Sie sind auf Seite 1von 9

Volume 48 & Number 4 & August 2016

215

LITERATURE R EVIEW

Nursing Interventions for Identifying and Managing Acute Dysphagia are Effective for Improving Patient Outcomes: A Systematic Review Update

Sonia Hines, Kate Kynoch, Judy Munday

ABSTRACT

Background: Dysphagia, or difficulty in swallowing, is a serious and life-threatening medical condition that affects a significant number of individuals with acute neurological impairment, largely from stroke. Dysphagia is not generally consider ed a major cause of mortality; however, the complications that result from this medical condition, namely, aspiration pneumonia and malnutrition, are among the most common causes of death in the older adults. Methods: This is an update of an existing systematic review. The standard systematic review methods of the Joanna Briggs Institute were used. Methods were specified in advance

in a published protocol. Awide range of databases were searched for quantitative research articles examining

the effectiveness of nursing interventions to identify and manage dysphagia in adult patients with acute neurological dysfunction, published between 2008 and 2013. Results: Four new studies were added in this update, for a total of 15 included studies. Strong evidence was found to show that nurse-initiated dysphagia screening is effective for reducing chest infections in patients with dysphagia (odds ratio [OR] = 0.45, 95% CI [0.33, 0.62], p G .00001). Nurse-initiated dysphagia screening by trained nurses may be effective for detection

of dysphagia, and training nurses in dysphagia screening improves the number and accuracy of screens conducted. The presence of formal dysphagia guidelines in a health facility is likely to reduce inpatient deaths (OR = 0.60, 95% CI [0.43, 0.84], p = .003) and chest infections (OR = 0.68, 95% CI [0.51, 0.90],

p = .008); however, it does not appear that formal guidelines have an effect on length of stay. Conclusions:

Nurse-initiated dysphagia screening for patients with acute neurological dysfunction is effective for a range of important patient outcomes. The presence of formal guidelines for the identification and management

of dysphagia may have a significant effect on serious adverse outcomes such as chest infections and death. Training nurses to conduct dysphagia screening will improve patient outcomes.

Keywords: deglutition disorders, dysphagia, nursing interventions, stroke, systematic review

Questions or comments about this article may be directed to Sonia Hines, RN BN GradDipEd, MAppSc, at sonia.hines@ mater.org.au. She is a Nurse Researcher, Mater Health Services Nursing Research Centre and The Queensland Centre for Evidence- Based Nursing and Midwifery: a Joanna Briggs Institute Centre of Excellence, Brisbane, Queensland.

Kate Kynoch, RN BN GradCert(ICN) MN(ICN) PhD candidate, Director, Mater Health Services Nursing Research Centre, and The Queensland Centre for Evidence-Based Nursing and Midwifery:

a Joanna Briggs Institute Centre of Excellence, Brisbane, Queensland.

Judy Munday, RN DipEd(Nurs) BA(Hons) PhD candidate, Clinical Research Nurse, Mater Health Services Nursing Research Centre, and The Queensland Centre for Evidence-Based Nursing and Midwifery:

a Joanna Briggs Institute Centre of Excellence, Brisbane, Queensland.

The authors declare no conflicts of interest.

Copyright B 2016 American Association of Neuroscience Nurses DOI: 10.1097/JNN.0000000000000200

Background

Dysphagia, that is, difficulty in swallowing, is a serious and life-threatening medical condition that affects a significant number of individuals with acute neurolog- ical impairment, largely from stroke. It is estimated that approximately 1 in 10 deaths worldwide are because of stroke (Mackay & Mensah, 2004). Of those who expe- rience a stroke, around 65% will develop neurogenic dysphagia (Daniels, 2006). Dysphagia is not generally considered a major cause of mortality; however, the com- plications that result from this medical condition, namely, aspiration pneumonia and malnutrition, are among the most common causes of death in the older adults (Wieseke, Bantz, Siktberg, & Dillard, 2008). In hospitals, nurses, who are available on a 24-hour basis, are in a prime position to undertake an initial

Copyright © 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

216

Journal of Neuroscience Nursing

L ITERATURE R EVIEW

screening and initiate interventions for patients with

swallowing difficulties (Davies, 2002). Nurses specif- ically trained in undertaking dysphagia screening have

an important role in reducing adverse outcomes associated

with dysphagia (Yeh et al., 2011). Nurses are often in the

position of explaining and educating family members on the patient’s management plan and have an important impact on the patient and family adherence to treatment for dysphagia (Lutz, Young, Cox, Martz, & Creasy, 2011). If nurses screen patients with an acute neuro-

logical impairment within 24 hours of admission, it may reduce the time that patients spend without appropriate nutrition and hydration and improve clinical outcomes (Hines et al., 2011). Dysphagia screening by nurses does not replace assessment by other health professionals; in- stead, it enhances the provision of care to patients at risk allowing for early recognition and intervention to occur. This review is an update of a review previously updated in 2008, using Joanna Briggs Institute (JBI) methods, which included articles published between

