Based on the PICO question the task to find evidence needed to show specific nursing interventions for dysphagia screening in addition patient selection criteria needed to be appropriately characterised this is discussed in a research paper by Balakas

emergency nursing care of patients
Contents Page

Page Number

Tasks 1-6 2-8

Reference List 8-10

Appendix 1 11-22

Appendix 2 23

Appendix 3 24-26

Appendix 4 27-30

Appendix 5 31-32

Appendix 6 33

Appendix 7 34-35

Appendix 8 36-40

Evaluation of practice

Task 1

The rationale for evidence-based guidelines for emergency nursing care of patients with acute stroke improves patient outcomes (SIGN, 2010) (Appendix 4). When a patient experiences a stroke the continuum of stroke care should be initiated in the Emergency Department using a critical care pathway as outlined by the authors Altman et al (2012). Dysphagia can be defined as difficulty in swallowing; this happens in approximately half of patients with symptoms of stroke (Martino et al, 2009). Altman et al, (2012) suggest that the care pathway for stroke should include a dysphagia screening tool done by registered nurses within 24 hours of admission. This is to identify the potential for dysphagia complications such as aspiration, aspiration pneumonia, dehydration and malnutrition (Cichero et al, 2009). Dysphagia screening by nurses is a rapid, minimally invasive assessment to decide if a patient is at risk of swallowing difficulties and if the patient requires further assessment by a speech pathologist (NSF, 2010; Murray,et al, 2011) (Appendix 5). In the emergency department it was observed that no nursing dysphagia screening practice/protocol existed for patients with stroke symptoms and time from admission to dysphagia screening was taking longer than the recommended 24 hours (Appendix 5)(National Stoke foundation, 2010). Patients were being kept ‘nil by mouth’ until the referral for a speech pathologist was initiated by an ED nurse or completed by the stroke care nurse. Nurses were unsure when to keep patients with stroke symptoms ‘nil by mouth’ and when to feed and hydrate them as there are no current practice guidelines/policies that existed within the department. This clinical gap was identified as previous experience in another emergency department had shown the benefit of prompt dysphagia screening by nurses utilising the Emergency Department Stroke and Transient Ischaemic Attack Care Bundle (Appendix 3) and previous experience in another hospital It is clear that a review of health area service policies is need to improve patient care in the area of dysphagia screening by nurses in the emergency department (Appendix 1).

Task 2

Initially a search was completed in the emergency department’s procedures and protocols manual. Presently there did not appear to be any available information regarding dysphagia screening. A meeting was arranged with the hospital’s stroke care nurse and emergency department’s clinical nurse consultant to ascertain what policies were in place with regards to dysphagia screening. It was not specified that currently no dysphagia screening tool or policy/guideline is in place in the emergency department nor were there any dysphagia screening competent nurses. In addition there is not any ED allocated speech pathologist further delaying time for dysphagia assessment (Murray,et al, 2011; Weinhardt, 2008) Additionally screening of stroke patients is done on an adhoc basis, whenever the stroke care nurse comes to the ED to review a patient. It was acknowledged that this was inadequate and meant patients were not screened within the recommended first 24hours (NSF, 2010; Martino et al, 2009); plus not in keeping with evidenced based practice. There are current policies within Queensland Health that can be adopted to support a dysphagia screening tool in ED (see Appendix 1) but are not currently used. The emergency department stroke and transient ischaemic attack care bundle (2009) supports recommended dysphagia screening (See Appendix 3). This bundle was developed for use in the emergency department by ED personnel (Appendix 3) the constituents of this care bundle were compiled from the NSF Clinical guidelines for acute stroke management (Appendix 5). Furthermore Evidence reviews developed for each component were based on international stroke guidelines.

Task 3

The PICO research question was devised from the information required to conduct research on, dysphagia screening by nurses. It was very specific for stroke patients and the emergency department care bundle guide was specific about bedside dysphagia screening by nurses. Quality literature needed to be relevant to nursing and dysphagia screening. The lack of policy and guidelines in the emergency department lead to the intervention and comparison being generalised so more articles would be available for review.

