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Covid-19 HSE Clinical Guidance and Evidence

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Swallow assessment and Naso-gastric feeding in stroke patients during COVID-19 pandemic

Swallow assessment and Naso-gastric feeding in stroke patients during COVID-19 pandemic (CD19-184-001 / 17.12.20)

General Principles
  • Below is an agreed statement of the British Association of Stroke Physicians (BASP) which is endorsed by the Clinical Advisory Group of the Irish National Stroke Programme among other bodies.
  • Swallow assessment is a core and critical early assessment of stroke patients and should ideally be performed within 4 hours (international guidelines)  or as soon as feasible otherwise as per the normal local stroke care pathways.
  • Adequate nutrition and hydration is important in ensuring maximal recovery after stroke and this may necessitate the use of naso-gastric tube feeding when indicated as per the normal local stroke care pathway. 
  • Swallow assessment is considered as a potential aerosol generating procedure (AGP) by professionals treating stroke and all trained healthcare staff  performing such assessments are encouraged to wear the appropriate PPE for AGPs as recommended by the Health  Protection Surveillance Centre  of  HSE, where there is a risk of the stroke patient having COVID-19 infection.
  • The insertion of nasogastric feeding tubes and the insertion of nasal bridles is not considered an Aerosol Generating Procedure associated with an increased risk of infection in the HPSC guidance. However there is variation in detail between national guidance on infection prevention and control issued in different countries. Similarly, many specialist societies have issued recommendations, which differ in some details from national or international guidelines on infection prevention and control particularly with respect to the categorisation of procedures as AGPs. There is a body of opinion among professionals treating stroke and that considers that these procedures are AGPs.
  • HPSC guidance recommends the application of contact and droplet precautions for these procedures.
  • The is a body of opinion among professionals treating stroke that these procedures should be managed in accordance with the HPSC guidance for managing AGPs when caring for a stroke patient with suspected or confirmed COVID-19. This is reflected in the British Association of Stroke Physicians Statement reproduced below.
  • Because of the possibility of COVID-19 infection in stroke patients during the current pandemic surveillance swabs should be sent urgently on all stroke patients. Swallow assessments and NG placement should ideally be deferred until surveillance swab results are known but this must be balanced by the need for early swallow assessment (within 4 hours) to ensure patient safety and comfort. In cases where swallow screening or assessment (or less commonly early NG placement) must occur for patient care before COVID-19 status is known, it is recommended that such should procedures take place with appropriate infection prevention and control precautions as above.
  • When changing or replacement of NG tubes is necessary on clinical grounds this should be performed with appropriate infection prevention and control precautions as above.
  • Prof. Ronan Collins – Clinical Lead of National Stroke Programme (on behalf of the clinical advisory group)

