A Feasibility Study of the Sensitivity of Emergency Physician Dysphagia Screening in Acute Stroke Patients

doi:10.1016/j.annemergmed.2009.03.007

Annals of Emergency Medicine

Volume 54, Issue 3, September 2009, Pages 344-348.e1

Presented as a poster at the American College of Emergency Physicians Scientific Assembly, October 2008, Chicago, IL.

https://doi.org/10.1016/j.annemergmed.2009.03.007 Get rights and content

Study objective

To determine the sensitivity of dysphagia screening by emergency physicians on acute stroke patients.

Methods

To develop a 2-tiered dysphagia screen and performed it on a convenience sample of acute stroke patients. Tier 1 examined voice quality, swallowing complaints, facial asymmetry, and aphasia. Tier 2 involved a water swallow test, with evaluation for swallowing difficulty, voice quality compromise, and pulse oximetry desaturation (≥2%). We classified patients passing both tiers as “low risk” and compared the screen's sensitivity to a formal assessment by speech language pathologists. To assess reproducibility, we performed 2 consecutive, blinded ED screens on a convenience sample of 32 patients.

Results

During 16 months, we enrolled a convenience sample of 103 patients, excluding 19 patients from data analysis for lack of a stroke discharge diagnosis (n=11), an incomplete speech language pathologist evaluation within 24 hours (n=7), or pneumonia on emergency department (ED) chest radiography (n=1). Of the 84 remaining patients, speech language pathologists identified dysphagia in 48. The sensitivity of the ED dysphagia screen was 96% (95% confidence interval [CI] 85% to 99%), with a negative likelihood ratio of 0.08 (95% CI 0.02 to 0.3). Reproducibility testing yielded a κ for the overall screen result of 0.9 (95% CI 0.9-1.0) and a simple agreement of 97%.

Conclusion

Preliminary data on the sensitivity and reliability of our ED dysphagia screening tool are promising. The simple screen provides an easy way for emergency physicians to identify acute stroke patients eligible for early oral medications and nutrition. Further validation and refinement of our screen are needed before its widespread adoption.

Introduction

Dysphagia occurs in up to 67% of patients presenting with an acute stroke.1, 2 It is an independent predictor of poor outcome,3, 4, 5 prolongs recovery, and lengthens hospital stay after stroke.⁴ Most important, dysphagia predisposes to aspiration, which can result in pneumonia, causing approximately 35% of deaths after acute stroke.¹

Studies show that dysphagia screening after stroke reduces the incidence of pneumonia1, 5 and improves overall outcome. Because of this benefit, The Joint Commission (TJC) recommends that “patients with ischemic or hemorrhagic stroke…undergo an evidence-based bedside testing protocol approved by the hospital before being given any food, fluids, or medication by mouth.”⁶ However, data are lacking about the best screen to perform, the period within which it should be conducted, and the qualifications necessary to perform a screening. Nonetheless, the use of some screening tool to identify stroke patients at risk for dysphagia has been shown to decrease pneumonia risk and improve overall outcome.⁷ Although many institutions defer dysphagia screening to an inpatient stroke unit, this is undermined when stroke patients are admitted to hospital units unfamiliar with the need to perform dysphagia screening. Performing the screen in the emergency department (ED) can facilitate early identification of patients with aspiration risk but also identify patients at low risk for aspiration, which may enable early administration of oral intake and medication, as well as improve patient satisfaction.

We designed this study to determine whether emergency physicians could accurately identify low risk for dysphagia in acute stroke patients by using a simple, sensitive screening tool. We hypothesized that patients passing our ED screening would be deemed as low aspiration risk by formal assessment by speech language pathologists.

Section snippets

Study Design and Setting

We conducted a prospective cohort study at our 850-bed, tertiary-care, TJC-certified, primary stroke center located in the southeast. Our urban ED treats approximately 105,000 patients per year. Our institutional review board approved and monitored the study.