PICO Question for Dysphagia Screening by Nurses

Population: Stroke Patients

Intervention: Dysphagia screening by nurses

Comparison: No dysphagia screening by nurses

Outcome: Prevention of dysphagia related complications for patients.

Task 4

Based on the PICO question the task to find evidence needed to show specific nursing interventions for dysphagia screening in addition patient selection criteria needed to be appropriately characterised this is discussed in a research paper by Balakas, & Sparks (2010) where they discuss critical evaluation of research findings to promote evidenced based practice.. A search was undertaken for research covering a period from 2007 to 2013 to ensure recency of research. Electronic nursing databases were accessed through the UTAS library website. The databases searched included, CINAHL, Medline, Cochrane and the Trip database; the level of evidence was then evaluated. The search terms were chosen by revising different combination of words and Mesh terms in relevant articles and databases and trying different meanings of the words utilised in the PICO question. Different terms for stroke were used such as CVA. The words were then linked to dysphagia, swallowing and deglutition, using a Boolean search system and smart search tool. The words were also abbreviated to extend the search for example swallow*, deglutition*. The last row of the search term was screening for stroke patients to ensure capture of the patient population. The words emergency department were left out of the PICO question because it gave a considerable narrowed search and not enough quality articles to review. Evidence Based literature that answered the Pico question was selected acknowledging the screening of dysphagia of patients with stroke symptoms by nurses (Hoogendam, Pieter, 2012). The literature search included peer reviewed qualitative and quantitative paper, systematic reviews and clinical guidelines; the quality of them was then assessed and synthesised. Nursing responsibilities were identified within the research reviews. The role of nursing in dysphagia screening was identified including the timely recognition then referral of patients who experienced dysphagia complications after experiencing stroke symptoms (Murray, et al, 2011). The first piece of evidence chosen was a systematic review by Daniels et al (2012) (Appendix 2) considered ‘the evidence-based validity of dysphagia screening items using instrumental evaluation as the reference standard’, This specifically addressed the PICO question and looked at dysphagia screening by nurses and showed external validity (Daniel et al, 2012) Secondly the Sign (2010) (Appendix 4) guidelines were chosen as they systematically reviewed literature about dysphagia screening and utilise evidenced based practice. Lastly the National Stroke Foundation Guidelines (2010) (Appendix 5) were chosen as it is based on Australia guiding principles and moreover levels of evidence assigned to recommendations supports current practices adopted which gives it internal validity and relevance.

