Review of Evidenced-Based Nursing Protocols for Dysphagia Assessment
2017; Lippincott Williams & Wilkins; Volume: 48; Issue: 4 Linguagem: Inglês
10.1161/strokeaha.116.011738
ISSN1524-4628
Autores Tópico(s)Tracheal and airway disorders
ResumoHomeStrokeVol. 48, No. 4Review of Evidenced-Based Nursing Protocols for Dysphagia Assessment Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBReview of Evidenced-Based Nursing Protocols for Dysphagia Assessment Wende N. Fedder, DNP, RN, MBA Wende N. FedderWende N. Fedder From the Neuro Stroke Division, Vanderbilt University Medical Center, Nashville, TN. Originally published9 Mar 2017https://doi.org/10.1161/STROKEAHA.116.011738Stroke. 2017;48:e99–e101Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2017: Previous Version 1 Stroke is the leading cause of serious adult long-term disability in the United States with the estimated cost of $33 billion dollars annually.1,2 Dysphagia, or impaired swallowing, is a common complication of acute stroke with an incidence that ranges from 37% to 78%.3 Dysphagia is associated with aspiration, pneumonia, and malnutrition and remains challenging to identify at the bedside. It has been estimated that approximately half of all aspiration caused by dysphagia goes unrecognized.3 With the aging of adults in the United States, there is a critical need to focus on the early detection of dysphagia symptoms in hospitalized patients who experienced a stroke, accompanied by the initiation of a validated dysphagia screening protocol (DSP).4 This article will provide an update of the most commonly used DSPs and will provide guidance in the selection of a DSP for use in nursing.Clinical Practice Recommendations for NursingNurses, on the forefront of stroke care delivery, maintain a key role in early identification of patients with dysphagia. Although the Joint Commission no longer requires dysphagia screening rates be reported for stroke center certification, the Joint Commission encourages consistent monitoring for dysphagia and use of evidence-based DSPs.5Recommendations from the American Heart Association declare that a swallow evaluation should be performed in the first 24 hours after stroke.6 Physician order sets should include a swallow assessment with nutrition and swallow evaluation before oral intake. Patients who cannot swallow should have a nasogastric tube placed or endoscopic gastrostomy tube depending on severity. Patients should be kept NPO (nil per os or nothing by mouth) with intravenous normal saline running at a rate of 75 to 100 mL/h until a formalized evaluation by speech-language pathologist (SLP; Class I; Level of Evidence B). When a formal evaluation cannot be completed by SLP before oral intake is required, other members of the multidisciplinary team may perform a swallow screen. Nurses, who are typically at the patient bedside for extended periods of time and often first to provide oral medications or nutrition, should be familiar with DSPs.6Essential Considerations for Nurses When Selecting an Evidence-Based Dysphagia ScreenHinchey et al7 published that the use of a formal DSP is associated with decreased risk for aspiration pneumonia. Therefore, in collaboration with a multidisciplinary team, nurses should identify an evidence-based DSP to reduce aspiration in hospitalized patients who experienced a stroke. Numerous behaviors are associated with aspiration and should be considered when selecting a protocol. These symptoms include choking, coughing, a wet voice, a delay in initiating swallow, uncoordinated chewing or swallowing, and extended time eating or drinking.5 Further signs include weight decrease, sore throat after meals, food storing in the oral cavity, and presence of recurrent pneumonia. If these symptoms are identified, patients should also be considered for aspiration precautions and DSP.8Identification of Standardized Assessment for Dysphagia PoststrokeThe VFSS (Videofluoroscopic Swallowing Study) is the standard assessment for dysphagia.9 The VFSS is commonly conducted in hospitals by radiology and SLP. It provides the