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Dysphagia Screening: Bedside Application and Mechanics of Screening Tools

Dysphagia Screening: Bedside Application and Mechanics of Screening Tools Jeff Edmiaston, M.S. CCC-SLP January 31, 2012
Jeff Edmiaston, M.S. CCC-SLP January 31, 2012

Jeff Edmiaston, M.S. CCC-SLP January 31, 2012

Objectives

Screening Tool Mechanics

Specific Screening Tools

Bedside Application

Screening in Acute Stroke

Screening in Acute Stroke

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What’s in a Screen?

15 Screens Reviewed 38 different components identified Variation in length

Most Simple-1 Item

Most Complex-16 items

Liquid Trial-93%

Level of Alertness-33%

Pneumonia Hx-7%

H/O Coughing with P.O.-20%

Dysarthria-20%

Aphasia-20%

Facial Symmetry-27%

Tongue Symmetry/Fx-27%

Palatal Fx-20%

Gag-20%

Voluntary Cough-20%

Positioning-7%

Salivary Management-27%

Respiratory Fx-20%

Vocal Quality-27%

Swallowing Complaints-13%

Pulse Oximetry-7%

Stroke Location-7%

Nasal Regurgitation-7%

Eyes Reddening/Tearing-7%

Oral Intake (Volume)-7%

Oral Intake (Rate)-7%

NPO Status-7%

Voice after Swallowing-20%

Confusion/Cognitive-7%

Solid Trial-13%

Pharyngeal Sensation-7%

Stroke Severity-7%

Cooperation-7%

Auditory Comprehension-7%

Cough Reflex-13%

Intubation/Recent Extubation-7%

Food Pocketing-7%

Suctioning Required-7%

Other-7%

Cough Reflex-13%  Intubation/Recent Extubation-7%  Food Pocketing-7%  Suctioning Required-7%  Other-7%

Specific Screens

3 oz Water Swallow Test

Give patient 3 oz water to drink uninterrupted from a

cup

Observe for 1 minute after the swallow

Coughing

Wet/Hoarse Vocal Quality

*Depippo K, Holas M, Reding M: Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol. 1992;49:1259-1261 *Suiter D, Leder S.:Clinical utility of the 3-ounce water swallow test. Dysphagia 2008, 23: 244-250

Burke Dysphagia Screen

Burke Dysphagia Screen

Burke Dysphagia Screen

Pass/Fail Failure on any one item results in failure

*DePippo K, Holas M, Reding M: The burke dysphagia screening test: validation of its use in patients with stroke. Arch Phys Med Rehabil 1994;

75:1284-1286

Massey Bedside Form

Massey

Bedside

Form

Massey Bedside Form

Massey Bedside Screening

Complete Pre-Assessment Form Administer single teaspoon of water

60cc glass of water

*Massey R, Jedlicka D.: The Massey Bedside Swallowing Screen. J. Neurosci Nurs. 2002; 34(5):252-253; 257-260

Timed Test

Timed

Test

Timed Test

Timed Test

GCS >13 Able to sit up

5-10ml of water to ensure safety 100-150ml as quickly as possible

Number of swallows counted

Timed

Abnormal=outside the 95% prediction interval for age

and sex or qualitative elements of coughing during or voice change after the test

*Hinds NP, Wiles CM: Assessment of swallowing and referral to speech and language therapists in acute stroke. QJ Med 1998; 91:829-835

“Any Two”

Administer following liquid bolus amounts:

5ml

10ml

20ml

Administer twice for a total of 70ml

“Any Two”

Presence of any two of the following indicators:

Abnormal volitional cough

Abnormal gag reflex

Dysphonia Dysarthria

Cough after swallow

Voice changes after swallow

*Daniels S, Lindsay B, Mahoney M, Foundas A: Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. Arch Phys Med Rehabil 2000; 81: 1030-1033

Barnes Jewish Hospital Stroke Dysphagia Screen (BJH-SDS)

5 items, each scored present/absent Presence of one, screen is failed

Failed screen-NPO with speech consult

Passed screen-Regular diet

*Edmiaston J, Tabor Connor L, Loehr L, Nassief A.: Validation of a dysphagia screening tool in acute stroke patients. Am J Crit Care, 2010; 19(4): 357-

364.

