Stroke survivors should be screened using an evidence based tool.

Transcription

1 MGH- Swallow Screening Tool (MGH-SST): Validation and Implementation in Acute Neuro Patients APSS Sept. 26, 2008 Audrey Kurash Cohen, MS, CCC-SLP Department of Speech, Language and Swallowing Disorders Massachusetts General Hospital Boston, MA MGH-SST Team Speech -Language Swallowing Disorders Tessa Goldsmith, MS, CCC-SLP, BRS-S Audrey Kurash Cohen, MS, CCC-SLP Carmen Vega-Barachowitz, MS, CCC-SLP Paige Nalipinski, MA, CCC-SLP Neurology Karen Furie, MD, MPH Aneesh Singhal, MD Lee Schwamm, MD Research Assistant Elizabeth Cadogan, BA Fiberoptic Endoscopists Danny Nunn, MS, CCC-SLP Allison Holman, MS, CCC-SLP Project Specialist Kathryn McCullough, MS Janine Santimauro, MS General Clinical Research Center Jackie Michaud, RN Mary Sullivan, RN NP Denise O Keefe RN Biostatistics- GCRC Hang Lee, PhD Nursing Jeanne Fahey, RN CNS Mary Guanci, RN CNS Marion Phipps, RN CNS Neuroscience Nurse Practitioners Mary Mott, RN NP Maryann Cantella, RN NP Christine Gray, RN NP Michelle Vidal, RN NP Stroke survivors should be screened using an evidence based tool.

2 Tool Development Validation Study Training / Implementation 2004 : Development of Swallow Screening Background: Dysphagia and aspiration in acute stroke x increased mortality secondary to aspiration pneumonia 4-5 National guidelines for dysphagia screening 6-8 Available swallow screening tools: None validated Focused on single sign 9-10 Complicated, detailed Our criteria: Evidence based items High sensitivity to detect aspiration ( > 0.85) Simple to administer; Binary 1.DePippo, 1992; 2. Smithard, 2007; 3. Martino, 2007; 4. Singh and Hamdy, 2005; 5. Katzan, 2003; 6. AHA; 7. JCAHO; 8. CDC 9. DePippo, 1994; 10. Kidd, 1993; 11. Logemann, 1996; 12. Perry, 2001 MGH-SST: Part One Wakefulness HOB elevated Stable breathing Clean Mouth STOP NPO Document No Yes Proceed to Part 2 Re-screen

3 MGH-SST: Part Two Tongue Movement: 1 point Volitional Cough: 1 point Total Score: 6 Pharyngeal Sensation: 1 point Water Swallowing: 2 points RESULTS: Pass: 5 or 6 points Fail: < 4 points Vocal Quality: 1 point MGH-SST-Management Algorithm Patient Admitted Maintain NPO MGH Swallow Screen within 24 hours of admission PART 1 FAIL NPO Non-Oral Meds Dietary Consult RESCREEN SCORE < 4 FAIL NPO Non-oral Meds SLP consult PASS Go to Part 2 PART 2 SCORE 5 or 6 PASS Oral Diet PO meds Observe 1 st meal

4 Tool Development Validation Study Training/ Implementation Validation Study: Subject Recruitment 1868 consecutive Neuroscience admissions (August April 2007) 253 met inclusion criteria 129 refused 124 consented 100 subjects completed testing; 52 stroke Study Cohort Subject Characteristics N= 37 males, 63 females Age range: yrs, mean age 63 years Neuromedical 72 Neurosurgical 28 Diagnoses CVA/TIA 52 SAH/SDH/Aneurysm 15 Neoplasm 13 Degenerative 7 Cervical spine dysfunction 5 Seizures 3 Other (vasculitis, encephalitis etc) 5

5 Administration of Screening 3 research RN s ; non-neuroscience nurses Trained High-degree of inter-rater reliability ICC = 0.92 Fiberoptic Endoscopic Evaluation of Swallowing (FEES) FEES Parameters 3 trained Speech-Language Pathologists: 1. Endolaryngeal secretions Delayed pharyngeal swallow 3 3. Laryngeal penetration 3 4. Transglottic aspiration 3 5. Pharyngeal residue 3 1. Murray; 1996; 2. Donzelli, 2003 ; 3. Langmore, 2005

6 Clinical Ratings Estimation of Risk of Dysphagia/Aspiration Category I : No clinical concerns No functional swallowing deficits Safe to start unrestricted oral diet without further evaluation Clinical Ratings Estimation of Risk of Dysphagia/Aspiration Category II: Clinical concerns Moderate swallowing dysfunction Do not feed Need comprehensive swallowing evaluation May be able to eat with therapeutic intervention Clinical Ratings Estimation of Risk of Dysphagia/Aspiration Category III: Significant clinical concerns Severe swallowing dysfunction with visualized aspiration Do not feed Non-oral nutrition Need comprehensive swallow evaluation

7 Procedures One of three RN s performed swallow screening One of three SLP s completed endoscopic evaluation Blinded to patient characteristics and to each other s test findings Median time between procedures= 1.5 hours Sensitivity Presence of a failed screen when there is true dysphagia/aspiration as detected on endoscopic evaluation (category II or III) Sensitivity = 0.89 Specificity The presence of passed screen when there is no aspiration or dysphagia detected on endoscopic evaluation (category I) Specificity = 0.61

8 Positive Predictive Value The likelihood of aspiration/dysphagia in subjects who failed swallow screening PPV = 0.66 Negative Predictive Value The likelihood of no aspiration/dysphagia in subjects who passed swallow screening NPV = 0.87 Study Conclusions SST effectively identifies neuroscience patients who are safe to eat by mouth Highly sensitive tool for at risk patients Easy-to-use Trained nurses can administer tool reliably

9 Tool Development Validation Study Training / Implementation Training Module Post-test Chart Audits Documentation Visibility Campaign Systems Improvement Electronic Orders Administration Support Competencies/ Skills List Demonstration