1998 and 2008 (Hines et al., 2011). The original re-

view (Ramritu, Finlayson, Mitchell, & Croft, 2000) sourced evidence from 1985 to 1998. This new update

aimed to review all available evidence from February

2008 to March 2013.

The level of evidence in the previous iteration of this review was overall moderate to low, with only one ran- domized controlled trial (RCT) included, with most being of lower quality observational or descriptive designs. This review includes stronger evidence. The objectives, inclusion criteria, and methods of analysis for this re- view were specified in advance and documented in a

published protocol (Hines, Kynoch, & Munday, 2013).

A version of this review with a large number of appen-

dices and supplementary materials is uploaded on the

JBI Library of Systematic Reviews and Implementation Reports (Hines, Kynoch, & Munday, 2014).

Searches

We searched CINAHL, Medline, Cochrane CENTRAL, Web of Science, and Embase. The search for gray liter- ature included Mednar, OpenSIGLE, New York Acad- emy of Medicine Library Grey Literature Report, and ProQuest Dissertations and Theses for published and unpublished studies. Searches were restricted to English language only. Initial search terms used were the following:

dysphagia (text word and MH) or gag reflex or swallow problem or impair or difficult neurological and impair or stroke or bedside swal- lowing assessment MH ‘‘Brain Diseases+’’ or neurological and impair* or disorder* or disease* or malfunction

MH ‘‘Deglutition Disorders’’ or MH ‘‘Gagging’’ or bedside swallowing assessment or swallowing assessment

Inclusion Criteria

Participants

Participants of interest were adults over the age of 18 years with acute neurogenic dysphagia. Populations with neurological impairment resulting from a long- term disease process (e.g., Huntington disease) were not included because their assessment needs are considered different to the focus of this review and largely the purview of speech and language professionals, not nurses.

Interventions

Interventions that focused on the nursing role in the recognition and screening for dysphagia; any formal observation of the ability to swallow undertaken/ documented by nurses, clinical/bedside swallowing screening undertaken by nurses, pulse oximetry moni- toring for the purposes of detecting aspiration, and other interventions concerned with the nursing management of dysphagia such as nurse education, either in com- parison with ‘‘usual care’’ or other interventions, were eligible for inclusion.

Exclusion Criteria

Studies focusing on diagnostic procedures ordered or undertaken by either medical or speech-language pathol- ogists (such as VFSS) were not of interest to this review. Studies focusing on dysphagia without a diagnosed neuro- logical impairment were also excluded. Any studies with participants with dysphagia resulting from cancer, radiotherapy, surgery, infection, or congenital abnormali- ties were excluded, unless these participants formed the control group.

Outcomes

This review considered studies that measured any out- comes related to the following areas:

Early recognition by nurses of those with difficulty swallowing Clinical screening by nurses of any patient with sus- pected swallowing difficulties Timely referral by nurses to speech-language pathol- ogists for formal assessment Any outcome measures from interventions that aimed to prevent aspiration, choking episodes, and/or asso- ciated morbidity

Study Designs

Experimental and epidemiological study designs includ- ing randomized controlled trials, nonrandomized controlled trials, quasi-experimental studies, before-and-after studies,

Copyright © 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

Volume 48 & Number 4 & August 2016

217

L ITERATURE REVIEW

prospective and retrospective cohort studies, case control studies, and cross-sectional studies were considered for inclusion.

Critical Appraisal

Articles selected for retrieval were assessed by two in- dependent reviewers for methodological validity before inclusion in the review using standardized critical appraisal instruments from the JBI Meta-Analysis of Statistics Assessment and Review Instrument. Any disagreements that arose between the reviewers were resolved through the adjudication of the third reviewer.

Data Extraction and Synthesis

Data were extracted from articles included in the review using the standardized data extraction tool from JBI Meta- Analysis of Statistics Assessment and Review Instrument. The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question, and specific ob- jectives. We attempted to contact study authors where necessary to clarify details and/or retrieve any missing data. Quantitative data were, where possible, pooled in statistical meta-analysis using RevMan 5.2. Effect sizes are expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data), and their 95% confidence intervals were calculated for analysis. Heterogeneity was assessed statistically using the stan- dard chi-square and I-squared tests. The small amount of additional data from this update was combined with data from the studies included in the previous update to enable a more accurate view of the effect of interventions.