Task 5

A dysphagia screening tool cannot be implemented without a systematic review of the literature to support current best practice (Donovan et al 2013). The Sign 2010 guideline (Appendix 4) relates to patient safety and the prevention of dysphagia related complications. Daniels et al. (2012) reviewed the sensitivity and validity of various dysphagia tools. The study determined that several screening tools can detect aspiration risk early and by not using a simple screening tool could compromise patient outcomes. This highlights the need to implement a recognised dysphagia screening tool in the emergency department as discussed by Cichero et al (2009). If a patient is inappropriately given oral intake without being screened they are at risk of developing aspiration pneumonia and malnutrition (Walker, 2010; Martino et al, 2009), the study also showed a potential for lack of quality of care by nurses through not using a validated evidenced based approach to dysphagia screening such as the Royal Brisbane and Women’s Hospital (RBWH) Daily Swallow Screen (Appendix 6) (2006). This tool involves a two-part question screen, and a water swallow test followed by a dysphagia management plan (Appendix 7) (Cichero et al, 2009). In contrast the emergency department has no formalised dysphagia screening programme and patients wait longer than the recommended 24 hour period as endorsed by NSF (2010). Daniels et al (2012) emphasises a need for further research and consistency in the approach to dysphagia screening not like the adhoc methods currently practiced in the ED with no formal policies in place, only a national policy to fall back on (NSF, 2010). The Scottish Intercollegiate Guidelines (2010) acknowledges that there is inadequate screening in hospitals and therefore adoption of this guideline is important to standardise screening across the board. This guideline was chosen as it directly answers the PICO question asked using supported research and reviews of high quality evidence. The purpose of the guideline is to support nurses in lessening complications related to dysphagia by early dysphagia screening. It recommends early recognition of swallowing issues in stroke patients and application of suitable methods to do this; in contrast it has been very difficult to locate guidelines to promote this in the ED. It also promotes training of nurses in dysphagia screening (Appendix 6). Various levels of evidence are shown in the guidelines to support claims; this indicates the need for the emergency department to adopted a valid dysphagia screening tool and policies to support its implementation. (Level 2) evidence (SIGN, 2010). Two of the commonly used validated tools are the Royal Brisbane and Women’s Hospital Dysphagia Screening Tool (RBWH) (Appendix 6) and Acute Swallow Screen in Stroke and TIA (ASSIST). (NSW Government, 2009). The RBWH Dysphagia Screening Tool is currently used in the Townsville Area Health Service by nursing staff who have been deemed competent in the running and understanding of this tool, it also has an accompanying policy (Queensland Health 2011) (Appendix 8). It has not been approved for use in the emergency department presently but an online training resource is available for implementation (Appendix 7) and has policy documents to support this (Appendix 8). The National Stroke foundation (2010) (Appendix 5) was the third quality evidence-based literature selected as it favours the water swallow test in screening for dysphagia such as the RBWH screening tool (Appendix 6). This can be presented to management to support the need for implementation of the tool underpinned by policy document (Appendix 1) NSF (2010) recommendations and SIGN guidelines. (2010) and RBWH (Appendix 7). A clinical gap definitely exists in the emergency department as highlighted in all three high quality evidenced based research reviewed. Safety issues exist for patients in screening for dysphagia prior to administration of oral medications (Sign, 2010)., this could delay time for aspirin administration for patients who have had an ischaemic stroke (Sign, 2010).The general consensus from evidence based practice such as NSF (2010) is that dysphagia screening can reduce the occurrence of aspiration pneumonia and mortality (Leder et al, 2010); also decrease length of hospital stay. Similarly dysphagia screening should be completed by specifically trained nurses (Appendix 7); if a patient fails the dysphagia screening tool they should be assessed by a speech pathologist as discussed by Nazarko (2009). Lastly if a patient passes the dysphagia screening tool, they can eat and drink as desired which leads to increased patient satisfaction and less incidence of unnecessary time spent nil by mouth. All of the issues discussed should be considered in implementing policies in the emergency department to close the clinical gap that presently exists.

Task 6

Barriers exist in the emergency department for nurses to perform dysphagia screening for patients. There is a general lack of knowledge and education by nurses with regards to dysphagia screening as it is not current practice (Donovan et al 2013). Time and money will have to be spent on training and education to give nurses the competencies to undertake the screening (Appendix 7). The reliability of the tool will have to be measured in the emergency department vigorously which may create a barrier to its acceptance as a valid tool by nurses due to time constraints. Queensland Health (2011) policies and guidelines need to be adopted/developed and implemented by the management team which may meet with resistance to change and promote the tool. This added with a lack of access to resources and lack of compliance by nurses could jeopardise the tool. Nursing in the emergency department is a busy environment lack of time may be a barrier along with not assuming responsibility for the application of the tool (Murray, et al, 2011. It may be argued by some nurses that lack of evidence does not validate implementation of the tool as suggested by Daniels et al (2012). Further research is needed in this area (Donovan et al 2013). The provision of training will reduce the time patients wait for dysphagia screening to less than 24 hours which will improve the quality of care provided by ED nurses. The reliability of the evidence analysed shows the need for the tool to be implemented in the ED. To promote implementation of the tool it should be fast and non-invasive such as the RWBH (2006) to prevent barriers that may occur. A screening tool underpinned by quality research adds validity to the dysphagia tool (Donovan et al 2013). Lastly working with the speech pathology department will enhance multidisciplinary team approaches and enhance patient outcomes in the long term according to a paper by Murray, et al, (2011). At the International Stroke Conference 2012 Donovan et al (2013) emphasised that all members of the team need to agree on best practices in process, for the dysphagia screening tool. Policies, resources and processes should be user friendly and accessible to promote evidenced based practice in dysphagia screening.

