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Changing practice

Developing a screening tool and training package to identify dysphagia in all settings

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Patients with a wide variety of conditions can develop feeding and swallowing problems. An observation screening tool aimed to increase detection of dysphagia

Author

Mariani Tanton, Cert MRCSLT, is clinical lead adult speech and language therapy/dysphagia specialist, Kirklees Community Healthcare Services, based at Dewsbury and District Hospital.

 

Abstract

Tanton M (2010) Developing a screening tool and training package to identify dysphagia in all settings. Nursing Times; 106: 15, early online publication.

Identifying dysphagia is vital to prevent further complications and problems. Although the condition is common in patients with stroke, nurses must be aware that feeding and swallowing problems can occur in a wide range of illnesses.

The Dewsbury Feeding and Swallowing Screen was developed as an observational screening tool for nurses to ensure early and accurate identification of such problems in all patients in all locations, both in hospital and the community.

In addition, a training package, consisting of two manuals and a DVD, was designed to assist with staff training in using the tool and also as a means of checking competence.

Keywords Dysphagia, Stroke, Screening tool, Feeding and swallowing

  • This article has been double-blind peer reviewed

 

Practice points

  • Since there are many causes of dysphagia, nurses need to think in much wider terms about which of their current patient group may have feeding and swallowing difficulties, rather than simply focusing on certain illnesses most commonly associated with the condition, such as stroke.
  • The Dewsbury Feeding and Swallowing Screen assesses patients’ capabilities and safety with both food and drink, and is quick and easy to use even for those with little or no experience of dysphagia. It also has clear instructions on when it is necessary to refer to speech and language therapy for a more detailed assessment.

 

 

Introduction

While it is widely recognised that dysphagia is a common consequence of stroke, it is also associated with a variety of other conditions. The perception among healthcare professionals that feeding and swallowing problems are primarily related to stroke could result in them being missed in patients with other conditions. In order to minimise this risk I developed a screening tool to assess these difficulties in all patients in all settings. This article describes the tool’s introduction into a hospital setting, and plans to use it in the community, as well as the development of a training package to accompany the tool. 

 

What is dysphagia?

Dysphagia is an impairment of eating and drinking throughout any or all of the different phases of swallowing. The phrase “feeding and swallowing problems” tends to describe a slightly wider remit including other considerations such as patients’ ability to feed themselves - not just a matter of swallowing. Speech and language therapists often use both terms interchangeably.

Problems can arise in any or all of the different phases of the swallow. The initial or oral preparatory phase occurs when food is put into the mouth, moved by the tongue in between the teeth to chew and coated with saliva to produce a manageably sized bolus.

The next, or oral phase, occurs when chewing has ceased and the tongue propels the bolus from the anterior to the posterior part of the oral cavity.

The pharyngeal phase occurs when the swallow is triggered, the nasal cavity is separated from the oral cavity by the action of the soft palate, the tongue base moves backwards to contact the posterior pharyngeal wall and the epiglottis moves horizontally to protect the airway. The larynx elevates and moves forwards and the vocal folds close together, again protecting the airway. It is this elevation and forward movement of the larynx that opens the cricopharyngeus that allows passage into the oesophagus, which is the final phase of the swallow. Peristaltic waves move the bolus of food towards the stomach. A similar, but not identical, process occurs in swallowing liquid.

Causes and risk factors

Causes

While the most common cause of dysphagia is probably stroke, many progressive neurological illnesses can also result in difficulties with eating and drinking. Dementia is another major cause of eating and swallowing difficulties and studies show there are high numbers of people in nursing homes with this problem.

Perhaps a slightly less recognised cause of dysphagia is respiratory illness. This produces breathlessness, which can interfere with swallowing which in turn interferes with the respiratory cycle.

Another common cause, particularly in older people, is urinary tract infection, which although temporary until cured by antibiotics, can lead to feeding and swallowing problems. If these are unrecognised and inappropriately managed they can lead to aspiration pneumonia.

Risks

There are a number of risks and consequences associated with having dysphagia (Royal College of Speech and Language Therapists, 2006). These are:

  • Anxiety and distress in the family;
  • Reduced quality of life;
  • Poor health;
  • Poor nutrition and weight loss;
  • Developing respiratory infection;
  • Aspiration;
  • Hospital admission or extended hospital stay;
  • Choking and death. 

