Meeting PSC Stroke 7 Standard

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Meeting PSC Stroke 7 Standard

• Tool creation
• Policy development
• Process to improving care

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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

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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

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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

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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)

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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

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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)

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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

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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

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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)

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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

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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

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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

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Performance Improvement

• Continue to provide motivators
• frequent education
• recognition
• transparent data
• ongoing prospective chart review
• multidisciplinary rounds

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Nursing Research StudyConcordance Between
Patient Bedside Swallow Screen and Dysphagia
Evaluation Results Obtained from Neurological
Nurses and Speech Pathologists

• Purpose
• compare staff nurse assessment with SLP
• look at influence of certain patient
  characteristics.
• Validation of SHS SS
• Endpoint100 stroke patients consented
• IRB approval

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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

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