USING WEB-BASED PRACTICE TO MAINTAIN DYSPHAGIA SCREENING SKILLS

USING WEB-BASED PRACTICE TO MAINTAIN DYSPHAGIA SCREENING SKILLS TOR- BSST Rosemary Martino, PhD Associate Professor, Associate Chair Department of Speech-Language Pathology University of Toronto Lori Herlihy-O Connor, MS, CCC/SLP Supervisor of Rehabilitation Services Our Lady of Lourdes Memorial Hospital, Binghamton, New York

DISCLOSURES 2

CONTENT Stroke Guidelines for Dysphagia Screening Practices Screening Research Status of the Literature Next steps. 3

..The year was 2000. Y2K Scare Martino/SLP1536

..The year was 2000. HSFO survey Dysphagia Management a Priority CASLPO Guidelines for Dysphagia Heart and Stroke Foundation of Ontario Emerging evidence that screening impacts positively on health Martino/SLP1536 Shortage of SLPs to provide dysphagia service

BEST PRACTICE GUIDELINES FOR MANAGING DYSPHAGIA Provides benchmark for organizations Stroke teams measure relative progress Maximize resources of regional stroke network 6

DYSPHAGIA GUIDELINES Heart and Stroke Foundation of Ontario. Improving recognition and management of dysphagia in acute stroke: A vision for Ontario. Toronto, ON: Heart and Stroke Foundation of Ontario, 2002 Canadian Stroke Strategy. Canadian best practice recommendations for stroke care. Ottawa, ON: Canadian Stroke Network, 2006. Lindsay PBP, Bayley MM, Hellings CB, Hill MMM, Woodbury EBM, Phillips SM. Canadian best practice recommendations for stroke care (Updated 2008). CMAJ. 2008;179: E1-E93. 7

LINDSAY et al (UPDATED) CMAJ. 2008;179: E1-E93 Patients should have swallowing ability screened using a simple, valid, reliable bedside testing protocol as part of their initial assessment, and before initiating oral intake of medications, fluids or food. Patients who are not alert within the first 24 hours should be monitored and dysphagia screening performed when clinically appropriate. Patients presenting with features indicating dysphagia should receive a full clinical assessment of their swallowing ability by a speech language pathologist who should advise on safety of swallowing ability and consistency of diet and fluids. Stroke patients with suspected nutritional and/or hydration deficits, including dysphagia, should be referred to a dietitian. 8

POLICIES AND PROCEDURES Stroke Survivor NPO Neg v Swallowing Team Screens for Dysphagia Pos v Eat or be Fed SLP Ax Swallow RD Ax Nutrition Low High Swallowing Team Monitors Swallow SLP Monitors Swallow 9

LINDSAY et al (UPDATED) CMAJ. 2008;179: E1-E93 All stroke patients should have an oral/dental assessment, which includes screening for obvious signs of dental disease, level of oral care and appliances, upon or soon after admission 11

LINDSAY et al (UPDATED) CMAJ. 2008;179: E1-E93 Canadian Performance Measures Proportion of patients with an initial dysphagia screening assessment performed during hospital admission. Proportion of patients with poor results on initial screening who then receive a comprehensive assessment by a speech language pathologist. Median time from patient arrival in the emergency department to initial swallowing screening by a trained clinician (in minutes). 12

1999 Centre of Excellence 2000 Registry 2002 Guidelines STROKE CARE IN CANADA In Canada, screening completed on 50% of all newly admitted stroke patients. Lindsay et al, CSN; 2011; Hall et al. ICES; 2011 In Ontario, screening practice increased from 47.9% in (2002) of all patients, to 62.3% (2008) Hall et al. ICES; 2011 There was a corresponding decline in the inpatient pneumonia rate across all hospital designations. Lindsay et al, CSN; 2011; Hall et al. ICES; 2011

DUNCAN et al STROKE. 2005;36: E100-E143 All patients have their swallow screened before initiating oral intake of fluids or food, utilizing a simple valid bedside testing protocol. Swallow screening be performed by the SLP or other trained personnel (eg, nurse or occupational therapist) if the SLP is not available. If the patient s swallow screening is abnormal, a complete bedside swallow examination is recommended. The exam should be performed by the SLP, who will define swallow physiology and make recommendations about management and treatment. All patients who have a positive bedside screening be tested using a videofluoroscopy. 14