Background to the screening tool

The National Service Framework for older people stated that all patients who have had a stroke should have a swallowing assessment within the first 24 hours (Department of Health, 2001). However, if it is important for one group of patients with dysphagia to have their problems identified early and accurately, then surely this should apply to all patients whatever their diagnosis – the consequences of late or missed identification are equally serious, whatever the underlying cause.

Design and development

The screen was designed as an observational tool to enable nurses to observe patients eating and drinking in a functional setting while following a checklist that is simple yet comprehensive. Many factors can indicate that a patient has a feeding and swallowing problem and nurses need to be vigilant for signs other than just coughing.

It is also important to ensure that capabilities with both food and drink are assessed. Too often feeding and swallowing assessments are undertaken using only fluids – the consistency most likely to cause problems. Patients who have problems with fluids may then be needlessly designated “nil by mouth” because food, which may be perfectly safe, has not been assessed.

When nursing staff at Dewsbury and District Hospital were initially approached in 2003 about introducing the screening tool, I was concerned that they may be resistant to having yet another form to fill in. However, my concerns were unfounded - all those approached were extremely enthusiastic.

Training

All nursing staff who would carry out screening attended a training session. This included night staff as patients can be admitted in the middle of the night. The session began by highlighting the high risk nature of dysphagia and the importance of early detection. Each item in the screening tool was discussed, so that those nurses who, as yet, had had no basic dysphagia training could still identify when there was a problem. There was also discussion about the remit for their ward – who was to be assessed and when to carry it out - and how to score it. All this took approximately 45 minutes.

Nursing staff completed a questionnaire before beginning the training, which was used to assess their baseline knowledge, skills and confidence in the area of dysphagia.

Trials

It was decided to carry out the initial trial on one of two wards for older people over 75 years of age. Many had feeding and swallowing difficulties caused by stroke and a variety of progressive disorders such as Parkinson’s disease and dementia. However, they often had other conditions which can cause feeding and swallowing problems, such as urinary tract infections and respiratory diseases such as chronic obstructive pulmonary disease, both common in older hospital patients.

At the time of this initial trial, nursing staff and speech and language therapists (SLTs) discussed which patients should be screened. As a large proportion of older people admitted to hospital were likely to be at risk of developing feeding and swallowing problems, it was decided, in conjunction with the ward sister, that the remit would be that all new patients admitted to the ward should be screened at the time of having their first food or drink.

When the tool was introduced to other wards later, ward sisters were also consulted about the appropriate remit for that particular ward. The remit, therefore, is always flexible according to the needs of each patient group. However, since the aim is to ensure that no patient is missed, it should always be as comprehensive as possible.

The trials on each ward generally continued for 100 screens. The ward clerk photocopied completed screening forms, which I evaluated continuously to ensure that documentation was complete, accurate and timely. Any problems, such as missing dates and signatures, incomplete scoring and missed sections, were fed back to the ward sister who discussed the issues with nursing staff. If it was clear that particular nurses were having difficulty, they were offered further training or given more clarification. However, the problems were minor and generally related to the tool’s unfamiliarity.

At the end of the trial period, when it was deemed that nursing staff were carrying out the screen appropriately, there was an agreement that supervision was no longer necessary and that nursing staff would train any nurses new to the ward. Nurses were asked to fill in a second questionnaire to establish what changes in knowledge, skills, confidence and practice use of the screening tool over the trial period had brought about.

Changes in practice

The second questionnaire recorded a number of changes in practice, and nursing staff and speech and language therapists also made verbal observations about these. The changes were:

  • Quicker identification of feeding and swallowing problems, which resulted in starting patients on the dysphagia care pathway more quickly, thereby reducing risk of related problems occurring;
  • A systematic assessment of both food and drink, reducing the probability of the need to put patients nil by mouth unnecessarily;
  • More prompt referrals to speech and language therapy for a detailed swallowing assessment;
  • More accurate and detailed content of these referrals;
  • Increased awareness and involvement of nursing staff in feeding and swallowing problems;
  • Increased confidence in identifying problems ; nurses preferred being able to use the checklist, rather than having to rely on their own knowledge and skills.

