dysphagya screening.pdf

8/17/2019 dysphagya screening.pdf

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Dysphagia Screening: BedsideApplication and Mechanics of

Screening Tools

Jeff Edmiaston, M.S. CCC-SLP

January 31, 2012


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Objectives

Screening Tool Mechanics Specific Screening Tools

Bedside Application


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Screening in Acute Stroke


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+

_________

8


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8+ 0

_________

8


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+ + + + + ____ ____ _____ _____ _____

8 8 8 8 8


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0 1 2 4 5+ 8 + 7 + 6 + 4 + 3 ____ ____ _____ _____ _____

8 8 8 8 8


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What’s in a Screen?

15 Screens Reviewed 38 different components identified

Variation in length

Most Simple-1 Item

Most Complex-16 items


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Liquid Trial-93%

Level of Alertness-33%

Dysarthria-20%

Aphasia-20%

Facial Symmetry-27%

Tongue Symmetry/Fx-27%

Palatal Fx-20%

Gag-20%

Voluntary Cough-20%

Positioning-7%

Salivary Management-27%

Respiratory Fx-20%

Vocal Quality-27%

Swallowing Complaints-13%

Pulse Oximetry-7%

Stroke Location-7%

Nasal Regurgitation-7%

Eyes Reddening/Tearing-7%

Pneumonia Hx-7%

H/O Coughing with P.O.-20%

Oral Intake (Volume)-7%

Oral Intake (Rate)-7%

NPO Status-7%

Voice after Swallowing-20%

Confusion/Cognitive-7%

Solid Trial-13%

Pharyngeal Sensation-7%

Stroke Severity-7%

Cooperation-7%

Auditory Comprehension-7%

Cough Reflex-13%

Intubation/Recent Extubation-7%

Food Pocketing-7%

Suctioning Required-7%

Other-7%


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Specific Screens


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3 oz Water Swallow Test

Give patient 3 oz water to drink uninterrupted from acup

Observe for 1 minute after the swallow

Coughing

Wet/Hoarse Vocal Quality

*Depippo K, Holas M, Reding M: Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol. 1992;49:1259-1261

*Suiter D, Leder S.:Clinical utility of the 3-ounce water swallow test. Dysphagia 2008, 23: 244-250


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Burke Dysphagia

Screen


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Burke Dysphagia Screen

Pass/Fail Failure on any one item results in failure

*DePippo K, Holas M, Reding M: The burke dysphagia screening test: validation of its use in patients with stroke. Arch Phys Med Rehabil 1994;

75:1284-1286


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MasseyBedside

Form


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Massey Bedside Screening

Complete Pre-Assessment Form Administer single teaspoon of water

60cc glass of water

*Massey R, Jedlicka D.: The Massey Bedside Swallowing Screen. J. Neurosci Nurs. 2002; 34(5):252-253; 257-260


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Timed

Test


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Timed Test

GCS >13 Able to sit up

5-10ml of water to ensure safety

100-150ml as quickly as possible

Number of swallows counted

Timed

Abnormal=outside the 95% prediction interval for age

and sex or qualitative elements of coughing during orvoice change after the test*Hinds NP, Wiles CM: Assessment of swallowing and referral to speech and language therapists in acute stroke. QJ Med 1998; 91:829-835


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“Any Two”

Administer following liquid bolus amounts: 5ml

10ml

20ml

Administer twice for a total of 70ml


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“Any Two”

Presence of any two of the following indicators: Abnormal volitional cough

Abnormal gag reflex

Dysphonia

Dysarthria Cough after swallow

Voice changes after swallow*Daniels S, Lindsay B, Mahoney M, Foundas A: Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients.

Arch Phys Med Rehabil 2000; 81: 1030-1033


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Barnes Jewish Hospital Stroke Dysphagia

Screen (BJH-SDS)

5 items, each scored present/absent Presence of one, screen is failed

Failed screen-NPO with speech consult

Passed screen-Regular diet

*Edmiaston J, Tabor Connor L, Loehr L, Nassief A.: Validation of a dysphagia screening tool in acute stroke patients. Am J Crit Care, 2010; 19(4): 357-364.


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BJH-SDS


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MetroHealth Dysphagia Screen

Administered in the Emergency Department Pass/Fail Criteria

No liquid or solid trials administered


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MetroHealth Dysphagia Screen

1. Is alertness level insufficient to remain awake for 10 minutes while

sitting upright?

