WHO IS INVOLVED WITH A PATIENT WITH BILATERAL HEMISPHERIC STROKE?
In an ideal situation, the health care professionals whose role it is to care for the patient’s swallowing safety and nutrition will collaborate to achieve the shared goal of improving the patient’s overall swallowing performance (Groher and Crary, 2010). Health professionals sharing a patient can communicate with each other informally on the ward, or formally in a multi-disciplinary meeting which is held once a week, when the patient’s assessment, on-going rehabilitation or possible discharge from the acute stroke unit or hospital may be discussed (Langhorne et al., 2002). The MDT meetings are generally attended by medical, nursing, speech language therapy, physiotherapy, occupational therapy, and social work staff. Members of the MDT can also stay abreast of the patient’s status and management in other areas by reading the patient’s medical file which should be updated by each health care professional following each encounter with the patient.
Speech-language Therapist
SLTs are responsible for assessing and providing intervention for the patient's communication, cognition and swallowing after a stroke. The SLT will also work closely with the patient's family and/or carers to ensure that they are informed about the patient's abilities and needs, and equipped to facilitate the patient's participation in communication (Ministry of Health, 2010).
Nursing Staff
As nurses are responsible for the patients throughout the day and night, they have an extremely important role in terms of observation and management. As discussed in the assessment section, in many hospital settings, it is the role of a specially trained nurse to administer the water swallow test as an aspiration screen (Barber et al., 2006). If any problems are noted during this procedure, the nurse is responsible for making a referral to an SLT for further assessment. The nurse’s role encompasses many aspects of the patient’s daily care, including performing oral cares following meals, sustaining good oral hygiene, and providing tube feedings (Groher and Crary, 2010). The nurses’ responsibilities also include monitoring and recording the patient’s food and liquid intake. The patient's weight should also be monitored (Ministry of Health, 2010). In regards to dysphagia management, the nurse can also provide the patient with continued support using any swallowing strategies recommended by the SLT. The nurse is trained to make observations of the patient's respiration, temperature and general state (Stroke Foundation NZ Inc., 2003). Information obtained by the nurses and recorded in the patient's file allows the MDT to keep informed of the patient's tolerance of a selected intervention. Information regarding temperature and respiration also allows nurses to identify any signs of silent aspiration in patients for whom dysphagia was not suspected to be a problem. In this instance, the nurse can make a referral to the SLT for a formal dysphagia assessment to be carried out.
Doctor
If a doctor suspects that swallowing may be problematic, a referral will be made to the SLT for further assessment. Following the assessment, if the patient is found to be at risk for aspiration, the SLT may make a recommendation for an NG tube or a PEG, in which case he or she must discuss the reasons for this with the attending physician (Groher and Crary, 2010). It is important to note that the patient's doctor is responsible for making decisions about the patient's care, particularly those pertaining to the patient's quality of life.
Dietitian
Every patient who presents with dysphagia and consequently requires food of a modified consistency must be referred to a dietician (Stroke Foundation NZ Inc., 2003). The dietician will assess the patient’s nutritional and hydration requirements and monitor these throughout the patient’s stay in hospital in order to achieve and maintain the patient’s medical stability (Groher and Crary, 2010). It is possible that a patient may already have diminished health due to poor nutrition and hydration emanating from swallowing problems sustained in their first stroke, so the dietician will need to account for this if necessary. If the patient is unable to eat and drink orally, the dietician can recommend tube feeding. It is common for the dietician to provide guidelines for the amount and rate of the tube feeding to the nursing staff. Following the SLT’s recommendation for consistency, the dietician can liaise with the staff from the food service to ensure that the food is prepared accordingly. The dietician will also have an important role in meeting with the patient’s family or caregiver prior to discharge, in order to discuss appropriate consistencies, meal plans and provide ideas and strategies to ensure that the patient’s daily caloric and nutritional needs are being met.
Occupational Therapist
The OT will work closely with the patient and the patient’s caregivers or family to help him or her regain as much independence as possible. The OT will assist the patient in relearning to self-feed using adaptive feeding devices if necessary (Groher and Crary, 2010).
Physiotherapist
In regards to dysphagia, the physio has an important role in redeveloping the patient’s strength and balance and retraining them to be able to sit up straight (Groher and Crary, 2010). The ability to achieve and maintain a stable and upright posture will contribute significantly to the patient’s ability to swallow safely.
The SLT may also find it useful to be aware of what time of day the physio usually visits the patient to conduct therapy as this may fatigue the patient and leave them unable to participate in any dysphagia or language assessments and therapy.
