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System Redesign of the Dysphagia Screening Tool at Richard L. Roudebush VA Medical Center. Stroke QUERI Dawn Bravata, MD Virginia S. Daggett, MSN, RN Teresa Damush, PhD Laura Plue, MS Scott Russell, BS

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system redesign of the dysphagia screening tool at richard l roudebush va medical center
System Redesign of the Dysphagia Screening Tool at Richard L. Roudebush VA Medical Center

Stroke QUERI

Dawn Bravata, MD

Virginia S. Daggett, MSN, RN

Teresa Damush, PhD

Laura Plue, MS

Scott Russell, BS

George Allen, MS

Neale Chumbler, PhD

Heather Woodward-Hagg, MS

Linda Williams, MD

Frontline Clinical

Staff

Celine Alba-Patina, RN

Tamra Arnold, Pharm-D

David Bickel, RN, CAC

Anna Bober, RN

Randi Bruns, RN

Rebecca Chapman, SLP

Vonda Coley-Mathews, RN

Jan Korte, RN

Diane Longerbone, Dietician

Katherine Sisk, RN

objective
Objective

Describe use of Lean methodology to redesign dysphagia screen by a frontline, multidisciplinary staff in response to OIG directive.

six sigma lean methodology deming philosophy
Six Sigma Lean Methodology: Deming Philosophy

Six Sigma = 3.4 per million units

Five Sigma = 230 per

million units

Four Sigma = 6,210 per million units

Three Sigma = 66,800

per million units

Two Sigma = 308,000

per million units

One Sigma = 690,000 per million units

Most VA Performance

Measures

slide4

National Agencies or Organizational Standards & Guidelines

  • OIG Dysphagia Directive:

“…Nursing assessment…must be conducted on all incoming patient within 24 hours of admission at all VA facilities…”

  • JCAHO Requirements:

“A screen for dysphagia should be performed on all ischemic/hemorrhagic stroke patients before being given food, fluids, or medication by mouth.”

  • American Speech-Language-Hearing Association (ASHA) literature
slide5

Current State at Roudebush VAMC

Dysphagia treatment/management processes are not

effective, resulting in:

  • Dysphagia screening tool is inadequate (sensitive but not specific).
  • Too many people place on NPO upon admission.
  • Additional burden on nursing and speech/language pathology staff.
  • Inadequate outpatient follow-up for dysphagia.
  • Delay in administration of oral medications.
  • Confusion with respect to diet requirements upon

discharge and positive screens.

slide6

Voice of the Customer

RNs:

  • Screen is not user friendly
  • RNs feel frustrated when consult is cancelled by physician; “Waste of time”
  • Screen Questions do not pertain to the patient

Physicians:

  • Physicians not aware of the screen; rely on H&P

Dieticians:

  • Staff not aware of the assessment; patients not on NPO; trays are wasted
process mapping current state pre assessment
PROCESS MAPPINGCURRENT STATE PRE-ASSESSMENT

Family

Providing

Food

Wait for

CT

Room

Cleaning

Med Pass

Delays

ER Delays

Order

Delays

Admit RN Conducts Assessment

Patient

Has Orders?

Diet

Order?

Admit

RN?

Patient Enters Hospital

Patient Assigned to Ward

Orders Initiated

5S:

No Admit RN

Until 10:30a

Yes

Prior to

2:30pm?

No

RN Assigned Conducts Assessment

Call Resident

slide8

Current State Process Map

Assessment  Order Consult

Other

Patient

Needs

No Consult

To Surgery

RNs not

Screening

Correctly

Stroke

History

Lack of

Education

Lack of

Communication

H&P

Impact

Assessment

RN Not

Checking Consult

Box

No RN

Policy

Dr.

Approves

Consult?

NPO

Order

Signed?

Positive

Screen?

Order

Consult?

Dysphagia

Assessment

Conducted

RN Makes NPO

Clinical

Judgment

Clinical

Status

Change

Patient

Not Labeled

NPO

MD Cancels

Order

RN Choice

Per Policy

RN Contacts Dr for Order

RN

Distractions

Questions

Not

Appropriate

No Policy

To Call

Using

Previous

Assessment

Admit

RN

Capacity

Unconscious

Assessment

No

Sip Test

time to admission assessment
Time to Admission Assessment

Range = 1 hour to 12 hours

slp consults by month
SLP Consults by Month

- 98% of Admissions Screened

- 8.2% of Admissions

Screened Positive

Dysphagia

Screen

Starts

time from consult to slp assessment
Time from Consult to SLP Assessment

28% (4/14) of observed patients

were found to not have dysphagia

by SLP

slide13

Current State Summary

  • ~50% of all observed patients (N=8) arrived on unit without orders
  • Admission Assessment occurs an average of 3 hours following Assessment (range 1-12 hours)
  • 2030/2071 (98.0%) of all veterans admitted to the facility received screening
  • 166/2030 (8.2%) had a positive screening
  • 46% of observed patients (N=14) were put on NPO following a positive screen   
  • 28% (N=14) of observed patients that failed screen were found to not have dysphagia
slide17

Usability Testing

  • Patient Actors were used to provide consistent responses to each of the Users.
  • Eight Users (RNs) interviewed each of the eight Patient Actors once, using the old design four times.
  • Ordering of patients and test designs were balanced to offset learning factors.
usability testing layout
Usability Testing Layout

Queue Area

with Snacks

Station 2

Observer

User

Patient Actor

Station 1

slide19

Usability Study Feedback

  • New design received consistently higher scores in user satisfaction
  • New design showed fairly consistent improvement in task time (~40 sec mean)
  • Old design performed similar screening, but did not perform similar consult ordering
  • New design showed an increase in unnecessary consults
usability study screenings
Usability Study Screenings
  • 2 consults missed
  • due to not checking
  • the consult box

- 5 false positive screens

due to patients with

difficulty ‘swallowing

large pills’

- False Negatives

screens due to one left

side paralysis patient

develop control plan
Develop Control Plan

Process Monitors:

  • Time from Admission to Dysphagia Screen
  • % of Patients placed on NPO following positive screen
  • Sensitivity of new screening tool

- Positive Rate

- False Positive Rate

- False Negative Rate

thoughts for discussion
Thoughts for Discussion
  • For hospitalized veterans with acute stroke, the re-designed dysphagia screen did not improve performance.
  • Change of patient status during hospitalization.
  • Context of the screen:

-what discipline in terms of patient safety,

work flow

-when/where in point of care

  • Consistency in policies: IG directive and JCAHO.
  • Is nursing performing a dysphagia screen or an aspiration risk assessment?