BJH-SDS

BJH-SDS

BJH-SDS

MetroHealth Dysphagia Screen

Administered in the Emergency Department Pass/Fail Criteria No liquid or solid trials administered

MetroHealth Dysphagia Screen

1. Is alertness level insufficient to remain awake for 10 minutes while

sitting upright?

2. Is voice weak, wet, or abnormal in any way? (If cannot speak, circle yes)

3. Does the patient drool?

4. Is speech slurred?

5. Is the patient’s cough weak or inaudible? (If cannot cough, circle yes)

One or more “yes” answers are considered a positive screen for possible

dysphagia

*Schrock J, Bernstein J, Glasenapp M, Drogell K, Hanna J.: A novel emergency department dysphagia screen for patients presenting with acute stroke. Academic Emergency Medicine 2011; 18:584-589

Modified Mann Assessment of Swallowing Ability

No food trials

Scoring system: 0-100

Specific task instructions

Score 95, start oral diet and progress as tolerated, monitor first oral intake. Consult SLP if issues

Score ≤ 94, NPO and consult SLP

*Antonios N, Mann G, Crary M, Miller L, Hubbard H, Hood K, Sambandam R, Xavier A, Silliman S.: Analysis of a physician tool for evaluation dysphagia on an inpatient stroke unit: The Modifed Mann Assessment of Swallowing Ability. Journal of Stroke and Cerebrovascular Diseases; 2010 19(1): 49-57.

Original Mann Assessment of Swallowing Ability

Mann Assessment of Swallowing Ability

Alertness 2=No response 5=Difficult 8=Fluctuates 10=Alert to speech to rouse Cooperation 2= No 5=Reluctant
Alertness
2=No response
5=Difficult
8=Fluctuates
10=Alert
to speech
to rouse
Cooperation
2= No
5=Reluctant
8=Fluctuating
10=
cooperation
cooperation
Cooperative
Auditory
2=No response
4=Occasional
6=follows simple
8=follows
10=No deficits
Comprehension
to speech
motor response
conversation
ordinary conversatio
noted
with repetition
little difficulty
Respiration
2=Chest
4=Coarse basal
6=Fine basal
8=Sputum in upper
10=Chest
infection
crepitations
crepitations
airway
clear
Respiratory rate
1=No independent
3=Some control
5=Able to control
for swallow
control
uncoordinated
rate for swallow
Aphasia
1=Unable to
2=No functional
3=Expresses self
4=Mild difficulty
5=No deficits
assess
speech
in limited manner
finding words or
noted
short phrase/words
expressing ideas
Apraxia
1=Unable to
2=Groping/
3=Speech crude.
4=Speech accurate
5=No deficits
assess
inaccurate/partial
defective in
after trial and error
noted
or irrelevant respons
accuracy or speed
Minor searching
movements
Dysarthria
1=Unable to
2=Speech
3=Speech intelligible
4=Slow with
5=No deficits
assess
unintelligible
but obvious defect
occasional halting
noted
Saliva
1=Gross drool
2=Some drool
3=Drooling at
4=Frothy/
5=No deficits
consistently
times
expectorated
noted
Lip seal
1=No closure
2=Incomplete
3=Unilaterally weak
4=Mild impairment
5=No deficits
unable to assess
seal
poor maintenance
occasional leakage
noted
Tongue
2=No movement
4=Minimal
6=Incomplete
8=Mild impairment
10=Full range
movement
movement
movement
in range
of motion
Tongue
2=Gross
5=Unilateral
8=Minimal
10=No deficits
strength
weakness
weakness
weakness
noted
Tongue
2=No movement
5=Gross
8=Mild
10=No deficits
coordination
unable to assess
incoordination
incoordination
noted
Oral
2=Unable to
4=No bolus
6=Minimal chew,
8=Lip or tongue
10=No deficits
preparation
assess
formation, no attemp
gravity assisted
seal, bolus escape
noted
Gag
1=No gag
2=Absent
3=Diminished
4=Diminished
5=Hyperreflexive
unilaterally
unilaterally
bilaterally
No deficits
Palate
2=No spread
4=Minimal
6=Unilateral
8=Slight
10=No deficits
or elevation
movement
weakness
asymmetry
noted
Bolus clearance
2=No clearance
5=Some
8=Significant clearance
10=Fully
clearance/residue
minimal residue
cleared
Oral transit
2=No movement
4=Delay >10 sec.
6=Delay >5 sec
8=Delay >1 sec
10=No deficit
Cough reflex
1=Unable to assess
3=Weak reflexive
5=No deficit
cough
noted
Voluntary
2=No attempt
5=Attempt
8=Attempt
10=No deficit
cough
inadequate
bovine
noted
Voice
2=Aphonic, not
4=Wet/gurgling
6=Hoarse
8=Mild impairment
10=No deficit
able to assess
slight huskiness
noted
Trach
1=Trach/cuffed
5=Trach/fenestrated
10=No trach
Pharyngeal
2=No swallow
5=Pooling/gurgling
8=Mildly restricted
10=Immediate
phase
Incomplete laryngeal
laryngeal elevation
laryngeal elevation
elevation
Slow initiation
Pharyngeal
1=Not coping/
5=Cough before
10=No deficit
response
gurgling
during
noted
or after swallow
Diet recommendations
Regular
Soft
Selected soft
Mechanical soft
Puree
No solid
by mouth
Fluid recommendation
Regular
Thins only
Nectar
Honey
No liquids by mouth
Patient Name:
Date:
SLP:
MASA #:
Score:

