ICU Trends: what does that mean to the SLP across the ... Fall Conference/Speaker...ICU Delirium is a predictor of •Increased mortality •Increased Length of Stay •Increased time

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ICU Trends: what does that mean to the SLP across the continuum of care

Jo Puntil M.S.CCC-SLP BCS-S ASHA Fellow

ASHA Board: CFCC: Council for Clinical Certification

Dixie Regional Medical Center: Dysphagia Clinical Specialist

[email protected]

Financial Disclosures

• Financial• Full time employee: Salary Dixie Regional Medical Center

• Honorarium for Speaking

• Non Financial: • ASHA Board: CFCC, Chair of CSCC, President in 2020

• Reviewer of Applications for Board Specialty in Swallowing/Swallowing Disorders

Puntil 2018

What are the Current ICU Trends?What is our Role?

• ABCDEF/Delirium

• Who/When/What screening patients for swallowing in the ICU

• PICS: Post Intensive Care Syndrome and what is our Role?

• SLP Communication

Puntil 2018

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Scope of the Problem with Intubated Patients

• In the United States, approximately 1 million (20%) of the 5 million intensive care unit admissions are intubated annually.

• Across the world the number of endotracheal intubations climbs to 13 – 20 million annually.

• Puntil/Suiter ASHA 2017

Scope of the Problem

• Although the oral (and sometimes the nasal) cavity is the initial pathway for the endotracheal tube, the pharynx, larynx, and trachea are the most affected by the tube and the apparatus.

• Endotracheal tubes traverse the vocal folds, creating opportunity for complications affecting voice and swallowing functions.

• Puntil/Suiter ASHA 2017

WHAT TO DO WITH A PATIENT THAT IS INTUBATED OR POST

EXTUBATION

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• Approximately 5.7 million ICU patients annually in US• over 22,000 patients cared for at Intermountain ICUs

• 88% of ICU patients are discharged alive• Up to 70% of ICU survivors develop post-intensive care

syndrome (PICS)• Cognitive, emotional, psychological, physical, and/or quality of

life impairments

• The ABCDE bundle of care is an effective framework for reducing incidence of PICS

Magnitude of Problem

http://www.sccm.org/Communications/Pages/CriticalCareStats.aspxhttp://www.myicucare.org/Adult-Support/Pages/Post-intensive-Care-Syndrome.aspxZimmerman et al. CCM 1998;26:1317-26Girard et al. CCM 2010;38:1513-20

Smith, M., Meyfroidt, G., Springer Verlag 2017

ABCDEF: What does this mean and what

is the SLP Role?

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A

• ASSESS FOR, PREVENT AND MANAGE PAIN

• How is the RN assessing pain?

• What are the best methods to reduce pain?

• What type of meds does one give for TBI patients for pain? What does narcotics do to TBI patients?

Puntil 2018

B

• Spontaneous Awakening Trials: SAT

• Spontaneous Breathing Trials: SBT

Puntil 2018

D

• Assessment for, and prevent Delirium

Puntil 2018

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What is Delirium?

• It is a disturbance of consciousness characterized by acute onset and fluctuating course of inattention accompanied by either a change in cognition or perceptual disturbance so that the patients ability to receive process, store, and recall information is impaired. It is usually reversible, and is a direct consequence of a medical condition, substance intoxication or withdrawal, use of a medication, toxin exposure or a combination of these factors.

Puntil 2018

What to Think?

• Rapid Onset

• Inattention

• Clouded consciousness (bewildered)

• Fluctuating

Puntil 2018

ICU Delirium is a predictor of

• Increased mortality

• Increased Length of Stay

• Increased time on vent

• Increased costs

• Increased re-intubation

• Increased long term Cognitive Impairment

• And increased risk of discharge to a long term care facility

Puntil 2018

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Subtypes of Delirium: Characteristics

• Hyperactive: agitation, restlessness and attempts to remove tubes/lines

• Hypoactive: withdrawal, flat affect, apathy, lethargy and decreased responsiveness

• Mixed: fluctuation between the two

• Most common: patients that are usually mixed or hypoactive

Puntil 2018

What it is NOT!

