Identifying Post-Extubation Dysphagia

November 27, 2020

Jenny Barker, M.H.Sc, Reg. CASLPO

Shauna Hellen, M.H.Sc, S-LP(C), Reg. CASLPO

Trish Williams, M. SLP, S-LP(C), Reg. CASLPO

Implementation of an Evidence-based Screening Algorithm in Critical Care

Background: Intensive Care Admissions

• Over 5 million ICU admissions annually in North America

• Rapidly growing sector of hospital care

• ICUs running at 60-80% capacity before the arrival of COVID-19 pandemic

• With arrival of COVID-19, even further increased need for ICU

Barrett et al. (2011), Information CIfH (2016), Adhikari (2010), van Walraven(2013), Halpern (2016)

Background: Intubation

• 20-40% of critically ill patients will be intubated

• 1-2 million intubations in North America

• Respiratory failure is the most common reason for ICU re-admission

Barrett et al. (2011), Information CIfH (2016), Wunsch et al (2013), Gonzalez-Castro et al. (2007), Lin et al (2018)

Dysphagia in the Critically Ill Patient

• Swallowing is a complex function that involves the coordination of many nerves and muscles in the oral cavity, pharynx and esophagus

• Dysphagia (swallowing impairment) is typically the result of neurological, surgical, structural or functional causes

• Dysphagia in the ICU

• Iatrogenic

• Can be longstanding

• Can have negative outcomes if not addressedhttps://tiglutik.com/risk-of-aspiration-due-to-dysphagia/

Endotracheal Tube (ETT) Placement

• https://medical-dictionary.thefreedictionary.com/Endotracheal+tube

Mechanisms of Post-Extubation Dysphagia

Macht, M, et al (2013)

Post- Extubation Dysphagia

• Dysphagia is prevalent post prolonged intubation

• Rates of post-extubation dysphagia (PED) vary from 3% - 93% (Marvin et al, 2018)

• A systematic review of PED (Skoretz et al, 2010)

• At least 20% of patients experienced PED in more than 50% of the studies reviewed

• Studies reporting the highest frequency of dysphagia ranged from 44 – 62% of patients with prolonged intubation

• 51% of patients intubated > 48 hr post cardiovascular surgery had dysphagia

(Barker et al, 2009)

The “48 Hour Rule”

• Significant increase in occurrence of dysphagia after 48 hr of intubation

• Patients twice as likely to develop dysphagia for every additional 12 hr period of intubation

Group I II III IV

Intubation Duration ≤ 12 h >12 h to ≤ 24 h > 24 h to ≤ 48 h >48 h

DysphagiaFrequency

1 % 8.2 % 16.7 % 67.5 %

Skoretz, et al, 2014

Survey says...

• Dutch National Survey of Intensivists (van Snippenburg, et al, 2019)

• 84% - dysphagia is relevant

• 82% - dysphagia = increased LOS

• 87% - dysphagia contributes to higher re-admission

• 61% - estimated that dysphagia occurs in <25% of Pts

• 22% of ICUs had a standardized screening protocol

• Survey of inpatient SLPs in US hospitals (Macht et al, 2012)

• 29% of hospitals have guideline in place to initiate an SLP consult

• Survey of 13 ICUs across 4 teaching hospitals in Baltimore, MD (Brodsky et al, 2014)

• One site had an algorithm to trigger referral for swallow assessment• Two-fold increase in ICU swallow assessment at that site

What's being done about it?

• In 2016, the American Association of Critical Care Nurses

• Practice alert:

• Importance of identifying patients at risk for PED

• Importance of an SLP assessment for patients after prolonged intubation

Mandell et al (2019)

What’s being done about it?

