Impetus for Dysphagia Nursing QUERI RRP

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Impetus for Dysphagia Nursing QUERI RRP

• Anna C. Alt-White, PhD, RN Office of Nursing
  Services

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2006 OIG Report

• Evaluation of the Management of Patients with
  Feeding and Swallowing Problems in VHA
  Facilities found not all initial nursing
  assessment forms triggered referrals when
  feeding/ swallowing problems identified

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Why the Concern??

• 300,000-600,000 people have dysphagia from
  neurological disorders
• 51-73 of patients with stroke 75 of nursing
  home residents have dysphagia
• Without intervention - 43-54 of these stroke
  patients/residents experience aspiration
• gt60,000 people die/year from complications
  related to dysphagia

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Consequences of Dysphagia

• Poor nutrition or dehydration
• Aspiration pneumonia or chronic lung disease
• Diminished enjoyment of eating or drinking
• Embarrassment
• Isolation in social situations involving eating

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VHA Response

• Interdisciplinary task group (SLP, RNs,
  Dietitians) charged with developing policy
• Outcome - VHA Directive 2006-032 Management of
  Patients with Swallowing (Dysphagia) or Feeding
  Disorders

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VHA Directive 2006-032

• Defines policy and procedures for patients/
  residents with dysphagia or feeding disorders
• Assess appropriately
• Refer for diagnostic evaluation (as needed)
• Treat
• Manage
• Monitor
• Follow-up
• Throughout continuum of care
• In patient
• Outpatient
• Long Term Care

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VHA Directive 2006-032

• Specifically mandated that nurses conduct an
  initial Assessment which includes an evaluation
  for swallowing and feeding problems on all
  patients admitted to an acute care setting within
  the first 24 hours of admission

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VHA Directive 2006-032

• Assessment defined as the screening for the
  presence of risk factors by means of self-report,
  clinical history, or clinical observation.

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Acute Care Dysphagia Screen

• Part 1. Risk Factors
• a. If any present keep NPO. Consult clinician and
  refer to Speech Pathology
• Decreased consciousness
• Decreased orientation
• Unable to follow simple commands
• Severe facial weakness
• Unable to control saliva (drooling)
• Weak, absent or unusual cough
• Abnormal or absent speaking voice
• Poorly articulated speech

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Acute Care Dysphagia Screen

• Part 1. Risk Factors (continued)
• b. If either of two factors below are noted,
  test swallow, using the procedure below, even if
  all risk factors are negative
• Cough after swallow
• Voice change after swallow

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Acute Care Dysphagia Screen

• Part 2. Swallow Testing Procedures
• Sit patient up at least 45 Degrees. Offer a cup
  of water and say
• Take a sip
• Take a mouthful
• Drink as you would normally
• For each part of swallow test- If coughing or
  change of voice, STOP, Keep NPO

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Acute Care Dysphagia Screen

• Part 3. When procedure completed
• If ANY abnormality observed, consult MD/health
  care clinician and refer to Speech Pathologist
• For ALL patients kept NPO follow clinicians
  orders or local protocol
• If NO abnormality observed consider diet at
  discretion of admitting team
• If ANY deterioration in neurological status, then
  repeat screen and notify attending medical
  officer

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Controversy over

• Swallow test
• Within Nursing
• Among disciplines

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Office of Nursing Services

• Recognized need to identify evidence of risk
  factors and best practices for screening
• Urged investigators to submit application for
  Nursing QUERI RRP