• Dementia: which is characterized by a state of generalized cognitive deficits in which there is a deterioration of previously acquired intellectual abilities.

• Think: gradual onset, intellectual impairment, memory disturbance, personality/mood changes no clouding of consciousness

Puntil 2018

How to assess Delirium in the ICUOVERVIEW OF RASS AND CAM-ICU

• RASS- Richmond Agitation and Assessment Scale

• CAM-ICU- Confusion Assessment Method

Puntil 2018

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RASS and CAM-ICU: 3 Levels for the RN to assess

• Step 1: Level of Consciousness: RASS: Sedation Agitation Score if RASS is a equal or less than -3 proceed to the CAM-ICU (is the patient positive or negative?) pre-hospital baseline and last 24hrs

• Step 2: Content of Consciousness: CAM-ICU which tests acute change or fluctuating course of mental status

• Step 3: Altered Level of Consciousness: Current RASS level (right now regardless of baseline status)

www.icudelirium.org

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Feature 1: Acute Onset or Fluctuating Course

A. Is there evidence of an acute change (difference) in mental status from baseline?

and / orB. Did the (abnormal) behavior fluctuate during the past 24 hours as evidenced by fluctuation in sedation scale (RASS), GCS or from previous delirium assessment? Include fluctuations caused by clinician induced sedation.Feature is Positive/Present: If either question is Yes

Feature 2: InattentionAlertness is a basic arousal process in which a patient can respond to any stimulus in the environment. The alert, but inattentive patient will respond to any sound, movement or event occurring in the vicinity, while the attentivepatient can screen out irrelevant stimuli. All attentive patients are alert, but not all alert patients are attentive.

Feature 3: Altered Level of Consciousness

+4 Combative overtly violent, dangerous

+3 Very agitated pulls tubes/catheters, aggressive

+2 Agitated fights ventilator, non-purposeful movements

+1 Restless anxious, movements not aggressive0 Alert / Calm

-1 Drowsy not alert, eyes open with contact ≥10 sec-2 Light sedation briefly awakens, eye contact <10 sec-3 Moderate movement, eye opening but no eye contact-4 Deep movement with physical touch-5 Unarousable no response to voice or touch

Richmond Agitation-Sedation Scale (RASS)

Sessler et al., AJRCCM 2002;166:1338-44Ely et al., JAMA 2003;289:2983-91

VerbalStimulus

PhysicalStimulus

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Feature 4: Disorganized Thinking

3A: Yes/No Questions (alternate using Set A or Set B):

Set A 1.Will a stone float on water?2.Are there fish in the sea?3.Does one pound weigh more than two pounds?4.Can you use a hammer to pound a nail?

Set B 1.Will a leaf float on water?2.Are there elephants in the sea?3.Does two pounds weigh more than one pound?4.Can you use a hammer to cut wood?

Score: Patient earns 1 point for each correct answer out of 4.

Feature 4: Disorganized Thinking3B: Command

Say to patient: “Hold up this many fingers”“Now do the same thing with the other hand” (Or “ Add one finger”)

Score: Patient earns 1 point if able to successfully complete the entire command

Feature is Positive/Present: If combined score (questions + command) <4

Putting it all together

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Video Presentation of CAM-ICU Assessment

• Icudelirium.org is a comprehensive website

E

• Early Mobility

Puntil 2018

What is the benefit from following the ABCDEF Bundle?

• Lets look at early Mobility, combined effort from the PT/OT/SLP

Puntil 2018

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F

• FAMILY

• WHAT CAN THE FAMILY DO TO HELP THE ICU TEAM• They want to help with daily needs, communication, cleaning, shaving, positioning

• Most importantly they want to communicate with their loved one while intubated

Puntil 2018

What is our role with trauma/intubated patients?

• Best to start while the patient is intubated

• Why?• Communication Abilities for the patient

• Communication/Education to the family

Puntil 2018

Provide Simple Communication Boards

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WHATHAPPENEDTO ME?

