Alyssa, a Speech Pathologist from Australia, reached out to me expressing interest in contributing a short article for Dysphagia Cafe. Her desire to contribute content as a means of fostering her ongoing interest in the field was impressive. A big thank you to Alyssa for this contribution.
Incomplete Referrals
“Speech Pathologist please review pt X, difficulty swallowing”. How many times have you sat down at your desk and seen a multitude of these referrals waiting for you? You spend the better part of the morning trying to sift through notes for more information to help you prioritise these patients, but often the information is scarce, non-descriptive and, in some cases, completely non-existent (how many times have you received the “difficulty swallowing” referral, only to see “tolerating diet and fluids” written all over the notes?).
Speech Pathologists working in the medical setting will be all too familiar with this type of referral. The trouble is that it does not provide the necessary information to triage a referral and requires additional resources to search through the notes to find specific information regarding the “difficulty swallowing”.
How do Speech Pathologists then prioritise referrals when this is all the information received? What sort of information do we want in a referral and how do we get nursing staff to provide it?
Studies have shown that the use of a formal dysphagia screening protocol, especially in the stroke population, is associated with decreased risk for aspiration pneumonia, reduced length of stay and reduced overall healthcare costs for acute patients (Fedder, 2016; Martino et al, 2009).
How do we hand over some responsibility for the management of dysphagia without completely relinquishing control? These sorts of questions have plagued Speech Pathologists since the beginning of our involvement in dysphagia management (De Pippo, Holas & Reding, 1994).
Incidence of Dysphagia
Dysphagia is a potentially life threatening condition, with consequences including: aspiration pneumonia, malnutrition, dehydration, increased risk of complications and higher mortality rate (Cichero, Heaton & Bassett, 2009; Joundi et al, 2017).
Dysphagia also has financial implications for the individual and the health service – costs associated with increased length of stay, medications (e.g. antibiotics), VFSS, X-rays, increased nursing and physician consultations etc. (Cichero et al, 2009). ).
Leslie et al (2003) found that dysphagia was associated with approximately 76,000 bed days per year. Timely identification of dysphagia is necessary to ensure the safe provision of food, fluids and oral medications and reduce the risk of aspiration.
In the acute setting, as many as 10-30% of adults aged over 65 are estimated to have dysphagia (Cichero et al, 2009). Pneumonia is the leading cause of death for elderly adults in nursing homes, with mortality rates reported between 7 and 41% (Bassim et al, 2008). These statistics highlight the critical need for identifying those at risk of dysphagia to ensure timely implementation of appropriate management.
Studies have shown that the use of a formal dysphagia screening protocol, especially in the stroke population, is associated with decreased risk for aspiration pneumonia, reduced length of stay and reduced overall healthcare costs for acute patients (Fedder, 2016; Martino et al, 2009).
Dysphagia Assessment
The assessment and management of dysphagia typically falls to Speech Pathologists (Logemann, 1999). Speech Pathologists, however, are typically not available 24 hours of the day and in many cases, are only available Monday to Friday. Nursing staff, in contrast, are with the patient 24 hours a day and are often the first people to administer oral intake and medications (Fedder, 2016; Cichero, 2009).
A screener with high sensitivity and low specificity, for example a tool which identifies with high likelihood that an individual has a particular disorder but over-identifies those who do not actually have the disorder, will not be as useful as a tool with equally high sensitivity and specificity (Logemann et al, 1999).
Nurses are at the forefront of patient care and as such, are ideally placed to be actively involved in dysphagia management. Enhancing their skills in identifying dysphagia is a logical step and one that has been actively studied over many years (Cichero et al, 2009; Fedder, 2016).
Screening vs Assessment
What is the difference between screening and evaluation? As Perry and Love (2001) describe, screening and evaluation are “two distinct procedures, carried out by different health professionals at different points in time in the investigation of an individual patient’s swallowing status”. A screening procedure should be designed to identify those who are risk of dysphagia, by identifying symptoms, whereas an evaluation (or diagnostic procedure) should examine anatomy and physiology to determine the cause of the problem (Logemann et al, 1999). Any health professional can be trained to complete a screener, but only an expert with the appropriate level of skills and knowledge can complete an evaluation.
Nurse Led Dysphagia Screening
Studies have shown that when nursing staff are trained to use a dysphagia screening tool, the time patients spend in hospital being inappropriately “NBM” (NPO) is reduced due to faster access to swallow screening (as opposed to waiting for an available Speech Pathologist).
Nurse led dysphagia screening tools for the post stroke population have been widely studied and developed (Lees, 2006; Fedder, 2017; Martino et al, 2009; DePippo et al, 1994). Despite the occurrence of dysphagia in populations such as neurodegenerative diseases, head injury, respiratory disorders, psychiatric conditions, head and neck cancers etc., there are fewer researched tools for use in these populations (Cichero et al, 2009).
Cichero et al (2009) found two screening tools for use in more general populations, however determined that the length of these tools was prohibitive, given that the acceptability of a screening tool is based in the time and cost taken to administer it (Cochrane & Holland, 1971).
What do we want from nurse led dysphagia screening?
What then does a dysphagia screening tool need to identify in order to successfully identify those at risk, while remaining quick and easy to administer? What questions should a screening tool ask? What information should it provide?