2. Is voice weak, wet, or abnormal in any way? (If cannot speak, circle

yes)

3. Does the patient drool?

4. Is speech slurred?

5. Is the patient’s cough weak or inaudible? (If cannot cough, circle yes)

________________________________________________

One or more “yes” answers are considered a positive screen for possible

dysphagia

*Schrock J, Bernstein J, Glasenapp M, Drogell K, Hanna J.: A novel emergency department dysphagia screen for patients presenting with

acute stroke. Academic Emergency Medicine 2011; 18:584-589


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Modified Mann Assessment of Swallowing

Ability

No food trials Scoring system: 0-100

Specific task instructions

Score 95, start oral diet and progress as tolerated,

monitor first oral intake. Consult SLP if issues Score ≤ 94, NPO and consult SLP

*Antonios N, Mann G, Crary M, Miller L, Hubbard H, Hood K, Sambandam R, Xavier A, Silliman S.: Analysis of a physician tool for evaluationdysphagia on an inpatient stroke unit: The Modifed Mann Assessment of Swallowing Ability. Journal of Stroke and Cerebrovascular Diseases; 201019(1): 49-57.


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Mann Assessment of Swallowing Ability

Patient Name:_________________________Date:_________________SLP:_______________________

MASA #:_____________ Score:_______________

Alertness 2=No responseto speech

5=Difficultto rouse

8=Fluctuates 10=Alert

Cooperation 2= Nocooperation

5=Reluctant 8=Fluctuatingcooperation

10=Cooperative

AuditoryComprehension

2=No responseto speech

4=Occasionalmotor response

6=follows simpleconversationwith repetition

8=followsordinary conversationlittle difficulty

10=No deficitsnoted

Respiration 2=Chestinfection

4=Coarse basalcrepitations

6=Fine basalcrepitations

8=Sputum in upperairway

10=Chestclear

Respiratory rate

for swallow1=No independentcontrol

3=Some controluncoordinated

5=Able to controlrate for swallow

Aphasia 1=Unable toassess

2=No functionalspeech

3=Expresses selfin limited mannershort phrase/words

4=Mild difficultyfinding words orexpressing ideas

5=No deficitsnoted

Apraxia 1=Unable toassess

2=Groping/inaccurate/partialor irrelevant response

3=Speech crude.defective inaccuracy or speed

4=Speech accurateafter trial and errorMinor searchingmovements

5=No deficitsnoted

Dysarthria 1=Unable toassess

2=Speechunintelligible

3=Speech intelligible but obvious defect

4=Slow withoccasional halting

5=No deficitsnoted

Saliva 1=Gross drool 2=Some droolconsistently

3=Drooling attimes

4=Frothy/expectorated

5=No deficitsnoted

Lip seal 1=No closureunable to assess

2=Incompleteseal

3=Unilaterally weak poor maintenance

4=Mild impairmentoccasional leakage

5=No deficitsnoted

Tongue

movement

2=No movement 4=Minimalmovement

6=Incompletemovement

8=Mild impairmentin range

10=Full rangeof motion

Tonguestrength

2=Grossweakness

5=Unilateralweakness

8=Minimalweakness

10=No deficitsnoted

Tongue

coordination

2=No movementunable to assess

5=Grossincoordination

8=Mildincoordination

10=No deficitsnoted

Oral

preparation

2=Unable toassess

4=No bolusformation, no attempt

6=Minimal chew,gravity assisted

8=Lip or tongueseal, bolus escape

10=No deficitsnoted

Gag 1=No gag 2=Absentunilaterally

3=Diminishedunilaterally

4=Diminished bilaterally

5=Hyperreflexive No deficits

Palate 2=No spreador elevation

4=Minimalmovement

6=Unilateralweakness

8=Slightasymmetry

10=No deficitsnoted

Bolus clearance 2=No clearance 5=Someclearance/residue

8=Significant clearanceminimal residue

10=Fullycleared

Oral transit 2=No movement 4=Delay >10 sec. 6=Delay >5 sec 8=Delay >1 sec 10=No deficit

Cough reflex 1=Unable to assess 3=Weak reflexivecough

5=No deficitnoted

Voluntary

cough

2=No attempt 5=Attemptinadequate

8=Attempt bovine

10=No deficitnoted

Voice 2=Aphonic, notable to assess

4=Wet/gurgling 6=Hoarse 8=Mild impairmentslight huskiness

10=No deficitnoted

Trach 1=Trach/cuffed 5=Trach/fenestrated 10=No trach

Pharyngealphase

2=No swallow 5=Pooling/gurglingIncomplete laryngeal

elevation

8=Mildly restrictedlaryngeal elevation

Slow initiation

10=Immediatelaryngeal elevation

Pharyngealresponse

1=Not coping/gurgling

5=Cough beforeduringor after swallow

10=No deficitnoted

Diet recommendations Regular Soft Selected soft Mechanical soft Puree No solid by mouth

Fluid recommendation Regular Thins only Nectar Honey No liquids by mouth

Original Mann Assessment of Swallowing Ability


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Alertness 10=Alert 8=Drowsy-fluctuating

awareness/alert level

5=Difficult to arouse

by speech or mvmt

2=Coma or

nonresponsvie

Cooperation 10=Cooperative 8=Fluctuatingcooperation 5=Reluctantcooperation 2=No cooperation/response

