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