Vol. 17 Issue 5
A protocol for the frontline of patient care
Hospitals that are credentialed as stroke centers must have a screening tool for dysphagia in place, according to the American Heart Association. Furthermore, the Joint Commission states that a screen for dysphagia should be administered to patients with stroke before they are given "food, fluids and medications by mouth."1
In compliance with these requirements, some hospitals are introducing a swallow screening procedure designed specifically for nurses. The purpose of the procedure is to enable them to screen newly admitted patients who may be at risk for aspiration and quickly determine if they are safe for oral intake.
It's important to note that the nurses who perform the screening are not performing swallow evaluations, nor are they replacing speech-language pathologists.
"My job is to perform a comprehensive evaluation on every patient. This [procedure] allows nurses to more accurately determine who needs a full evaluation and who can start their oral intake. An evaluation is far greater than that," said Audrey Cohen, MS, CCC-SLP, of the Department of Speech, Language and Swallowing at Massachusetts General Hospital (MGH)in Boston.
Because patients with stroke are at risk for many problems, MGH is trying to establish a method for nurses to determine if they need to get a speech-language pathologist to do a comprehensive swallow evaluation.
While many facilities assign this duty to the nursing staff, other professionals such as neurologists and residents also are trained to use the tool.
"It doesn't inherently have to be a nurse who screens the patients," Cohen told ADVANCE. "Our nurses are using it at the moment because they are on the front lines of giving patient care. They are the ones who have the first contact with the patient. They're at the entry point, and they're at the bedside."
At MGH the protocol is still in the implementation phase and awaiting validation. Therefore, it is only being used on the inpatient neuroscience units.
"We wanted to make sure that the tool we use is validated against a gold standard; but given the need to put a screening tool in place as soon as possible, we agreed to train our nurses concurrently with the validation study," said MGH clinical specialist Tessa Goldsmith, MA, CCC-SLP, BRS-S.
Staff can access a Web-based training module via CD or the hospital Intranet. The module includes background information on the nature of dysphagia, aspiration and oral hygiene. It also differentiates between a swallow screen and a comprehensive evaluation and explains the role of the nurse in caring for patients with dysphagia.
The training module shows a demonstration of how to perform the screening appropriately, with video clips of patients exhibiting normal and abnormal responses. As part of their training, nurses must perform the screening at least five times under the supervision of a speech-language pathologist.
The tool is only as good as the person performing it, cautioned Cohen. "It takes a real skill, and that's based on the individual and how many patients they've seen and their years of experience."
While training is the most critical part of the process, it is also probably one of the most challenging, she noted. "Assessing swallowing is not an objective measurement that is dependent on observation, listening and accurate interpretation; it's a physiological process. Training the screener to understand all the components of what they're looking for is a huge challenge."
MGH is in the process of establishing competencies for the nurses. "Our nurses watched the Web-based training and took the pre- and post-tests, but we're trying to get them all up to speed on being observed in administering the tool," stated Goldsmith.
The training and screening process must be collaborative to be successful, according to Cohen. "There's no way that only a speech-language pathologist or speech-language pathology department can make this work. From the very beginning it has been a collaborative effort with neurologists, nurses and speech-language pathologists."
The goal is for the screening tool to become part of the nursing routine.
Collaboration between the nursing and speech departments has been formalized at Good Shepherd Rehabilitation Hospital inAllentown, PA. Clinical specialist Sherri Repsher, MS, CCC-SLP, educates the nursing staff through group and individualized inservices on a regular basis. This includes checking their competency on safe swallowing and aspiration precautions.
"We're with the patients, hopefully, for an hour a day; but nurses are with them all day," she said. "Nursing needs education all the time, and dysphagia is a huge part of it because it affects the patient's safety."
The relationship between the two departments is simple. Speech-language pathologists provide treatment and recommendations, and nursing provides supervision.
"Our role is to determine what is appropriate for the patient," Repsher explained. "We educate and train the patient, but it's nursing's responsibility to supervise carry-over with the patient during mealtime."
