Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
This statewide project aimed to improve the capability of Queensland hospitals and emergency departments in identifying swallowing difficulties in stroke patients.
Dates: August 2025 - June 2026
Implementation sites: Queensland statewide
Partnerships: STARS, Healthcare Improvement Unit, University of Queensland
This project was presented as a Poster at CEQ Showcase 2026 (PDF 396KB).
Aim
To improve statewide rates of screening for swallowing difficulties in acute stroke patients toward national benchmarks, i.e. before any food, fluids or medications and within four hours arrival to hospital.
Outcomes
This project is underway, with data collection to be completed in May 2026. Statewide reach has already been achieved:
- Engaged and consulted with seven statewide networks/programs, and >20 clinical stakeholders (and counting) including nurses, speech pathologists, doctors and emergency department managers from across the rural, regional and metropolitan hospitals in the state
- Working with services such as Queensland Telestroke Service and the Stroke Foundation's StrokeLink program.
- A communications strategy has been developed to maximise reach and engagement in swallow screening.
A subset of Queensland Health sites from our working group will pilot and evaluate an online toolkit of resources and communication plan to target their swallow screening goals and evaluate project outputs.
Background
Swallowing problems affect approximately 42% of patients who experience stroke (1) and can lead to debilitating complications such as malnutrition, dehydration and pneumonia (2). These complications increase length of stay in hospital, impede stroke recovery and can even result in death (1, 3, 4). Early identification of swallowing problems through screening and assessment can reduce the risk of swallowing-related complications (4). As such, the National Stroke Foundation recommends screening or assessment of swallowing abilities is completed with all stroke patients prior to them receiving any food, drinks or medications (5).
National data about the completion of swallowing assessment/screening is also collected annually and monitored against benchmarks set by the Australian Stroke Clinical Registry (AuSCR), which majority of Queensland Health hospitals report to. However, rates of swallowing screening and assessment across the state remain well below benchmark despite substantial effort across sites to improve practice. In the 2024-2025 financial year, only 65% of Queensland stroke patients received a screener or assessment of swallowing prior to receiving food, fluids or medications. This means that for many patients, swallowing difficulties would have been identified too late, placing their health and recovery at risk. Additionally, there is great variation in how screening/assessment is completed between rural, regional and metropolitan, impacting equity of care for stroke patients.
Clinicians have reported several challenging barriers which impact rates of swallow screening. Common barriers include difficulties delivering and maintaining adequate training in swallow screening tools, reduced knowledge and awareness of the potential impact of not completing swallow screening and lack of clear processes. Although local quality improvement initiatives to bolster training and awareness have anecdotally resulted in short-term benefits to patients, initiatives have not been sustained long term. A statewide improvement project was therefore established to harness local learning and develop scalable, sustainable solutions which make the safe thing (swallow screening), the easy thing.
Methods
This project adopted a designs-thinking quality improvement approach. This approach incorporates five key phases.
- Plan phase (completed): the scope of the project was defined and a project plan developed.
- Discovery and diagnostics phase (completed): we obtained a comprehensive understanding of the problem (including barriers and enablers), identified current processes for swallowing screening across hospitals and learned about local improvement initiatives and their outcomes. These aims were achieved through the formation of a project working group, which included nurses and speech pathologists in stroke and emergency care from eight health services, review of documented stroke and swallow screening procedures, stroke procedure mapping, and broad consultation via statewide clinical networks/groups. Two frameworks guided this phase. The COM-B model (6) enabled identification of ways in which this project could build Capability, Opportunity and Motivation of clinical teams in dysphagia screening based on analysis of barriers and enablers to swallow screening.
- Solutions design (completed): existing essential clinical resources for swallow screening from the perspectives of clinicians were identified and collated. Additional resources were co-developed through clinician consultation to address barriers to swallow screening. Resources include tailorable training tools, a recommended screening pathway, posters and visual reminders, and methods to optimise access to screening data. Resources were packaged within an online toolkit, to be available via the Stroke Care Connect SharePoint site. Instructions on how to use the toolkit and its resources (depending on local barriers) was included. Information from steps 2 and 3 also informed the development of a strategic communications plan to promote the project, toolkit and swallow screening across the state and a Swallow Screening Champion model which could be delivered as part of usual clinical duties.