HEADOFBED UP

HEADOFBEDDOWN

BRUSHMYTEETH

SUCTIONMYMOUTH

SUCTIONMYLUNGS

GOTOBATHROOM

PLEASECLEANME

I’M HOT I’M COLD

PAIN

NAUSEATED

I’M THROWING UP

INEED SLEEP

ICAN’T BREATHE WELL

SCRATCHMYNOSE

I’M SCARED

DON’T LEAVEME

LEAVEME ALONE

LIGHTS ON

T.V ON

LIGHTS OFF

T.V OFF

DOWNCHANNEL UP

IWANT MUSIC

ILOVE YOU

QUIET ROOM PLEASE

THANK YOUPLEASE

BLANKET OFF ON

SOCKS OFF ON

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READTOME

NEEDA TISSUE

WHATISHAPPENING ATHOME?

WHERE ARE YOU GOING?

WHENWILLYOU BE BACK?

Provide a means to get to know the patient

GET TO KNOW ME…

Pictures in this area…

Name:Nickname:Occupation:Favorites:

-Book:-Movie:-T.V. Show:-Song:-Sport:-Color:-Foods:-Animal/Pet:-Other:Quote/Saying:

Activities/Hobbies: What I am proud of: What stresses me out: What cheers me up: Other things I’d like you to know about me:

Check all that apply:Glasses Hearing Aid Dentures Contacts Other:

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POST INTUBATION SWALLOW SCREEN

• LEDER

• SUITER

• WARNER

Post-Extubation Swallow Protocol

• No evidence-based guidelines exist to screen for aspiration risk or test for dysphagia in post-extubation ICU patients.

• There are two equally important questions to answer:

• How do I test for swallowing post-extubation?

• When do I test for swallowing post-extubation?

Puntil/Suiter ASHA 2017

Rationale

• In clinical practice, swallow assessment is often delayed until 24 hours post-extubation (Macht et al., 2012).

• Ensures respiratory and medical stability

• Restoration of airflow through the upper airway

• Latency of the swallow was observed to be increased on day 0 post-extubation.

• Significant shortening of latency was noted on days 1 and 2 post-extubation (deLarminat et al., 1995).


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•Purpose:To determine how & when to assess aspiration risk and dysphagia in post-extubation ICU patients.


Post-Extubation Swallow ProtocolModeled after the YSP

•Methods• Daily calls to respiratory therapy/charge nurse in the ICUs of

Yale-New Haven Hospital• Cardiac

• Cardio-Thoracic

• Medical

• Neurosurgical

• Surgical



• Subjects:• Prospectively accrued cohort of 202 patients from the Cardiac,

Cardio-Thoracic, Medical, Neurosurgical, and Surgical ICUs


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• Yale Swallow Protocol administered to all patients

• Brief Cognitive Screen: Name, Place, Year, Command following

• Oral Mechanism Examination

• 3-ounce water swallow challenge

Leder SB, Suiter DM. The Yale Swallow Protocol: An Evidence-Based Approach to Decision Making. Springer Science+Business Media, NY 2014.


• The protocol was administered at intervals of 1 hour + 10 minutes, 4 hours + 10 minutes, and 24 hours + 10 minutes, as needed, post-extubation to determine aspiration risk.

• When passed at any interval, no further testing was done and an oral diet was recommended.



• Protocol given 1 hour + 10 minutes post-extubation & if passed patient began oral diet.

• If failed at 1 hour, nil per os continued & protocol repeated 4 hours + 10 minutes post-extubation & if passed patient began an oral diet.

• If failed at 4 hours, nil per os continued & protocol repeated 24 hours + 10 minutes post-extubation & if passed patient began an oral diet.

• If failed at 24 hours, SLP determined appropriateness for FEES to diagnose dysphagia and make diet recommendations.


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• Results• 1 hour post-extubation:

• 166/202 (82.2%) patients passed the protocol & began PO/oral medications

• 4 hours post-extubation:


• 24 hours post-extubation:




• The Yale Swallow Protocol successfully screened for aspiration risk and allowed for safe oral alimentation/medications as early as 1 hour post-extubation.

• If the protocol is failed 3 times over a 24 hour period a FEES should be performed, as determined by SLP, to diagnose dysphagia and make appropriate diet recommendations.


PICSPost Intensive Care Syndrome

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PICS: Post intensive care syndrome

• PICS: is a group of symptoms that may occur in people after discharge from the ICU. PICS can affect daily living, slow thinking, or cause difficulty with processing thoughts.