Correlation between nurse and speech and language therapist assessments

It was important to find out whether nurses were able to accurately identify both normal and abnormal swallows when checked against SLTs’ findings. The SLTs therefore reassessed 80 patients whom nurses had identified as having abnormal swallows and 20 patients identified as having normal swallows, as soon as possible after nurses’ assessments. While this delay varied from patient to patient, reassessment generally took place within the same working day according to local departmental standards.

In 99 out of 100 patients, the results of the nurse screen and the SLT assessment agreed. In the one case where there was a difference of opinion, nursing staff reported a spontaneous improvement in the patient’s general condition and that the swallow had normalised before the SLT assessment.

The screening tool is, therefore, an excellent means of identifying both normal and abnormal swallows in patients with a variety of different diagnoses and there is an excellent correlation between nursing and SLT assessments.

The training package

When it became obvious that the screening tool had the potential to be used more widely, it was clear that a training package was needed to accompany it. As a result The Dewsbury Feeding and Swallowing Screen training package was developed.

The package consists of two training manuals and a DVD. The main manual covers the background to the screening tool, the causes and risks of feeding and swallowing problems, how to administer the tool and a description of each item on the checklist. The DVD, filmed using SLTs, demonstrates different kinds of normal and abnormal swallows.

The second manual describes the DVD and also contains the 12 completed assessments of the swallows seen on the DVD. These can be used both in training staff on how to use the tool and also in checking competence.

Current use and future plans

Hospitals

The tool has been in use at Dewsbury and District Hospital since 2003 and has been extremely successful in identifying feeding and swallowing problems in thousands of patients. These patients have been on a variety of wards including the medical assessment unit, stroke unit, older people’s ward and two medical wards.

At the request of a senior sister, it is shortly to be introduced on to the respiratory ward. It has also been introduced to two other local hospitals, not covered by my service, which are initially using it with patients who have had a stroke.

Community

Heads of nursing and residential homes have commented in previous dysphagia training questionnaires that they would like to use the screening tool in their homes and have been extremely enthusiastic about the prospect of doing so. Since its recent availability, some local homes have introduced it, as have other homes outside the district. The Kirklees multidisciplinary intermediate care team has also expressed an interest in using it. Although the tool was originally designed for nurses, its flexibility and simplicity means a variety of other professionals can use it to identify dysphagic problems. In the community, commissioners have said they want the tool to be a quality indicator in service specifications for stroke indicators and will take this forward in Kirklees through the stroke health improvement team. Further plans to include use of the screen to identify non-stroke patients with dysphagia are currently under discussion.

By using the screening tool in the same way as hospital nursing staff, it is expected that community nurses will find similar changes in their practice:

  • An increased awareness of feeding and swallowing difficulties and the risks associated with them;
  • Quicker referrals to speech and language therapy for a detailed assessment and treatment plan;
  • A reduction in GP callouts and courses of antibiotics – unless the cause of the problem is treated, antibiotics will only improve symptoms temporarily;
  • Improved health and quality of life for patients;
  • A reduction in the number and frequency of hospital admissions.

Conclusion

The importance of early and accurate identification of feeding and swallowing difficulties in stroke has been recognised both locally and nationally, in documents such as NICE (2008) guidance. However, patients with Parkinson’s disease, dementia and indeed any other kind of illness that causes feeding and swallowing problems need prompt assessment and treatment of their life threatening dysphagia as much as those with stroke. This can only happen once the problem has been identified, and nursing staff are in an ideal position to do this.

By implementing The Dewsbury Feeding and Swallowing Screen locally, we aim to ensure that all nursing staff focus on screening all those at risk of dysphagia in all settings, to ensure early and accurate identification.

 

Background

  • Nursing staff are the obvious choice of healthcare professional to carry out initial feeding and swallowing assessments as they are the only professionals who are with patients day and night, including weekends and bank holidays.
  • NICE (2008) said that when screening for malnutrition and the risk of it, healthcare professionals should be aware that dysphagia, poor oral health and reduced ability to self feed will affect nutrition in people with stroke.
  • However, as this also applies to many other kinds of illnesses, not just stroke, healthcare professionals should be vigilant in identifying feeding and swallowing difficulties in all patients in order to avoid not only malnutrition but also aspiration and its associated risks.

 

 

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