Respiration 10=Chest clear 8=Sputum in upper

airway

6=Fine basal

crepitations

4=Coarse basal

crepitations

2=Suspected

infections/ freq

suction/ respirator

dependent

Expressive

Dysphasia

5=No abnormality 4=Mild wording finding

difficulty

3=Expresses self in

limited manner

2=No functional

speech

1=Unable to assess

Auditory

Comprehension

10=No abnormality 8=Follows ordinary

conversation with

little difficulty

6=Follows simple

conversation

4=Occasional

response

1=No response

Dysarthria 5=No abnormality 4=Slow with

occasional hesitation

3=Speech intelligible

but defective

2=Speech unintelligible 1=Unable to assess

Saliva 5=No abnormality 4=Frothy/

expectorated in cup

3=Drooling at times 2=Some drool

consistently

1=Gross drooling

Tongue Movement 10=Full R.O.M. 8=Mild impairment 6=Incomplete mvmt 4=Minimal mvmt 2=No movement

Tongue Strength 10=No abnormality 8=Minimal weakness 5=Obvious unilateral

weakness

2=Gross weakness

Gag 5=No abnormality 4=Diminished

bilaterally

3=Diminished

unilaterally

2=Absent unilaterally 1=No gag response

Cough Reflex 10-No abnormality 8=Cough attempted

but hoarse in quality

5=Attempt inadequate 2=No attempt/unable

to perform

Palate 10=No abnormality 8=Slight asymmetry 6=Unilaterally weak 4=Minimal movement 2=No movement

Modified Mann Assessment of Swallowing Ability


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EATS

• Two Phases

Questionnaire

Food/Liquid Trials

• Must show no deficits in both phases to pass screen

Courtney B, Flier L.: RN dysphagia screening, a stepwise approach. Journal of Neuroscience Nursing 2009; 41(1):28-38


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EATS


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The Gugging Swallow Screen

Includes a semi-solid, liquid, and solid trial

Severity scoring system

Allows diet to be altered


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Figure I. GUSS.

Trapl M et al. Stroke 2007;38:2948-2952

Copyright © American Heart Association


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Figure I Continued.

Trapl M et al. Stroke 2007;38:2948-2952

Copyright © American Heart Association


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What Screen Should I Use?


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+ + + + + ____ ____ _____ _____ _____

8 8 8 8 8


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0 1 2 4 5+ 8 + 7 + 6 + 4 + 3 ____ ____ _____ _____ _____

8 8 8 8 8


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+ + + + + ____ ____ _____ _____ _____

8 8 8 8 8

Use only odd numbers to answer the question


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+ + _____ _____

8 8


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5 1+ 3 + 7

_____ _____

8 8


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Screening Purpose

Identify individuals with or at risk of swallowing

dysfunction following a stroke.


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Sensitivity vs. Specificity

Always a trade-off

Dysphagia screening is tilted towards sensitivity


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The Perfect Screen

Do you have stroke-like

symptoms?


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The Perfect Screen

100% Sensitivity to Dysphagia

0% Specificity to Dysphagia

Theoretical Result: Never a dysphagia related

complication

Bedside Result 6 out of 10 patients are angry!


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Not all bedsides are the same


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BJC Healthcare1. Alton Memorial

2. Barnes Jewish3. Barnes Jewish St. Peters

4. Barnes Jewish West County

5. Boone Hospital

6. Christian Hospital

7. Clay County Hospital8. Missouri Baptist Medical Center

9. Missouri Baptist Sullivan Hospital

10. Northwest Healthcare

11. Parkland Health Center

12. Progress West HealthCare Center13. Rehabilitation Institute of St. Louis

14. St. Louis Children’s Hospital

15. Siteman Cancer Center


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Barnes Jewish Hospital


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Stroke Fellow Neuroradiology & Neurosurgery

MRI, Angiography, PET Scanner

Dedicated Stroke Neurologists

Dedicated Stroke Nursing Unit Dedicated 20 Bed Neuro-ICU with Portable CT

Intra-operative MRI Suite

Two Stroke Nursing Coordinators

Dedicated Stroke Rehabilitation Services (PT,OT, andSpeech)

Administrative group dedicated to Neurosciences


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Clay County Hospital


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Factors that may effect screen choice

Availability of Speech Pathology

Availability of Radiology Services (i.e. Videofluoroscopy)

Volume of patients

Nursing numbers


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Fewer Resources Available

May be less tolerant of false positives

May be more comprehensive

May resemble an assessment rather than screen

Potentially more burden on nursing


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More Resources Available

May tolerate false positives

May be less comprehensive (pass/fail)

Potentially less burden on nursing


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No Perfect Screen

Perfection= 100% Sensitivity & 100% Specificity

There will be false positives

There will be false negatives

How many of each can be tolerated?


