1. Impetus for Dysphagia Nursing QUERI RRP Anna C. Alt-White, PhD, RN Office of Nursing Services

2. 2006 OIG Report “Evaluation of the Management of Patients with Feeding and Swallowing Problems in VHA Facilities” found not all initial nursing assessment forms triggered referrals when feeding/ swallowing problems identified

3. Why the Concern?? ~ 300,000-600,000 people have dysphagia from neurological disorders 51-73% of patients with stroke & 75% of nursing home residents have dysphagia Without intervention - 43-54% of these stroke patients/residents experience aspiration >60,000 people die/year from complications related to dysphagia

4. Consequences of Dysphagia Poor nutrition or dehydration Aspiration pneumonia or chronic lung disease Diminished enjoyment of eating or drinking Embarrassment Isolation in social situations involving eating

5. VHA Response Interdisciplinary task group (SLP, RNs, Dietitians) charged with developing policy Outcome - VHA Directive 2006-032: Management of Patients with Swallowing (Dysphagia) or Feeding Disorders

6. VHA Directive 2006-032 Defines policy and procedures for patients/ residents with dysphagia or feeding disorders: –Assess appropriately –Refer for diagnostic evaluation (as needed) –Treat –Manage –Monitor –Follow-up Throughout continuum of care –In patient –Outpatient –Long Term Care

7. VHA Directive 2006-032 Specifically mandated that nurses conduct an “initial Assessment which includes an evaluation for swallowing and feeding problems” on all patients admitted to an acute care setting within the first 24 hours of admission

8. VHA Directive 2006-032 Assessment defined as: the screening for the presence of risk factors by means of self-report, clinical history, or clinical observation.

9. Acute Care Dysphagia Screen Acute Care Dysphagia Screen Part 1. Risk Factors: a. If any present keep NPO. Consult clinician and refer to Speech Pathology –Decreased consciousness –Decreased orientation –Unable to follow simple commands –Severe facial weakness –Unable to control saliva (drooling) –Weak, absent or unusual cough –Abnormal or absent speaking voice –Poorly articulated speech

10. Acute Care Dysphagia Screen Part 1. Risk Factors (continued): b. If either of two factors below are noted, test swallow, using the procedure below, even if all risk factors are negative b. If either of two factors below are noted, test swallow, using the procedure below, even if all risk factors are negative –Cough after swallow –Voice change after swallow

11. Acute Care Dysphagia Screen Part 2. Swallow Testing Procedures Sit patient up at least 45 Degrees. Offer a cup of water and say: –Take a sip –Take a mouthful –Drink as you would normally For each part of swallow test- If coughing or change of voice, STOP, Keep NPO

12. Acute Care Dysphagia Screen Part 3. When procedure completed: –If ANY abnormality observed, consult MD/health care clinician and refer to Speech Pathologist –For ALL patients kept NPO follow clinician‘s orders or local protocol –If NO abnormality observed consider diet at discretion of admitting team –If ANY deterioration in neurological status, then repeat screen and notify attending medical officer

13. Controversy over Swallow test –Within Nursing –Among disciplines

14. Office of Nursing Services Recognized need to identify evidence of risk factors and best practices for screening Recognized need to identify evidence of risk factors and best practices for screening Urged investigators to submit application for Nursing QUERI RRP