11 Dysphagia Screening – State of the Art Conference Proceedings from the State of the Art Nursing Symposium International Stroke Conference 2012 Neila

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Dysphagia Screening – State of the ArtConference Proceedings from the State of the Art

Nursing SymposiumInternational Stroke Conference 2012

Neila J. Donovan, PhD, CCC-SLP

Stephanie K Daniels, PhD, CCC-SLP, BRS-S

Jeff Edmiaston, MS, CCC-SLP

Jan Weinhardt, MSN, RN, GCNS-BC

Debbie Summers, RN, MSN, FAHA, ARNP

Pamela Mitchell, PhD, RN, FAAN, FAHA

©2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.

The Clinical Dilemma

• National Quality Forum (NQF) was unable to endorse dysphagia screening because there were no clinical trials completed that identified an optimal swallow screening.

• 2010 - Joint Commission retired the dysphagia screening performance standard due to the lack of a standardized screening tool.

• There is concern that clinicians will omit dysphagia screening, leading to worse patient outcomes.


Conference Purpose

– Review characteristics of valid and reliable screening and assessment tools

– Identify strengths and limitations of most commonly used current tools

– Describe how to make decisions about dysphagia screening selection

– Provide an example of institutional quality improvement in establishing swallow screening for stroke


Background• Stroke is a leading cause of dysphagia

-- 42%

• Aspiration occurs in 50% of dysphagic patients– 1/3 develop pneumonia– Associated with three-fold higher mortality

• To avoid aspiration, new stroke patients are left NPO until dysphagia screen: “no ice chips, no oral medications, no water, no exceptions!” (several guidelines)


What is Needed: Reliable and Valid Screening Tools

• Dysphagia screening - pass/fail procedure to identify an individual who may or may not need a complete dysphagia assessment

– Can be performed by trained clinician

• Contrasted with Swallowing Assessment – a behavioral evaluation of swallowing function that consists of an extensive cranial nerve evaluation and direct examination of swallowing

– Performed by Speech-Language Pathologist (SLP) Instrumental dysphagia assessment aims to Identify swallowing impairment and the effects of compensatory strategies


Background• Research has shown that swallow screening by trained

nurses and physicians is feasible and reliable.

• Important predictors of dysphagia and risk of aspiration may include:

– Abnormal volitional cough

– Dysphonia

– Dysarthria

– Cough after swallow

– Voice change after swallow


Effective Screening Tool • Quick and minimally invasive with high sensitivity

and specificity to identify dysphagia and aspiration risk

• Defined scoring system– Pass – patient can be fed– Fail – patient kept NPO and speech language

pathology consulted

• Specifies level of training required for staff performing screening


Several Dysphagia Screenings are Available for Nurses to Administer in

Acute Care– 3-ounce water test (DePippo et al., 1992; Suiter & Leder, 2008)

– Burke Dysphagia Screening Test (DePippo et al., 1994)

– Toronto Bedside Swallowing Screening Test (Martino et al., 2009)

– Bedside Swallowing Assessment (Smithard, 1997)

– The Timed Test (Hinds, 1998)

– Standardized Swallowing Assessment (Perry, 2001)

– Gugging Swallow Screening (Trapl et al., 2007)

– Acute Stroke Dysphagia Screening (Edmiaston et al., 2010


Screening Tool Selection• No single screening tool is best for all contexts

• Contextual elements– Organization structure– Patient flow and composition of heath care– Size of hospital, volume of stroke patients– Personnel – nursing and speech language

pathology– Availability of radiology


Screening Tool Selection• Kepner Tregoe Decision Matrix (K-T Matrix) can be

utilized to best determine a multidisciplinary teams’ needs when choosing a screening tool– Easily identifies important factors deemed most

important– In context of personnel and training needs


Screening Tool Selection and Implementation

• Conceptual Model: Each component is a sequential step in the process of organizing a clinical interdisciplinary team and CQI – Agree– Build – Commence– Document– Evaluate– Feedback


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• What? Select Screening tool

• Consider evidence for reliability and validity

• Consider ease of administration, time, safety for patient at risk- input from the staff nurse or designated nurse(s)

• Consider resources available and tailor it to the specific institution

• Remember, nurses do screens, SLPs do evaluations

CQI and Tool selection


Evaluate for your context• Was the tool valid?

• Was it easy, efficient, safe? Modifications?

• Was there congruence between nurse and SLP?

• Was there compliance in keeping patient NPO until screen completed?

• Long term:– Aspiration pneumonia rate

– Patient satisfaction

– Physician satisfaction

– Readmission, LOS, cost effectiveness


Conclusions from Symposium• Screening of swallowing in stroke patients is critical, to prevent

adverse outcomes related to aspiration and inadequate hydration/nutrition

• Absence of consensus on best screening instrument does not mean no screening should be done

• Use the American Speech Language Hearing Association (ASHA) definition: “Swallowing screening is a pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services.”


Documents

11 Dysphagia Screening – State of the Art Conference Proceedings from the State of the Art Nursing Symposium International Stroke Conference 2012 Neila