• Symptoms of PICS: divided into 3 groups:

• Cognitive problems may include: reduced attention or ability to concentrate, memory loss, slower thought processing speed, difficulty with problem solving/reasoning and executive functions

• Emotional problems: anxiety, depression, PTSD

• Physical problems: slower movements, multiple falls, muscle weakness

Puntil 2018

Post ICU Cognitive impairment occurs in multiple domains BUT is most pronounced in areas of:

• Memory

• Executive Function

• Attention

• “Minimization of harm from therapies for supporting critically ill patients is possibly more relevant to the brain than any other organ system”

Tasker, RC, Menon DK, Critical Care and the brain, JAMA, 2016

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The ICU Team: Goals should be patient centered

• MD’s (ICU, Trauma, Neuro, Physiatrist)

• Speech Pathology

• Physical Therapy

• Occupational Therapy

• Respiratory Therapy

• Dietitian

• Social Work

• Pharmacist

• Chaplin

• Family

Puntil 2018

How do SLP’s evaluate/treat the ICU patient and their family, what can we do to support the patient

and the ICU staff?

• Speech/Language/Cognitive and Swallowing Evaluations

• Organization of cluster care

• Communication in rounds and throughout the day

• Education to patient, family, ICU team, SLP across the continuum of care

Puntil 2018

WHAT/HOW DO WE EVALUATE OR SCREEN

• Stroke issues

• RN Screens

Puntil 2018

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

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

Background Information

Puntil 2018

Acute Treatment for Ischemic Stroke

• Many drugs studied… tPA works• ~20% more patients improve within 3 months if

a strict protocol is followed• 5.8% risk of intracranial bleeding

Puntil 2018

Acute Treatment for Ischemic Stroke

• 3 hours – IV tPA – all patients who meet criteria

• 4.5 hours – IV tPA – no history of stroke or diabetes, anticoagulation use, very large stroke, age > 80

• 6 to now 24 hours – Endovascular therapy

•Intra-arterial tPA or mechanical clot distribution

•Large vessel occlusion-large vessel occlusion

Puntil 2018

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NIH Stroke Scale

• Must be done on all TIA/Hemorrhagic/Ischemic stroke patients• If giving Activase/tPA… must be done (1) before tPA, (2) at

completion of tPA, (3) upon admit to ICU, (4) 24 hours after admission

Monitoring following Activase/tPA administration

Vital signs & Neuro Checks according to TPA Flow Sheet

Stroke Center Guidelines for inpatient stay

• DVT Prophylaxis & Antithrombotic therapy (by end of hospital day 2) – ASA, SCD’s (ted hose do not count), Lovenox, Heparin

• Rehab assessment – within 24 hours of admission assess by PT/OT/SLP

• Stroke education

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Stroke/Dysphagia • Stroke is a leading cause of dysphagia

-- 42%• Aspiration occurs in 40-50% 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)

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

Validation, Implementation and follow through of RN swallowing screening

tools for newly admitted Stroke patients

•What is needed?•Why is it needed?•What is the best screen for your institution?

Swallowing Screens: Review

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• Validity• Reliability • Sensitivity• Specificity• Scoring system meets purpose of identifying risk of

aspiration

Features of a Good Screening Tool

Puntil 2018

• Allows for serial screening/rescreening• Feasibility: easy to use and quick (less than 20 min)• Minimally invasive• Poses little risk to the patient• Appropriate screeners and level of training identified

Features of a good screening instrument

Puntil 2018

Swallowing Screens

How many screens are there?Which ones are used the most in the USA?

