MGH- Swallow Screening Tool (MGH-SST): Validation and Implementation in Acute Neuro Patients APSS Sept. 26, 2008

1. MGH- Swallow Screening Tool (MGH-SST):Validation and Implementation in Acute Neuro PatientsAPSSSept. 26, 2008 Audrey Kurash Cohen, MS, CCC-SLP Department of Speech, Language and Swallowing Disorders Massachusetts General Hospital Boston, MA

2. Speech -Language –Swallowing Disorders Tessa Goldsmith, MS, CCC-SLP, BRS-S Audrey Kurash Cohen, MS, CCC-SLP Carmen Vega-Barachowitz, MS, CCC-SLP Paige Nalipinski, MA, CCC-SLP Neurology Karen Furie, MD, MPH Aneesh Singhal, MD Lee Schwamm, MD Research Assistant Elizabeth Cadogan, BA Fiberoptic Endoscopists Danny Nunn, MS, CCC-SLP Allison Holman, MS, CCC-SLP Project Specialist Kathryn McCullough, MS Janine Santimauro, MS General Clinical Research Center Jackie Michaud, RN Mary Sullivan, RN NP Denise O’Keefe RN Biostatistics- GCRC Hang Lee, PhD Nursing Jeanne Fahey, RN CNS Mary Guanci, RN CNS Marion Phipps, RN CNS Neuroscience Nurse Practitioners Mary Mott, RN NP Maryann Cantella, RN NP Christine Gray, RN NP Michelle Vidal, RN NP MGH-SST Team

3. “Stroke survivors should be screened using an evidence based tool.”

4. Tool Development • Validation Study • Training / Implementation

5. 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

6. MGH-SST: Part One • Wakefulness • HOB elevated • Stable breathing • Clean Mouth • STOP • NPO • Document • Re-screen Yes No • Proceed to Part 2

7. MGH-SST: Part Two Tongue Movement: 1 point Water Swallowing: 2 points Total Score: 6 Pharyngeal Sensation: 1 point Volitional Cough: 1 point Vocal Quality: 1 point RESULTS: Pass: 5 or 6 points Fail: < 4 points

8. MGH-SST-Management Algorithm Patient Admitted Maintain NPO MGH Swallow Screen within 24 hours of admission PART 1 FAIL PASS NPO Non-Oral Meds Dietary Consult RESCREEN Go to Part 2 PART 2 SCORE <4 FAIL SCORE 5 or 6 PASS NPO Non-oral Meds SLP consult Oral Diet PO meds Observe 1st meal

10. Tool Development • Validation Study • Training/ Implementation

11. Validation Study:Subject Recruitment 1868 consecutive Neuroscience admissions (August 2006 - April 2007) 253 met inclusion criteria 129 refused 124 consented 100 subjects completed testing; 52 stroke

12. Study Cohort Subject Characteristics • N= 37 males, 63 females • Age range: 23-88 yrs, mean age 63 years • Neuromedical 72 • Neurosurgical 28 Diagnoses CVA/TIA 52 SAH/SDH/Aneurysm 15 Neoplasm 13 Degenerative 7 Cervical spine dysfunction 5 Seizures 3 Other (vasculitis, encephalitis etc) 5

13. Administration of Screening • 3 research RN’s ; non-neuroscience nurses • Trained • High-degree of inter-rater reliability • ICC = 0.92

14. Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

15. FEES Parameters 3 trained Speech-Language Pathologists: • Endolaryngeal secretions 1-2 • Delayed pharyngeal swallow 3 • Laryngeal penetration 3 • Transglottic aspiration 3 • Pharyngeal residue 3 1. Murray; 1996; 2. Donzelli, 2003 ; 3. Langmore, 2005

16. Clinical Ratings – Estimation of Risk of Dysphagia/Aspiration Category I : • No clinicalconcerns • No functional swallowing deficits Safe to start unrestricted oral diet without further evaluation

17. 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

18. 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

19. 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

20. Sensitivity Presence of a failed screen when there is true dysphagia/aspiration as detected on endoscopic evaluation (category II or III) Sensitivity = 0.89

21. Specificity The presence of passed screen when there is no aspiration or dysphagia detected on endoscopic evaluation (category I) Specificity = 0.61

22. Positive Predictive Value The likelihood of aspiration/dysphagia in subjects who failed swallow screening PPV = 0.66

23. Negative Predictive Value The likelihood of no aspiration/dysphagia in subjects who passed swallow screening NPV = 0.87

24. 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

25. Tool Development • Validation Study • Training / Implementation

26. Training Module Post-test Chart Audits Documentation Systems Improvement Visibility Campaign Administration Support Electronic Orders Competencies/SkillsList Demonstration