Early detection of dysphagia is critical in acute stroke as it allows for immediate intervention thereby reducing morbidity, length of stay, and healthcare costs. Completing a swallowing screening test (SST) in the emergency department (ED) appears most logical given American Heart Association/American Stroke Association recommendations and the potential need for rapid administration of medication. Research has suggested that SSTs with trial water swallows are the most accurate in identification of patients with risk of dysphagia. Barriers to implementing a SST, particularly one with a water swallow component, in the ED are unknown.
The specific aims of this research study were to: 1) implement a SST with a water swallow component in the emergency department and track ED healthcare providers adherence with the protocol over time, 2) identify barriers and facilitators to administering the SST in the ED through focus group sessions, and 3) develop and implement a process improvement plan to address identified barriers to administering a SST with water swallows in the ED.
Semi-structured interviews were completed in a convenience sample of nurses and physicians who administer the stroke SST. Staff was queried on perceived barriers and facilitators to implementation of the SST with water swallow protocol. Resolutions to barriers were identified with focus group participants and taken back to the ED for implementation.
Two hundred seventy-eight individuals with stroke symptoms were screened in the MEDVAMC from October 2009 through June 2010. The percent of patients screened increased from 22.6 in October 2009 to a high of 80.8 in March, followed by a decrease to 61.9% in June (Cochran-Armitage test z = -5.1042, p<.0001). The percent of patients decreased to its lowest point of 51.9 in April but rebounded to 77.8 in May following training to address barriers. The odds of being screened was 4.0 times higher post-implementation (95% CI, 2.2 to 7.3), compared to the 2 months pre-implementation. Barriers identified from interviews were: 1) documentation in CPRS, 2) recall of screening items during administration, and 3) inconsistent method of SST administration. To address these identified barriers, the following were implemented: 1) providing pocket cards with SST steps, 2) producing a video training module of the SST procedure, and 3) a dysphagia screening template in CPRS, and 4) continued focused staff education with demonstration feedback.
This study indicates that it is feasible for nurses to administer a SST with a water swallow component and that this screening tool can implemented in the ED. This finding is important to all VHAs given the Office of the Inspector General's mandate that the initial nurse assessment include a screening of swallowing. Findings should facilitate improved quality of care for patients with suspected stroke and improve multidisciplinary collaboration in the screening of swallowing. Continued research through a service directed project will be focused on applying this processed approach to swallowing screening at multiple VHAs.
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- Anderson JA, Petersen N, Daniels S. Feasibility of screening swallowing in patients with stroke symptoms in the emergency department. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2011 Mar 1; 42(3):e328.
- Anderson JA, Petersen NJ, Daniels SK. Feasibility of screening swallowing in patients with stroke symptoms in the emergency department. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2011 Feb 9; Los Angeles, CA.