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Swallowing Screens

• YSP: Yale Swallow Protocol

• TOR-BSST: Toronto Bedside Swallow Screening Tool

• MMASA: Modified MASA (The Mann Assessment of Swallowing)

Puntil 2018

• MGH-SST: Mass General Hospital Swallow Screening Tool

• GUSS: The Gugging Swallowing Screen

• BJH-SDS: Barnes-Jewish Hospital Stroke Dysphagia Screen

Swallowing Screens:

Puntil 2018

Screening

• Screening used in a population to detect a disease in individuals without signs or symptoms of that disease

• Screening is NOT a substitute for assessment• Screening does not diagnose illness• Screening tests used for diseases with a low prevalence

(dysphagia?) must have a good specificity in addition to acceptable sensitivity

• Adequate screening should be rapid, cheap and simple

Puntil 2018

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Yale Swallow Protocol: Dr. Steven Leder, Dr. Debra Suiter

Tested on over 4000 subjects crossing all dx

• Alert, Oriented• Facial Symmetry, Bilabial Seal, Lingual ROM• 90ml Water Challenge

Puntil 2018

Yale Swallow Protocol

• To be clinically useful tool a swallow screen for aspiration risk must answer 3 questions• Can the vast majority of patients who are an

aspiration risk be identified?• Can patients who need an instrumental test

be identified?• Can specific diet recommendations be made

after passing without an instrumental exam?Puntil 2018


• Consists of:

• Brief Cognitive Screen: (N= 4,102) Leder SB, Suiter DM, Warner HL, Answering Orientation Questions and Following Single-step verbal commands: Effect on Aspiration Status. Dysphagia 2009; 24 290-295

• Oral Mech Exam: (N=4,102) Leder, SB, Suiter DM, Murray J. Can a oral mechanism examination contribute to the assessment of odds of aspiration? Dysphagia 2013; 28: 370-374

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• Step 1:

• Protocol deferred if any YES answer to the following criteria:• Unable to remain alert for testing• No thin liquids due to a pre-existing dysphagia• Head of Bed restricted to < 30 degrees• Tracheostomy Tube Placement• Nil per oral order for medical/surgical reason

Puntil 2018

Yale Swallow Protocol• Step 2:

• Brief Cognitive Screen: What is your name? Where are you right now? What year is it?

• Oral Mech Screen: Stick out your tongue, Labial closure, facial symmetry (smile/pucker) lingual range of motion: move tongue to the left/right

• 3 oz water challenge: Ask patient to drink entire 90ml with a straw or cup, assess for coughing or choking during or immediately after completion of drinking

Puntil 2018


• Step 3: Results/Interpretation

• Pass: Successful uninterrupted drinking of all 90ml without overt signs of distress during or IMMEDIATELY after drinking

• Fail: Inability to drink entire amount, interrupted drinking, or coughing/choking during or immediately after drinking.

Puntil 2018

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• YSP:

• Validated with large numbers of potentially at risk patients

• Simple, quick, and cheap to administer• Easy to interpret• Able to make diet recommendations• Can be used by other health professionals• 96.5% Sensitivity• 95.5% Specificity

Puntil 2018

MODIFIED MANN ASSESSMENT OF SWALLOWING ABILITY:

MMASA

Dr. Giselle Carnaby Mann

MMASA:

• Developed off the MASA• Original items evaluated via discriminant analysis

to identify potential screening items statistically strong

• Items also considered with regard to the familiarity and utility by neurologist

• MMASA included 12 of the 24 original MASA items

Puntil 2018

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MMASA: Modified MASA

• Includes 12 of the 24 original MASA items

Alertness CooperationAuditory Comprehension RespirationDysphagia DysarthriaSaliva PalateLingual Movement Lingual StrengthGag

90ml water challenge

Cough: voluntary

Puntil 2018

MMASA

• SCORE: greater than 95 start oral diet

• SCORE: less than 94: Consult SLP for formal evaluation and possible instrumental Eval

Puntil 2018

MMASA

• Validation Process: • 150 consecutive patients (inpatient acute care)• 2 neurologists performed the MMASA within 2 hours of each other

(blinded)• SLP conducted the MASA no earlier than 2 hours before the first

neurologist’s assessment• Psychometric evaluation

Puntil 2018

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MMASA / PSYCHOMETRICS

• Internal validity = alpha 0.94• Reliability between raters = k= 0.76; SE = 0.082• Ability to distinguish dysphagia = 98%• Classification accuracy = 0.88

Puntil 2018

MMASA Conclusions

• Value of a screen lies in ability to discriminate between individuals requiring further diagnostic evaluation

• MMASA adequately screens dysphagia in acute care• Inexpensive and simple to use by neurologists• Comparison to other screeners STRONG• Results replicated in a UK study- show PNA reduction with