Selection of Participants

Between November 2006 and February 2008, emergency medicine attending and resident physicians identified, consented, and enrolled a convenience sample of acute stroke patients presenting to the ED within 24 hours of symptom onset. Initial

Results

During the 16-month study enrollment period, we prospectively enrolled 103 patients. During that same period, 727 stroke patients were discharged from our hospital. Among the 103 enrolled patients, we excluded 19 patients from the final data analysis for lack of a discharge diagnosis of acute stroke, an incomplete speech language pathologist evaluation within 24 hours, or pneumonia on initial ED chest radiography (Figure). We list the patient characteristics of the 84 patients included in the

Limitations

Despite our promising results, our study has several limitations. First, as a preliminary study, our investigation was not powered to definitively demonstrate the accuracy of ED dysphagia screening. We lacked enrollment of a consecutive cohort and did not measure stroke severity or anatomic location. Selection bias for patients with moderate to high stroke severity may exist in our study population because a considerable number of the patients were discharged to extended care facilities.

Discussion

The importance of dysphagia screening is underscored by TJC, who include dysphagia screening of all stroke patients as a monitored performance measure for certified stroke centers.⁶ Although various dysphagia screening strategies have been described in the literature, none have described screening in the ED performed by emergency physicians.3, 4, 5 Our study suggests that dysphagia screening performed by emergency physicians is a feasible strategy for dysphagia screening in stroke patients. Our

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Formal dysphagia screening protocols prevent pneumonia
Stroke
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The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool
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There are more references available in the full text version of this article.

Cited by (34)