Patient Impact

• PED places patients at risk for:

• Aspiration pneumonias

• Re-intubation

• Prolonged hospital stay/ICU stay

• Increased overall mortality

• Re-admission to ICU

• Contributor to thirst, hunger, malnutrition and discomfort, which is a source of distress and reduces QOLJohnson et al (2018)

Cost of Aspiration

• $ 547M in US hospital costs secondary to dysphagia

• Aspiration pneumonia increases hospital stays by 5 times

• $94,000 CAD/patient

Ajemian et al., (2001); Altman et al., (2010); Kozlow et al., (2003); Sutherland, Hamm, & Hatcher, (2010)

Critical Care, University Health Network, Toronto

• At UHN• 4 ICUs- CVICU, CICU, MSICU,

MSNICU• 101 ICU beds and 5600 admissions

per year• 3780 patients annually are at

risk for developing PED

• Best practice guidelines for screening and referral to speech-language pathology (SLP) for PED do not exist at our facility

What Currently Exists

• Yale Swallow Protocol

• The Toronto Bedside Swallowing Screening Test (TOR-BSST)

• Screening Tool for Acute Neurological Dysphagia (STAND)

• Post-Extubation Dysphagia Screening (PEDS)

• Gugging Swallow Screen-ICU (GuSS-ICU)

Objectives

• To develop an evidence-based screening algorithm for PED to identify appropriate referrals for assessment

• To assess the feasibility and uptake of a screening algorithm across four ICUs

Method

Results: Phase 1 – Draft Algorithm

Swallowing Algorithm Post-Extubation

(SAPE)

Results: Phase 2 – Pilot Testing (Training)

• RNs

• Allied Health

• MDs and FellowsWho

• In-Services

• Bedside Teaching

• Daily Safety Huddles

• Email RemindersWhat

60-100% ofRegistered Nurses

Trained

Results: Phase 2 – Pilot Testing (Outcomes)

Indicator

Identify Risk Factors for PED

Confident Initiating PO Intake

Consult SLP Post Extubation

Pre-Training

30%

30%

35%

Post-Pilot

74%

64%

84%

% Increase

147%

113%

140%

Results: Phase 3 –Revised Algorithm

Stakeholder Feedback

• Anesthesiologists

• Nurse Educators

• Nurse Managers

• Critical Care Quality Committee

• Director of Critical Care

• Surgeon-in-Chief

• Registered Nurses

SwallowingAlgorithmPostExtubation

SLP Required

Intubation Duration

Consider PO intake

Benefits of SAPE

• Evidence-based

• Created by multidisciplinary group of clinicians

• Risk reduction

• Trialed on heterogeneous patient population

• 4 ICUs including specialized populations

• Highlights specific criteria and procedures known to cause dysphagia

• i.e TAAA (Ishii et al 2009), ACDF (Wolf 2013)

• We do not include a water swallow screening• Not validated on this population

• Risk of silent aspiration

• Get certain patients eating sooner (those who meet criteria)

• Empower nurses

• Given the increases in ICU admissions, as the population ages and the ongoing impact of the COVID-19 pandemic, a tool like this is highly beneficial

Benefits of SAPE

COVID-19 in UHN ICU

• Approximately 120-140 patients

• Prolonged intubation

• Tracheostomy consideration

• Impact of prone positioning

• Longer use of sedation and paralytics

• Swallowing and voice disorders

Conclusions

• Developed Swallowing Algorithm Post-Extubation (SAPE) based on best evidence to identify patients at risk of post-extubation dysphagia

• Implemented across 4 critical care units

• Increased number of referrals to SLP

• Earlier access to swallow rehabilitation

Future DirectionsResearch

• SAPE validation

• Sensitivity

• Specificity

• Patient outcomes

UHN Critical Care Policy

Sustainability

• Orientation for new ICU staff

• Refresher training

Acknowledgements

Thank you!

• SLPs: Hayley Herman, Lisa Durkin

• Nursing: Morgan Davidson, Clare Fielding, Lindsay Love, Raaj Sekhon, Yan Shao, Adrienne Whitehead, Vanessa Clements, Kaila Wingrove

• RTs: Tara Fowler, Julie Malone, Sean Marshall, Angela McGauley

• RDs: Cathy You, Rosemary Hayhoe, Debra MacGarvie

• MDs: Warren Luksun, Niall Ferguson, Jeff Singh

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Questions?