MMASA screening• Still don’t know: predictive validity, first responder use

Puntil 2018

• 4 hour course to be trained $500.00

The Toronto Bedside Swallowing Screening Test TOR-BSST

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• Earlier identification will initiate earlier intervention • First validated with 300 stroke patients in acute and rehab settings• Takes les than 10 minutes to administer• Trained professionals can administer: training takes 4 hours• 3 sections of the test:

• 2 brief oral exams• One water swallowFailure on any item discontinues the screen and prompts a SLP evaluation

TOR-BSST: Toronto Bedside Swallowing Screening Test: Rosemary Martino

Puntil 2018

TOR-BSST: Dr. Rosemary Martino

• Speech Intelligibility• Voice • Tongue movements• Pharyngeal Sensation• Several water swallows in gradual volume

increases• Voice afterwards• Score for pass/fail

Puntil 2018

• Say “ah” 5 seconds• Open mouth, stick out tongue, move from side to side• Sensation in posterior cavity, soft palate, gag, PPW• Water swallows, tsp, sequential swallows 10 trials• Voice after water swallows

TOR-BSST

Puntil 2018

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Mass General Hospital Swallowing Screening Tool:

MGH-SST

MGH-SST

• The "Material" (MGH - SST) is designed as a swallow screening to determine risk of aspiration.

• The "material" does not determine etiology, explore the physiology or nature of the deficit, nor determine a treatment plan. The "Material" is not intended to give definite medical consultation and must not be used to replace or overrule a clinician's judgment or clinician's diagnostic decision making.

Puntil 2018

MGH-SST

• Two parts: if any of part 1 fails (yes/no) NPO

• Part One:• Wakefulness: alert for 5 min• Head of bed: upright at least 30 degrees• Breathing: O2 SAT’s in 90’s• Clean Mouth: meet standards of care

Puntil 2018

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MGH-SST• Part Two: Add points, max 6 : 5/6= pass, 4 or

less is a failure

• Tongue Movement: 1 point• Cough: 1 point• Vocal Quality: 1 point• Pharyngeal Sensation: 1 point• Swallowing water: 2 points

Puntil 2018

The Gugging Swallowing Screen: GUSS

• Divided into 2 parts:

• Indirect swallowing test

• Direct Swallowing test

• 3 subtests

A point system was chosen to higher numbers denote better performance

The Gugging Swallowing Screen: GUSS

Puntil 2018

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• Saliva swallow is the precondition for

• Vigilance/alert for 15 minutes, voluntary cough, throat clearing, and saliva swallow

GUSS: PART ONE: Indirect Swallowing test

Puntil 2018

• Semisolid Swallowing Trial: 1/3 to ½ teaspoons of pudding thick liquids, followed by 5 more half teaspoons. Abort the investigation if 1 of the 4 aspiration signs (cough, drooling, and voice change)

• Liquid Swallowing Trials:

• Starting with 3ml• 5ml• 10ml• 20ml• 50ml as fast as they can

GUSS: Part two- Direct Swallowing Test

Puntil 2018

• Solid Swallowing Trials: • A small piece of dry bread is the first bolus• Repeat 5x• 10 second limit for oral phase

GUSS: Part two- Direct Swallowing Test

Puntil 2018

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• 0-9 = severe• 10-14= moderate• 15-19= mild• 20 points= no dysphagia

• Risk of aspiration vs No risk19 points: no risk of aspiration14 points: risk of aspiration

GUSS: 4 categories of severity

Puntil 2018

Barnes Jewish Hospital Stroke Dysphagia Screen: (BJH-SDS)

Puntil 2018

• 5 Items, each scored as present/absent• Presence of one, screen is failed• Failed Screen-NPO with speech consult• Passed screen-Regular Diet


Puntil 2018

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• Is the Glasgow Coma Scale LESS than 13? Yes/No• Is there facial Asymmetry/Weakness? Yes/No• Is there Tongue Asymmetry/Weakness Yes/No• Is there Palatal Asymmetry/Weakness? Yes/NoIf all findings for the first 4 questions are NO proceed to the 3 oz. water test