In conclusion the emergency department is the optimum environment to perform dysphagia screening: on patients with stroke symptoms as nurses are in a perfect position to screen patients in a timely fashion (Murray, et al, 2011). This clinical gap was identified and evaluated; dysphagia screening by nurses in the emergency department has been researched using the PICO format. Quality evidence has been analysed and compared with current practice.

References

Altman, K, Takizawa, C, Martino, R, Speyer, R, Derex, L, Chevrou-Severac, H, & Altman, R 2012, Dysphagia screening, evaluation and treatment in stroke: implementation and integration with multiple concurrent clinical pathways, International Journal Of Care Pathways, 16, 2, p. 33, CINAHL with Full Text, EBSCOhost, viewed 25 May 2013

Balakas, K, & Sparks, L 2010, ‘Teaching Research and Evidence-Based Practice Using a Service-Learning Approach’, Journal Of Nursing Education, 49, 12, pp. 691-695, CINAHL with Full Text, EBSCOhost, viewed 30 May 2013.

Cichero, J, Heaton, S, & Bassett, L 2009, Triaging dysphagia: nurse screening for dysphagia in an acute hospital, Journal of Clinical Nursing, 18, 11, pp. 1649-1659, CINAHL with Full Text, EBSCOhost, viewed 25 May 2013.

Daneils, SK, Anderson, JA, Petersen, NJ 2012,” Implementation of Stroke Dysphagia Screening in the Emergency Department”, Stroke. 2012; 43:892-897, doi:10.1161/STROKEAHA.111.640946, http://stroke.ahajournals.org/citmgr?gca=strokeaha;43/3/892, viewed 25 May 2013.
Donovan, N, Daniels, S, Edmiaston, J, Weinhardt, J, Summers, D, & Mitchell, P 2013, ‘Dysphagia Screening: State of the Art: Invitational Conference Proceeding From the State-of-the-Art Nursing Symposium, International Stroke Conference 2012’, Stroke (00392499), 44, 4, pp. e24-31, CINAHL with Full Text, EBSCOhost, viewed 29 May 2013.

Hoogendam, A, Pieter F., R, & P.M. 2012, ‘Comparing patient characteristics, type of intervention, control, and outcome (PICO) queries with unguided searching: a randomized controlled crossover trial’, Journal Of The Medical Library Association, 100, 2, pp. 121-126, CINAHL with Full Text, EBSCOhost, viewed 30 May 2013

Leder, S. B., Suiter, D. M. & Green, B. G. 2010, ‘Silent Aspiration Risk is Volume-dependent’. Dysphagia, online first. doi: 10.1007/s00455-010-9312-2, viewed 13 May 2013.

Martino, R, Silver, F, Teasell, R, Bayley, M, Nicholson, G, Streiner, D, & Diamant, N 2009, ‘The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and Validation of a Dysphagia Screening Tool for Patients With Stroke’, Stroke (00392499), 40, 2, pp. 555-561, CINAHL with Full Text, EBSCOhost, viewed 26 May 2013.

Murray, J, Milich, A, & Ormerod, D 2011, Screening for dysphagia, Australian Nursing Journal, 18, 11, pp. 44-46, CINAHL with Full Text, EBSCOhost, viewed 30 May 2013.

National Stroke Foundation 2010, ‘Clinical guidelines for stroke management’, Melbourne, Australia. Report No.: ISSBN0‐978‐0‐9805933‐3‐4 http://strokefoundation.com.au/site/media/clinical_guidelines_stroke_managment_2010_interactive.pdf, viewed 21 May 2013.

National Institute of Clinical Studies 2009, ‘Emergency department stroke and transient ischaemic attack care bundle: information and implementation package’. Melbourne: National Health and Medical Research Council; 2009, www.nhmrc.gov.au/nics, viewed 23 May, 2013.

Nazarko, L 2009, ‘Hyper-acute stroke treatment: the first 48 hours ‘, Nursing & Residential Care 11, no. 2: 80-83. CINAHL with Full Text, EBSCOhost, viewed 20 April, 2013,

New South Wales Government 2009, ‘Assist: Acute Swallow Screen in Stroke and TIA’ http://www.ircst.health.nsw.gov.au/__data/assets/pdf , viewed 26 May 2013.