Modified Mann Assessment of Swallowing Ability

Alertness

10=Alert

8=Drowsy-fluctuating

5=Difficult to arouse by speech or mvmt

2=Coma or

 

awareness/alert level

nonresponsvie

Cooperation

10=Cooperative

8=Fluctuating

5=Reluctant

2=No cooperation/

 

cooperation

cooperation

response

Respiration

10=Chest clear

8=Sputum in upper airway

6=Fine basal

4=Coarse basal

2=Suspected

crepitations

crepitations

infections/ freq

 

suction/ respirator

dependent

Expressive

5=No abnormality

4=Mild wording finding difficulty

3=Expresses self in limited manner

2=No functional

1=Unable to assess

Dysphasia

speech

Auditory

10=No abnormality

8=Follows ordinary

6=Follows simple

4=Occasional

1=No response

Comprehension

conversation with

conversation

response

little difficulty

Dysarthria

5=No abnormality

4=Slow with

3=Speech intelligible

2=Speech unintelligible

1=Unable to assess

occasional hesitation

but defective

Saliva

5=No abnormality

4=Frothy/

3=Drooling at times

2=Some drool

1=Gross drooling

expectorated in cup

consistently

Tongue Movement

10=Full R.O.M.

8=Mild impairment

6=Incomplete mvmt

4=Minimal mvmt

2=No movement

Tongue Strength

10=No abnormality

8=Minimal weakness

5=Obvious unilateral weakness

2=Gross weakness

 

Gag

5=No abnormality

4=Diminished

3=Diminished

2=Absent unilaterally

1=No gag response

bilaterally

unilaterally

Cough Reflex

10-No abnormality

8=Cough attempted but hoarse in quality

5=Attempt inadequate

2=No attempt/unable to perform

 

Palate

10=No abnormality

8=Slight asymmetry

6=Unilaterally weak

4=Minimal movement

2=No movement

  Palate 10=No abnormality 8=Slight asymmetry 6=Unilaterally weak 4=Minimal movement 2=No movement

EATS

Two Phases

Questionnaire

Food/Liquid Trials

Must show no deficits in both phases to pass screen

Courtney B, Flier L.: RN dysphagia screening, a stepwise approach. Journal of Neuroscience Nursing 2009; 41(1):28-38

EATS

EATS

The Gugging Swallow Screen

Includes a semi-solid, liquid, and solid trial Severity scoring system

Allows diet to be altered

Figure I. GUSS.

Figure I. GUSS. Trapl M et al. Stroke 2007;38:2948-2952 Copyright © American Heart Association

Trapl M et al. Stroke 2007;38:2948-2952

Figure I. GUSS. Trapl M et al. Stroke 2007;38:2948-2952 Copyright © American Heart Association

Copyright © American Heart Association

Figure I. GUSS. Trapl M et al. Stroke 2007;38:2948-2952 Copyright © American Heart Association

Figure I Continued.

