Evidence into Nursing Practice - Symposium 2011
The LMH ASSIST pilot trial
(Acute Screening of Swallow in Stroke / TIA)
- a multi disciplinary 'evidence into practice'
partnership.
Cathi Montague, RN, MClinNsg
NMF, SA Prison Health Service
With acknowledgement to:
Linda Nimmo, Patti Holtze and Yvonne Hindman
Speech Pathologists - LMH Speech Pathology Dept.
Background
> Lyell McEwin Hospital, 2006
• 265 funded beds
• ~51000 ED presentations per year
• ~500+ patients per year with 10 CVA / TIA
•
  ED bed block (48+ hours)
•  focus on strategies to actively manage E.D.
overcrowding.
The Problem
>  E.D. bed block - delays in patient
journey.
>  delays to formal speech assessment
> No formal swallow screening process in
E.D.
> No weekend speech pathology service
> No formal best practice clinical pathways
for stroke care.
The Problem con’t
Patients with Stroke / TIA either:
• Fasted, up to 72 hours over
weekend.

or
RISKS:
•
 deconditioning
•
 inadvertant feeding
•
 aspiration
•
inconsistent IV hydration practices
Fed
RISKS:
• inconsistent, cursory or no swallow
screen
• aspiration / choking / inappropriate diet
• unsafe discharge
WHY?
• ~65% acute stroke patients
• Not always assessed
• Swallow clearance quality?
• Prolonged recovery
• Risk of complications
e.g. decubitis ulcer, falls
•  Length of stay
~10% of acute stroke patients. Can be silent
 Antibiotic use  Length of stay  deconditioning
Risk  ~3x in this population
The EBP Process in 5 easy steps!
1. Ask a focused question
2. Assess the appropriate evidence
3. Appraise the evidence for validity, impact and
precision
4. Apply evidence - account for patient values,
preferences, clinical and policy issues.
5. Audit your practice
Schneider et al. 2007 Nursing and Midwifery Research – Methods and
appraisal for evidence based practice 3rd Edition Mosby /Elsevier, New
South Wales – based on work by Sackett et al (2000) and Jackson et al
(2006)
ETHICS ???
The focussed question - PICO
> Patient Population:
•
All patients in the E.D. with Stroke / TIA
> Intervention / Area of Interest:
•
Early standardised screening of swallow
> Comparison Intervention:
•
No screen, untrained screen or formal screen by speech pathologist
> Outcome desired:
•
improved swallow screening in this at-risk group.
‘What can be done in the E.D. to minimise
swallow-related adverse health outcomes for
patients with stroke / TIA?’
Assess and Appraise the Evidence
>  Conference presentations in the
Speech Pathology field on this topic.
>  focus in the speech pathology and
medical literature.
> 2000 onwards -  development in NSW
of consolidated care (bundles) under the
TASC banner, including standardised
EBP based swallow screen tool for stroke
/ TIA:
• ASSIST tool.
> Levels of evidence sufficient to implement
pilot trial.
Apply the evidence : The Multi-D team
> Speech Pathology
• Director, Speech Pathology team with ED focus.
> ED CSC
• inform Nursing Director
> ED Liaison Nurses x2
> ED Medical Director
• + inform LMH Physicians
> LMH Librarian
• + SALUS
The Process
> 2 phases of the pilot trial
• First ~3months
• Second – next 9 months.
> Communication!
> ASSIST tool
> EDL Nurse education in swallow screen
• Theory and Practical
• Proof of competency
> Education of ED staff and Inpatient Medical
teams.
The Audit
> Integral to process
> Provides rigour
> Database review
> Speech Pathology random audit of
completed screening forms.
Phase One (First 105 days)
> Only 21% (N=26) of eligible population (n=123)
screened by EDLN
> Age range 40 to 90yrs (Medium=71yrs)
> Average wait time to EDLN screen from
admission= 8.09hours.
> 25% (n= 15) failed ASSIST at Step 1 (highest
risk) and subsequently received Speech
Pathology assessment within 24hrs of initial
screen.
> Of those, 1 subsequently cleared for normal diet
by Speech pathologist.
The Audit – Phase One
Collateral patient populations
> Those with a secondary diagnosis of Stroke / TIA
were excluded (n=176 in phase 1)
> However the audit process identified these patients
who would also benefit from early speech
pathology input.
Benefits
Improved profile and multidisciplinary
teamwork.
Those patients were safer!
Turn problems into solutions - Ongoing problem
identification and problem solving
Identified Problems
> Visibility of service
> Allowed for minor revision of ASSIST tool
> Limitations of hours of cover
> Documentation, communication and education!
> Patients fed inadvertently
> Fasting status didn’t always move with patient
> Visiting Medical staff continuing ‘adhoc’ or no
screen
The Audit cont
Phase Two (next 9 months)
> Further 41 patients screened by EDLN
• 27% (n=11) Pass
• 73% (n=30) Fail
> A number of other patients outside of
ASSIST guidelines were initially reviewed
and referred for Speech Pathology.
STROKE / TIA?
‘THINK SWALLOW’
Final Outcomes
> Speech Pathology and ED Leadership
decided not to continue screening by EDLN.
Issues:
Cost vs benefits
Ongoing assessment of nursing competency
Hours of trained nursing staff cover limited
Concerns over role / profession overlap
Right fit?
Ongoing Benefits
>  activity capture
> Collateral implementation of ED Allied
Health Assessment Team
> EDLN’s as an ongoing ‘expert’ resource
> FASTING armbands
> Demonstrated sensitivity of the ASSIST
tool
Take Home Messages
> Evidence into Practice uptake has to remain
a focus of healthcare to benefit the patient.
> Solitary discipline approaches will limit
approaches to care – whole of patient care
demands a whole of team approach.
> Individual health disciplines each bring a
unique focus to the table and can prompt
new questions.
Take Home Messages con’t
> National standards / guidelines to support
best practice.
> Improving the focus can be equally as
valuable as the outcomes
> Lateral problems solved along the way also
valuable!
> Don’t duplicate or replicate - Use your
librarians!!
> Other great resources – your library,
search tools, EBP websites
‘You treat a disease, you win, you lose.
You treat a person,
I guarantee you, you'll win,
no matter what the outcome.’
Robin Williams ‘Patch Adams’
QUESTIONS?