Queensland Health 2011, ‘Nutrition risk screening, assessment and support implementation’, www.health.qld.gov.au/qhpolicy/docs/imp/qh-imp-345-1.pdf, viewed 22 May, 2013.

Queensland Health 2006, ‘The Royal Brisbane and Women’s Hospital (RBWH) Dysphagia Screening, Tool and Daily Swallow Screen’, Speech Pathology Department RBWH Health Service.

Scottish Intercollegiate Guidelines Network 2010, ‘Management of patients with stroke: identification and management of dysphagia: A national clinical guideline’, Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; 2010, www.sign.ac.uk/guidelines/fulltext/119, viewed 02 April, 2013.

Schepp SK, Tirschwell DL, Miller RM, Longstreth WT 2012, ‘Swallowing screens after acute stroke: a systematic review’, Stroke. 2012; 43:869-871, http://stroke.ahajournals.org/, viewed 29 March 2012.

Walker, N, Stevens, D, & Musgrave, S 2010, ‘Management of dysphagia’, GM: Midlife & Beyond, 40, 8, pp. 403-405, CINAHL with Full Text, EBSCOhost, viewed 26 May 2013.

Weinhardt, J, Hazelett, S, Barrett, D, Lada, R, Enos, T, & Keleman, R 2008, Accuracy of a bedside dysphagia screening: a comparison of registered nurses and speech therapists, Rehabilitation Nursing, 33, 6, pp. 247-252, CINAHL with Full Text, EBSCOhost, viewed 25 May 2013.

Appendix 1Appendix 1Appendix 1Appendix 1Appendix 1Appendix 1Appendix 1Appendix 1Appendix 1Appendix 1Appendix 1

Appendix 1

Valid Items for Screening Dysphagia Risk in Patients with Stroke

A Systematic Review

Stephanie K. Daniels, PhD;
Jane A. Anderson, PhD;
Pamela C. Willson, PhD
Abstract

Background and Purpose—Screening for dysphagia is essential to the implementation of preventive therapies for patients with stroke. A systematic review was undertaken to determine the evidence-based validity of dysphagia screening items using instrumental evaluation as the reference standard.

Methods—Four databases from 1985 through March 2011 were searched using the terms cerebrovascular disease, stroke deglutition disorders, and dysphagia. Eligibility criteria were: homogeneous stroke population, comparison to instrumental examination, clinical examination without equipment, outcome measures of dysphagia or aspiration, and validity of screening items reported or able to be calculated. Articles meeting inclusion criteria were evaluated for methodological rigor. Sensitivity, specificity, and predictive capabilities were calculated for each item.

Results—Total source documents numbered 832; 86 were reviewed in full and 16 met inclusion criteria. Study quality was variable. Testing swallowing, generally with water, was the most commonly administered item across studies. Both swallowing and nonswallowing items were identified as predictive of aspiration. Neither swallowing protocols nor validity were consistent across studies.

Conclusions—Numerous behaviors were found to be associated with aspiration. The best combination of nonswallowing and swallowing items as well as the best swallowing protocol remains unclear. Findings of this review will assist in development of valid clinical screening instruments.

Key Words: dysphagia

Screening

Stroke

Validity

Daneils, SK, Anderson, JA, Petersen, NJ,” Implementation of Stroke Dysphagia Screening in the Emergency Department”, Stroke. 2012;43:892-897, , doi:10.1161/STROKEAHA.111.640946, http://stroke.ahajournals.org/citmgr?gca=strokeaha; 2, viewed 25 May 2013.

Appendix 2
Appendix 3Appendix 3 Appendix 3

Scottish Intercollegiate Guidelines Network 2010, ‘Management of patients with stroke: identification and management of dysphagia: A national clinical guideline’

Appendix 4

NUTRITIONAL INTERVENTIONS

EVALUATING SWALLOWING AND NUTRITION AFTER STROKE

NUTRITIONAL SCREENING

Assessment of nutritional risk should be carried out within the first 48 hours with regular re-assessment thereafter during the patient’s recovery and be recorded prior to any discharge.

