MGH Swallow Screening Tool MGHSST: Validation and Implementation in Acute Neuro Patients APSS Sept'

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MGH- 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

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MGH-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

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Stroke survivors should be screened using an
evidence based tool.
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• Tool Development
• Validation Study
• Training / Implementation

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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 ( 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

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MGH-SST Part One

• Wakefulness
• HOB elevated
• Stable breathing
• Clean Mouth

• STOP
• NPO
• Document
• Re-screen

Yes
No

• Proceed to Part 2

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MGH-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
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MGH-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
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• Tool Development
• Validation Study
• Training/ Implementation

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Validation StudySubject Recruitment

• 1868 consecutive Neuroscience admissions
• (August 2006 - April 2007)
• 253 met inclusion criteria
• 129 refused
• 124 consented
• 100 subjects completed testing 52 stroke

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Study 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

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Administration of Screening

• 3 research RNs non-neuroscience nurses
• Trained
• High-degree of inter-rater reliability
• ICC 0.92

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Fiberoptic Endoscopic Evaluation of Swallowing
(FEES)
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FEES 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

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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

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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

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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

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Procedures

• 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

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Sensitivity
Presence of a failed screen when there is true
dysphagia/aspiration as detected on endoscopic
evaluation (category II or III)
Sensitivity 0.89
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Specificity
The presence of passed screen when there is no
aspiration or dysphagia detected on endoscopic
evaluation (category I)
Specificity 0.61
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Positive Predictive Value
The likelihood of aspiration/dysphagia in
subjects who failed swallow screening
PPV 0.66
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Negative Predictive Value
The likelihood of no aspiration/dysphagia in
subjects who passed swallow screening
NPV 0.87
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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

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• Tool Development
• Validation Study
• Training / Implementation

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Training Module
Post-test
Chart Audits
Documentation
Systems Improvement
Visibility Campaign
Administration Support
Electronic Orders
Competencies/Skills List
Demonstration