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At St. Joseph Hospital in Nashua, NH, ED nurses do at least 90% of bedside dysphagia screens while the patient is still in the ED, says Susan L. Barnard, MS, APRN, CCRN, trauma coordinator. "They have come to understand the importance of the screens getting done ASAP before the patient is given anything by mouth," she says.
To make it easier for ED nurses to do dysphagia screens, use these practices.
Create a user-friendly dysphagia screening tool.
"Otherwise, it will be too complex to do accurately," says Barnard. "We developed an algorithm that the nurses find easy to use." When the ED nurses saw that the screen is easy, quick, and effective, says Barnard, they began to use it more often.
At Atlanticare Regional Medical Center City Campus in Atlantic City, NJ, ED nurses perform dysphagia screens as part of their assessment of all patients presenting with stroke symptoms, says Nancy Hayes, RN, an ED nurse. "Our dysphagia screening tool is a set of five questions. If the answer is 'yes' to any question, the test is then stopped and NPO maintained," says Hayes.
Educate nurses on atypical presentations.
A patient may present with vertigo, for example, and be treated with meclizine before a stroke is recognized, says Barnard. "We have done ED education on atypical presentations, and identifying when the patient could be having a stroke and should have a dysphagia screen," she says.
Include the screen on the ED order sheet.
Your ED's stroke order sets should include a swallow assessment before oral intake, performed by a nurse, and institution of NPO status with intravenous normal saline at 75 to 100 mL/h until an evaluation by the speech-language pathologist, says Mark Goldstein, RN, MSN, EMT-P I/C, clinical nurse specialist at the Emergency Center at Beaumont Hospital in Grosse Pointe, MI.
St. Joseph's ED medical director added the nursing screens on the ED order sheet. "This provides another 'trigger' for the screens to get done," says Barnard. "It reminds the ED physicians not to order oral medications until the screen is done and passed. They will order rectal aspirin for failed dysphagia screens."
Use direct observation.
Look for the presence of choking, coughing, a wet voice, a delay in initiating swallow, uncoordinated chewing or swallowing, extended time eating or drinking, pocketing of food, and loss of food from the mouth, says Goldstein.
Document the screening.
Hayes says that often, the dysphagia screens are being performed but not documented. "In the age of computerized documentation, free-text charting is very limited," says Hayes. "Therefore, it is imperative that such screening tools be built into the system." (See related stories on working with speech-language pathologists and the outcome of an ED pilot, and which patients should be screened, below.)
For more information on dysphagia screening in the ED, contact:
Work as team with speech experts
Most ED patients given dysphagia screens will receive speech therapy, explains Susan L. Barnard, MS, APRN, CCRN, trauma coordinator at St. Joseph Hospital in Nashua, NH.
"Our speech-language pathologists helped develop the dysphagia screen," says Barnard. Here are other ways to collaborate:
1. Do comparative audits.
See if the results of ED nurses' screens are consistent with the findings of speech pathologists on certain patients, says Barnard.
2. Have speech-language pathologists do inservices.
At St. Joseph Hospital, speech-language pathologists did 15-minute inservices several times each day in order to reach every ED nurse. "It is now part of our ED orientation for new nurses," says Barnard. "We also educated the ED physicians on why the nursing dysphagia screens are being done and the importance of the screens."
3. When oral intake is authorized, the nurse should follow the speech-language pathologist's recommendations.
This may include improving the patient's ability to concentrate while eating with minimal distractions, says Mark Goldstein, RN, MSN, EMT-P I/C, clinical nurse specialist at the Emergency Center at Beaumont Hospital in Grosse Pointe, MI. "These assessments and interventions may make the difference between improved recovery and increased morbidity or even mortality," he says.
ED nurses now do dysphagia screening
Until recently, dysphagia screening for stroke patients at Thomas Jefferson University Hospital in Philadelphia was completed by ED physicians, reports Jenny Bosley, RN, MS, CEN, an ED clinical nurse specialist.
The neurological clinical nurse specialist developed an educational packet for staff on the acute stroke unit as part of a pilot involving nurses completing and documenting the dysphagia screening. "The pilot was successful, with no adverse patient outcomes. This was rolled out to all of the neuro units," says Bosley. "It is now being rolled out to the ED nursing staff."
ED nurses use the same educational packet developed by the neurological clinical nurse specialist, which includes a post-test. The ED night-shift education committee took the lead to distribute the packets and do small group inservices, says Bosley.
After attending the inservices, ED nurses completed the post-test and returned it to Bosley or the ED educator, who will include dysphagia screening at the ED's annual skills fair.
"I will start monitoring compliance, as I currently review charts for all stroke patients presenting to the ED," says Bosley.
Swallow screen? Cast a wide net!
With any initial neurological assessment, consider adding a nursing swallowing screening, says Martha Underwood, RN, clinical specialist for the ED at Baltimore Washington Medical Center in Glen Burnie, MD. If the patient presents with physical symptoms that could be a part of stroke presentation, even subtle signs such as weakness or headache, then a swallowing screening should be done, she advises.
"Identification of unilateral weakness as a stroke symptom is easy. Protecting our patients from aspiration when their symptoms are more subtle is priceless," says Underwood. "When considering whether or not a swallowing screen is indicated, cast your net wide."