mgh- swallow screening tool (mgh-sst): validation and implementation in acute neuro patients apss...
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MGH- Swallow Screening Tool (MGH-SST):Validation and
Implementation in Acute Neuro Patients
APSSSept. 26, 2008
Audrey Kurash Cohen, MS, CCC-SLPDepartment of Speech, Language and Swallowing Disorders
Massachusetts General HospitalBoston, MA
MGH-SST Team
Speech -Language –Swallowing Disorders
Tessa Goldsmith, MS, CCC-SLP, BRS-SAudrey Kurash Cohen, MS, CCC-SLPCarmen Vega-Barachowitz, MS, CCC-
SLPPaige Nalipinski, MA, CCC-SLP
NeurologyKaren Furie, MD, MPHAneesh Singhal, MDLee Schwamm, MD
Research AssistantElizabeth Cadogan, BA
Fiberoptic EndoscopistsDanny Nunn, MS, CCC-SLPAllison Holman, MS, CCC-SLP
Project SpecialistKathryn McCullough, MSJanine Santimauro, MS
General Clinical Research CenterJackie Michaud, RNMary Sullivan, RN NPDenise O’Keefe RN
Biostatistics- GCRCHang Lee, PhD
NursingJeanne Fahey, RN CNS Mary Guanci, RN CNSMarion Phipps, RN CNS
Neuroscience Nurse PractitionersMary Mott, RN NPMaryann Cantella, RN NPChristine Gray, RN NPMichelle Vidal, RN NP
“Stroke survivors should be screened using an evidence
based tool.”
•Tool Development
•Validation Study
•Training / Implementation
2004 : Development of Swallow Screening
• Background:– Dysphagia and aspiration in acute stroke 1-3
– 3 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 11-12
• 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
Yes No
STOP
NPO
Document
Re-screen
Proceed to Part 2
Tongue Movement:
1 point
Volitional Cough:
1 point
MGH-SST: Part Two
Pharyngeal Sensation:
1 point
Vocal Quality:
1 point
Water Swallowing:
2 points
Total Score:
6
RESULTS:
Pass: 5 or 6 points
Fail: < 4 points
MGH-SST-Management Algorithm
Patient AdmittedMaintain
NPO
MGH Swallow Screen within 24 hours of admissionMGH Swallow Screen within 24 hours of admission
PART 1PART 1
FAIL PASS NPO
Non-Oral Meds
Dietary Consult
RESCREEN
NPO
Non-Oral Meds
Dietary Consult
RESCREEN
Go
to
Part 2
Go
to
Part 2
PART 2PART 2SCORE < 4
FAILSCORE 5 or 6
PASS
Oral DietPO meds
Observe 1st meal
Oral DietPO meds
Observe 1st meal
NPO Non-oral Meds
SLP consult
•Tool Development
•Validation Study
•Training/ Implementation
1868 consecutive Neuroscience admissions (August 2006 - April 2007)
253 met inclusion criteria
129 refused
124 consented
100 subjects completed testing; 52 stroke
Validation Study:Subject Recruitment
Subject Characteristics• N= 37 males, 63 females• Age range: 23-88 yrs, mean age 63 years• Neuromedical 72• Neurosurgical 28
DiagnosesCVA/TIA 52SAH/SDH/Aneurysm 15Neoplasm 13
Degenerative 7Cervical spine dysfunction 5Seizures 3Other (vasculitis, encephalitis etc) 5
Study Cohort
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 1-2
2. 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
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
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
Sensitivity = 0.89
Presence of a failed screen when there is true dysphagia/aspiration as detected on endoscopic evaluation (category II or III)
Specificity = 0.61
SpecificityThe presence of passed screen when there is no aspiration or dysphagia detected on endoscopic evaluation (category I)
PPV = 0.66
Positive Predictive ValueThe likelihood of aspiration/dysphagia in subjects who failed swallow screening
NPV = 0.87
Negative Predictive Value The likelihood of no aspiration/dysphagia in subjects who passed swallow screening
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
•Tool Development
•Validation Study
•Training / Implementation
Training Module
Training Module
Post-testPost-test
DemonstrationDemonstration
Competencies/Skills List
Competencies/Skills List
Systems Systems ImprovemeImprovementnt
Systems Systems ImprovemeImprovementnt
Visibility CampaignVisibility Campaign Electronic
OrdersElectronic Orders
Administration SupportAdministration Support
DocumentationDocumentation
Chart AuditsChart Audits