meeting psc stroke 7 standard tool creation policy development process to improving care

Meeting PSC Stroke 7 Standard

Tool creation

Policy development

Process to improving care

Purpose of performing swallow screen (SS) by nursing (Perry, 2001):

• Quickly identify overt dysphagia• Performed before ANYTHING PO• No withholding PO if pt passes screening• Failures ensure rapid SLP referral • Decrease unneeded Dysphagia Eval (DE) by SLP• Comprehensive nursing assessment

Purpose of performing SS…(cont.)

• NOT DE (i.e., water only)• Screening for possibility of dysphagia • H2O less irritating if aspirated (DePippo, et al.,1992)• Less time consuming tool

– 5cc, 10cc, & 90cc of water

• Improves communication between nursing and SLP

SS and Nursing Scope of Practice

• MI Public Health Code are generic guidelines– MI does not have Nurse Practice Act

• SS not specifically addressed• Must consider:

– Basic formal nursing training– Professional experience– Continuing Ed programs with formal instruction– Infringement on trained SLP dedication, time &

education

Process for Designing Protocol

• Developed SS in 2004 before PSC certification• Collaboration between SLP and Stroke CNS• Combined several screening tools• Evidence based:

– BSS study (‘98), – BDST (’92)– Kidd Water Test (“93)– SSA (’01)– Massey Bedside (’02)

Bedside Swallow Screen Performed by Nursing

• Individual & small group education • Education performed ED & adult units by SLP & CNS • Staff concerns:

– time issues– clinical expertise– SS confused with DE – confusion in documentation affects billing – RN/SLP scope of practice

Bedside Swallow Screen Performed by Nursing

• HOB elevated 90 degrees to slow bolus entrance into pharynx and allows for maximum airway

protection (Cherney, 1994)• No straws by nursing during screen • Straws increase risk of aspiration due to difficulty

coordinating suck using oral pressure vs. inhalation (Logemann, 1998)

Bedside Swallow Screen Performed by Nursing

• initially designed for stroke pts• where to document results?

– different nursing forms each unit– stickers vs standardized location on forms

• physician education– ordering appropriately– holding all PO (include meds) for failure

• continuing ed & education of new employees

Process:

• Developed swallow screen • Developed teaching tools (hand outs)

– algorithm instruction card, sheets, short lecture• Addressed staff concerns during education• Maintain f/u with DM/ADM• Reward &/or recognition for performance

Process:

• Stroke CNS presence in ED• Add order & nursing policy # to TIA/Stroke Orders• Continued chart review & data sharing in

meetings/postings• Update forms • SS added to standardized nursing notes & Stroke Care

Plan (highlighted)

Process:

• Article in nursing newsletter• Added swallow screen pass/fail to neuro t sheet in ED• Educate admit/ED physicians • Reeducate during nursing competency programs• Continue feedback on performance to DM/ADMs• SLP & CNS developed research study to validate SS

Expanded Policy

• PI Physician champion (Pneumonia Team) approved core team to review & redesign policy

• Expanded to all patients at risk• Redesigned algorithm• Mandatory ed for adult med/surg unit nursing staff• Transparent data

Expanded Policy• Computerized teaching module objectives:

» Define & add complications of dysphagia» Specify high risk patient populations» Identify patients for whom SS is

contraindicated» Describe proper SS procedure» Determine what constitutes failure of SS» Describe documentation of findings

• Added scenarios & test questions

Performance Improvement

• Continue to provide motivators:

– frequent education– recognition– transparent data – ongoing prospective chart review– multidisciplinary rounds

Nursing Research Study:“Concordance Between Patient Bedside Swallow

Screen and Dysphagia Evaluation Results Obtained from Neurological Nurses and Speech Pathologists”

• Purpose:

1. compare staff nurse assessment with SLP &

2. look at influence of certain patient characteristics.• Validation of SHS SS• Endpoint:100 stroke patients consented• IRB approval

Nursing Research Study

• Neuro nurses education 1 on 1 for reliability• Improved nursing and physician staff by in• Orders for SS from many physician services• Data collection by CNS and SLP• Patient collection from Neuro/Stroke ICU and Neuro

Stepdown• Study abstract submitted to AHA ISC 2010