Meeting PSC Stroke 7 Standard Tool creation Policy development Process to improving care

Purpose of performing swallow screen (SS) by nursing (Perry, 2001):

• Quickly identify overt dysphagia • Performed before ANYTHING PO • No withholding PO if pt passes screening • Failures ensure rapid SLP referral • Decrease unneeded Dysphagia Eval (DE) by SLP • Comprehensive nursing assessment

Purpose of performing SS…(cont.)

• NOT DE (i.e., water only) • Screening for possibility of dysphagia • H2O less irritating if aspirated (DePippo, et al.,1992) • Less time consuming tool – 5cc, 10cc, & 90cc of water • Improves communication between nursing and SLP

SS and Nursing Scope of Practice

• MI Public Health Code are generic guidelines – MI does not have Nurse Practice Act • SS not specifically addressed • Must consider: – Basic formal nursing training – Professional experience – Continuing Ed programs with formal instruction – Infringement on trained SLP dedication, time & education

Process for Designing Protocol

• Developed SS in 2004 before PSC certification • Collaboration between SLP and Stroke CNS • Combined several screening tools • Evidence based: – – – – – BSS study (‘98), BDST (’92) Kidd Water Test (“93) SSA (’01) Massey Bedside (’02)

Bedside Swallow Screen Performed by Nursing

• • Individual & small group education • Education performed ED & adult units by SLP & CNS

Staff concerns

: – time issues – clinical expertise – SS confused with DE – confusion in documentation affects billing – RN/SLP scope of practice

Bedside Swallow Screen Performed by Nursing

• • • HOB elevated 90 degrees to slow bolus entrance into pharynx and allows for maximum airway protection (Cherney, 1994) No straws by nursing during screen Straws increase risk of aspiration due to difficulty coordinating suck using oral pressure vs. inhalation (Logemann, 1998)

Bedside Swallow Screen Performed by Nursing

• initially designed for stroke pts • where to document results?

– different nursing forms each unit – stickers vs standardized location on forms • physician education – ordering appropriately – holding all PO (include meds) for failure • continuing ed & education of new employees

Process:

• Developed swallow screen • Developed teaching tools (hand outs) – algorithm instruction card, sheets, short lecture • Addressed staff concerns during education • Maintain f/u with DM/ADM • Reward &/or recognition for performance

Process:

• Stroke CNS presence in ED • Add order & nursing policy # to TIA/Stroke Orders • Continued chart review & data sharing in meetings/postings • Update forms • SS added to standardized nursing notes & Stroke Care Plan (highlighted)

Process:

• Article in nursing newsletter • Added swallow screen pass/fail to neuro t sheet in ED • Educate admit/ED physicians • Reeducate during nursing competency programs • Continue feedback on performance to DM/ADMs • SLP & CNS developed research study to validate SS

Expanded Policy

• PI Physician champion (Pneumonia Team) approved core team to review & redesign policy • Expanded to all patients at risk • Redesigned algorithm • Mandatory ed for adult med/surg unit nursing staff • Transparent data

Expanded Policy

• • Computerized teaching module objectives: » Define & add complications of dysphagia » Specify high risk patient populations » Identify patients for whom SS is contraindicated » Describe proper SS procedure » Determine what constitutes failure of SS » Describe documentation of findings Added scenarios & test questions

Performance Improvement

• Continue to provide motivators: – frequent education – recognition – transparent data – ongoing prospective chart review – multidisciplinary rounds

Nursing Research Study:

“Concordance Between Patient Bedside Swallow

Screen and Dysphagia Evaluation Results Obtained from Neurological Nurses and Speech Pathologists

”

• • • • Purpose: 1. compare staff nurse assessment with SLP & 2. look at influence of certain patient characteristics.

Validation of SHS SS Endpoint:100 stroke patients consented IRB approval

Nursing Research Study

• Neuro nurses education 1 on 1 for reliability • Improved nursing and physician staff by in • Orders for SS from many physician services • Data collection by CNS and SLP • Patient collection from Neuro/Stroke ICU and Neuro Stepdown • Study abstract submitted to AHA ISC 2010