DUNCAN et al STROKE. 2005;36: E100-E143 Consider fiberoptic endoscopic examination of swallowing (FEES) as an alternative to VFS. There is insufficient evidence to recommend for or against fiberoptic endoscopic examination of swallowing with sensory testing (FEESST) for the assessment of dysphagia. Diagnostic assessment, whether VFS or another modality, include a definition of swallow physiology with identification of the physiological abnormality and treatment strategies to directly assess their effectiveness. Discuss food consistency with dietetics to ensure standardization, consistency, and palatability. 15

GET WITH THE GUIDELINES DYSPHAGIA TOOL KIT 2012 These documents have been provided to the American Heart Association by the below hospitals as examples of dysphagia screening tools. This document is available only to give you an idea of how some hospitals might use dysphagia screening tools. By including this document on its Web site, the American Heart Association does not represent that this document is complete, accurate or efficacious, or that it follows all of the American Heart Association guidelines for secondary and primary prevention of cardiovascular events or stroke. Hospitals should design their own dysphagia screening tools based on their own procedures and professional experience. Beloit Memorial Hospital: Dysphagia Screening Tool Butler Memorial Hospital: Dysphagia Screening Oregon Health & Science University: Bedside Nurse Swallow Screen Palms of Pasadena Hospital: Swallow Screen St. Francis: Modified Massey Bedside Swallowing Screen University of Toledo Medical Center: Nursing Swallowing Screen 16

IMPLEMENTATION OF TOR-BSST AT NEW YORK STATE HOSPITAL Proposal outlined, presented, and approved by hospital senior administration for swallow screening. Pilot group of selected professionals were trained, feedback obtained, and outcomes measured. SLP staff collaboration with nursing management to develop a training schedule, policy, and procedure.

PROGRAM DESIGN SLP provides quarterly training sessions for a select group of nurses (ED, ICU, telemetry). Training is built into new hire nursing orientation and scheduled via the hospital learning center. Implementation of documentation and system alerts via electronic medical record. 100% of screenings reviewed by SLP. Stroke Patient Management Tool: Indicators include dysphagia screen ordered, screen done within 24 hours, and patient kept NPO until screen completed and passed. Outcomes discussed at monthly CVD committee meeting.

NEW YORK STATE STROKE DESIGNATED HOSPITAL Lourdes has been a NYS Stroke Designated Hospital since 2006. The Medical Director is a neurologist. In 2010 Lourdes had 173 CVA/TIA patients and 164 in 2011. Six beds are dedicated for CVA s and have the ability to utilize more beds as needed. Lourdes has achieved the Gold Plus award via Get With the Guidelines for meeting stroke care measures in 2010 and 2011. TOR-BSST has been a crucial tool in facilitating our ability to meet quality measures.

TOR-BSST Screeners receive SLP live instruction 4 items, each with binary response Voice baseline Oral motor, response to Water swallowing (tsp cup) Voice post Martino, et al. 2000 Dysphagia

TOR-BSST TOR-BSST Total Score Reliability: ICC = 0.92 (95% CI,.85 -.96) Accuracy (acute & rehab): SN = 91.3% (95% CI, 72-98) Accuracy (acute): SN = 96.3% (95% CI, 73-97) NPV (acute) = 93.3% (95% CI, 58 99) Martino, et al. 2009 Stroke

ARE 10 TSPS NECESSARY? YES Martino, et al. 2009 Dysphagia 22

SUSTAINABILITY OVER TIME LET S SCREEN LET S SCREEN LET S SCREEN START I YEAR Martino, et al. 2008 Dysphagia 23

RELIABILITY OVER TIME TOR-BSST over 3 yr study (Martino et al 2006 Dysphagia) Year 1 - Inter-rater reliability = Kappa of.90 (95% CI.78-98) Year 3 - Inter-rater reliability = Kappa of.82 (95% CI.66-98) CPR as early as 16 wks post training in clinicians without practice (Kovacs et al, 2000 Annals of Emerg Medicine) NIH-SS mindset to recertify skills yearly

WEB-BASED REFRESHER Independent and Interactive Practice modules with a series of patient video clips Competency Test using random patient samples

STUDY OBJECTIVE Premise Screeners must be competent in identifying dysphagia Primary Outcomes 1. Determine screening skill performance over time 2. Assess the benefit of independent web-based practice

STUDY DESIGN - RCT 38 Screeners without SLP training 58 Screeners with SLP training Baseline TOR-BSST (c) Test Baseline TOR-BSST (c) Test 4-hr Live training by SLP 1-hr Live Refresher by SLP Post Training TOR-BSST (c) Test Post Trainng TOR-BST (c) Test