British Association of Stroke Physicians (B.A.S.P.) Statement about personal protective equipment for healthcare workers performing swallow assessments and nasogastric tube insertion
  • We are concerned that conducting swallow assessments and placing nasogastric tubes for patients after a stroke are aerosol generating procedures (AGPs) of the respiratory tract. Consequently, healthcare professionals conducting these potentially infectious procedures require adequate personal protective equipment during the SARS-CoV-2 pandemic.
  • National guidance about which procedures may be considered AGPs is inconsistent between some nations (1) and the guidance from all nations is not consistent with our clinical experience in stroke services. This may reflect the quality and quantity of the evidence available to make this decision.
  • The evidence available to decide which AGPs put healthcare workers at risk of infection by respiratory pathogens is poor. The most recent assessment of the risk of transmission of infection by AGPs by WHO (2014) was based on a systematic review (2), which identified 5 case-control and 5 retrospective cohort studies) which evaluated transmission of SARS to healthcare workers. It is important to note that the GRADE study quality of all ten studies was independently rated as “very low”, the sample sizes of the studies were small, and swallow assessments were not assessed. Procedures reported to present an increased risk of transmission included tracheal intubation, non-invasive ventilation, tracheotomy and manual ventilation before intubation. (2) However, the authors wrote, “pooled estimates suggest that activities such as chest compressions (cardiopulmonary resuscitation), suction before intubation, suction after intubation, manipulation of oxygen mask, bronchoscopy, insertion of nasogastric tube (pooled odds ratio 1.2, 95% CI 0.4-4.0), and defibrillation might be associated with an increased risk of transmission, but the odds ratios were not statistically significant.” (2) Consequently, the authors concluded, “Any conclusions drawn from this systematic review must be interpreted with caution, given the number and quality of the identified studies”, (2) and Public Health Scotland concluded, “given the extremely limited volume and quality of studies available this hierarchy should be used for academic purposes only and not for clinical decision making.” (1)
  • We believe that swallow assessments and nasogastric tube insertion are AGPs. In our extensive clinical experience, patients with dysphagia after stroke who undergo swallow assessments often cough or choke. Nasogastric tube insertions, with or without the use of a nasal bridle  are upper ENT procedures involving suction, with occasional instrumentation of the upper and lower airways, with frequent coughing, sneezing and retching . Therefore, both of these procedures may generate an aerosol from a patient’s upper respiratory tract. The consequences of these procedures are not dissimilar from induction of sputum, which is recognised as an AGP. (1) We are not alone in making this judgement, which is shared by the Royal College of Speech and Language Therapists, (3,4) who have conducted a detailed review of the evidence in support of this position, (5) and the British Association for Parenteral and Enteral Nutrition. (6)
  • Therefore, we believe that swallow assessments and nasogastric tube insertion are AGPs and put healthcare workers at further risk during the COVID-19 pandemic. In particular, most patients with stroke are more vulnerable to SARS-CoV-2, but may not be manifesting symptoms at the time they present to healthcare services when they undergo these assessments and procedures.
  • As at least 113 UK healthcare workers have died with COVID-19 by 28 April 2020, (7) we ask for the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) to recognise swallow assessments for patients with stroke and nasogastric tube insertion as AGPs, so that adequate personal protective equipment is recommended to be donned during the SARS-CoV-2 pandemic by the joint guidance from the Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS), Public Health England and NHS England and Health Protection Surveillance Centre of the  Health  Service Executive (HSE) of Ireland. (8,9)

Guidance Development Group
  • Rustam Al-Shahi Salman - British Association of Stroke Physicians (BASP) President
  • Gillian Mead - BASP President Elect
  • Tom Robinson - BASP Past President
  • Deb Lowe - National Clinical Director for Stroke Medicine in England, Joint National Clinical Lead for Stroke Medicine NHSI GIRFT Programme, and BASP ordinary member for England
  • David Hargroves - Joint National Clinical Lead for Stroke Medicine NHSI GIRFT Programme, and Urgent and Acute Stroke care work stream lead, Clinical Policy Unit, NHSE
  • Sarah Marsh - Deputy Head of Clinical Policy, NHS England
  • Indira Natarajan - BASP ordinary member for England
  • Martin Dennis - Medical advisor to Chief Medical Officer, Scotland
  • Fiona Wright - Deputy medical advisor to Chief Medical Officer, Scotland
  • Terry Quinn - BASP ordinary member for Scotland
  • Phil Jones - National Clinical Lead for Stroke, Wales
  • Tom Hughes - BASP ordinary member for Wales
  • Michael McCormick - BASP ordinary member for Northern Ireland
  • Fiona Quigg - Regional Stroke Network Manager for Northern Ireland
  • Rónán Collins - National Stroke Programme, Republic of Ireland
  • Juliet Bouverie - Chief Executive, The Stroke Association
  • Alexis Kolodziej - Director Policy & Influencing, The Stroke Association
  • Mark MacDonald - Deputy Director Policy & Influencing, The Stroke Association

  1. Infection Control Team. Aerosol Generating Procedures (AGPs). NHS National Services Scotland. November 2019. (accessed 28 April 2020)
  2. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One 2012;7(4):e35797.
  7. BBC News. Coronavirus: Remembering 100 NHS and healthcare workers who have died. (accessed 28 April 2020)
  8. COVID-19 personal protective equipment (PPE). (accessed 28 April 2020)
  9. Health Surveillance and Protection Unit Health service Executive. Current recommendations for the use of Personal Protective Equipment (PPE) in the management of suspected or confirmed COVID-19

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