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

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slide1

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

mgh sst team
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
slide4
Tool Development
  • Validation Study
  • Training / Implementation
2004 development of swallow screening
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

slide6

MGH-SST:

Part One

  • Wakefulness
  • HOB elevated
  • Stable breathing
  • Clean Mouth
  • STOP
  • NPO
  • Document
  • Re-screen

Yes

No

  • Proceed to Part 2
slide7

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

mgh sst management algorithm
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

slide10
Tool Development
  • Validation Study
  • Training/ Implementation
validation study subject recruitment
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

slide12

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

administration of screening
Administration of Screening
  • 3 research RN’s ; non-neuroscience nurses
  • Trained
  • High-degree of inter-rater reliability
      • ICC = 0.92
fees parameters
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

clinical ratings estimation of risk of dysphagia aspiration
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

clinical ratings estimation of risk of dysphagia aspiration1
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
clinical ratings estimation of risk of dysphagia aspiration2
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
procedures
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
sensitivity
Sensitivity

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

Sensitivity = 0.89

specificity
Specificity

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

Specificity = 0.61

positive predictive value
Positive Predictive Value

The likelihood of aspiration/dysphagia in subjects who failed swallow screening

PPV = 0.66

negative predictive value
Negative Predictive Value

The likelihood of no aspiration/dysphagia in subjects who passed swallow screening

NPV = 0.87

study conclusions
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
slide25
Tool Development
  • Validation Study
  • Training / Implementation
slide26

Training Module

Post-test

Chart Audits

Documentation

Systems Improvement

Visibility Campaign

Administration Support

Electronic Orders

Competencies/SkillsList

Demonstration