Cichero et al (2009) described the risk factors for dysphagia and aspiration in an acute hospital setting by dividing these risk factors into two distinct groups – 1) past medical history and 2) current presentation. The evidence tells us that there are specific medical diagnoses that are known to have a high association with dysphagia and risk for aspiration (Logemann et al, 1999). These include: pre-morbid dysphagia, COPD, upper GI disorders, stroke, neurological impairment, head injury, head and neck surgery, chemotherapy/radiation to head or neck, acutely unwell, frailty with co-morbidities, aged with co-morbidities, severe disability, history of recurrent chest infections etc. We also know that there are specific indicators that may identify those at risk for dysphagia including: reduced level of alertness, increased respiratory rate, slurred speech, weak/absent cough, drooling, wet voice, weak voice etc. The majority of screening tools available in the literature have a narrow focus and tend to target specifically the identification of overt signs of aspiration, rather than focusing on the broader identification of risk for dysphagia or risk for aspiration as described by Cichero et al (2009).
A screening tool needs to be able to accurately identify those at risk for dysphagia or aspiration (sensitivity), while not over-identifying those who may not be at risk (specificity). A screener with high sensitivity and low specificity, for example a tool which identifies with high likelihood that an individual has a particular disorder but over-identifies those who do not actually have the disorder, will not be as useful as a tool with equally high sensitivity and specificity (Logemann et al, 1999). Generally, an increase in sensitivity will result in a decrease in specificity and therefore, a useful screening tool will need to balance this. A tool with high sensitivity and low specificity will result in increased numbers of patients remaining NBM inappropriately.
What tools are available?
There are a large number of screening tools described in the literature, with varying levels of research and evidence behind them. As described previously, the vast majority of the literature focuses on screening tools for post stroke dysphagia. The screening tools available in the literature vary in their focus, be it on identification of overt signs of aspiration or identification of the risk for dysphagia. Some screening tools described include:
- Questionnaires or interviews with patients and/or caregivers to determine if there is any awareness of past difficulty swallowing (Cichero et al, 2009; Mari et al, 1997)
- Review of past medical history for identification of specific eitiologies associated with high risk for dysphagia (Logemann et al, 199; Cichero et al, 2009)
- Observations for overt signs of aspiration during usual oral intake (Kidd et al, 1993)
- Observations of patients for identification of specific oral motor and speech signs that may indicate risk for dysphagia (Cichero et al, 2009; Logemann et al, 1999)
- Observations for overt signs of aspiration with specified quantities of thin fluids (Lees et al, 2006; Martino, 2009; DePippo et al, 1994)
- Using pulse oximetry to detect aspiration (Exley, 2000)
Conclusion
The evidence is clear that the implementation of dysphagia screening tools is beneficial in reducing complications and consequences associated with dysphagia. Nurse led dysphagia screening is a logical step. Nurse led dysphagia screening also has the added benefit of empowering nursing staff in the management of dysphagia. Nurses gain knowledge and skills that will allow them to use clinical reasoning to make appropriate referrals, critically observe their patients and include detailed information in their notes. Teams looking to implement nurse led dysphagia screening need to be aware of the variety of tools available and also have a clear understanding of what they wish to achieve, due to variability of focus for each available tool.
References
Bassim CW, Gibson G, Ward T, Paphides BM, Denucci DJ. 2008. Modification of the risk of mortality from pneumonia with oral hygiene care. J Am Geriatr Soc. 56:1601–1607.
Cichero, J., Heaton, S. and Bassett, L. (2009). Triaging dysphagia: nurse screening for dysphagia in an acute hospital. Journal of Clinical Nursing, 18(11), pp.1649-1659.
Cochrane, A. and Holland, W. (1971). VALIDATION OF SCREENING PROCEDURES. British Medical Bulletin, 27(1), pp.3-8.
DePippo, K., Holas, M. and Reding, M. (1994). The Burke Dysphagia Screening Test: Validation of Its Use in Patients With Stroke. Arch Phys Med Rehabilitation, 75.
Exley, C. (2000). Pulse oximetry as a screening tool in detecting aspiration. Age and Ageing, 29(6), pp.475-476.
Fedder, W. (2017). Review of Evidenced-Based Nursing Protocols for Dysphagia Assessment. Stroke, 48(4), pp.e99-e101.
Joundi, R., Martino, R., Saposnik, G., Giannakeas, V., Fang, J. and Kapral, M. (2017). Predictors and Outcomes of Dysphagia Screening After Acute Ischemic Stroke. Stroke, 48(4), pp.900-906.
Lees, L., Sharpe, L. and Edwards, A. (2006). Nurse-led dysphagia screening in acute stroke patients. Nursing Standard, 21(6), pp.35-42.
Leslie, P. (2003). Investigation and management of chronic dysphagia. BMJ, 326(7386), pp.433-436.
Logemann, J., Veis, S. and Colangelo, L. (1999). A Screening Procedure for Oropharyngeal Dysphagia. Dysphagia, 14(1), pp.44-51.
Kidd, D., Lawson, J., Nesbitt, R. and MacMahon, J. (1993). Aspiration in acute stroke: a clinical study with videofluoroscopy. QJM: An International Journal of Medicine.
Mari, F., Matei, M., Ceravolo, M., Pisani, A., Montesi, A. and Provinciali, L. (1997). Predictive value of clinical indices in detecting aspiration in patients with neurological disorders. Journal of Neurology, Neurosurgery & Psychiatry, 63(4), pp.456-460.
Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D. and Diamant, N. (2008). The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and Validation of a Dysphagia Screening Tool for Patients With Stroke. Stroke, 40(2), pp.555-561.
Perry, L. and Love, C. (2001). Screening for Dysphagia and Aspiration in Acute Stroke: A Systematic Review. Dysphagia, 16(1), pp.7-18.