most comprehensive information on anatomic and physiological malfunction in swallowing.10 However, because of availability, cost, patient compliance, and expertise needed by SLP, it is not possible to perform instrumental examination on every patient with suspected dysphagia. Therefore, several less invasive DSPs conducted by various members of the healthcare team have been developed with varying degrees of acceptance.9,10Various meta-analysis reviews have been performed on published DSPs in the past 5 years with differing recommendations and no consensus. First, O'Horo et al9 published a meta-analysis in 2015 that identified over 800 articles referencing various screening and assessment tools. Their results showed that most DSPs lack the sensitivity to be used across all patient populations. They also identified that no DSP has been shown to provide adequate predictive value for the presence of aspiration.9 Second, Shepp et al11 performed a systematic review of DSPs after stroke and identified several criteria that established relevancy. These criteria include having consistently reliable data, validity against a radiographic study, and a complete published description of the tool.11 Further, Daniels et al5 published that there have been numerous studies published in the last decade that identified clinical features associated with dysphagia poststroke and should be considered for DSPs, but the quality of the studies are variable and have not provided a uniform DSP recommendation. DSPs referenced by these authors are summarized in Table.5–21Table. Sample of Evidence-Based Dysphagia Screening ToolsAssessment NameConsiderations for ImplementationAdministration Time (in min)Validation for Use by NursesVFSS (per ASHA, highly valid, reliable, sensitive, and specific in clinical determination of aspiration and dysphagia)Cost prohibitive; requires patient compliance; technician expertise; patient exposure elevated to toxic barium; often not available 24/715–60NoBarnes Jewish Hospital Stroke Dysphagia Screen (also known as Acute Stroke Dysphagia Screen)Validated against MASA; sensitivity for dysphagia and aspiration >90%; specificity 74%; reliability 94%<2Yes, with 10-min trainingBurke Dysphagia Screening TestNot valid for aspiration or dysphagia screening; lacks reliability, sensitivity, and specificity data; authors report test is for dysphagia-related medical complications not dysphagia screening; sensitivity for dysphagia-related medical complications was 92%<10 minYes, for dysphagia-related complicationsGugging Swallow ScreenValidated; reliability, sensitivity, and specificity established<10 minNo; SLP administeredMassey Bedside Swallow ScreenSmall study; not validated against VF<15 minYesModified MASAN/A (not performed by RNs). Validated, sensitivity 87% to 93%; specificity 84% to 86%; reliability 76%<10No; published for use by physiciansSimple Swallow Provocation TestNot validated by VF; low sensitivity <70%, does not require patient cooperation; limited applicabilityVariableYes; with trainingSwallow screen by emergency physicianN/A (not performed by RNs). Validated; sensitivity 96%, specificity 56%, reliability 90% 1 study; questionable reliability unless combined with other tests. Specificity established; sensitivity <80% for aspiration<5YesToronto Bedside Swallow ScreeningValidated for use across clinical settings (copyright protected); sensitivity 96%; specificity 64%; reliability 92% (adherence to copyright protections required)<10Yes, with 4 h trainingYale Swallow ProtocolValidated: reliable and useful; not recommended for patients who require tracheotomy, ongoing mechanical ventilation, or pulmonary toilet; sensitivity 100%; specificity 64%; reliability 100%Simple clinical screenYesASHA indicates American Speech-Language-Hearing Association; MASA, Mann Assessment of Swallowing Ability; N/A, not available; RN, registered nurse; SLP, speech-language pathologist; VF, videofluoroscopy; and VFSS, Videofluoroscopic Swallowing Study.According to the American Speech-Language-Hearing Association (ASHA), screening tests should