Department of Health (DOH)

Transcription

1 The Victorian Dysphagia Screening Project Department of Health (DOH) Victorian Stroke Clinical Network

2 O ur tools.

3 Impact of Dysphagia Aspiration Pneumonia Malnutrition Dehydration Increased LOS Increased Mortality Increased Disability Institutional Care at Discharge

4 Screening versus Assessment A procedure to detect any clinical indication of potential swallowing impairment / aspiration risk by specifically trained personnel

5 Literature 3 Systematic reviews were unable to conclude on the best method for dysphagia screening due to variability in the studies

6 Improved Patient Outcomes Authors Test Sample Results Odderson et al (1995) Swallow Screen part of pathway 124 Acute Stroke Reduction in aspiration pneumonia Significantly reduced LOS Hinchey et al (2005) Formal Swallow Screen Program 2532 cases across 15 sites Acute Stroke Increased adherence Incidence of pneumonia Shorter LOS Perry & McLaren (2003) Guidelines including swallow screening 400 Acute Stroke Incidence of pneumonia Time spent without nutrition

7 Water Test and Pulse Oximetry Authors Test Sample & Gold Standard Sensitivit y Specificity DePippo et al (1992) Water Test 44 Stroke Rehab VMBS 76% 94% Severe 59% 26% Severe Garon et al (1995) Water Test 100 Various Diagnosis 54% 79% VMBS Mari et al (1997) Water Test 93 Consecutive Neurological 52% 86% VMBS 72 hrs water test Suiter et al (2008) Water Test 3000 Various Diagnosis 96.5% 48.7% FEES

8 Water Test Authors Test Sample & Gold Standard Sensitivit y Specificity DePippo et al (1992) Water Test 44 Stroke Rehab VMBS 76% 94% Severe 59% 26% Severe Garon et al (1995) Water Test 100 Various Diagnosis 54% 79% VMBS Mari et al (1997) Water Test 93 Consecutive Neurological 52% 86% VMBS 72 hrs water test Suiter et al (2008) Water Test 3000 Various Diagnosis 96.5% 48.7%

9 Clinical Features Authors Features Sample and Gold Standard Results Daniels et al (2000) 1) Dysphonia 2) Dysarthria 3) Abnormal Vol cough 4) Abnormal gag reflex 5) Cough > swallow 56 Consecutive Stroke VMBS 63% with 2 > features modseverely dysphagic on VMBS 6) Voice change > swall

10 Mildura Base Hospital Robinvale District HS Survey Distribution Mallee Track Health & CS, Ouyen Loddon Mallee Manangatang & District Hospital Swan Hill District Hospital Regional Victorian public hospitals including Department of Human Services regional boundaries Cobram District Hospital Yarrawonga District HS Nathalia District Hospital Boort District Hospital Numurkah District HS Echuca Regional Health Wodonga Regional HS Rural Northwest Health Tallangatta HS Rochester & Elmore District HS Kyabram & District HS Northeast Health Wangaratta West Wimmera HS, Nhill Goulburn Valley Health, Shepparton Beechworth HS Grampians 13 Inglewood & District HS Benalla & District Memorial Hospital Dunmunkle HS East Wimmera HS, Birchip Wimmera Health Care Group, Dimboola Bendigo Health Care Group Casterton Memorial Hospital Ballarat HS Djerriwarrh HS, Bacchus Marsh Western District HS, Hamilton Barwon South Western Kerang District Health Cohuna District Hospital Heywood Rural Health Barwon Health, Geelong Terang & Mortlake HS, Terang Kooweerup Regional HS Portland District Health Hesse Rural HS, Winchelsea Colac Area Health Moyne HS, Port Fairy South West Healthcare, Warrnambool Timboon & District Healthcare Service Lorne Community Hospital Bass Coast Regional Health, Wonthaggi Otway Health & CS, Apollo Bay Kilometres 11 Hume McIvor Health & CS, Heathcote Edenhope & District Hospital Maryborough District HS Maldon Hospital Seymour District Memorial Hospital Stawell Regional Health Mt Alexander Hospital, Castlemaine Mansfield District Hospital Alexandra District Hospital East Grampians HS, Ararat Kyneton District HS Yea & District Memorial Hospital Hepburn HS, Daylesford Kilmore & District Hospital Beaufort & Skipton HS, Beaufort Metropolitan map Alpine Health, Myrtleford 12 Bairnsdale Regional HS Gippsland Central Gippsland HS, Sale West Gippsland Healthcare Group, Warragul Latrobe Regional Hospital, Traralgon Gippsland Southern HS, Leongatha Yarram & District HS Upper Murray Health & CS, Corryong Omeo District Health Orbost Regional Health South Gippsland Hospital, Foster Department of Human Services regional boundaries based on Local Government Areas Australian Standard Geographical Classification 1 July 2004 Hospitals current at 1 July 2006