Characteristics of Included Studies

Initially, 38 studies were identified from the searches as being potentially relevant. We were unable to retrieve full-text versions of two of the studies, which were only available as conference abstracts, and seven were dupli- cates. Twenty-nine studies in full text were checked for congruence to the review’s inclusion criteria, and of these, six met the criteria and were critically appraised. After critical appraisal, four studies meeting the inclu- sion criteria were found to be of sufficient quality to be included in the review (Bravata et al., 2009; Edmiaston, Connor, Loehr, & Nassief, 2010; Martino et al., 2009; Middleton et al., 2011). These were added to 11 studies (Anderson et al., 2000; Chang, Pattie, & Finlayson, 2005; Daniels, Ballo, Mahoney, & Foundas, 2000; Goulding & Bakheit, 2000; Lees, Sharpe, & Edwards, 2006; Nishiwaki et al., 2005; Perry, 2001a, 2001b; Perry & McLaren, 2000, 2003; Westergren, Hallberg, & Ohlsson, 1999) from the last update of this review. Although the previous update included 14 studies, three of these are no longer considered to meet the inclusion criteria and

have been excluded (please see the Differences Be- tween This Update and the Previous Version section for further details). The total number of included studies in this review update is 15 (see Fig 1 for further details of the search and retrieval process). Studies included in this review update were conducted in Australia (Anderson et al., 2000; Chang et al., 2005; Middleton et al., 2011), Japan (Nishiwaki et al., 2005), Sweden (Westergren et al., 1999), Canada (Martino et al., 2009), United Kingdom (Goulding & Bakheit, 2000; Lees et al., 2006; Perry, 2001a, 2001b; Perry & McLaren, 2000, 2003), and United States (Bravata et al., 2009; Daniels et al., 2000; Edmiaston et al., 2010) and had a total of 6,092 participants.

Risk of Bias

Four studies were added by this update: one RCT (Middleton et al., 2011), two tool validation studies using observational methods (Edmiaston et al., 2010; Martino et al., 2009), and one retrospective pre/post descriptive study (Bravata et al., 2009). The RCT (Middleton et al., 2011) was found to be high quality, with adequate randomization, concealment of allocation, and blinding of participants; however, it was unclear if intention-to-treat analysis was utilized. The prospective observational tool validation study by Edmiaston et al. (2010) was lacking in some details of the methodology used; however, it was deemed of adequate quality to include, as was the prospective observational study by Martino et al. (2009), which was of similar quality. The retrospective pre/post descriptive study to validate a tool (Bravata et al., 2009) used high-quality methods to minimize the risk of bias.

Results

To truly update the evidence on this question rather than simply create a new review of the most recent evidence, we have combined data from the previous review, where it was possible and appropriate, to conduct meta- analyses. Findings are grouped by types of intervention and then further grouped by outcome as it relates to each intervention.

Nurse-Initiated Dysphagia Screening for Reducing Chest Infections

Five studies with 4,519 participants reported data on this intervention and outcome. Two new studies reported data on nurse-initiated screening for dysphagia (Bravata et al., 2009; Middleton et al., 2011)Vdata from which were added to three included studies (Hinchey et al., 2005; Perry, 2001b; Perry & McLaren, 2000) and the dichotomous data pooled (Fig 2). Nurse-initiated screen- ing was significantly more effective than usual care

Copyright © 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

218

Journal of Neuroscience Nursing

L ITERATURE R EVIEW

for preventing chest infections (odds ratio = 0.45, 95% confidence interval [0.33, 0.62], p G .00001).

Nurse-Initiated Dysphagia Screening for Reducing Days Spent Nil by Mouth

Three studies with 557 participants reported data on this intervention and outcome. One new study (Bravata et al., 2009) investigating nurse-initiated screening re- ported data on days spent nil by mouth, which was added to one included study (Perry, 2001b) that also reported this outcome. For this comparison, there was no statis- tically significant difference between the group receiv- ing nurse-initiated screening and the usual care group. Days spent without oral intake were also measured in one additional study (Perry & McLaren, 2000). Similar to Bravata et al. (2009) and Perry (2001b), Perry and McLaren (2000) report a significant reduction in days spent nil by mouth in the group receiving nurse-initiated dysphagia screening ( p G .001); however, the data were unsuitable to be included in the analysis, introducing significant heterogeneity ( 2 2 = 56.88, df = 2, p G .00001, I 2 = 96%) and exerting considerable effect on

the pooled result. The considerable methodological differences (audit vs. prospective observational study) between these studies are likely to be the cause of the heterogeneity. It would seem from the results of the included studies that it remains unclear whether this is an effective intervention for reducing the number of days spent without oral intake (Fig 3).

