Title: MGH Swallow Screening Tool MGHSST: Validation and Implementation in Acute Neuro Patients APSS Sept'
1MGH- Swallow Screening Tool
(MGH-SST)Validation and Implementation in Acute
Neuro PatientsAPSSSept. 26, 2008
- Audrey Kurash Cohen, MS, CCC-SLP
- Department of Speech, Language and Swallowing
Disorders - Massachusetts General Hospital
- Boston, MA
2MGH-SST Team
- Speech -Language Swallowing Disorders
- Tessa Goldsmith, MS, CCC-SLP, BRS-S
- Audrey Kurash Cohen, MS, CCC-SLP
- Carmen Vega-Barachowitz, MS, CCC-SLP
- Paige Nalipinski, MA, CCC-SLP
- Neurology
- Karen Furie, MD, MPH
- Aneesh Singhal, MD
- Lee Schwamm, MD
- Research Assistant
- Elizabeth Cadogan, BA
- Fiberoptic Endoscopists
- Danny Nunn, MS, CCC-SLP
- Allison Holman, MS, CCC-SLP
- General Clinical Research Center
- Jackie Michaud, RN
- Mary Sullivan, RN NP
- Denise OKeefe RN
- Biostatistics- GCRC
- Hang Lee, PhD
- Nursing
- Jeanne Fahey, RN CNS
- Mary Guanci, RN CNS
- Marion Phipps, RN CNS
- Neuroscience Nurse Practitioners
- Mary Mott, RN NP
- Maryann Cantella, RN NP
- Christine Gray, RN NP
- Michelle Vidal, RN NP
3Stroke survivors should be screened using an
evidence based tool.
4- Tool Development
- Validation Study
- Training / Implementation
52004 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 ( gt 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
6MGH-SST Part One
- Wakefulness
- HOB elevated
- Stable breathing
- Clean Mouth
- STOP
- NPO
- Document
- Re-screen
Yes
No
7MGH-SST Part Two
Tongue Movement 1 point
Water Swallowing 2 points
Total Score 6
Pharyngeal Sensation 1 point
Volitional Cough 1 point
Vocal Quality 1 point
RESULTS Pass 5 or 6 points Fail lt 4
points
8MGH-SST-Management Algorithm
Patient Admitted Maintain NPO
MGH Swallow Screen within 24 hours of admission
PART 1
FAIL
PASS
NPO Non-Oral Meds Dietary Consult RESCREEN
Go to Part 2
PART 2
SCORE lt 4 FAIL
SCORE 5 or 6 PASS
NPO Non-oral Meds SLP consult
Oral Diet PO meds Observe 1st meal
9(No Transcript)
10- Tool Development
- Validation Study
- Training/ Implementation
11Validation StudySubject Recruitment
- 1868 consecutive Neuroscience admissions
- (August 2006 - April 2007)
- 253 met inclusion criteria
- 129 refused
- 124 consented
- 100 subjects completed testing 52 stroke
12Study Cohort
- Subject Characteristics
- N 37 males, 63 females
- Age range 23-88 yrs, mean age 63 years
- Neuromedical 72
- Neurosurgical 28
- Diagnoses
- CVA/TIA 52
- SAH/SDH/Aneurysm 15
- Neoplasm 13
- Degenerative 7
- Cervical spine dysfunction 5
- Seizures 3
- Other (vasculitis, encephalitis etc) 5
13Administration of Screening
- 3 research RNs non-neuroscience nurses
- Trained
- High-degree of inter-rater reliability
- ICC 0.92
14Fiberoptic Endoscopic Evaluation of Swallowing
(FEES)
15FEES Parameters
- 3 trained Speech-Language Pathologists
- Endolaryngeal secretions 1-2
- Delayed pharyngeal swallow 3
- Laryngeal penetration 3
- Transglottic aspiration 3
- Pharyngeal residue 3
- 1. Murray 1996 2. Donzelli, 2003 3. Langmore,
2005
16Clinical 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
17Clinical 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
18Clinical 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
19Procedures
- One of three RNs performed swallow screening
- One of three SLPs completed endoscopic
evaluation - Blinded to patient characteristics and to each
others test findings - Median time between procedures 1.5 hours
20Sensitivity
Presence of a failed screen when there is true
dysphagia/aspiration as detected on endoscopic
evaluation (category II or III)
Sensitivity 0.89
21Specificity
The presence of passed screen when there is no
aspiration or dysphagia detected on endoscopic
evaluation (category I)
Specificity 0.61
22Positive Predictive Value
The likelihood of aspiration/dysphagia in
subjects who failed swallow screening
PPV 0.66
23Negative Predictive Value
The likelihood of no aspiration/dysphagia in
subjects who passed swallow screening
NPV 0.87
24Study 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
25- Tool Development
- Validation Study
- Training / Implementation
26Training Module
Post-test
Chart Audits
Documentation
Systems Improvement
Visibility Campaign
Administration Support
Electronic Orders
Competencies/Skills List
Demonstration