Social worker
A social worker can be called upon to provide support and counselling to the patient and his or her family. The social worker can also provide holistic information to the family and/or carer about how to maximise the social, physical, emotional and spiritual aspects of the patient's well-being (Ministry of Health, 2010). Community resources can also be organised through the social worker.
Otolaryngologist (ENT)
The ENT plays an important role in the administration of the FEES. Furthermore, the ENT can offer the SLT further insight into the structures visible during the procedure.
In the event that the patient requires a tracheostomy tube, the ENT can assist in its insertion and removal. Furthermore, as the tracheostomy tube may interfere with the patient’s swallow, it is important that the ENT convene with the SLT, as well as the rest of medical team, to ensure the tube’s removal when it is safe to do so (Groher and Crary, 2010).
Radiologist
The SLT will work in conjunction with the radiologist to perform and interpret the patient’s videofluoroscopy.

Neurologist
The neurologist can provide important information concerning the site and size of the patient's lesion. In regards to a patient with bilateral hemispheric stroke, the neurologist may also be able to provide similar information about the first lesion.
Gastroenterologist
The gastroenterologist is responsible for the insertion of a feeding tube into the patient's stomach. Therefore if the recommended intervention is a PEG, the SLT will need to liaise with this specialist (Groher and Crary, 2010).
Other SLTs
As bilateral hemispheric stroke is somewhat uncommon, the SLT may find it useful to liaise with his or her peers for advice on how to treat the patient. Furthermore, in view of the majority of the literature upholding the importance of inter-rater reliability when analysing VFS, the SLT may also want to consult with his or her peers when conducting instrumental assessments.
A key component of patient care that has been identified is communication between the acute and rehabilitative stroke services and the provision of a coordinated transition between the two (Barber et al., 2004). In this respect, the acute stroke unit SLT should liaise with the rehab stroke unit SLT to ensure continued and consistent care.
Family members/Whanau and Caregivers
Health professionals must acknowledge a patient's caregivers and/or family members as key members of the team.
Family members and caregivers play an important role throughout the assessment and intervention process. They may play a key role during the assessment, in terms of gauging a patient's medical history and swallowing abilities prior to the second stroke. If the patient is unable to communicate, the SLT must rely on family or the caregiver to be the sole provider of this background information. The SLT should liaise with the family or caregiver often and keep them informed of the patient's state and planned intervention. The health professional should be aware of his or her language and aim for optimum understanding when explaining complex issues to the patient and their carers and/or family (Stroke Foundation NZ Inc., 2003).

The SLT should attempt to develop a good relationship with the patient's carer or family members as following discharge, the SLT may need to speak to this person to follow up on the patient's condition. The carer and/or family members should be empowered with information so that they are better equipped to handle the changes in lifestyle and new requirements for supporting their loved one. For example, a meeting with the dietician and SLT prior to discharge about types of food, meals, and strategies needed for the patient should be held. Ongoing input from the MDT may include support from the OT, social worker, physio, dietician and SLT through home visits or outpatient clinics.
Health professionals also need to recognise that the concept of family has different meaning in different cultures. Maori and Pacific Island patients place a lot of importance on extended family, and the SLT should be inclusive of this through recognition and acknowledgement. Maori patients and their families may choose a person to be their whanau spokesperson, in which case this person needs to be informed and included in the patient's care.
Statistics show that Maori are more likely to be discharged into the care of family members or whanau following having a stroke, so it is particularly important that the whanau of these patients receive support and education (Stroke Foundation NZ Inc., 2003). Furthermore, the goal-setting and intervention planned by the SLT should take into account not just the communicative and/or swallowing disorder, but also encompass the context in which the patient will be living and their cultural and social needs (Stroke Foundation NZ Inc., 2003).
Maori Health Services
These services, while in place for the patient and their family, may also be of use to health professionals who are seeking advice about certain medical practices and their cultural appropriateness.
Kaiatawhai
The Kaiatawhai are hospital staff whose role it is to focus on the cultural and spiritual needs of the patient and their whanau (Auckland District Health Board, 2003).
Whanau Support Team
Some hospitals, such as Middlemore Hospital, have a Whanau Support Team whose role encompasses (Counties Manukau District Health Board, 2010):
  • Organising emergency accommodation for the patient's whanau;
  • Taking on an integral role in the MDT to provide cultural support to the patient and whanau;
  • Ensuring that the patient and whanau understand the process of care;
  • Ensuring that the patients and their whanau are aware of the resources that are available to them;
  • Advising and guiding the other members of the MDT about cultural safety and best practice;
  • Collaborate with the MDT to ensure that the patient's discharge plan is appropriate.