1. 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

2. 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
Many inovlved

3. “Stroke survivors should be screened using an evidence based tool.”
Margaret Grant of APSS, to me your charge
We had a similar charge when we started several years ago at the MGH,
Share our process/ developed.

4. Training / Implementation
Tool Development
Validation Study
Training / Implementation
Tool development, how we validated our tool, and how we look at training and implementation.
Start with the MGH-SST itself.

5. 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; Perry, 2001
The high incidence of dysphagia in the first weeks after stroke and the subsequent increased mortality risk secondary to aspiration pna well recognized in the literature (three times) (Singh and Hamdy, 2005, Katzan et al 2003).
Importance underscored by regulation guidelines that screening swallowing in all acute stroke patients prior to food, liquid or oral meds is imperative for safe, quality stroke care.
in no validated dysphagia screening tools. Available screenings were either too focused, i.e. on cough with water, or too detailed and involved multiple behavioral observations.
Our goal: to develop an evidence based swallow screening tool including items with high sensitivity to aspiration.
Items simple to administer; readily incorporated into daily practice.

6. MGH-SST: Part One Wakefulness HOB elevated Stable breathing
Clean Mouth
Components of MGH-SST
Two tiered
Hemodynamic stability
STOP
NPO
Document
Re-screen
Yes No
Proceed to Part 2

7. Pharyngeal Sensation:
MGH-SST: Part Two
Tongue Movement:
1 point
Water Swallowing:
2 points
Total Score: 6
Pharyngeal Sensation:
1 point
Volitional Cough:
1 point
Part two
5 clinical features to assist in determining if your patient is safe to start and oral diet and to take meds orally.
A positive screen is a fail ( a score of 4 or less).
Vocal Quality:
1 point
RESULTS:
Pass: 5 or 6 points
Fail: < 4 points

8. 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

10. Training/ Implementation
Tool Development
Validation Study
Training/ Implementation
Plagued by the question of did our screening test what we want it to test? —
Screening is a triage—to categorize patients as high risk or low risk for aspiration, do patients who pass really have “low risk” for aspiration and patients who fail really have “high risk” for aspiration?
Resources and institutional review board approval to complete a validation study.

11. Validation Study: Subject Recruitment
1868 consecutive Neuroscience admissions
(August April 2007)
253 met inclusion criteria
129 refused
124 consented
100 subjects completed testing; 52 stroke
Subject enrollment on three dedicated neuroscience inpatient units, including a neuroscience ICU.
All neuroscience consecutive admissions within 72 hours of admission.
In order to be enrolled in our study, subjects needed to be alert, stable, able to sit up and medically cleared for an endoscopic swallowing evaluation.
Excluded if they were obtunded, hemodynamically unstable, tracheostomized/intubated or considered at high risk for nose bleeds.

12. Study Cohort Subject Characteristics Diagnoses N= 37 males, 63 females
Age range: yrs, mean age 63 years
Neuromedical 72
Neurosurgical 28
Diagnoses
CVA/TIA 52
SAH/SDH/Aneurysm 15
Neoplasm 13
Degenerative
Cervical spine dysfunction
Seizures
Other (vasculitis, encephalitis etc) 5
early detection of aspiration risk is prudent in all patients with neurologic disease; include all comers to our neuromedicine and neurosurgical services.

13. Administration of Screening
3 research RN’s ; non-neuroscience nurses
Trained
High-degree of inter-rater reliability
ICC = 0.92
Administered by one of three research nurses; trained with a high degree of inter rater reliability using a web based tutorial and direct observation by the study SLP

14. Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
FEES as reference or “gold” standard.
Convenience at the bedside, didn’t require moving acute neuro patients to radiology, already part of our customary practice at MGH, allows direct observation of the pharynx and larynx.
Study was videorecorded for later analysis.
Patient was fed various trials of green dyed milk, pudding and cookie if deemed safe.
Range of sensitivities that has been reported under different conditions (0.88).Some studies have cited even higher sensitivities (leder 96%)

15. 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
The endoscopic videorecordings reviewed after data collection by three SLP’s for the presence and absence of these standard parameters.
Secretions present in larynx
Bolus fills vallecular space, reaches pyriform sinuses or touches laryngeal rim before swallow is triggered
3.Bolus enters the laryngeal vestibule over the rim of the larynx; Remains above true vocal folds
4.Bolus passes below the true vocal folds
5. More than a coating of the bolus remains in the vallecular space, pyriform sinuses and/or on the posterior pharyngeal wall after the swallow
*******************************************************************************************************
Definitions:
1. Secretions observed in the larynx before giving food or liquid. Presence highly predictive of subsequent aspiration of food or liquid
Murray et al developed a four point rating scale to describe accumulated oropharyngeal secretions in a retrospective study of 69 patients
Donzelli et al 100 consecutive patients, and performed endoscopic swallowing evaluation. Found that 86% of their patients who demonstrated laryngeal penetration and aspiration of their own secretions aspirated or showed laryngeal penetration on food or liquid.
2. Bolus fills vallecular space, reaches pyriform sinuses or touches laryngeal rim before swallow is triggered
(Langmore, 2005)
Percentage of the bolus that reached these locations
> 50% is considered delay
Dwell time (Langmore, 2005)
Penetration (Langmore, 2005)
A speck in the larynx was not counted
4.Bolus passes below the true vocal folds Aspiration: Bolus noted transglottically
Bolus pouring over the post-cricoid region below the true vocal folds
5. More than a coating of the bolus remains in the vallecular space, pyriform sinuses and/or on the posterior pharyngeal wall after the swallow. If the patient swallowed spontaneously to clear, scored as normal)

