# Presentation: 007637

## Development of an Evidence-Based Acute Care Screen

- Anna Alt-White, PhD, RN
- Connie Case, BSN, RN
- Jackie Hind, MS
- Karin Kirchhoff, PhD, RN
- Beverly Priefer, PhD, RN
- Maude, Rittman, PhD, RN
- JoAnne Robbins, PhD
- Paula Sullivan, MS
- Helen Werner, PhD, RN

## QUERI RRP: Purpose

- Systematically evaluate research literature
- Identify risk factors
- Define best practices for dysphagia screening in specific populations
- Using evidence, determine which risk factors and best practices are appropriate for screening all patients admitted to acute care units as required by the national VHA directive.

## August 2007 

- Objectives
- Define  screening vs clinical bedside assessment
- Determine if screen should include a water test
- Identify search terms for systematic review

## Screening

- ASHA,  Scottish Intercollegiate Guidelines Network (SIGN), Perry (2001) Martino (2000, 2005), Logeman(1999)
- Process/procedure to identify patients at risk for dysphagia
- Risk rather than diagnosis
- Referral to SLP
- Literature definitions primarily in context of screening for dysphagia in patients with stroke

**Notes:**
Missing here is statement equating screening with diagnosis

## Working Definition of Screening

- Process used by nurses to identify those all newly admitted inpatients who are at risk for dysphagia and who need to be seen by an SLP for further evaluation

**Notes:**
In addition to determining definition of screening, we also looked to published guidelines.

## Search terms

- Incidence
- Signs/Symptoms
- Screening tests including water tests (many different terms)

**Notes:**
3ounce, sip test, 50ml, Burke, 

## March 2008: Develop Screening Questions

- Literature Search
- 1990-2007
- Adults
- English
- Broad
- Reviewed literature abstracts
- 3 Guiding systematic reviews
- Perry 2001
- Martino 2000 and 2005
- Articles since 2004

## Findings

- Majority of articles based on stroke patients
- Incidence depended on when assessed
- Variety of signs associated with dysphagia
- Drooling, abnormal gag, choking, wet voice
- Inconsistency of terminology
- Screening vs clinical bedside exam

**Notes:**
Inconsistency of terms
Inconsistency of terms
Inconsistency of terms: screening vs clinical bedside exam  Different outcome measures: dysphagia as determined by aspiration on VSS, aspiration, respiratory infection; different professional performing exam—slp, md rn, dds

## Findings (cont)

- Tests varied considerably as to what assessed
- Gold standard: VSS vs FEES
- VSS not standardized, order of presentation, pill optional
- Different outcome measures
- Dysphagia as determined by aspiration on VSS, aspiration, respiratory infection
- Different professionals performing exam
- SLP, MD, RN, DDS

**Notes:**
Inconsistency of terms
Inconsistency of terms
Inconsistency of terms: screening vs clinical bedside exam  Different outcome measures: dysphagia as determined by aspiration on VSS, aspiration, respiratory infection; different professional performing exam—slp, md rn, dds

## Consensus Development of Screening Questions

- No water test
- Inconsistent data
- Training issue (4-8 hours training sessions)
- Signs discussed in literature rejected
- Gag
- Self-report
- Voluntary cough

## Screening Questions

**Dysphagia Risk Assessment Questions:  Place check in box for any “yes” answer**
- Diagnosis of  _new stroke_, _head and neck cancer_, or _traumatic brain injury_
- Modified texture Diet/Eating maneuvers (e.g.chin tuck; head turn)
- Unable to follow commands
- Wet gurgly voice
- Drooling while awake
- Tongue deviation from midline
**If any of above boxes checked, keep patient NPO, notify provider, and send speech pathology consult.**
*Unable to complete screen. Reason: Ventilator,  unconscious*

## Current Status: Pilot Testing

- Pilot testing

## Dysphagia Screening and  Stroke Initiatives

## JC Guide for Primary Stroke Center Certification (Rev 10/08): Dysphagia Performance Measurement 

- Patients with ischemic or hemorrhagic stroke who undergo evidence-based bedside testing protocol *approved by the hospital* before being given any food, fluids, or medication by mouth.

## 2003 VA/DoD Guidelines

**G-1 Assessment of Swallowing (Dysphagia) ***Recommendations *
- All patients have their swallow screened prior to initiating oral intake of fluids or food,  (no mention of medication) utilizing a simple valid bedside testing protocol. (ECRI, 1999; Perry & Love, 2001; Martino, Pron, & Diamant, 2000) (***QE*****: II-2; *****Overall Quality*****: Fair; *****R*****: B**)

## Stroke Dysphagia Initiatives

- VA/DoD/AHA Stroke Rehabilitation Guidelines Update
- VA HSR&D Stroke Toolkit

## Canadian Stroke Guidelines:CMAJ 12/2/08

- Best Practice Recommendation 6.1: Dysphagia assessment
- Patients with stroke should have their swallowing ability screened using a simple, valid, reliable bedside testing protocol as part of their initial assessment, and before initiating oral intake of medications, fluid or food

## SIGN (Scottish Intercollegiate Guidelines Network) Stroke Guidelines 2008

- On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid, or medication.
- If the admission screen indicates problems with swallowing, the person should have a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours

## VA Stroke Quality Improvement Toolkit

*VA Stroke Quality Improvement Toolkit*

## VA Stroke Quality Improvement Toolkit

- Dysphagia screen uses Indianapolis screen

## Screening prior to initiation of Food, Fluid, Medications

- Medications not part of 2003 VADoD Guidelines
- Concerns regarding medications
- None of the studies evaluate safe medication swallowing
- Videofluroroscopic studies do not necessarily include pill swallowing performance
- Swallowing pills is a different process than swallowing fluids or food
- Patients vary considerably in their pill taking behavior

## Pill Swallowing

- Robbins et al, Madison VA GRECC

## Discussion Questions

- What is the purpose of dysphagia screening by nursing?
- Referral to the next level of care vs detection of aspiration
- Should the VA have a common voice regarding dysphagia screening across programs?
- How should the nursing screen be validated?
- What data should we collect for validation?
- How should medication safety be assessed?
- What is the best way to implement dysphagia screening by nursing