Trapl M et al. Stroke 2007;38:2948-2952
Trapl M et al. Stroke 2007;38:2948-2952
Figure I Continued. Trapl M et al. Stroke 2007;38:2948-2952 Copyright © American Heart Association

Copyright © American Heart Association

What Screen Should I Use?

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Use only odd numbers to answer the question

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Use only odd numbers to answer the question

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Use only odd numbers to answer the question

 

5

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8

8

Screening Purpose

Identify individuals with or at risk of swallowing dysfunction following a stroke.

Sensitivity vs. Specificity

Always a trade-off Dysphagia screening is tilted towards sensitivity

The Perfect Screen

Do you have stroke-like symptoms?

The Perfect Screen

100% Sensitivity to Dysphagia

0% Specificity to Dysphagia

Theoretical Result: Never a dysphagia related complication

Bedside Result

6 out of 10 patients are angry!

Not all bedsides are the same

BJC Healthcare

1. Alton Memorial

2. Barnes Jewish

3. Barnes Jewish St. Peters

4. Barnes Jewish West County

5. Boone Hospital

6. Christian Hospital

7. Clay County Hospital

8. Missouri Baptist Medical Center

9. Missouri Baptist Sullivan Hospital

10. Northwest Healthcare

11. Parkland Health Center

12. Progress West HealthCare Center

13. Rehabilitation Institute of St. Louis

14. St. Louis Children’s Hospital

15. Siteman Cancer Center

Barnes Jewish Hospital

Barnes Jewish Hospital

Stroke Fellow Neuroradiology & Neurosurgery

MRI,Angiography, PET Scanner

Dedicated Stroke Neurologists

Dedicated Stroke Nursing Unit

Dedicated 20 Bed Neuro-ICU with Portable CT

Intra-operative MRI Suite

Two Stroke Nursing Coordinators

Dedicated Stroke Rehabilitation Services (PT,OT, and

Speech)

Administrative group dedicated to Neurosciences

Clay County Hospital

Clay County Hospital

Factors that may effect screen choice

Availability of Speech Pathology Availability of Radiology Services (i.e.Videofluoroscopy)

Volume of patients Nursing numbers

Fewer Resources Available

May be less tolerant of false positives May be more comprehensive

May resemble an assessment rather than screen

Potentially more burden on nursing

More Resources Available

May tolerate false positives May be less comprehensive (pass/fail)

Potentially less burden on nursing

No Perfect Screen

Perfection= 100% Sensitivity & 100% Specificity There will be false positives

There will be false negatives

How many of each can be tolerated?

What is a good Screen?

Valid Reliable

Works for your setting

Validity

External Internal

Criterion

Content

Concurrent

Predictive

Content

Construct

Face

External  Internal  Criterion  Content  Concurrent  Predictive  Content  Construct 
External  Internal  Criterion  Content  Concurrent  Predictive  Content  Construct 

Reliability

Inter-rater Reliability Test-Retest Reliability

Parallel-Forms Reliability

Internal Consistency

 Inter-rater Reliability  Test-Retest Reliability  Parallel-Forms Reliability  Internal Consistency
 Inter-rater Reliability  Test-Retest Reliability  Parallel-Forms Reliability  Internal Consistency

What Works for You?

No numeric value to derive this Dependent on multiple factors

Specific to a given institution

Making a Decision

Expert Opinion Data Driven-Dependent on quality of data

Group Consensus

Kepner-Tregoe Decision Matrix

Kepner-Tregoe Decision Matrix

Timed Up and Go

Timed Up and Go (R)

Get Up and Go

BJC Get Up and Go

Easily

Administered

Valid

Reliable

Easily

Documented

Sensitivity/Spec ificity (5)

Evidence Based

(10)

Kepner-Tregoe Decision Matrix

 
 

Timed Up and Go

Timed Up and Go (R)

Get Up and Go

BJC Get Up and Go

Easily

 

x

x

x

Administered

Valid

x

x

X

X

Reliable

x

x

   

Easily

x

x

x

x

Documented

Sensitivity/Spec ificity (5)

5

5

5

 

Evidence Based

10

10

10

10

(10)

K-T Analysis of Swallow Screens

3 oz Massey Timed Burke Metro Any EATS Mini GUSS BJH water Test Screen Health
3 oz
Massey
Timed
Burke
Metro
Any
EATS
Mini
GUSS
BJH
water
Test
Screen
Health
Two
MASA
SDS
Sensitivity
>90%
Face Validity
Easy to
administer
Reliable
Concurrent
Validity
Scoring
Severity
Easy to learn
Specificity
>50%

