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RRP 07-303 – HSR&D Study

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RRP 07-303
Development of an Evidenced-Based Acute Care Dysphagia Screen
Beverly A. Priefer PhD
William S. Middleton Memorial Veterans Hospital, Madison, WI
Madison, WI
Funding Period: July 2007 - March 2008

BACKGROUND/RATIONALE:
Patients with a variety of diagnoses - stroke, Parkinson's Disease, amyotrophic lateral sclerosis (ALS), multiple sclerosis, Alzheimer's Disease, head and neck cancer - are at risk for dysphagia. Failure to identify swallowing problems on admission may result in unsafe swallowing of medications and food, resulting in episodes of aspiration or coughing with oxygen desaturation. For some patients, such unsafe swallowing may contribute to increased morbidity (aspiration pneumonia, decreased nutritional status) and may increase length of stay. VHA Directive 2006-032 mandates that nurses screen all patients within 24 hours of admission for risk factors for dysphagia. An acute care dysphagia screen was distributed to VHA nurses in fall, 2006. This screen generated considerable controversy within nursing and between nursing and speech language pathology. Central to this controversy were the structure of the screen and the lack of evidence to support the screen. The purpose of this RRP was to systematically evaluate research literature to identify risk factors for dysphagia, and to define best practices for dysphagia screening in specific patient populations. The final product was a dysphagia screening tool.

OBJECTIVE(S):
The goal of this project was to recommend to the Office of Nursing Service an evidence-based nursing dysphagia screening tool to be use by VA nurses as part of their initial admission assessment for patients admitted to acute care services. The following were the study aims:
Aim 1: To systematically evaluate research evidence to identify critical risk factors for dysphagia, and to define best practices for bedside screening by nurses in acute care. Aim 2: To develop an evidence-based Acute Care Dysphagia Screen that will be pilot tested on 25 patients for ease of use, time required for administration, and patient acceptance. Aim 3: Following pilot testing, to recommend an Acute Care Dysphagia Screen to the Office of Nursing Service for implementation across the VHA.

METHODS:
We assembled two teams to complete this work, a Project Team - the PI, Co-Investigator, an Evidence-based Practice Expert, a Nurse Research Associate, a SLP Research Associate, and librarian - and an Advisory Team - comprised of 3 national nurse researchers and the Madison VA Chief, Speech and Audiology. The two teams met at the beginning of the project to generate the questions that guided the systematic evaluation of the research. This systematic evaluation of research evidence was guided by an expert in evidence-based practice methodology and completed by the Project Team. The Project/Advisory Teams met to review and discuss the systematic evidence report and developed the Acute Care Dsyphagia Screen.

FINDINGS/RESULTS:
The Project/Advisory Teams developed the following dysphagia screen:
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
(Not sure if some type of reminder can pop up in some predetermined number of days to remind the RN that the screen still needs to be completed

IMPACT:
After pilot testing, the final version of the dysphagia screen will be included in the National Patient Assessment template used in all VA facilities.

PUBLICATIONS:
None at this time.


DRA: none
DRE: Diagnosis, Prevention
Keywords: Nursing, Risk factors
MeSH Terms: none

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