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Research paper
The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia
  1. Benjamin D Bray1,
  2. Craig J Smith2,
  3. Geoffrey C Cloud3,
  4. Pam Enderby4,
  5. Martin James5,
  6. Lizz Paley6,
  7. Pippa J Tyrrell2,
  8. Charles D A Wolfe7,8,
  9. Anthony G Rudd7,8
  10. On behalf of the SSNAP Collaboration
  1. 1Farr Institute of Health Informatics, University College London, London, UK
  2. 2Stroke and Vascular Research Centre, Institute of Cardiovascular Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
  3. 3St George's University Hospitals NHS Foundation Trust, London, UK
  4. 4School of Health and Related Research, University of Sheffield, Sheffield, UK
  5. 5Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
  6. 6Royal College of Physicians, London, UK
  7. 7Division of Health and Social Care Research, King's College London, London, UK
  8. 8National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
  1. Correspondence to Dr Benjamin D Bray, Farr Institute of Health Informatics, 222 Euston Road, London, UK; benjamin.bray{at}


Background There is no robust evidence that screening patients with acute stroke for dysphagia reduces the risk of stroke-associated pneumonia (SAP), or of how quickly it should be done after admission. We aimed to identify if delays in bedside dysphagia screening and comprehensive dysphagia assessments by a speech and language therapist (SALT) were associated with patients' risk of SAP.

Methods Nationwide, registry-based, prospective cohort study of patients admitted with acute stroke in England and Wales. Multilevel multivariable logistic regression models were fitted, adjusting for patient variables and stroke severity. The exposures were time from (1) admission to bedside dysphagia screen, and (2) admission to comprehensive dysphagia assessment.

Results Of 63 650 patients admitted with acute stroke, 55 838 (88%) had a dysphagia screen, and 24 542 (39%) a comprehensive dysphagia assessment. Patients with the longest delays in dysphagia screening (4th quartile adjusted OR 1.14, 1.03 to 1.24) and SALT dysphagia assessment (4th quartile adjusted OR 2.01, 1.76 to 2.30) had a higher risk of SAP. The risk of SAP increased in a dose-response manner with delays in SALT dysphagia assessment, with an absolute increase of pneumonia incidence of 1% per day of delay.

Conclusions Delays in screening for and assessing dysphagia after stroke, are associated with higher risk of SAP. Since SAP is one of the main causes of mortality after acute stroke, early dysphagia assessment may contribute to preventing deaths from acute stroke and could be implemented even in settings without access to high-technology specialist stroke care.

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  • Twitter Follow Benjamin Bray at @benthebray

  • Contributors BDB involved in study design, analysis, writing. CJS involved in study design, writing. GCC, PE, MJ, PJT, CDAW and AGR involved in writing. LP involved in analysis and writing.

  • Funding SSNAP is funded by the Healthcare Quality Improvement Partnership on behalf of the Department of Health. The research was supported by the National Institute for Health Research Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London; MJ is supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula. No funders were involved in the design and conduct of the study; the collection, management, analysis and interpretation of the data; or the preparation, review, or approval of the manuscript. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

  • Competing interests None declared.

  • Ethics approval National Information Governance Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data from SSNAP are available to view and access at