Barnes Jewish Hospital- KT Matrix

Barnes Jewish Hospital- KT Matrix
3 oz Massey Timed Burke Metro Any EATS Mini GUSS BJH water Test Screen Health
3 oz
Massey
Timed
Burke
Metro
Any
EATS
Mini
GUSS
BJH
water
Test
Screen
Health
Two
MASA
SDS
Sensitivity
>90%
Face Validity
Easy to
administer
Reliable
Concurrent
Validity (8)
Scoring
Severity (1)
Easy to
learn (10)
Specificity
>50% (5)
 

3 oz

Massey

Timed

Burke

Metro

Any

EATS

Mini

GUSS

BJH

water

Test

Screen

Health

Two

MASA

SDS

Sensitivity

                   
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

>90%

Face Validity

 
X
X
X
X
X
X
 
X
X
X
X
X
X
X
X
X
X

Easy to

X
X
X
X
X
X
X
X
X
X
X
X
     
X
X

administer

Reliable

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

Concurrent

                   

Validity (8)

Scoring

                   

Severity (1)

Easy to learn

                   

(10)

Specificity

                   

>50% (5)

Burke Massey Timed Test Any Two BJH SDS Screen Sensitivity >90% X X X X
Burke
Massey
Timed Test
Any Two
BJH SDS
Screen
Sensitivity >90%
X
X
X
X
X
Face Validity
X
X
X
X
X
Easy to administer
X
X
X
X
X
Reliable
X
X
X
X
X
Concurrent
Validity with
MBS/FEES (8)
0
0
0
8
8
Scoring Severity
0
0
0
0
0
(1)
Easy to learn (10)
10
10
10
10
10
Specificity
5
5
0
5
5
>50% (5)
TOTAL
15
15
10
23
23

Clay County Hospital-KT Matrix

Clay County Hospital-KT Matrix
3 oz Massey Timed Burke Metro Any EATS Mini GUSS BJH water Test Screen Health
3 oz
Massey
Timed
Burke
Metro
Any
EATS
Mini
GUSS
BJH
water
Test
Screen
Health
Two
MASA
SDS
Sensitivity
>90%
Face
Validity
Easy to
learn
Specificity
>50%
Reliable
Concurren
t Validity
Scoring
Severity
Easy to
administer
 

3 oz

Massey

Timed

Burke

Metro

Any

EATS

Mini

GUSS

BJH

water

Test

Screen

Health

Two

MASA

SDS

Sensitivity

                   
X
X
X
X
X
X
X
X
X
X
X
X
 
X
X
X
X
X
X

>90%

Face Validity

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

Easy to learn

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

Specificity

 
X
X
X
X
 
X
X
X
X
 
X
X
X
X
X
X

>50%

Reliable

                   

Concurrent

                   

Validity

Scoring

                   

Severity

Easy to

                   

administer

 

Massey

Timed

Metro

Any

Mini

GUSS
GUSS

BJH

Test

Health

Two

MASA

SDS

Sensitivity >90%

X
X
X
X
X
X
X
X
X
X
X
X
X
X

Face Validity

X
X
X
X
X
X
X
X
X
X
X
X
X
X

Easy to learn

X
X
X
X
X
X
X
X
X
X
X
X
X
X

Specificity

X
X
X
X
X
X
X
X
X
X
X
X
X
X

>50%

Reliable (2)

2
2
2
2
2
2
2
2
2
2
2
2
2
2

ConcurrentValidity with MBS/FEES (10)

0
0
0
0
10
10
10
10
10
10
10
10
10
10

Scoring Severity (8)

0
0
0
0
0
0
0
0
0
0
8
8
0
0

Easy to administer

4
4
4
4
4
4
4
4
4
4
0
0
4
4

(4)

TOTAL

6
6
6
6
16
16
16
16
16
16
20
20
16
16
4 4 4 4 4 0 4 (4) TOTAL 6 6 16 16 16 20 16

Conclusion

Much research has been done Many screens, most are pretty good

When choosing a screen, be objective and systematic

There is no “best” screen

The best screen is the one that is best for your institution