identifying post-extubation dysphagia...post- extubation dysphagia •dysphagia is prevalent post...
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Identifying Post-Extubation Dysphagia
November 27, 2020
Jenny Barker, M.H.Sc, Reg. CASLPO
Shauna Hellen, M.H.Sc, S-LP(C), Reg. CASLPO
Trish Williams, M. SLP, S-LP(C), Reg. CASLPO
Implementation of an Evidence-based Screening Algorithm in Critical Care
Background: Intensive Care Admissions
• Over 5 million ICU admissions annually in North America
• Rapidly growing sector of hospital care
• ICUs running at 60-80% capacity before the arrival of COVID-19 pandemic
• With arrival of COVID-19, even further increased need for ICU
Barrett et al. (2011), Information CIfH (2016), Adhikari (2010), van Walraven(2013), Halpern (2016)
Background: Intubation
• 20-40% of critically ill patients will be intubated
• 1-2 million intubations in North America
• Respiratory failure is the most common reason for ICU re-admission
Barrett et al. (2011), Information CIfH (2016), Wunsch et al (2013), Gonzalez-Castro et al. (2007), Lin et al (2018)
Dysphagia in the Critically Ill Patient
• Swallowing is a complex function that involves the coordination of many nerves and muscles in the oral cavity, pharynx and esophagus
• Dysphagia (swallowing impairment) is typically the result of neurological, surgical, structural or functional causes
• Dysphagia in the ICU
• Iatrogenic
• Can be longstanding
• Can have negative outcomes if not addressedhttps://tiglutik.com/risk-of-aspiration-due-to-dysphagia/
Endotracheal Tube (ETT) Placement
• https://medical-dictionary.thefreedictionary.com/Endotracheal+tube
Mechanisms of Post-Extubation Dysphagia
Macht, M, et al (2013)
Post- Extubation Dysphagia
• Dysphagia is prevalent post prolonged intubation
• Rates of post-extubation dysphagia (PED) vary from 3% - 93% (Marvin et al, 2018)
• A systematic review of PED (Skoretz et al, 2010)
• At least 20% of patients experienced PED in more than 50% of the studies reviewed
• Studies reporting the highest frequency of dysphagia ranged from 44 – 62% of patients with prolonged intubation
• 51% of patients intubated > 48 hr post cardiovascular surgery had dysphagia
(Barker et al, 2009)
The “48 Hour Rule”
• Significant increase in occurrence of dysphagia after 48 hr of intubation
• Patients twice as likely to develop dysphagia for every additional 12 hr period of intubation
Group I II III IV
Intubation Duration ≤ 12 h >12 h to ≤ 24 h > 24 h to ≤ 48 h >48 h
DysphagiaFrequency
1 % 8.2 % 16.7 % 67.5 %
Skoretz, et al, 2014
Survey says...
• Dutch National Survey of Intensivists (van Snippenburg, et al, 2019)
• 84% - dysphagia is relevant
• 82% - dysphagia = increased LOS
• 87% - dysphagia contributes to higher re-admission
• 61% - estimated that dysphagia occurs in <25% of Pts
• 22% of ICUs had a standardized screening protocol
• Survey of inpatient SLPs in US hospitals (Macht et al, 2012)
• 29% of hospitals have guideline in place to initiate an SLP consult
• Survey of 13 ICUs across 4 teaching hospitals in Baltimore, MD (Brodsky et al, 2014)
• One site had an algorithm to trigger referral for swallow assessment• Two-fold increase in ICU swallow assessment at that site
What's being done about it?
• In 2016, the American Association of Critical Care Nurses
• Practice alert:
• Importance of identifying patients at risk for PED
• Importance of an SLP assessment for patients after prolonged intubation
Mandell et al (2019)
What’s being done about it?