Nurse-Initiated Dysphagia Screening for Detection of Dysphagia by Trained Nurses

Six studies (Anderson et al., 2000; Edmiaston et al., 2010; Lees et al., 2006; Perry, 2001a, 2001b; Westergren et al., 1999) with greater than 511 instances of screening (one study reported only percentage accuracy, not num- ber of screens) reported data on the accuracy of dysphagia screening conducted by nurses using screening tools for which they had received training. A variety of tools were employed in the studies; however, as can be seen in the analysis, very few inaccurate screens (false positive or false negative) were reported. Where accuracy was not reported as a percentage, we calculated it from the re- ported numerical data. The data and percentage of

FIGURE 1 FIGURE 1 Flowchart of Studies
FIGURE 1
FIGURE 1
Flowchart of Studies

Copyright © 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

Volume 48 & Number 4 & August 2016

219

L ITERATURE REVIEW

FIGURE 2 FIGURE 2 Occurrence of Chest Infections: Nurse Screening Versus Usual Care
FIGURE 2
FIGURE 2
Occurrence of Chest Infections: Nurse Screening Versus Usual Care

accurate screens performed are shown in Table 1. Ac- curacy of screens ranged from approximately 70% to over 94%. Accuracy of screening was considerably greater in studies using validated tools (Edmiaston et al., 2010; Lees et al., 2006; Perry, 2001a, 2001b) rather than clinical assessment (Westergren et al., 1999). Although the accuracy reported in Anderson et al. is also high, the actual numbers of screens was small (Anderson et al., 2000). Screening accuracy in all studies was determined by comparison with screens conducted by speech and language professionals. Overall, it appears that nurse- initiated dysphagia screening by nurses trained in the use of a validated tool is effective for detecting dysphagia. In addition, training nurses in the use of validated dysphagia screening tools has been found to increase the number of patients with acute neurological dysfunc- tion who are screened for swallowing problems (Table 2). Although a meta-analysis of these studies showed sig- nificant effect (p G .00001), the heterogeneity was too

great (2 2 = 58.38, df = 2, p G .00001, I = 97%) to include the pooled results, and this was not improved by attempting sensitivity analysis. The high degree of heterogeneity was likely because of the extensive clin- ical variability between the studies.

˙

Nurse-Initiated Dysphagia Screening for Time to Initial Assessment

One study with 50 participants reported data on the ef- fect of nurse-initiated dysphagia screening on the time

to swallow assessment (Lees et al., 2006). In this study of acute stroke admissions to an acute observation unit, the mean time to assessment by speech and language therapists (SLTs) before the intervention was 1.53 days (Lees et al., 2006). After a training program to give nurses the skills to conduct dysphagia screening, there was a considerable reduction in time to swallow assess- ment, with patients with acute stroke admitted via the emergency department being assessed at 5Y29 hours after admission and most patients with acute stroke (91%) admitted directly to the acute observation unit assessed within the first hour after admission (Lees et al., 2006).

Nurse-Initiated Dysphagia Screening for Time to SLT Assessment and Referral to SLT

Four studies with 655 participants (608 patients/47 staff) reported data on the effect of nurse-initiated dysphagia

screening on the time to SLT referral and/or SLT as- sessment (Anderson et al., 2000; Chang et al., 2005; Lees et al., 2006; Perry & McLaren, 2003). Nurses were found to have made the appropriate referral to SLTs in 100% of Chang et al.’s (2005) experimental group, 87.5% of cases in Lees et al.’s (2006) study, and 72% of cases in Anderson et al.’s (2000) study. Perry and McLaren (2003) report that, before introduction of nurse-initiated dysphagia screening, 39% (n = 30) of referrals of patients with suspected dysphagia for SLT assessment were made within 72 hours of admission,

TABLE 1. Accuracy of Screening by Nurses Trained in Dysphagia Screening

 

Study

Tool

Accurate

Inaccurate

Total Screens

Accuracy

Anderson et al., 2000 Edmiaston et al., 2010 Lees et al., 2006 Perry, 2001b Perry, 2001a Westergren et al., 1999

PFC/FT

18/19

1/0

19

95%/100%

ASDS

238

62

300

79.3%

SSA

35

5

40

87.5%

SSA

64

12

76

84.2%

SSA

64

4

68

94.1%

Clinical evaluation

19

8

27

70.3%

Note. ASDS = acute stroke dysphagia screen; PFC/FT = prefeeding checklist/feeding trial; SSA = standardized swallow assessment.