Following nutritional screening, those identified as undernourished, and those at risk of becoming undernourished, should be referred to a dietitian and considered for prescription of oral nutritional supplements as part of their overall nutritional care plan.

D

C

Dysphagia affects a large proportion of stroke patients. Swallowing difficulties can result in aspiration and reduced oral intake, leading to the potentially serious complications of pneumonia, undernutrition and dehydration.

Assessment of a patient’s nutritional risk should include an assessment of their ability to eat independently and a periodic record of their food consumption.

D



Patients with dysphagia who are unable to meet their nutritional requirements orally should be considered for initial NG feeding as soon as possible, within one week of onset. This decision should be made by the multidisciplinary team in consultation with the patient and their carers/family.

All stroke patients should be screened for dysphagia before being given food or drink.

C

D

Ongoing monitoring of nutritional status should include a combination of the following parameters:

.biochemical measures (ie low pre-albumin, impaired glucose metabolism)

.swallowing status

.unintentional weight loss

.eating assessment and dependence

.nutritional intake.

ASPIRATION PNEUMONIA

The water swallow test should be used as part of the screening for aspiration risk in stroke patients.

B

D

Patients in the early recovery phase should be reviewed weekly by the multidisciplinary team to ascertain if longer term (>4 weeks) feeding is required.

Clinical history taking should take into account comorbidities and other risk factors (eg smoking, respiratory disease) to identify increased risk of developing aspiration pneumonia.

C

B

Feeding via percutaneous endoscopic gastrostomy (PEG) is the recommended feeding route for long term (>4 weeks) enteral feeding. Patients requiring long term tube feeding should be reviewed regularly.

D

Nutritional screening should cover; body mass index (BMI), ability to eat, appetite, physical condition, mental condition.

SWALLOW SCREENING

ASSESSMENT

Patient’s and carer’s perceptions and expectations of PEG feeding should be taken into account and the benefits, risks and burden of care fully explained before initiating feeding.

D

D

Patients with dysphagia should be monitored daily in the first week to identify rapid recovery. Observations should be recorded as part of the care plan.

B

.A standardised clinical bedside assessment (CBA) should be used by a professional skilled in the management of dysphagia

.The CBA developed and tested by Logemann, or a similar tool, is recommended.

ROLE OF REGULAR REVIEW



Patients not fit for assessment should be screened daily to avoid delay in referral for full clinical assessment.

Patients with persistent dysphagia should be reviewed regularly, at a frequency related to their individual swallowing function and dietary intake, by a professional skilled in the management of dysphagia.

D

The modified barium swallow (MBS) test and fibreoptic endoscopic evaluation (FEES) of swallow are both valid methods for assessing dysphagia. The clinician should consider which is the most appropriate for different patients in different settings.

C

A typical swallow screening procedure should include:

.initial observations of the patient’s consciousness level

.observations of the degree of postural control

If the patient is able to actively cooperate and is able to be supported in an upright position the procedure should also include:

.observations of oral hygiene

.observations of control of oral secretions

.if appropriate, a water swallow test.

D

ORAL HYGIENE

Good oral hygiene should be maintained in patients with dysphagia, particularly in those with PEG or NG tubes, in order to promote oral health and patient comfort.

D

D

Hospital and community pharmacists or medicines information centres should be consulted on the most appropriate method of administering medication.

An appropriate oral care protocol should be used for every patient with dysphagia, including those who use dentures.



DYSPHAGIA THERAPY

CARING FOR PATIENTS WITH DYSPHAGIA

All patients who have dysphagia for more than one week should be assessed to determine their suitability for a rehabilitative swallowing therapy programme. Consideration should be given to:

.the nature of the underlying swallowing impairment

.patient suitability in terms of motivation and cognitive status.

D

Patients on nil by mouth or modified diet should continue to receive clinically essential medication by an appropriate route as advised by a pharmacist.