Swallow Screen Associated With Airway Protection and Dysphagia After Acute Stroke
2019, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
These results are not surprising, in that a screen cannot perfectly predict the outcome of a full evaluation. However, it should be noted that the sensitivity and specificity of our swallow screen differed from that reported by other studies.7,13,17,18 This may be due to several reasons, including the adoption of the current swallow screen prior to publication of these valid and reliable measures, selection of dysphagia on VFSS rather than aspiration as the outcome for the purposes of this study, and differences in etiology, dysphagia prevalence, and other participant variables.
The goal was to examine the outcomes of an existing swallow screen protocol in comparison to results from a formal videofluoroscopic protocol.
Prospective cohort study.
Acute hospital.
Patients after acute stroke (N=48).
Not applicable.
The Johns Hopkins Hospital Brain Rescue Unit 3 oz Swallow Screen was implemented by nursing staff upon admission. Videofluoroscopy was conducted within 72 hours of diagnostic neuroimaging and initial swallow screen. Predictive values of the bedside swallow screen (pass/fail) for clinical judgment of dysphagia on videofluoroscopy (presence/absence) were calculated. Overall impairment scores from the Modified Barium Swallowing Impairment Profile were analyzed with respect to swallow screen results.
Thirteen participants failed the swallow screen, and 35 passed. Of the 35 patients who passed the swallow screen, 15 were clinically diagnosed with dysphagia on videofluoroscopy. Although pass/fail of the swallow screen was not a significant predictor of presence/absence of dysphagia, a logistic regression model including components of Laryngeal Elevation, Laryngeal Vestibule Closure, and Anterior Hyoid Excursion, and sex was statistically significant for swallow screen outcome.
The results of this study suggest that a swallow screen of aspiration risk can identify patients with the most need for videofluoroscopic evaluation and dysphagia management. Additionally, patients who fail a swallow screen are more likely to present with physiologic impairments related to airway protection on videofluoroscopy.
The use of an emergency department dysphagia screen is associated with decreased pneumonia in acute strokes
2018, American Journal of Emergency Medicine
Citation Excerpt :
Since most patients are treated with aspirin, if they are to begin aspirin therapy in the ED, the screen should be performed prior to the medication being given. Only a few ED dysphagia screens have been developed, tested, and described in a peer reviewed format [9-11]. No published studies have evaluated a single ED based screen to determine if the use of the screen lowers rates of subsequent HAP.
Dysphagia is a common problem for patients after an acute stroke which can lead to hospital acquired pneumonia (HAP) increasing morbidity and mortality. The Joint Commission has directed that stroke certified hospitals perform a dysphagia screen at the time of initial presentation. We sought to evaluate if our ED dysphagia screen was correlated with lower rates of pneumonia in acute stroke patients.
We conducted a pre-post trial evaluating rates of pneumonia in patients with ischemic and hemorrhagic stroke both before and after the use of our ED dysphagia screen. We defined HAP as a new infiltrate treated with antibiotics. Rates of HAP were compared using the χ² test. Any patients transferred out of our health system were excluded.
We evaluated 419 and 469 preintervention hemorrhagic strokes and 1022 and 462 post screen ischemic strokes respectively. In the hemorrhagic groups rates of dysphagia were similar but rates of HAP decreased from 19% to 15% (P < 0.001) in the pre- post groups respectively. In the ischemic stroke groups rates of HAP decreased from 13.8% to 8% in the pre-post groups respectively, (P = 0.007). Rates of intubation were similar in the hemorrhagic groups and were higher in the post screen ischemic stroke cohort.
The use of our ED dysphagia screen was associated with a significant reduction in the rates of HAP in both ischemic and hemorrhagic stroke patients. Given the high rates of dysphagia and significant comorbidity and complications for these stroke patients, the use of a screen is warranted.
Spontaneous swallow frequency compared with clinical screening in the identification of dysphagia in acute stroke
2014, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Moreover, because the criterion referent (MASA) was administered on the same day as swallow frequency screening, the nurse screening may have overestimated the number of cases positive for dysphagia (inflated false-positive rate) based on MASA score. However, this time delay is similar to study delay time reported in validation studies in 3 of the highly rated, validated clinical dysphagia screening protocols.9,33,34 Finally, SFA was not significantly correlated with time poststroke onset in a prior study.18
The aim of this study was to compare spontaneous swallow frequency analysis (SFA) with clinical screening protocols for identification of dysphagia in acute stroke.
In all, 62 patients with acute stroke were evaluated for spontaneous swallow frequency rates using a validated acoustic analysis technique. Independent of SFA, these same patients received a routine nurse-administered clinical dysphagia screening as part of standard stroke care. Both screening tools were compared against a validated clinical assessment of dysphagia for acute stroke. In addition, psychometric properties of SFA were compared against published, validated clinical screening protocols.
Spontaneous SFA differentiates patients with versus without dysphagia after acute stroke. Using a previously identified cut point based on swallows per minute, spontaneous SFA demonstrated superior ability to identify dysphagia cases compared with a nurse-administered clinical screening tool. In addition, spontaneous SFA demonstrated equal or superior psychometric properties to 4 validated, published clinical dysphagia screening tools.
Spontaneous SFA has high potential to identify dysphagia in acute stroke with psychometric properties equal or superior to clinical screening protocols.
Dysphagia: Implications for older people
2014, Reviews in Clinical Gerontology
Nature and timeliness of dysphagia management within an emergency setting
2023, International Journal of Speech-Language Pathology
Prevalence of dysphagia and risk of pneumonia and mortality in acute stroke patients: a meta-analysis
2022, BMC Geriatrics

View all citing articles on Scopus

: Supervising editor: Robert Silbergleit, MD

: Author contributions: DET-L and AWA conceived the study, designed the trial, and obtained research funding. DET-L, MP, MFP, and AWA supervised the conduct of the trial, patient enrollment, and data collection. DET-L and SJS performed chart review and some data collection. DET-L and AWA provided statistical advice. DET-L performed all data analyses. DET-L drafted the article, and AWA contributed substantially to its revision. DET-L and AWA take responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Supported by an Emergency Medicine Foundation 2007-2008 Resident Research Grant.

: Publication date: Available online May 2, 2009.

: Reprints not available from the authors.

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Neurology/brief research reportA Feasibility Study of the Sensitivity of Emergency Physician Dysphagia Screening in Acute Stroke Patients

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design and Setting

Selection of Participants

Results

Limitations

Discussion

Lancet Neurol

Formal dysphagia screening protocols prevent pneumonia

Stroke

The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool

Age Ageing

Long-term outcome after stroke: does dysphagia matter?

Age Ageing

Complications and outcome after acute stroke?Does dysphagia matter?

Stroke

Neurology/brief research report
A Feasibility Study of the Sensitivity of Emergency Physician Dysphagia Screening in Acute Stroke Patients