Copyright © 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

220

Journal of Neuroscience Nursing

L ITERATURE R EVIEW

TABLE 2. Nurse Dysphagia Screen Training for Number of Patients Screened

 

No Training

Training

Study

Tool

Screens

N

Screens

N

Significance

Chang et al., 2005 Middleton et al., 2011 Perry & McLaren, 2003

SSA

0

80

33

61

p = .002 p G .0001 p G .001

ASSIST

24

350

242

522

SSA

106

200

123

200

Note. SSA = standardized swallow assessment.

 

which rose to 56% (n = 42) once nurses were con- ducting dysphagia screening; however, the difference was not statistically significant (Perry & McLaren, 2003). Similarly, the time to SLT assessment also rose slightly from 64% (n = 49) before nurse dysphagia screening to 68% (n = 51) after nurse dysphagia screen- ing, which was also statistically insignificant (Perry & McLaren, 2003). It is interesting to note that, in Chang et al.’s study, the number of SLT referrals decreased in the group that had received dysphagia screening with no difference in the appropriateness of those referrals.

Formal Dysphagia Guidelines for Screening Within 24 Hours, Chest Infections, Death, and Length of Stay

Four studies (Hinchey et al., 2005; Middleton et al., 2011; Perry & McLaren, 2000, 2003) with 4,528 par- ticipants reported data on the effectiveness of formal dysphagia guidelines within an organization in com- parison with no guidelines or informal guidelines for a variety of outcomes including screening within 24 hours, rates of chest infections, death, and length of stay. The presence of formal dysphagia guidelines has been found to be effective, in all studies reporting this outcome, for increasing the number of patients screened for dysphagia within 24 hours of admission, as shown by the results from the two studies in Table 3 below. We attempted to meta-analyze these results; however, heterogeneity was very high (2 2 = 44.9, df = 1, p G .00001, I 2 = 98%), which is likely because of the methodological dissim- ilarity between the studies. For chest infections such as pneumonia, both Hinchey et al. (2005) and Perry and McLaren (2003) report

significant decreases in the presence of formal dyspha- gia management guidelines ( p = .001 and p G .003, respectively); however, Middleton et al. (2011) report no significant difference in chest infection incidence between sites with and without formal guidelines ( p = .36). When these results are meta-analyzed, a significant effect is seen ( p G .008; Fig 4). The moderate het- erogeneity seen (I 2 = 57%) is likely because of meth- odological dissimilarities between the studies. Death rates between hospital sites with and without formal guidelines were reported by two studies with differing results (Hinchey et al., 2005; Middleton et al., 2011). Middleton et al. (2011) report no difference in death rates at sites with or without formal dysphagia guidelines ( p = .36), whereas Hinchey et al. (2005) report a significantly greater number of patients dis- charged alive ( p = .013) from sites with formal dysphagia

guidelines. When these study results are pooled, a statistically significant effect is seen, with fewer deaths seen in sites with formal dysphagia guidelines in place ( p = .003; Fig 5). It should be emphasized, however, that Middleton et al.’s study examined a bundle of stroke care interventions that included dysphagia screen- ing, not dysphagia screening alone, and so the effect on mortality may be because of several factors (Middleton et al., 2011). Length of stay data were reported by three studies (Hinchey et al., 2005; Middleton et al., 2011; Perry, 2001b). Middleton et al. (2011) report no significant difference in length of stay between sites with or with-

out formal dysphagia

Hinchey et al. (2005) state a median length of stay of 4 days for sites with dysphagia guidelines and 5 days

guidelines ( p = .144), whereas

FIGURE 3 FIGURE 3 Days Spent Nil by Mouth: Nurse Screening Versus Usual Care, Sensitivity
FIGURE 3
FIGURE 3
Days Spent Nil by Mouth: Nurse Screening Versus Usual Care,
Sensitivity Analysis
Copyright © 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

Volume 48 & Number 4 & August 2016

221

L ITERATURE REVIEW

TABLE 3. Dysphagia Guidelines for Dysphagia Screening Within 24 Hours

 

No Guidelines

With Guidelines

Screened Within

Screened Within

Study

24 Hours

N

24 Hours

N

p Value

Middleton et al., 2011

24

350

242

522

p G .0001

Perry & McLaren, 2000

106

185

123

185

p G .001

for those without and report no further statistical data for this outcome. Conversely, Perry’s (2001b) audit of standardized swallow assessment use found a signif- icantly shorter length of stay in the group receiving standardized swallow assessment screening by nurses ( p = .04).