Staff, carers and patients should be trained in feeding techniques. This training should include:

.modifications of positioning and diet

.food placement

.management of behavioural and environmental factors

.delivery of oral care

.management of choking.

D

DIET MODIFICATION

D

.Advice on diet modification and compensatory techniques (postures and manoeuvres) should be given following full swallowing assessment

.Texture modified food should be attractively presented and appetising. Patients should have a choice of dishes.

Patients with dysphagia should have an oropharyngeal swallowing rehabilitation programme that includes restorative exercises in addition to compensatory techniques and diet modification.

Appendix 4.Texture modified meals may be fortified to enable patients to meet nutritional requirements

.Food and fluid intake should be monitored and, if indicated, a referral made to the dietitian.



This Quick Reference Guide provides a summary of the main recommendations in SIGN 119 Management of patients with stroke: Identification and management of dysphagia.

Recommendations are graded A B C D to indicate the strength of the supporting evidence. Good practice points are provided where the guideline development group wishes to highlight specific aspects of accepted clinical practice. Details of the evidence supporting these recommendations can be found in the full guideline, available on the SIGN website: www.sign.ac.uk

Scottish Intercollegiate Guidelines Network 2010, ‘Management of patients with stroke: identification and management of dysphagia: A national clinical guideline’, Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; 2010, www.sign.ac.uk/guidelines/fulltext/119, viewed 02 April, 2013.

Guideline Summary Guideline Title Management of patients with stroke: identification and management of dysphagia. A national clinical guideline. Bibliographic Source(s) Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: identification and management of dysphagia. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010 Jun. 42 p. (SIGN publication; no. 119). [169 references] Guideline Status This is the current release of the guideline. This guideline updates a previous version: Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: identification and management of dysphagia. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2004 Sep. 38 p. (SIGN publication; no. 78). [154 references] Age of Target Population: Aged, 80 and over; Aged (65 to 79 years); Middle Age (45 to 64 years); Adult (19 to 44 years) UMLS Concepts (what’s this?)
Click to view all guideline(s) indexed with these concepts HCPCS: DYSPHAGIA SCREENING; FOOD THICKENER, ADMINISTERED ORALLY, PER OUNCE
ICD9CM: Administration of psychologic test (94.02); Cerebral artery occlusion, unspecified with cerebral infarction (434.91); Dysphagia, unspecified (787.20)
MSH: Auscultation; Deglutition; Dislocations
MTH: Auscultation; Deglutition; Dislocations

Disease/Condition(s) Dysphagia after stroke Intended Users Advanced Practice Nurses
Allied Health Personnel Appendix 4
Dietitians
Nurses
Occupational Therapists
Physician Assistants
Physicians
Speech-Language Pathologists Guideline Objective(s) To assist practitioners in reducing the morbidity associated with dysphagia by early detection of swallowing disorders in stroke patients and application of appropriate methods to support food and fluid intake Target Population Stroke patients in Scotland throughout the care pathway from initial primary care response, through hospital admission, on to continuing care in the community. The emphasis is on patients in the acute setting. Note: The guideline does not apply to people with neurological conditions other than stroke or to people with subarachnoid haemorrhage. Interventions and Practices Considered Evaluation/Assessment/Screening Initial clinical evaluation of swallowing and nutrition after stroke: Assessing risk of pneumonia (assessing risk of aspiration, water swallow test) Swallow screening Assessing risk of under nutrition Nutritional screening Assessing risk of dehydration Assessment: Provider training for screening and assessments Scottish Intercollegiate Guidelines Network 2010, ‘Management of patients with stroke: identification and management of dysphagia: A national clinical guideline’ Appendix 4
Appendix 5Appendix 5

RBWH Daily Swallow Screen http://hi.bns.health.qld.gov.au/allied_health/forms/speech_pathology/daily_swallow.pdf

Appendix 6

E-learning module available http://www.sdc.qld.edu.au/elearning/elearning_programs.htm

Appendix 7

Appendix 7

Royal Brisbane and Women’s Hospital Health Service District Policy: Dysphagia Screening – Adults Appendix 8

Appendix 8Appendix 8

Appendix 8

Appendix 8

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