Puntil 2018

• Administer 3 oz. of water for sequential drinks, note any throat clearing, cough or change in vocal quality immediately after and 1 minutes following the swallow. If clearing, coughing, or changes in vocal quality is noted, refer to Speech Therapy

• If all answers to the above questions are NO, then start the patient on a regular diet


Puntil 2018

• Training Methods• Cross Training• Review and Updating Quarterly • Monitoring RN Screens proficiency

How to train and Implement Screens

Puntil 2018

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• SLP follow up

• Training: Who needs to be trained? Depends on the institution

• How often does this need to be done?• Cross training• Pass off’s and skills day

Pro’s and Con’s

Puntil 2018

Bibliography

• Holas, M.A., DePippo, K.L., Redding, M. 1994 Aspiration and relative risk of medical complication following a stroke.Neurology, 51: 1051-1053

• Jette, A.M., Feldman, H.A., Oral disease and physical disability in community-dwelling older persons. Journal of the American Geriatric Society, 41: 1102-1108.

• Langmore, S.E., Terpenning, M.S., Schork, A., et.al.,1998 Predictors of aspiration pneumonia: How important is dysphagia,13: 69-81.

• Reynolds, H.V. 1998. J.T. Murray & J.A. Nadel (eds) Bronchoalveolar lavage. Textbook of Respiratory Medicine (p. 598) Philadelphia, PA; W.B Saunders Co.

• Schmidt, J., Holas., M., Halvorson, K., Reding., M. 1994. Video fluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia, 9: 7-11.

• Yoneyama, T., Yoshida, M., et. al. Oral Care reduces pneumonia I older patients in nursing homes. Journal of American Geriatrics Society, 50 (3): 430-433.

• Antonios N, Carnaby-Mann G, Crary, M., et al,. Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit; the Modified Mann Assessment of Swallowing Ability. J Stroke Cerebrovascular Dis. 2010; 19:48-57

• Crary MA, Carnaby GD, et al., Spontaneous swallowing frequency has potential to identify dysphagia in acute stroke, Stroke 2013 44(12) 3452-3457

• Hinchey J, Shepard T, et al., Formal Dysphagia Screening Protocols Prevent Pneumonia, Stroke 2005, 36 1972-1976

• Jauch EC, Saver JL, Adams HP Jr., et al., Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013: 44(3) 870-947.

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• Lakshminarayan K, Tsai AW et al. Utility of dysphagia screening results in predicting poststroke pneumonia. Stroke 2010; 41 (12): 2849-2854.

• Leder S., Suiter, D., The Yale Swallow Protocol: An Evidence-Based Approach to Decision Making. 2014 Springer Verlag

• Martino R, Foley N, et al, Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 36: 2756-2763.

• Martino R, Silver F, et. al, The Toronto Bedside Swallowing Screening Test (TOR-BSST): development and validation of a dysphagia screening tool with stroke. Stroke 2009; 40: 555-561

• Masrur S, Smith EE, et al Dysphagia Screening and Hospital-Acquired Pneumonia in Patients with Acute Ischemic Stroke; Finding from Get with the Guidelines-Stroke. J Stroke Cerebrovascular Dis 2013 (8) 301-309

• Murguia, M, Corey, D, Daniels, S. Comparison of Sequential Swallowing in Patients with Acute Stroke and Healthy Adults. Arch of Phys Med Rehab, Nov 2009,Vol 90

• Turner-Lawrence DE, Peebles M, et al., A Feasibility study of the sensitivity of emergency physician dysphagia screening in acute stroke patients. Ann Emerg Med. 2009; 54:344-348

• Turner M, Barber M, Dodds H, et al., Implementing a simple care bundle is associated with improved outcomes in a national cohort of patients with ischemic stroke. Stroke 2015, 46(4), 10-65-70.

• Weinhardt J, Hazelett S, Accuracy of a bedside dysphagia screening: a comparison of registered nurses and speech therapists, Rehabil Nurs. 2008 (6) 247-252

• Wolfe CD, Rudd AG, Improvement of care in acute stroke units. Lancet 2011; 378: 1679-1680.

Documents

ICU Trends: what does that mean to the SLP across the ... Fall Conference/Speaker...ICU Delirium is a predictor of •Increased mortality •Increased Length of Stay •Increased time