If a swallow evaluation is warranted by an RN, nurse practitioner or physician, the speech-language pathologist establishes the patient's safest diet level and discusses safe swallowing techniques with nursing. All of the information is placed on a swallowing instruction sheet in a Communication Binder that the departments pass back and forth.
"We write down the patient's diet level and any safe swallowing strategies that we feel need to be implemented with the patient during the meal," said Repsher.
In each dining room a trained certified nursing assistant (CNA) is assigned to a supervision table and uses the information on the swallowing instruction sheet to ensure the patients eat safely. The CNA adds specific comments, such as if patients are having difficulty during the meal.
The facility offers dysphagia groups for patients. Speech-language pathologists instruct patients on compensatory strategies and safe swallowing techniques. They assess the safety of the patient's swallow and increase the diet level as tolerated.
When appropriate, the nursing staff is given a demonstration on how to carry out these instructions.
"We show them what the patient needs to do," said Repsher. "If the nursing assistant is in the dining room at the same time that we're at the supervision table, we would instruct the nursing assistant on the strategies the patient needs to use."
This information is then included in the Communication Binder.
The Illinois Neurological Institute at OSF Saint Francis Medical Center, in Peoria, has a written swallow screening protocol in place. Included is a checklist of pre-existing factors that patients may present with, including distractibility, drooling and intubation during current admission. If patients meet these criteria, they are labeled as NPO (nothing per oral), protocol is discontinued, and a speech therapy consult is ordered.
Per the swallow screening protocol, nurses start the patient on applesauce, move on to liquids, and then to a solid food. If a patient can tolerate presented items without signs of aspiration, nurses initiate a mechanical soft diet.
Most of the neurology nurses at the medical center are aware of the characteristics of dysphagia. All nurses are given a checklist of overt signs of the disorder, such as pocketing of food, coughing or choking, or wet voice quality.
"We try to be overly cautious so they can check everything they possibly can if they think there's any suspicion of dysphagia," said Jessica Prochnow, MS, CCC-SLP.
If a patient is made NPO, the speech-language pathologist will perform a swallow evaluation and place the patient on a mechanical soft diet with thin liquids, if appropriate.
Speech-language pathologists continue to work closely with nurses following training.
"We're up on the floor everyday," said Nicole McKinley, MS, CCC-SLP. "Often they're in the room with us when we do bedside swallow evaluation."
A nursing swallow screening tool was in place even before the speech department got involved. The tool was developed by a staff nurse and refined by Prochnow and McKinley to assure it would be successful.
Initially, the nursing department was not consistent in its use of the protocol. As a result, the speech pathology department conducted inservices and completed extensive education on dysphagia. At times, nurses could observe bedside swallow evaluations, while speech-language pathologists observed nurses during screenings and offer feedback as appropriate.
"We answered their questions, and they saw what we were looking for specifically," recalled Prochnow.
Although bedside nurses have always had some responsibility in determining whether patients can eat or take medications, the swallow protocol met with some resistance from nurses, she said. "We added to their workload and responsibilities, and they don't like that. Some are nervous about doing something like this, which is completely understandable."
Strong collaboration between the two departments helped to overcome the initial resistance, and things have gone smoothly since then.
"We're not asking nurses to do something that they haven't been asked to do before," said Cohen. "They now have an evidence-based tool to assist in the process, and a better formula for trying to figure out if it's safe for the patient to eat."
1. The Joint Commission. (2007). Stroke Performance Measurement Implementation Guide. Available at www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/guide_table_contents.htm.
For More Information
Audrey Kurash Cohen, e-mail: firstname.lastname@example.org
Tessa Goldsmith, e-mail: email@example.com
Nicole McKinley, e-mail: Nicole.A.McKinley@osfhealthcare.org
Jessica Prochnow, e-mail: Jessica.M.Prochnow@osfhealthcare.org
Sherri Repsher, e-mail: firstname.lastname@example.org
Jason Mosheim is an Associate Editor at ADVANCE. He can be reached at email@example.com.