include an assessment capturing a history of dysphagia, a medical diagnosis that affects swallowing (ie, stroke), overt signs of aspiration, complaints of swallowing difficulties, and a pass or fail recommendation. Further, observation of patient's alertness, signs of motor speech, and voice abnormalities, signs of dysphagia with and without the presentation of food and water, and overall assessment of risk factors should be included. On training recommendations, ASHA recommends that SLP trains nurses to conduct initial swallow screenings and makes referrals based on these finds to SLP as appropriate. Patient and process outcomes should be considered when measuring effectiveness of the screening tool selected. These measurements may include: how many patients were kept NPO until initial screening, time from admission to initial screening, how many patients were referred to SLP, frequency of screenings throughout hospitalization, and how many patients experienced complications, such as aspiration, related to dysphagia post-screening.19The DSPs referenced in Table may be considered when selecting a validated tool. The Yale Swallow Protocol, Toronto Bedside Swallow Screen, and the Barnes Jewish Hospital Stroke Dysphagia Screen are evidence-based DSPs validated for use by nurses in the clinical setting. Time to complete all 3 DSPs is under 15 minutes with proper training. Many of ASHA recommendations are included. The Toronto Bedside Swallow Screen, originally published in 2008, remains a reliable and sensitive test validated against the VFSS standard for nurses to implement in the acute and rehabilitation settings. It requires a 4-hour training for nurses before utilization. The Yale Swallow Protocol is a validated, reliable, and sensitive DSP that is created for health professionals, such as nurses, to use in patients who experienced a stroke. It is a combination of the 3 oz water test and a brief cognitive assessment. The Yale Swallow Protocol is not recommended for patients who require tracheotomy, ongoing mechanical ventilation, or pulmonary toilet. The Barnes Jewish Hospital Stroke Dysphagia Screen, also known as the Acute Stroke Dysphagia Screen, is evidence based and validated for use by nurses in the clinical setting. It requires a 10-minute training before use and can be completed in <2 minutes. Regardless of which validated tool is selected, nurses should be aware that stroke patient's symptoms may fluctuate, and DSPs should be considered throughout the recovery process.19ConclusionsOverall, early detection of impaired swallowing is imperative to reduce complications poststroke. A multidisciplinary team, that includes nursing and SLP, should select a validated nurse administered DSP for use poststroke. Nurses recognize that no single DSP will meet the assessment needs of all multidisciplinary stroke professionals at every level of stroke care; every DSP has strengths and limitations. Therefore, because nurses are often at the bedside first and most often, they are in a position to help lead the initial DSP selection efforts. Ultimately, this review established 3 valid, reliable, sensitive, and specific tests designed to be performed by nurses. The Yale Swallow Protocol, Toronto Bedside Swallow Screen, and Barnes Jewish Hospital Stroke Dysphagia Screen are evidence-based DSPs available for use by nurses in the clinical setting. Further research is needed to investigate the long-term clinical and economic effects of the nurse validated DSPs on stroke patient outcomes.TAKE-HOME POINTSThe degree of swallow impairment may fluctuate after stroke. Nurses should use a validated swallow screening tool as part of their ongoing assessment of dysphagia poststroke.Nurses play a key part in working with the multidisciplinary team to develop a process for assessing dysphagia poststroke: this team should include speech-language pathologist to assist with selection, training, and proper utilization of a validated dysphagia screening protocol.Now that validated dysphagia screening protocols are available for nurses, additional studies should include the impact of the screenings on patient long-term outcomes poststroke.DisclosuresNone.FootnotesCorrespondence to Wende N. Fedder, RN, DNP, MBA, Neuro Stroke Division, Vanderbilt University Medical Center, 1215 21st Ave S, Nashville, TN 37232. E-mail [email protected]; [email protected]References1. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2016 update: a report from the American Heart Association.Circulation. 2016; 133:e38–e360. doi: 10.1161/CIR.0000000000000350.LinkGoogle Scholar2. Fang J, Shaw KM, George MG. Prevalence of stroke—United States, 2006–2010. MMWR Morb Mortal Wkly Rep. 2012; 61:379–382.MedlineGoogle Scholar3. Schrock JW, Bernstein J, Glasenapp M, Drogell K, Hanna J. A novel emergency department dysphagia screen for patients presenting with acute stroke.Acad Emerg Med. 2011; 18:584–589. doi: 10.1111/j.1553-2712.2011.01087.x.CrossrefMedlineGoogle Scholar4. Bravata DM, Daggett VS, Woodward-Hagg H, Damush T, Plue L, Russell S, et al. Comparison of two approaches to screen for dysphagia among acute ischemic stroke patients: nursing admission screening tool versus National Institutes of Health stroke scale.J Rehabil Res Dev. 2009; 46:1127–1134.CrossrefMedlineGoogle Scholar5. Daniels SK, Anderson JA, Willson PC. Valid items for screening dysphagia risk in patients with stroke: a systematic review.Stroke. 2012; 43:892–897. doi: 10.1161/STROKEAHA.111.640946.LinkGoogle Scholar6. Summers D, Leonard A, Wentworth D, Saver JL, Simpson J, Spilker JA, et al; American Heart Association Council on Cardiovascular Nursing and the Stroke Council. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association.Stroke. 2009; 40:2911–2944. doi: 10.1161/STROKEAHA.109.192362.LinkGoogle Scholar7. Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S; Stroke Practice Improvement Network Investigators. Formal dysphagia screening protocols prevent pneumonia.Stroke. 2005; 36:1972–1976. doi: 10.1161/01.STR.0000177529.86868.8d.LinkGoogle Scholar8. Iliescu A, Albulescu D, Hurezenu A, Voiculescu C. When and how nurses's interventions are beneficial for the dysphagic patient?Curr Health Sci J. 2010; 36:52–54.Google Scholar9. O'Horo JC, Rogus-Pulia N, Garcia-Arguello L, Robbins J, Safdar N. Bedside diagnosis of dysphagia: a systematic review.J Hosp Med. 2015; 10:256–265. doi: 10.1002/jhm.2313.CrossrefMedlineGoogle Scholar10. Hind JA. New dietary compensatory strategies for dysphagia after stroke.Poster presented at: International Stroke Conference, State-of-the-Science Stroke Nursing Symposium; February 16, 2016; Los Angeles, CA.Google Scholar11. Shepp S, Tirshwell D, Miller R, Longstrength W. Swallow screens after acute stroke: a systematic review.Stroke. 2012; 43:869–871.LinkGoogle Scholar12. Donovan N, Daniels S, Edmiaston , Weinhardt J, Summers D, Mitchell PH;American Heart Association Council on Cardiovascular Nursing and Stroke Council. Dysphagia screening: state of the art: invitational conference proceeding from State-of-the-Art Nursing Symposium, International Stroke Conference 2012.Stroke. 2013; 44:e24–e31. doi: 10.1161/STR.0b013e3182877f57.LinkGoogle Scholar13. Warnecke T, Teismann I, Meimann W, Olenberg S, Zimmermann J, Krämer C, et al. Assessment of aspiration risk in acute ischaemic stroke–evaluation of the simple swallowing provocation test.J Neurol Neurosurg Psychiatry. 2008; 79:312–314. doi: 10.1136/jnnp.2007.134551.CrossrefMedlineGoogle Scholar14. Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A, et al. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen.Stroke. 2007; 38:2948–2952. doi: 10.1161/STROKEAHA.107.483933.LinkGoogle Scholar15. Gottlieb D, Kipnis M, Sister E, Vardi Y, Brill S. Validation of the 50 ml3 drinking test for evaluation of post-stroke dysphagia.Disabil Rehabil. 1996; 18:529–532.CrossrefMedlineGoogle Scholar16. Massey R, Jedlicka D. The Massey Bedside Swallowing Screen.J Neurosci Nurs. 2002; 34:252–253, 257.CrossrefMedlineGoogle Scholar17. DePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke.Arch Neurol. 