Patient Impact
• PED places patients at risk for:
• Aspiration pneumonias
• Re-intubation
• Prolonged hospital stay/ICU stay
• Increased overall mortality
• Re-admission to ICU
• Contributor to thirst, hunger, malnutrition and discomfort, which is a source of distress and reduces QOLJohnson et al (2018)
Cost of Aspiration
• $ 547M in US hospital costs secondary to dysphagia
• Aspiration pneumonia increases hospital stays by 5 times
• $94,000 CAD/patient
Ajemian et al., (2001); Altman et al., (2010); Kozlow et al., (2003); Sutherland, Hamm, & Hatcher, (2010)
Critical Care, University Health Network, Toronto
• At UHN• 4 ICUs- CVICU, CICU, MSICU,
MSNICU• 101 ICU beds and 5600 admissions
per year• 3780 patients annually are at
risk for developing PED
• Best practice guidelines for screening and referral to speech-language pathology (SLP) for PED do not exist at our facility
What Currently Exists
• Yale Swallow Protocol
• The Toronto Bedside Swallowing Screening Test (TOR-BSST)
• Screening Tool for Acute Neurological Dysphagia (STAND)
• Post-Extubation Dysphagia Screening (PEDS)
• Gugging Swallow Screen-ICU (GuSS-ICU)
Objectives
• To develop an evidence-based screening algorithm for PED to identify appropriate referrals for assessment
• To assess the feasibility and uptake of a screening algorithm across four ICUs
Method
Results: Phase 1 – Draft Algorithm
Swallowing Algorithm Post-Extubation
(SAPE)
Results: Phase 2 – Pilot Testing (Training)
• RNs
• Allied Health
• MDs and FellowsWho
• In-Services
• Bedside Teaching
• Daily Safety Huddles
• Email RemindersWhat
60-100% ofRegistered Nurses
Trained
Results: Phase 2 – Pilot Testing (Outcomes)
Indicator
Identify Risk Factors for PED
Confident Initiating PO Intake
Consult SLP Post Extubation
Pre-Training
30%
30%
35%
Post-Pilot
74%
64%
84%
% Increase
147%
113%
140%
Results: Phase 3 –Revised Algorithm
Stakeholder Feedback
• Anesthesiologists
• Nurse Educators
• Nurse Managers
• Critical Care Quality Committee
• Director of Critical Care
• Surgeon-in-Chief
• Registered Nurses
SwallowingAlgorithmPostExtubation
SLP Required
Intubation Duration
Consider PO intake
Benefits of SAPE
• Evidence-based
• Created by multidisciplinary group of clinicians
• Risk reduction
• Trialed on heterogeneous patient population
• 4 ICUs including specialized populations
• Highlights specific criteria and procedures known to cause dysphagia
• i.e TAAA (Ishii et al 2009), ACDF (Wolf 2013)
• We do not include a water swallow screening• Not validated on this population
• Risk of silent aspiration
• Get certain patients eating sooner (those who meet criteria)
• Empower nurses
• Given the increases in ICU admissions, as the population ages and the ongoing impact of the COVID-19 pandemic, a tool like this is highly beneficial
Benefits of SAPE
COVID-19 in UHN ICU
• Approximately 120-140 patients
• Prolonged intubation
• Tracheostomy consideration
• Impact of prone positioning
• Longer use of sedation and paralytics
• Swallowing and voice disorders
Conclusions
• Developed Swallowing Algorithm Post-Extubation (SAPE) based on best evidence to identify patients at risk of post-extubation dysphagia
• Implemented across 4 critical care units
• Increased number of referrals to SLP
• Earlier access to swallow rehabilitation
Future DirectionsResearch
• SAPE validation
• Sensitivity
• Specificity
• Patient outcomes
UHN Critical Care Policy
Sustainability
• Orientation for new ICU staff
• Refresher training
Acknowledgements
Thank you!
• SLPs: Hayley Herman, Lisa Durkin
• Nursing: Morgan Davidson, Clare Fielding, Lindsay Love, Raaj Sekhon, Yan Shao, Adrienne Whitehead, Vanessa Clements, Kaila Wingrove
• RTs: Tara Fowler, Julie Malone, Sean Marshall, Angela McGauley
• RDs: Cathy You, Rosemary Hayhoe, Debra MacGarvie
• MDs: Warren Luksun, Niall Ferguson, Jeff Singh
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Questions?