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