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Nursing Swallow Screen Validated for Detection of Dysphagia in
Acute Stroke Patients
Janet Carlson, RN, MSN
Melissa Hofmann, PhD
Financial Disclosures
We have no disclosures
Background
• The importance of screening for dysphagia in stroke patients is well established, yet an optimal tool has not been identified.
• The CCW (cough on command, control of saliva and water swallow) Swallow Screen builds on existing data for item selection.
Purpose
The purpose of the study was to compare the CCW Swallow Screen against the Gold Standard speech language pathology (SLP) swallow evaluation for detection of dysphagia in acute stroke patients.
Definitions• Dysphagia refers to swallowing disorders.
• Swallowing screening is a pass/fail procedure to identify individuals who require a swallow evaluation for comprehensive assessment of swallowing function. Swallow screening is usually performed by registered nurses.
• A clinical swallow evaluation is a behavioral assessment of swallowing function that consists of an extensive cranial nerve evaluation and direct examination of swallowing using food and liquids of various textures and consistencies. Swallow evaluations are performed by speech language pathologists (SLP).
CCW Swallow Screen
Item Response and Direction Rationale
Item Selection and RationaleBased on Review of the Literature
Pre-screen
Patient alert,
able to follow
commands,
and sit up?
Yes No Comment:
_________________________________
If No, STOP screening and re-evaluate
patient when appropriate and before
anything PO is given.
Determine if patient can
participate.
Earlier studies included
some measure of alertness
either as a pre-screen or
initial item.
Patients failing this item
were not included in the
study
Can the patient cough
when asked?
Yes No Comment:
_______________________________
If No, STOP screening. Keep patient
NPO. Obtain order for Speech
Therapy Swallow Evaluation
Non-swallow items:
volitional cough and
control of saliva
These items had
stronger agreement
with finding of
dysphagia in two
earlier studies.
Supports safety by
identifying patients at
higher risk for
aspiration.
Patient able to maintain
control of their saliva?
Yes No Comment:
_______________________________
If No, STOP screening. Keep patient
NPO. Obtain order for Speech
Therapy Swallow Evaluation
Item Response and Direction Rationale
Patient able to
swallow a teaspoon
of water?
Yes No Comment: Water swallow:
One teaspoon of water
Water swallow protocols in earlier
studies varied in amount of water
and number of trials. Beginning with
a teaspoon of water one time
supported feasibility.
Three-ounce water swallow
Earlier studies, that required drinking
3 ounces in uninterrupted fashion,
reported high sensitivity and
moderate specificity for predicting
aspiration.
This study did not specify drinking
water in an uninterrupted fashion,
with the hypothesis that higher levels
of specificity would be achieved
without sacrificing sensitivity.
Present patient with a teaspoon of water
If no attempt to swallow, water leaks out of mouth, coughs,
exhibits choking, breathlessness, clears throat, voice becomes
wet/hoarse or makes gurgling sounds: STOP screening. Keep
patient NPO. Obtain order for Speech Therapy Swallow
Evaluation
Patient able to
drink 3 ounces of
water ?
Yes No Comment:
Present the patient with a glass of water (3 ounces)
If no attempt to swallow, water leaks out of mouth, coughs,
exhibits choking, breathlessness, clears throat, voice becomes
wet/hoarse or makes gurgling sounds: STOP screening. Keep
patient NPO. Obtain order for Speech Therapy Swallow
Evaluation
If no problem swallowing water, test patient’s ability to chew
and swallow solid food.
Item Response and Direction Rationale
Patient able to
chew and swallow
solid food?
Yes No Comment: Solid food trial
Earlier studies varied in
inclusion of solid food,
some with direction to
observe first meal after
passing swallow screen.
Included to support
earlier SLP swallow
evaluation for patients
with difficulty in
swallowing solid food.
May test with crackers.
If coughing, pocketing food, or any
symptoms of choking on the solid
food: Keep the patient NPO. Obtain
order for Speech Therapy Swallow
Evaluation
If no problems, patient may have
oral intake. Check for a diet order.
Item Response and Direction Rationale
Methods
• Using the CCW Swallow Screen and SLP swallow evaluation outcome measures, a prospective correlation study was performed on a sample of 88 acute stroke patients. (SEM = 1.63).
• Inclusion required passing the CCW pre-screen component: be alert, follow commands and sit up.
• SLP swallow evaluation was completed within 3 hours after the nurse administered CCW screen, to support concurrent criterion-related validity.
• Data analysis included sensitivity and specificity, and positive (+LR) and negative (-LR) likelihood ratios.
• Specific statistics generated included chi-square (χ2), correlation (Phi ≥ .80).
• Inter-rater reliability (IRR) was supported by prior training, testing and competency validation of nurses, plus performance monitoring during data collection. IRR was computed with Cohen’s kappa.
Demographic Characteristics of the SampleDemographic Variables Subgroups N M/SD Frequency (%)
Age - 88 71.92/15.25 -
NIHSS Score - 88 5.55/6.60 -
Time Interval (Minutes) Between
Swallow Screen and SLP Evaluation
- 88 58.45/43.67 -
GenderMale
Female
88 - 48 (55)
40 (45)
CVA TypeIschemic
Hemorrhagic
88 - 78 (89)
10 (11)
CVA Location
Right Hemisphere
Left Hemisphere
Cerebellar
Brainstem
Other
88 - 34 (39)
36 (41)
6 (7)
2 (2)
10 (11)
Hospital-Acquired Pneumonia No
Yes
88 - 85 (97)
3 (3)
Results• CCW Swallow Screen correctly detected the presence and absence of dysphagia
• Sensitivity = 84%; Specificity = 95%)
• Likelihood ratios indicated strong certainty that dysphagia was present or not present
• +LR = 16.8; -LR = 0.17
• A statistically significant association between the CCW Swallow Screen and the SLP evaluation indicated that the CCW Swallow Screen and the SLP evaluation equally measured dysphagia in this stroke sample.
• χ2 (1) = 56.66, p < .001
• The association between the two tests was found to be strong
• Phi = .80
• IRR results revealed zero variance as both raters observed and passed all nurses in perfect agreement for competency validation and data collection observation.
• IRR = 1
Results – Summary Statistics Table
Statistical Test ResultsChi-Square (𝜒2)
Estimate
df
p
56.66
1
<.001
Phi Correlation .80
Sensitivity 84%
Specificity 95%
Positive Likelihood Ratio 16.80
Negative Likelihood Ratio 0.17
Discussion
•Specificity improved to 95% with the 3-ounce water swallow not taken in an uninterrupted fashion.
•Sensitivity remained high at 84%.Sensitivity in detecting dysphagia is especially important in avoiding the risk of aspiration.
Discussion - continued•Safety of the tool supported•Hospital acquired pneumonia – 3% of sample• False negatives (4) – None had clinical findings of
aspiration pneumonia •Pre-screening and the two non-swallow items
appeared to support safety
•Testing with solid food – Important component• Four (4) subjects failed at this point, indicating need
for SLP evaluation
Limitations•24/88 subjects failed the swallow screen
•Relatively small number of subjects who failed, could be attributed to study design• Subjects who failed pre-screen were excluded• Consent requirement excluded potential subjects with
more severe strokes who were unable to consent, and did not have a legally authorized representative available within the time constraints of the study.
• These exclusions may have had an unfavorable effect on sensitivity results.
Conclusions
•The CCW Swallow Screen is a reliable, valid tool for detection of dysphagia in acute stroke patients.
•The simplicity of the tool supports feasibility in a variety of clinical settings.
•Cross validation with a similar sample is warranted.
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