Concealed Random Allocation Group A No Web- Refresher Group B Web- Refresher Time 2 TOR- BSST (c) Test Time 2 TOR- BSST (c) Test Time 3 TOR- BSST (c) Test Time 3 TOR- BSST (c) Test Time 4 TOR- BSST (c) Test Time 4 TOR- BSST (c) Test

STUDY RESULTS - SITES Site 1 Site 2 Site 3 Site 4 Stroke adm/yr 650 1200 95 174 Beds Stroke (n) 44 32+ 0 6+ Beds Total (n) 1328 1062 120 267 Stroke Team Y Y N Y Stroke Centre Y Y N Y Screeners Enrolled(n) 19 10 33 34 Screeners Lost (n) 2 5 3 13

STUDY RESULTS - SCREENERS No Previous Live Training (N=38) Previous Live Training (N=58) p-value Female (%) 89.5 87.9 ns RN (%) 73.3 70.7 ns License yrs (median, SD) Shifts (median, SD) SLP access (median, SD) 2.5 (11.3) 13 (12.5).001 8 (1.9) 8 (9.9) ns 2 (1.8) 2 (1.3) ns

STUDY RESULTS SKILL DECAY Times No Prior SLP Training Prior SLP Training p-value Baseline 77.2 71.9 94.3 87.4 Post #1 94.7 91.2 97.3 93.1 ns Times No Web Web No Web Web p-value Post #2 94.4 96.3 100 94.1 ns Post #3 97.0 93.9 100 96.1 ns Post #4 97.4 100.0 97.3 93.7 ns

STUDY RESULTS GROUP B Full access to Web Training More practice increased performance 1. Water swallow OR = 1.51 (95% CI 1.16-1.95) 2. Voice quality OR = 1.34 (95% CI 1.03-1.75)

STUDY RESULTS GROUP A&B None vs. Prior SLP Training Times No Prior SLP Training Prior SLP Training p-value Baseline 77.2 71.9 94.3 87.4 p<.02 Post #1 94.7 91.2 97.3 93.1 ns Times No Web Web No Web Web p-value Post #2 94.4 96.3 100 94.1 ns Post #3 97.0 93.9 100 96.1 ns Post #4 97.4 100.0 97.3 93.7 ns

STUDY RESULTS GROUP A&B Overall Times No Prior SLP Training Prior SLP Training p-value Baseline 77.2 71.9 94.3 87.4 p<.02 Post #1 94.7 91.2 97.3 93.1 ns Times No Web Web No Web Web p-value Post #2 94.4 96.3 100 94.1 ns Post #3 97.0 93.9 100 96.1 ns Post #4 97.4 100.0 97.3 93.7 ns Total score accuracy increased over time (p<.001) Total score accuracy > single item at all times (p<.001)

CONCLUSIONS At baseline, live SLP TOR-BSST improves screening performance to highly accurate levels After baseline, all trained screeners maintained high accuracy over time for up to one year, regardless of access or amount of practice After baseline, total TOR-BSST score was consistently more accurate than any item alone

TOR-BSST UP-TAKE 38

SWALLOWING SCREENS FOR STROKE Systematic review of screening protocols Identified 35 Rated based on reliability, validity and feasibility Concluded 2 met all criteria. Schepp et al., Stroke 2012; 43:869-871 39

Dysphagia & Pneumonia Martino et al., Stroke 2005; 36:2756-2763 3 x greater 40

Dysphagia & Pneumonia Martino et al., Stroke 2005; 36:2756-2763 11 x greater 41

SCREENING REDUCES PNEUMONIA Hinchey, et al. 2005 Stroke 42

NEXT STEPS SCREEN Change in choice or timing of Treatment LUNG HEALTH Detection Martino et al, 2000, Dysphagia. 15:19-30. Treatment Compensatory Physiological Neuroplastic 43 Outcomes MOD

NEXT STEPS SCREEN Change in choice or timing of Treatment LUNG NUT/HYD MOOD HEALTH Detection Martino et al, 2000, Dysphagia. 15:19-30. Treatment Compensatory Physiological Neuroplastic 44 Outcomes

CONCLUDING COMMENTS Guidelines are available to direct high level dysphagia screening care in patients with stroke. Available tools with good reliability, validity and emerging up-take What we need next is to assess the benefit of screening to the patient health and recovery. 45

THANK YOU FOR YOUR TIME! 46