The Joint Commission requires, as one of its stroke performance measures, that "a screen for dysphagia should be performed on all ischemic/hemorrhagic stroke patients before being given food, fluids, or medication by mouth" (Joint Commission, 2006). In response to this requirement, many speech-language pathologists have become involved in designing and operating dysphagia screening programs for patients with stroke.
The strong interest in dysphagia screening was clearly evident at the recent 2006 ASHA Convention in Miami, with presentations on this topic including a short course, two mini-seminars and several posters. A strong interest in the topic of dysphagia screening also became apparent to the Steering Committee of ASHA's Special Interest Division 13, Swallowing and Swallowing Disorders during the summer of 2006, as evidenced by a review of recent e-mail activity on the division's electronic discussion list.
Screening vs. Clinical Bedside Exam
Many clinicians struggle with the differentiation between screening and a clinical bedside exam. For some, the clinical dysphagia or bedside exam is the equivalent to a swallow screening. To others, the term "swallowing screening" may imply a minimally invasive evaluation procedure that provides quick determination of:
- the likelihood of the presence of dysphagia
- the need for a full swallow assessment
- whether it is safe to feed the patient orally
- whether a referral for nutritional support or hydration is warranted
ASHA's Preferred Practice Pattern on Swallowing Screening states: "Swallowing screening is a pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services" (ASHA, 2004, p. 3-1). The process is described as including interview, observation, and formulation and communication of results and recommendations. It should be noted that Medicare guidelines define a "screening" as a "hands-off" assessment. Most screening procedures described in the literature have focused on identifying overt signs of aspiration, not on addressing the above-mentioned items.
The Joint Commission performance indicator on swallow screening has heightened the awareness of the need to develop a screening tool, identify who is to perform it, and differentiate it from the assessment conducted by the SLP when called in for a consult (be it via a clinical bedside evaluation and/or an instrumental exam).
The Division 13 Steering Committee sought input from affiliates through the electronic discussion list. Input was received from affiliates who worked in Joint Commission-accredited stroke centers or facilities that were planning to seek Joint Commission accreditation. The responses indicated four different models of swallowing screening:
- Model A. The SLP trains nursing staff to conduct swallowing screenings, and patients who fail are referred to speech-language pathology for a comprehensive swallowing assessment.
- Model B. The physician performs swallowing screening in the course of his/her regular medical evaluation and requests further swallowing assessment by the SLP when signs of swallowing difficulty are observed. Physician swallowing screening tends to be less structured than swallowing screening conducted by nursing staff.
- Model C. Model A or B followed by an automatic referral within a specific time frame (often 24-48 hours) for swallowing assessment by an SLP for all patients, regardless of screening results.
- Model D. All patients are automatically referred to speech-language pathology for swallowing screening or assessment.
Of the four possible swallowing screening models listed above, Model A (in which nurses are trained to perform screening) has received the most attention in research studies. Two sessions at the 2006 ASHA Convention highlighted research in this area. In Canada, Martino and colleagues have designed an extensive eight-hour training program for nurses to perform screening procedures using a tool known as the TOR-BSST. The accuracy of screening results has been studied in comparison to videofluoroscopy. In Boston, SLPs at the Massachusetts General Hospital (MGH) have compared the results of swallowing screenings performed by specially trained neuroscience nurses to the results of endoscopic evaluation of swallowing. A specific outcome of the MGH research has been the development of a short self-study Web-based training program for nurses.
The literature primarily describes quick bedside procedures that probe pharyngeal sensation (e.g., gag reflex tests) or observe the patient for overt signs of difficulty during trial swallows of water. In designing a swallowing screening program, it is important to consider the performance of that procedure on the following measures:
- Construct validity: whether the swallowing screening procedure measures the intended phenomenon-in this case, the presence or absence of signs of dysphagia.
- Sensitivity: the number of patients with a swallowing problem who are correctly identified as having a swallowing problem by the screening procedure.
- Specificity: the number of patients with no swallowing problem who are correctly identified as having no swallowing problem by the screening procedure.
Two systematic reviews have found a lack of evidence that any one screening procedure has good accuracy in detecting dysphagia (Martino, Pron, & Diamant, 2000; Perry & Love, 2001). The nature of dysphagia, and especially silent aspiration, means that no screening procedure will be able to match the accuracy of comprehensive clinical and instrumental swallowing examinations in identifying the presence of swallowing difficulties.
SLPs implementing a screening protocol report challenges encountered with each of the models, including providing adequate training for nursing staff, the timely availability of speech-language pathology staff, and turnover of staff trained to perform the screening. Regardless of who performs the screening, one of the biggest challenges is determining how medication—in particular, those that can be administered only by mouth—can be administered to a patient who has failed the screening but who has not yet been assessed by the SLP. Facilities also report some resistance by medical staff to keeping all patients with stroke from taking anything by mouth until screened. This reluctance seems problematic, especially for patients who have had a transient ischemic attack (TIA) and appear to have no deficits at all.
Regardless of the model chosen and training methodology employed, there are limitations to screening. There will be false positive and false negatives. Patients' status may change after the screening. However, the Joint Commission requirement for patients with stroke to remain NPO (e.g., nothing by mouth) until screened for dysphagia has thrust dysphagia programs, typically led by a speech-language pathologist, into the forefront of patient care. This affords a wonderful opportunity for SLPs to demonstrate their knowledge and skills, become involved in dysphagia research, and take a leadership role in the management of patients with dysphagia.