mgh- swallow screening tool (mgh-sst): validation and implementation in acute neuro patients apss...

MGH- Swallow Screening Tool (MGH-SST):Validation and

Implementation in Acute Neuro Patients

APSSSept. 26, 2008

Audrey Kurash Cohen, MS, CCC-SLPDepartment of Speech, Language and Swallowing Disorders

Massachusetts General HospitalBoston, MA

MGH-SST Team

Speech -Language –Swallowing Disorders

Tessa Goldsmith, MS, CCC-SLP, BRS-SAudrey Kurash Cohen, MS, CCC-SLPCarmen Vega-Barachowitz, MS, CCC-

SLPPaige Nalipinski, MA, CCC-SLP

NeurologyKaren Furie, MD, MPHAneesh Singhal, MDLee Schwamm, MD

Research AssistantElizabeth Cadogan, BA

Fiberoptic EndoscopistsDanny Nunn, MS, CCC-SLPAllison Holman, MS, CCC-SLP

Project SpecialistKathryn McCullough, MSJanine Santimauro, MS

General Clinical Research CenterJackie Michaud, RNMary Sullivan, RN NPDenise O’Keefe RN

Biostatistics- GCRCHang Lee, PhD

NursingJeanne Fahey, RN CNS Mary Guanci, RN CNSMarion Phipps, RN CNS

Neuroscience Nurse PractitionersMary Mott, RN NPMaryann Cantella, RN NPChristine Gray, RN NPMichelle Vidal, RN NP

“Stroke survivors should be screened using an evidence

based tool.”

•Tool Development

•Validation Study

•Training / Implementation

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 ( > 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

MGH-SST: Part One

• Wakefulness• HOB elevated• Stable breathing• Clean Mouth

Yes No

STOP

NPO

Document

Re-screen

Proceed to Part 2

Tongue Movement:

1 point

Volitional Cough:

1 point

MGH-SST: Part Two

Pharyngeal Sensation:

1 point

Vocal Quality:

1 point

Water Swallowing:

2 points

Total Score:

6

RESULTS:

Pass: 5 or 6 points

Fail: < 4 points

MGH-SST-Management Algorithm

Patient AdmittedMaintain

NPO

MGH Swallow Screen within 24 hours of admissionMGH Swallow Screen within 24 hours of admission

PART 1PART 1

FAIL PASS NPO

Non-Oral Meds

Dietary Consult

RESCREEN

NPO

Non-Oral Meds

Dietary Consult

RESCREEN

Go

to

Part 2

Go

to

Part 2

PART 2PART 2SCORE < 4

FAILSCORE 5 or 6

PASS

Oral DietPO meds

Observe 1st meal

Oral DietPO meds

Observe 1st meal

NPO Non-oral Meds

SLP consult

•Tool Development

•Validation Study

•Training/ Implementation

1868 consecutive Neuroscience admissions (August 2006 - April 2007)

253 met inclusion criteria

129 refused

124 consented

100 subjects completed testing; 52 stroke

Validation Study:Subject Recruitment

Subject Characteristics• N= 37 males, 63 females• Age range: 23-88 yrs, mean age 63 years• Neuromedical 72• Neurosurgical 28

DiagnosesCVA/TIA 52SAH/SDH/Aneurysm 15Neoplasm 13

Degenerative 7Cervical spine dysfunction 5Seizures 3Other (vasculitis, encephalitis etc) 5

Study Cohort

Administration of Screening

– 3 research RN’s ; non-neuroscience nurses

– Trained– High-degree of inter-rater

reliability– ICC = 0.92

Fiberoptic Endoscopic Evaluation of Swallowing

(FEES)

FEES Parameters

3 trained Speech-Language Pathologists:

1. Endolaryngeal secretions 1-2

2. Delayed pharyngeal swallow 3

3. Laryngeal penetration 3

4. Transglottic aspiration 3

5. Pharyngeal residue 3

1. Murray; 1996; 2. Donzelli, 2003 ; 3. Langmore, 2005

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

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

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

Procedures

• One of three RN’s performed swallow screening

• One of three SLP’s completed endoscopic evaluation

• Blinded to patient characteristics and to each other’s test findings

• Median time between procedures= 1.5 hours

Sensitivity

Sensitivity = 0.89

Presence of a failed screen when there is true dysphagia/aspiration as detected on endoscopic evaluation (category II or III)

Specificity = 0.61

SpecificityThe presence of passed screen when there is no aspiration or dysphagia detected on endoscopic evaluation (category I)

PPV = 0.66

Positive Predictive ValueThe likelihood of aspiration/dysphagia in subjects who failed swallow screening

NPV = 0.87

Negative Predictive Value The likelihood of no aspiration/dysphagia in subjects who passed swallow screening

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

•Tool Development

•Validation Study

•Training / Implementation

Training Module

Training Module

Post-testPost-test

DemonstrationDemonstration

Competencies/Skills List

Competencies/Skills List

Systems Systems ImprovemeImprovementnt

Systems Systems ImprovemeImprovementnt

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