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What is a good Screen?

Valid

Reliable

Works for your setting


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Validity

External

Internal

Criterion

Content

Concurrent

Predictive

Content

Construct Face


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Reliability

Inter-rater Reliability

Test-Retest Reliability

Parallel-Forms Reliability

Internal Consistency


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What Works for You?

No numeric value to derive this

Dependent on multiple factors

Specific to a given institution


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Making a Decision

Expert Opinion

Data Driven-Dependent on quality of data

Group Consensus

Kepner-Tregoe Decision Matrix


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Timed Up

and Go

Timed Up

and Go (R)

Get Up and

Go

BJC Get Up

and GoEasily

Administered

Valid

Reliable

Easily

Documented

Sensitivity/Spec

ificity (5)

Evidence Based

(10)


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Timed Up

and Go

Timed Up

and Go (R)

Get Up and

Go

BJC Get Up

and GoEasily

Administered

x x x

Valid x x X X

Reliable x x

Easily

Documented

x x x x

Sensitivity/Spec

ificity (5)

5 5 5

Evidence Based

(10)

10 10 10 10

K T Analysis of Swallow Screens


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3 oz

water

Massey Timed

Test

Burke

Screen

Metro

Health

Any

Two

EATS Mini

MASA

GUSS BJH

SDS

Sensitivity>90%

Face Validity

Easy to

administer

Reliable

Concurrent

Validity

Scoring

Severity

Easy to learn

Specificity

>50%

K-T Analysis of Swallow Screens


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Barnes Jewish Hospital- KT Matrix

3 M Ti d B k M t A EATS Mi i GUSS BJH


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3 oz

water

Massey Timed

Test

Burke

Screen

Metro

Health

Any

Two

EATS Mini

MASA

GUSS BJH

SDS

Sensitivity

>90%

Face Validity

Easy to

administer

Reliable

Concurrent

Validity (8)

Scoring

Severity (1)

Easy to

learn (10)

Specificity

>50% (5)

3 M Ti d B k M t A EATS Mi i GUSS BJH


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3 oz

water

Massey Timed

Test

Burke

Screen

Metro

Health

Any

Two

EATS Mini

MASA

GUSS BJH

SDS

Sensitivity

>90% X X X X X X X X X X

Face ValidityX X X X X X X X

Easy to

administer X X X X X X X

ReliableX X X X X X X X X X

Concurrent

Validity (8)

Scoring

Severity (1)

Easy to learn

(10)

Specificity

>50% (5)


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Massey Timed TestBurke

ScreenAny Two BJH SDS

Sensitivity >90%X X X X X

Face ValidityX X X X X

Easy to administer X X X X X

ReliableX X X X X

Concurrent

Validity with

MBS/FEES (8)0 0 0 8 8

Scoring Severity

(1) 0 0 0 0 0

Easy to learn (10) 10 10 10 10 10

Specificity

>50% (5) 5 5 0 5 5

TOTAL 15 15 10 23 23


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Clay County Hospital-KT Matrix

3 oz Massey Timed Burke Metro Any EATS Mini GUSS BJH


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3 oz

water

Massey Timed

Test

Burke

Screen

Metro

Health

Any

Two

EATS Mini

MASA

GUSS BJH

SDS

Sensitivity

>90%

FaceValidity

Easy to

learn

Specificity

>50%

Reliable

Concurren

t Validity

Scoring

Severity

Easy to

administer

3 oz Massey Timed Burke Metro Any EATS Mini GUSS BJH


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3 oz

water

Massey Timed

Test

Burke

Screen

Metro

Health

Any

Two

EATS Mini

MASA

GUSS BJH

SDS

Sensitivity

>90% X X X X X X X X X

Face ValidityX X X X X X X X X X

Easy to learnX X X X X X X X X X

Specificity

>50% X X X X X X X

Reliable

Concurrent

Validity

Scoring

Severity

Easy to

administer

Ti d M t A Mi i BJH


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MasseyTimed

Test

Metro

Health

Any

Two

Mini

MASAGUSS

BJH

SDS

Sensitivity >90%X X X X X X X

Face ValidityX X X X X X X

Easy to learnX X X X X X X

Specificity

>50% X X X X X X X

Reliable (2)2 2 2 2 2 2 2

Concurrent Validity

with MBS/FEES (10) 0 0 10 10 10 10 10

Scoring Severity (8)

0 0 0 0 0 8 0Easy to administer

(4) 4 4 4 4 4 0 4

TOTAL 6 6 16 16 16 20 16


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Conclusion

Much research has been done

Many screens, most are pretty good

When choosing a screen, be objective and systematic

There is no “best” screen

The best screen is the one that is best for your institution

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