Strategies for Nursing Management of Dysphagia

In addition to the above evidence on the effectiveness of nurse-initiated dysphagia screening and formal dyspha- gia guidelines, three studies provide additional guid- ance on strategies for nursing management of dysphagia for three different aspects of practice. Chang et al. (2005) examined strategies to improve nurses’ knowledge about dysphagia, Bravata et al. (2009) looked at ways to im- prove nursing admission processes for people with acute stroke and dysphagia, and the benefits of monitoring fluid thickness were evaluated by Goulding and Bakheit

(2000).

Goulding and Bakheit’s (2000) RCT examined the effectiveness of thickening fluids for preventing aspi- ration in patients with dysphagia, using pulse oximetry to detect aspiration, with the aim of addressing the problem of patients with dysphagia being prescribed thickened fluids of different consistencies based on subjective assessment only. Using fluids thickened to either ‘‘yoghurt’’ or ‘‘syrup’’ consistency, the study was unable to find any significant difference between aspirators and nonaspirators and concluded that in- creasing fluid thickness may not be an effective intervention to prevent aspiration and in fact may lead patients to decrease their fluid intake to a harmful

degree (Goulding & Bakheit, 2000). Ten (43%) patients in the study group and nine (39.1%) control subjects showed evidence of pulmonary aspiration, and the total frequency of observed aspiration was 12 and 10 times, respectively. The difference between the two groups was not statistically significant ( p = .7). Improving nurses’ knowledge about dysphagia can lead to significant improvements in dysphagia manage- ment at the ward level (Chang et al., 2005). In two 1-hour sessions, Chang et al. (2005) delivered an educational program, developed by a speech pathologist, to nurses caring for patients with acute neurological dysfunction with the aim of increasing the number of dysphagia screens done by nurses. Median results on the knowl- edge questionnaire administered to participants improved significantly between the pretest and posttest measures ( p G .001) and between nurses who received the edu- cational intervention and those in a control ward who did not ( p = .006), which led to a significantly greater number of dysphagia screens being conducted by nurses who had received education ( p = .002; Chang et al., 2005). Adding nurse-initiated dysphagia screening to admis- sion processes has also been found to be effective (Bravata et al., 2009). After the introduction of nurse-initiated dysphagia screening, Bravata et al. (2009) found a significant decrease in the number of patients transferred to skilled nursing facilities postdischarge ( p G .001) as well as a significant decrease in the number of nutri- tionist consultations performed ( p = .05). It should be noted, however, that no significant improvements were made in a number of key outcomes such as rates of chest infection, days spent nil by mouth, or inpatient death (Bravata et al., 2009).

FIGURE 4 FIGURE 4 Formal Dysphagia Guidelines for Chest Infections
FIGURE 4
FIGURE 4
Formal Dysphagia Guidelines for Chest Infections

Copyright © 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

222

Journal of Neuroscience Nursing

L ITERATURE R EVIEW

FIGURE 5

Formal Guidelines Versus Informal or No Guidelines for Inpatient Death

Versus Informal or No Guidelines for Inpatient Death Conclusions It is important that formal dysphagia screening

Conclusions

It is important that formal dysphagia screening guide- lines are in place in healthcare organizations and that the guidelines include recommendations that patients are screened for dysphagia with a validated tool within 24 hours of admission. If nurses are trained to use a dysphagia screening too l, the number of accurate screens performed will in crease. Dysphagia screen- ing may reduce the rates of death, chest infections, and days spent nil by mouth; however, the latter requires more evidence. Dysphagia screening by nurses does not replace screening by other health professionals but is a necessary addition and is in the best interests of patients.