1992; 49:1259–1261.CrossrefMedlineGoogle Scholar18. DePippo KL, Holas MA, Reding MJ. The Burke dysphagia screening test: validation of its use in patients with stroke.Arch Phys Med Rehabil. 1994; 75:1284–1286.MedlineGoogle Scholar19. Frequently Asked Questions (FAQ) on Swallowing Screening: Special Emphasis on Patients With Acute Stroke. ASHA website.http://www.asha.org. Accessed April 1, 2016.Google Scholar20. Suiter DM, Sloggy J, Leder SB. Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study.Dysphagia. 2014; 29:199–203. doi: 10.1007/s00455-013-9488-3.CrossrefMedlineGoogle Scholar21. Edmiaston J, Connor LT, Loehr L, Nassief A. Validation of a dysphagia screening tool in acute stroke patients.Am J Crit Care. 2010; 19:357–364. doi: 10.4037/ajcc2009961.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Huang Q, He X, Yang W, Ye J, Lin Z, Xiong C and Liang Y (2021) Nutritional status in patients of mandibular osteoradionecrosis: A single‐institution experience, Oral Diseases, 10.1111/odi.13762, 28:2, (513-520), Online publication date: 1-Mar-2022. Dziewas R, Allescher H, Aroyo I, Bartolome G, Beilenhoff U, Bohlender J, Breitbach-Snowdon H, Fheodoroff K, Glahn J, Heppner H, Hörmann K, Ledl C, Lücking C, Pokieser P, Schefold J, Schröter-Morasch H, Schweikert K, Sparing R, Trapl-Grundschober M, Wallesch C, Warnecke T, Werner C, Weßling J, Wirth R and Pflug C (2021) Diagnosis and treatment of neurogenic dysphagia – S1 guideline of the German Society of Neurology, Neurological Research and Practice, 10.1186/s42466-021-00122-3, 3:1, Online publication date: 1-Dec-2021. L. C. Jones C and Porterfield S (2019) Nursing Students' Knowledge of the Nurse's Role in the Management of Dysphagia, Rehabilitation Nursing, 10.1097/rnj.0000000000000213, 45:5, (299-307), Online publication date: 1-Sep-2020. Tamburri L, Hollender K and Orzano D (2020) Protecting Patient Safety and Preventing Modifiable Complications After Acute Ischemic Stroke, Critical Care Nurse, 10.4037/ccn2020859, 40:1, (56-65), Online publication date: 1-Feb-2020. Omura K, Komine A, Yanagigawa M, Chiba N and Osada M (2018) Frequency and outcome of post‐extubation dysphagia using nurse‐performed swallowing screening protocol, Nursing in Critical Care, 10.1111/nicc.12359, 24:2, (70-75), Online publication date: 1-Mar-2019. Guo Y, Sun Z, Cai S, Jin Z, Wei Q, Jiang F, Wang M and Yin H (2018) Fire-needle therapy for deglutition disorders in post-stroke pseudobulbar palsy: a randomized controlled trial火针治疗中风后假性延髓麻痹吞咽困难的随机对照试验, Journal of Acupuncture and Tuina Science, 10.1007/s11726-018-1077-4, 16:6, (375-381), Online publication date: 1-Dec-2018. Schwarz M, Coccetti A, Murdoch A and Cardell E (2017) The impact of aspiration pneumonia and nasogastric feeding on clinical outcomes in stroke patients: A retrospective cohort study, Journal of Clinical Nursing, 10.1111/jocn.13922, 27:1-2, (e235-e241), Online publication date: 1-Jan-2018. Palli C, Fandler S, Doppelhofer K, Niederkorn K, Enzinger C, Vetta C, Trampusch E, Schmidt R, Fazekas F and Gattringer T (2017) Early Dysphagia Screening by Trained Nurses Reduces Pneumonia Rate in Stroke Patients, Stroke, 48:9, (2583-2585), Online publication date: 1-Sep-2017. Rabaut J, Thirugnanachandran T, Singhal S, Martin J, Iievliev S, Ma H and Phan T (2022) Clinical Outcomes and Patient Safety of Nasogastric Tube in Acute Stroke Patients, Dysphagia, 10.1007/s00455-022-10437-1 Dias S, Queluci G, Mendonça A and Souza V (2020) Protocolo de cuidado de enfermagem no paciente disfágico hospitalizado, CoDAS, 10.1590/2317-1782/20202019060, 32:3 Lima M, Sassi F, Medeiros G, Jayanthi S and Andrade C (2020) Precisão diagnóstica para o risco de broncoaspiração em população heterogênea, CoDAS, 10.1590/2317-1782/20202019166, 32:5 April 2017Vol 48, Issue 4 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.116.011738PMID: 28280136 Manuscript receivedMay 24, 2016Manuscript acceptedDecember 21, 2016Originally publishedMarch 9, 2017Manuscript revisedDecember 19, 2016 Keywordsrisk factorsrehabilitation nursingstrokegastrostomyincidencePDF download Advertisement SubjectsIschemic Stroke
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