11 Dysphagia Screening Practice 32% conduct dysphagia screening 40% Metro 29% Regional 49% stroke patients are screened 45% Metro 60% Regional

12 Numbers of Patients Screened in Vic (survey sample) Metro no screening 2,402 Metro with screening 1, 942 Rural with screening 1,045 Rural No Screening 704

13 The Tools in Use There is no validated tool for dysphagia screening in acute stroke 42% use a standardised tool Majority use external tools (with minor and substantive changes) RBWH, ASSIST, MMC collaborative 58% developed own tools. Not validated.

14 Administration Majority are administered by trained nursing staff Majority conduct screening in the Emergency Department, Stroke Unit and General Medical Wards Majority conduct screening within first 24 hours of admission

15 Training & Competency Programs 95% have training programs 42% have competency programs

16 Barriers to Conducting Screening 68% not conducting screening Lack of resources / EFT Not enough demand High nursing staff turn over Adherence to screening guidelines

17 Access to Speech Pathology 65% On Site 20% Out Reach 15% No Service Out of Hours 15% have out of hours

18 Out of Hours and Screening No screening programs 83% do not have an out of hours service 17% have out of hours service 1/3 has 4hr on a Saturday 1/3 Sat & Sun 1/3 on call for one day of the weekend

19 Outreach Services and Screening 75% do not conduct screening The rest have a program in place

20 Regional Areas 77% have access to Speech Pathology 65% admit & treat stroke & have Speech on site 35% have outreach. Admit and treat Do not admit and have up transfer protocols No Access to Speech Pathology 71% do not admit stroke patients 29% admit stroke patients

21 Summary There is a need for prompt dysphagia screening Evidence Base 32% conducting screening Variability Barriers to not conducting screening

22 Project Aim Develop a state wide consistent and validated model for dysphagia screening in line with best practice for the acute stroke population

23 Deliverables Current Service Provision Literature Review Governance Framework Development of the Victorian Dysphagia Screening Model (VDSM) Screening Tool (ASSIST) VDSM follow up plan Training and Competency Package Evaluation

24 Project Timelines Screening Tool Training and Competency Final model L Evaluation Feb March June Sept Oct Nov Feb July

25 Governance Framework Dysphagia Screening Steering Committee DYSPHAGIA SCREENING STEERING COMMITTEE Model Development Working Party SPEECH PATHOLOGY WORKING PARTY Consultative Reference Group SPEECH REFERENCE GROUP

26 ASSIST Tool

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29 VDSM follow Up Plan Each site varies in management of patients who are NBM Each patient is different e.g. palliative vs. active management Aims to provide active consultation by the treating teams within the context of individual organisation protocol and context.

30 ASSIST dysphagia screening tool administered Pt. passes screen Pt. fails screen Commence premorbid oral diet Document in medical record Place patient Nil By Mouth (NBM) document in medical record Nursing staff to observe patient with first meal Place patient Nil By Mouth (NBM), if indicated when observing first meal Refer to Speech Pathology (SP) for comprehensive assessment within 24 hours as per standard hospital referral Date: / / Time: : hrs If Speech Pathology services are unavailable the patient is to remain NBM and alternative means of nutrition, hydration and medication should be considered by the treating medical team and dietitian If patient continues to fail repeat screening after 72 hours, consult local guidelines regarding transfer of patient to enable SP assessment Repeat ASSIST screen when all of the parameters in section 1 are answered YES or every 24 hours until SP is available

31 Training and Competency Developed by Recognised training provider expert in competency based assessment Nationally recognised framework Documentation and process to support competency assessment

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34 Questions