Implications for Practice

The following are rated using JBI grades of recom- mendation (JBI, 2013):

Nurse-initiated dysphagia screening is effective for reducing chest infections in patients with dysphagia (Grade A). Nurse-initiated dysphagia screening may be effec- tive for reducing days spent nil by mouth, but more evidence is needed (Grade B). Nurse-initiated dysphagia screening by trained nur- ses is effective for detection of dysphagia (Grade A). Training nurses in dysphagia screening improves the number and accuracy of screens conducted (Grade A). Nurse-initiated dysphagia screening may reduce time to initial dysphagia assessment (Grade B). It is unclear whether nurse-initiated dysphagia screen- ing has an effect on time to SLT assessment; however, training nurses in dysphagia screening may improve the appropriateness of their referrals of patients to SLT (Grade B). Formal dysphagia guidelines are likely to reduce in- patient deaths and chest infections; however, it does not appear that formal guidelines have an effect on length of stay (Grade A). Formal dysphagia guidelines are effective for increas- ing the number of patients screened for dysphagia within 24 hours (Grade A).

It is important to use a validated dysphagia screening tool that is both sensitive and specific to dysphagia, such as the standardized swallow assessment (Grade A). Cough during swallowing and voice change after swallowing are the clinical signs most likely to in- dicate the presence of dysphagia (Grade A). There is little evidence to suggest that greater thick- ness of fluids decreases aspiration (Grade B). Dysphagia education is likely to improve nurses’ dysphagia practices (Grade A). Nurse-initiated dysphagia screening at admission may have an effect on patient outcomes such as discharge destination, but more evidence is needed (Grade B).

Implications for Research

A considerable body of research now exists on this subject; however, some gaps still remain. High-quality research is needed to provide evidence about the effect of nurse-initiated dysphagia screening on the number of days patients spend nil by mouth, the time patients wait for SLT assessment, and the effect of nurse-initiated dysphagia screening on length of stay and discharge destination.

Differences Between This Update and the Previous Version

The studies by McCullough et al. (2005), Terr2 and Mearin (2006), and Smith, Lee, O’Neill, and Connolly (2000) that were included in the previous update, on further consideration, have been excluded from this ver- sion because the outcome of interest in these studies was detection of aspiration in patients diagnosed with dysphagia and not detection of dysphagia. Therefore, the studies were beyond the scope of this review.

References

Anderson, A., Byers, S., Luscombe, V., McDougall, J., Reeves, L., Russell, K., I Wilson, H. (2000). Dysphagia Screening Project: A descriptive quality assurance project. Australasian Journal of Neuroscience, 13(4), 10Y24. Bravata, D. M., Daggett, V. S., Woodward-Hagg, H., Damush, T., Plue, L., Russell, S., I Chumbler, N. R. (2009). Compar- ison of two approaches to screen for dysphagia among acute ischemic stroke patients: Nursing admission screening tool

Copyright © 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

Volume 48 & Number 4 & August 2016

223

L ITERATURE REVIEW

versus National Institutes of Health stroke scale. Journal of Rehabilitation Research and Development, 46(9), 1127Y1134. Chang, A., Pattie, M., & Finlayson, K. (2005). Early detection of swallowing problems in patients with neurological condi- tions (p. 32). Brisbane, Queensland: QUT. Daniels, S. K. (2006). Neurological disorders affecting oral, pharyngeal swallowing. GI Motility Online. doi:10.1038/ gimo34. Retrieved from http://www.nature.com/gimo/ contents/pt1/full/gimo34.html. Accessed May 18, 2008. Daniels, S. K., Ballo, L. A., Mahoney, M. C., & Foundas, A. L. (2000). Clinical predictors of dysphagia and aspiration risk:

Outcome measures in acute stroke patients. Archives of Physical Medicine and Rehabilitation, 81(8), 1030Y1033. Davies, S. (2002). An interdisciplinary approach to the man- agement of dysphagia. Professional Nurse, 18(1), 22Y25. Edmiaston, J., Connor, L. T., Loehr, L., & Nassief, A. (2010). Validation of a dysphagia screening tool in acute stroke patients. American Journal of Critical Care, 19(4), 357Y364. Goulding, R., & Bakheit, A. M. (2000). Evaluation of the benefits of monitoring fluid thickness in the dietary man- agement of dysphagic stroke patients. Clinical Rehabilitation, 14(2), 119Y124. Hinchey, J. A., Shephard, T., Furie, K., Smith, D., Wang, D., Tonn, S.; & Stroke Practice Improvement Network In- vestigators. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke, 36(9), 1972Y1976. Hines, S., Kynoch, K., & Munday, J. (2013). Identification and nursing management of dysphagia in individuals with acute neurological impairment (new update protocol). The JBI Database of Systematic Reviews and Implementation Reports , 11(7), 312Y323. Hines, S., Kynoch, K., & Munday, J. (2014). Identification and nursing management of dysphagia in individuals with acute neurological impairment: A systematic review (new update). JBI Database of Systematic Reviews and Imple- mentation Reports , 12 (5), 195 Y236. Hines, S., Wallace, K., Crowe, L., Finlayson, K., Chang, A., & Pattie, M. (2011). Identification and nursing management of dysphagia in individuals with acute neurological impair- ment (update). International Journal of Evidence-Based Healthcare, 9(2), 148Y150. Joanna Briggs Institute. (2013). Grades of recommendation . Retrieved from http://joannabriggs.org/jbi-approach .html#tabbed-nav=Grades-of-Recommendation Lees, L., Sharpe, L., & Edwards, A. (2006). Nurse-led dysphagia screening in acute stroke patients. Nursing Standard, 21(6),