- Implementation (in progress): The project lead delivered/will deliver presentations about the project to different clinical groups (e.g. statewide speech pathology groups, nurse educator groups, medical forums) to raise the profile of swallowing screening. The communications package will run across the implementation period to build awareness and desire for dysphagia screening. A subset of sites from the project working group representing metropolitan, regional and rural Queensland will participate in the evaluation. The project lead will meet with self-nominated local change leaders and clinical leaders at each site to plan for improvement in their setting using the online toolkit. Sites will select relevant toolkit resources to target their swallow screening goals. These planning meetings were used to inform content for a ‘how to' video which would support future sites wishing to use the toolkit. Improvement efforts will be supported by the change leaders and Swallow Screening Champions in EDs who will be identified in liaison with ED nursing managers.
- Evaluation (in progress): project outcomes will be measured in terms of rates of swallow screening pre- and post-project, clinician engagement with the toolkit resources, clinician awareness, knowledge and skills in swallow screening, and perspectives on the toolkit resources. Data will be collected at evaluation sites via online clinician surveys post-implementation.
Discussion
We aimed to improve rates of swallow screening in stroke patients by designing a multi-faceted improvement initiative with and for clinicians. This project incorporated a statewide strategic communications package, suite of online resources designed with and for clinicians and a change champion approach. Communication strategies and resources were designed with the emergency department in mind specifically, where screening most commonly occurs. Importantly, resources can be adapted to meet the needs of individual settings. The impact of this project will be evaluated within five different hospitals representing rural, regional and metropolitan Queensland. Preliminary feedback demonstrates excitement about the outputs of the project and optimism that this work will lead to meaningful change.
Several factors have contributed to success to date:
- Engagement from clinicians across professions (e.g. nurses, doctors, speech pathologists, dietitians), at different levels of seniority (from junior floor staff to executive leaders) and across the state ensured that a broad range of perspectives and needs was considered in the development of the Toolkit.
- The project lead role was essential in pooling lessons learned from across the state and creating linkages with support services and clinical groups across the state. Pooled knowledge of experiences in swallow screening across the state was an important first step in developing Toolkit resources. Establishing linkages was important for generating awareness of the Toolkit into the long-term.
- Developing resources with and for clinicians using the designs-thinking approach was essential to ensure recommendations could be easily implemented and would be acceptable to clinicians.
Limitations:
- Evaluation occurred with a small sample of Queensland Health hospitals who had established goals for improving swallow screening and representatives from these sites having participated in the project's working group to develop the toolkit. These sites may be more likely to demonstrate improvements in swallow screening and may have a more favourable view of the toolkit.
- It was not possible to evaluate the benefits of our outputs more broadly within the timeframe of this project and therefore only inferences about scalability from the results of our pilot evaluation can be made. A strength of this project was seeking input about the toolkit across its development from clinicians of different professions across the state, which will enhance scalability.
- It was also not possible to evaluate the role of our outputs in sustaining swallowing screening improvements within the project timeframe. Rates of swallow screening will continue to be monitored via the QSCN Steering Committee which can inform any future refinements to the toolkit.
Next steps:
- Statewide roll-out of the toolkit and communications strategy
- The Dysphagia Screening for Stroke Toolkit will be handed over to the Queensland Stroke Clinical Network for periodic review and maintenance of resources
- StrokeLink and Queensland Telestroke Service can continue to share the toolkit via SharePoint as they work with sites to improve stroke care
- Longer-term monitoring of swallow screening/assessment rates to evaluate sustainment of improvements
References
1. Banda KJ, Chu H, Kang XL, Liu D, Pien L-C, Jen H-J, et al. Prevalence of dysphagia and risk of pneumonia and mortality in acute stroke patients: a meta-analysis. BMC geriatrics. 2022;22(1):420-10.
2. Altman KW, Yu G-P, Schaefer SD. Consequence of Dysphagia in the Hospitalized Patient: Impact on Prognosis and Hospital Resources. Archives of otolaryngology--head & neck surgery. 2010;136(8):784-9.
3. Ali AN, Howe J, Majid A, Redgrave J, Pownall S, Abdelhafiz AH. The economic cost of stroke-associated pneumonia in a UK setting. Topics in stroke rehabilitation. 2018;25(3):214-23.
4. Bray BD, Smith CJ, Cloud GC, Enderby P, James M, Paley L, et al. The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia. Journal of neurology, neurosurgery and psychiatry. 2017;88(1):25-30.
5. Stroke Foundation. Living clinical guidelines for stroke management 2025 [Available from: https://informme.org.au/guidelines/living-clinical-guidelines-for-stroke-management#.
6. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.
Key contact
Rachel Levine
Project lead
Healthcare Improvement Unit
Clinical Excellence Queensland