve University in Cleveland and led by Irene Katzan, MD, MS, assistant professor of neurology at the Cleveland Clinic and MetroHealth Medical Center, reviewed local hospital records of 11,286 stroke patients admitted between 1991 and 1997. They found that 5.6% of those patients developed pneumonia, which tripled a patient's chance of dying within 30 days, and was linked with a greater need of extended care after discharge and a greater chance of re-admittance for complications.

In addition, the study reports that the typical case of pneumonia costs about $15,000 per patient. With an estimated 500,000 such patients nationwide per year, the annual cost would be near $459 million, the authors asserted.

While the study did not specifically determine if the swallow test was given, "other studies done largely pre- and post-implementation of the [swallow test] protocol have shown that implementation of such a systematic protocol can reduce pneumonia by 50%; one even showed a 100% reduction," asserts Katzan.

This particular study, she notes, is part of a larger data initiative to look at the care provided under Cleveland Health Quality Choice on six diagnoses, including stroke. "My background is stroke, and pneumonia is one of the most frequent serious complications after stroke," she explains. "We are doing a fairly large study evaluating the predictors [of stroke] and the best ways to prevent it. This was a supplemental study evaluating pneumonia occurring after stroke."

The study on cost was designed to uncover the incremental costs that hospitals absorb when stroke patients develop pneumonia and require a lengthier hospital stay, she continues. "DRGs like stroke get a certain reimbursement no matter what testing is issued, so when any patient that goes above [the per diem rate] it is absorbed by the hospital," Katzan notes.

Improving poor performance

While the swallow test is a recognized best practice and easy to perform, "it is documented to occur in discouragingly low levels" in hospitals, notes Katzan.


"The hospitals have a lot to deal with [with stroke patients] and this is one of the systematic things that is hard to do in all places at all times," Katzan observes, "but it is clearly a best practice."

Still, when a stroke victim comes in at 2 a.m., or sits in the ED for eight hours, "the test may not get done," she concedes. Nevertheless, she says, "there is an increased awareness of the importance of doing this test, and over time I suspect the screening will be done more frequently."

Standardized orders

What processes can be put in place to improve the regularity with which this test is done? "You should first of all have standardized orders that include the swallow test, so things are less able to fall through the cracks," says Katzan. "The other thing is, as new nurses come on, as part of their training, it should become one of the standards of care." For a nurse with 10 years' experience, she notes, doing the test regularly might represent a change in practice. "But if you learn this when you join the staff, it will just be seen as 'the way it is.'" As for veteran staffers, "in-services are absolutely necessary, because nurses have so much to watch and deal with," Katzan asserts.

Several initiatives are currently in place to help quality professionals and hospital staffs optimize this practice, notes Katzan. One is the American Heart Association's "Get with the Guidelines," and the other is the Physician Quality Reporting Initiative (PQRI) of the Centers for Medicare & Medicaid Services (CMS). "Screening for dysphasia is one of eight stroke quality indicators that is part of a set of PQRI measures being used this year, and that puts dollars behind [compliance]," notes Katzan.

In terms of determining whether your staff are following the standardized order set, she recommends "auditing [the charts for] a subgroup of patients to see whether it was done and documented prior to oral intake, which includes oral medication." For example, she notes, "A nurse might give a stroke patient aspirin without checking their ability to swallow — which is now one of the quality measures. The bar is becoming much stricter with CMS, and it is moving higher."

The direct "take-home" of this study for quality managers, says Katzan:

"Is that the cost of pneumonia care is significant; not only does pneumonia increase the risk of mortality and have negative effects on morbidity, but it is costly." Ancillary data from other studies, she emphasizes, suggest that such pneumonias are preventable, "and screening for dysphasia is one of the simple, basic ways to reduce pneumonia."

[For additional information, contact: Irene Katzan, MD, MS, Assistant Professor of Neurology, Cleveland Clinic and MetroHealth Medical Center, Cleveland, OH. E-mail:]


1. Katzan IL, Dawson NV, Thomas CL, Votruba ME, and Cebul RD. The cost of pneumonia after acute stroke. Neurology 2007; 68:1,938-1,943.