Stroke Swallowing Screening Tool Validation
Condition: Cerebrovascular Disorders; Deglutition Disorders
MeSH terms: Deglutition Disorders; Cerebrovascular Disorders
Study type: Observational

Summary: 
      Stroke is a major medical problem in the United States, and veterans are at significant risk
      given that the most critical risk factors of stroke, older age and associated medical
      problems such as high blood pressure, are common. Dysphagia, swallowing problems, can lead to
      aspiration which in turn may result increased pneumonia, particularly in stroke patients.
      Development and implementation of an accurate and consistent nursing swallowing screening
      tool to identify risk of aspiration in individuals admitted with suspected stroke is critical
      as it allows for immediate intervention, thereby reducing associated medical complications,
      length of stay, and healthcare costs. The availability of such screening tools, however, is
      limited. The primary objective of this study is to construct a reliable and valid swallowing
      screening tool to identify risk of aspiration in individuals admitted with suspected stroke.
    

Detailed description: 
      Early detection of aspiration risk in acute stroke is critical as it allows for immediate
      intervention, thereby reducing mortality, morbidity, length of hospitalization, and
      healthcare costs. Screening of swallowing prior to the administration of food, liquid or
      medication, including aspirin, in individuals presenting with stroke symptoms is a guideline
      American Heart Association/American Stroke Association. In accordance with this guideline,
      the Veterans Health Administration (VHA) has advocated the screening of swallowing be a
      quality performance measure in acute stroke. Moreover, the Office of the Inspector General
      recently issued VHA Directive 2006-032 mandating that the initial nurse assessment must
      include a screening of swallowing. In response to the directive, many VHA facilities created
      and implemented some version of a nursing swallowing screening tool (SST), but to our
      knowledge, none have been validated using an instrumental swallowing examination nor has
      reliability been established. In developing and establishing a valid and reproducible SST for
      patients with stroke, clinicians are divided on the need to include trial water swallows as
      part of the SST. The current notion is that administering trial swallows by disciplines
      without expertise in dysphagia would compromise patient safety, thus this step is opposed by
      many speech pathologists and nurses. The prudency of introducing non-validated,
      non-reproducible SSTs is questionable. The primary objective of this study is to construct a
      reliable and valid SST to identify risk of aspiration in individuals admitted with suspected
      stroke. The specific aims of this proposal are to: 1) determine if nurses can make reliable
      inter-rater judgments of swallowing and non-swallowing features historically used by speech
      pathologists to make judgments of aspiration, and 2) identify the combination of items that
      provide the highest level of both sensitivity and specificity in the identification of
      aspiration risk as measured by a videofluoroscopic swallow study (VFSS) in individuals
      admitted with suspected stroke. Outcomes of this research will inform as to the execution of
      a multi-site feasibility study on the implementation of a reliable and valid SST by nurses
      Methods: Consecutive individuals admitted with suspected stroke (N = 270) will be recruited
      to participate. Individuals will undergo screening of swallowing and a VFSS. Screening items
      selected for validation in the identification of risk of aspiration in patients presenting
      with stroke symptoms were based on extensive literature review using Cochrane and QUADAS
      guidelines. Eight screening items will be tested for validity and inter-rater reliability: 6
      non-swallowing features and 2 swallowing features. Reliability in nursing observations of
      each screening item will be completed in all participants. Speech pathologists will serve as
      the reference standard from which to compare reliability with registered nurses who routinely
      work on the hospital ward with stroke patients.
    

Intervention name(s): Establishing Validity and Reliability
Intervention type(s): Behavioral
Intervention description(s): Consecutive individuals admitted with suspected stroke will be recruited to participate. Individuals will undergo screening of swallowing and a videofluoroscopic swallow study within two hours. Eight screening items will be tested for validity and inter-rater reliability: 6 nonswallowing features and 2 swallowing features. Reliability in nursing observations of each screening item will be completed in all participants. Speech pathologists trained in the screening items will serve as the reference standard from which to compare reliability with registered nurses who routinely work on the hospital ward with stroke patients
Observational model: Cohort
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        -  Veterans admitted with stroke symptoms

          -  Nurses working on the stroke ward
      
Biospecimen description: 
      no samples will be collected
    
Keywords: Stroke; Deglutition; Deglutition Disorders; Nurse Screening