35Y42.

Lutz, B. J., Young, M. E., Cox, K. J., Martz, C., & Creasy, K. R. (2011). The crisis of stroke: Experiences of patients and their family caregivers. Topics in Stroke Rehabilitation , 18 (6), 786 Y797. Mackay, J., & Mensah, G. (2004). The atlas of heart disease and stroke . Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/cardiovascular_diseases/

en/cvd_atlas_15_burden_stroke.pdf

Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D. L., & Diamant, N. E. (2009). The Toronto bed- side swallowing screening test (TOR-BSST): Development

and validation of a dysphagia screening tool for patients with stroke. Stroke, 40(2), 555Y 561.

McCullough, G. H., Rosenbek, J. C., Wertz, R. T., McCoy, S., Mann, G., & McCullough, K. (2005). Utility of clinical swallowing examination measures for detecting aspiration post-stroke. Journal of Speech, Language, and Hearing Re- search, 48(6), 1280Y1293. Middleton, S., McElduff, P., Ward, J., Grimshaw, J. M., Dale, S., D’Este, C., I. QASC Trialists Group. (2011). Implementa- tion of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): A cluster randomised controlled trial. Lancet, 378(9804), 1699Y1706. Nishiwaki, K., Tsuji, T., Liu, M., Hase, K., Tanaka, N., & Fujiwara, T. (2005). Identification of a simple screening tool for dysphagia in patients with stroke using factor analysis of multiple dysphagia variables. Journal of Rehabilitation Medicine, 37(4), 247Y251. Perry, L. (2001a). Screening swallowing function of patients with acute stroke. Part one: Identification, implementation and initial evaluation of a screening tool for use by nurses. Journal of Clinical Nursing, 10(4), 463Y473. Perry, L. (2001b). Screening swallowing function of patients with acute stroke. Part two: Detailed evaluation of the tool used by nurses. Journal of Clinical Nursing, 10(4), 474Y481. Perry, L., & McLaren, S. (2000). An evaluation of implementa- tion of evidence-based guidelines for dysphagia screening and assessment following acute stroke: phase 2 of an evidence-based practice project. Journal of Clinical Excellence, 2(3), 147Y156. Perry, L., & McLaren, S. (2003). Nutritional support in acute stroke: The impact of evidence-based guidelines. Clinical Nutrition , 22(3), 283Y293. Ramritu, P., Finlayson, K., Mitchell, A., & Croft, G. (2000). Identification and nursing management of dysphagia in individuals with neurological impairment: A systematic review. The JBI Database of Systematic Reviews and Implementation Reports, 3(1), 1Y87. Smith, H. A., Lee, S. H., O’Neill, P. A., & Connolly, M. J. (2000). The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: A safe and humane screening tool. Age and Ageing, 29(6), 495Y499. Terr 2, R., & Mearin, F. (2006). Oropharyngeal dysphagia after the acute phase of stroke: Predictors of aspiration. Neuro- gastroenterology and Motility, 18 (3), 200Y205. Westergren, A., Hallberg, I. R., & Ohlsson, O. (1999). Nurs- ing assessment of dysphagia among patients with stroke. Scandinavian Journal of Caring Sciences, 13(4), 274Y282. Wieseke, A., Bantz, D., Siktberg, L., & Dillard, N. (2008). Assessment and early diagnosis of dysphagia. Geriatric Nursing, 29(6), 376Y383. http://dx.doi.org/10.1016/j.gerinurse.

2007.12.001

Yeh, S. J., Huang, K. Y., Wang, T. G., Chen, Y. C., Chen, C. H., Tang, S. C., I Jeng, J. S. (2011). Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit. Journal of the Neurological Sciences, 306(1Y2), 38Y41.

Copyright © 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.