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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
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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
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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 ( > 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
Yes No
STOP
NPO
Document
Re-screen
Proceed to Part 2
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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
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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
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•Tool Development
•Validation Study
•Training/ Implementation
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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
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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
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Administration of Screening
– 3 research RN’s ; 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:
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
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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 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
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Sensitivity
Sensitivity = 0.89
Presence of a failed screen when there is true dysphagia/aspiration as detected on endoscopic evaluation (category II or III)
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Specificity = 0.61
SpecificityThe presence of passed screen when there is no aspiration or dysphagia detected on endoscopic evaluation (category I)
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PPV = 0.66
Positive Predictive ValueThe likelihood of aspiration/dysphagia in subjects who failed swallow screening
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NPV = 0.87
Negative Predictive Value The likelihood of no aspiration/dysphagia in subjects who passed swallow screening
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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
Training Module
Post-testPost-test
DemonstrationDemonstration
Competencies/Skills List
Competencies/Skills List
Systems Systems ImprovemeImprovementnt
Systems Systems ImprovemeImprovementnt
Visibility CampaignVisibility Campaign Electronic
OrdersElectronic Orders
Administration SupportAdministration Support
DocumentationDocumentation
Chart AuditsChart Audits