16. Clinical Ratings – Estimation of Risk of Dysphagia/Aspiration
Category I :
No clinical concerns
No functional swallowing deficits
Safe to start unrestricted oral diet without further evaluation
Based on review of the endoscopic recordings.
Subject assigned to one of three clinical ratings; categorizing as safe to eat unrestricted or needs further evaluation.
Category I were patients without clinical risk for aspiration and were felt safe to begin an oral diet without limitations.

17. 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
Category II : endoscopic study results were of moderate clinical concern due to risk of aspiration.
Patients not safe to feed until a comprehensive swallow evaluation better determined their swallowing ability.

18. 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
Category III: significant clinical concern with visualized aspiration.
Patients deemed unsafe for oral intake; required comprehensive swallow evaluation to assist with proper management.

19. 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
Subject enrolled and consented, swallow screening, and FEES.
Blinded to patient characteristics and to the results of the other’s testing.
Time between the two exams ranged from 5 minutes to 5 hours with median time 1.5 hours

20. Sensitivity Sensitivity = 0.89
Presence of a failed screen when there is true dysphagia/aspiration as detected on endoscopic evaluation (category II or III)
To determine sensitivity, specificity and predictive value: Pass/Fail results of the RN swallow screening compared to Clinical Category ratings
Clinical categories II and III grouped together as unsafe to start an oral diet.
41 of 46 subjects in clinical category II or III (dysphagia—do not feed) failed the swallow screen. (True positives)
Sensitivity 89%.
Sensitivity = 0.89

21. Specificity Specificity = 0.61
The presence of passed screen when there is no aspiration or dysphagia detected on endoscopic evaluation (category I)
33 out of 54 patients placed in clinical category of I (no dysphagia—considered safe to feed ) based on endoscopic results also passed the screen (True negatives)
Specificity= 33/33+21=.61
9 false positives= patients who failed the swallow screening but did not have visualized aspiration or dysphagia on the endoscopic evaluation.
May lie in the fact that some neuro patients are unable to accurately complete the screening items due to comprehension or motor planning deficits ; failed the screening in the absence of a true dysphagia.
Specificity = 0.61

22. Positive Predictive Value
The likelihood of aspiration/dysphagia in subjects who failed swallow screening
If you obtain a positive result on the screen (i.e. a failed screen), there is a 66% chance that the patient truly has dysphagia.
(41/41+62=.66)
Making some patients NPO who don’t need to be—but much safer than risk of missing aspirators
PPV = 0.66

23. Negative Predictive Value
The likelihood of no aspiration/dysphagia in subjects who passed swallow screening
Most important, negative predictive value, ( probability of not having aspiration or dysphagia if the screening is passed) = 87%.
I.e. 87% certain that if a patient passes the swallow screening, they can safely eat a diet unrestricted.
Stroke cohort results to overall study population, no substantive differences
NPV = 0.87

24. 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
MGH-swallow screening tool accurately identifies acute neuroscience patients who are safe to eat.
Patients with questionable swallowing ability, are protected until a more comprehensive swallow evaluation can be done by the SLP.
MGH swallow screening is highly sensitive and easy-to-use when performed by trained nurses.

25. Training / Implementation
Tool Development
Validation Study
Training / Implementation
Clinical experience shows us that comprehensive and ongoing training module is imperative for the success.
Best designed tool less effective unless staff performing the screening are fully trained and competent

26. Competencies/Skills List Demonstration
Training Module
Post-test
Chart Audits
Documentation
Systems Improvement
Visibility Campaign
Administration Support
Electronic Orders
Swallow screening is a high risk test with low knowledge.
Background info on swallowing and dysphagia—a foundation upon which to place the screening
Aspiration pneumonia- causes , rates, impact of individual role
Oral care- Stress connection between oral care and pna
Clarify the role of a screening vs. comprehensive swallow evaluation (assesses the swallowing physiology, as well as determines a treatment plan and determines possible etiologies and prognosis.)
Clinical items—rationale for each, simulated patients, demonstrations
How to determine if staff have learned what we want them to learn.
How to maintain skills over time?
Don’t know if better with a 30 minute training vs. 8 hour, vs. 5 minutes— what is really critical—Not training dysphagia specialists.
Beyond the scope of this talk but critical to the success are “systems improvement” or process issues—ensuring that screening is done, that it’s done properly, that results are documented, that results of screening drive diet orders
Competencies/Skills List
Demonstration