For our patients in the ED, if there is ever a question about dysphagia and a PO medication is due to be given, the RN will perform a swallow evaluation by giving 5 mls of H2O and observe for any choking, coughing, oxygen desaturation, inability to keep the water in the mouth, or any other concerns. After that is repeated two more times and the patient successfully passes all three trials, then 30 mls of H2O is given. If the patient is able to drink the H2O without difficulty or concern, then the patient should be able to receive the PO medication that has been ordered. Nursing judgement is always a top priority, however. If the RN has any concerns, the patient should remain NPO until further evaluated by speech therapy.

Ideally full swallow ax should be carried out within 24hours by SLT...capacity is always an issue. Figures 2 and 3 of this article might shed some light on clinical decision making and prioritisation for dysphagia patients.

http://www.speechmag.com/content/files/Spr08SLTiPANewtonLPriestnall.pdf

Hi Jackie,

In our critical care wards, all tracheostomy patients are seen for full swallow assessment by SLT/SLP prior to commencing oral intake. All other patients, particularly those post prolonged intubation, are screened for risk factors for dysphagia/observed closely on initial oral intake for signs of dysphagia/aspiration by nursing staff. Patients with presenting/potential swallow difficulties are then referred to SLT for full swallow assessment. There is some interesting work ongoing at University of Toronto, led by Rosemary Martino, where they are currently developing a screening tool specifically for patients in the critical care setting post prolonged endotracheal intubation. http://swallowinglab.uhnres.utoronto.ca/index.html

Hi Jackie,

in a lot of German hospitals, dysphagia screening is administered by a SLT.

being an SLT myself I would recommend to check on breathing patterns and ascertain whether the patient is breathing naturally. If there are any signs of paradoxcial respiration or irregular breathing, this could be an indication for a primary or secondary dysphagia. Check wheher there is spontaneous swallowing and/or if you can, elicit swallowing (stroking the genioglossus from front to back). If there is a swallow check whether check breathing again. Alternatively, check whether there is swallowing after pressing on the tongue.If the patient is able to speak, check whether there is swallowing after/while communicating. Only after checking all this and getting positive results, I personally started giving small amounts of liquid (on a spoon). Then check for any signs of aspiration- I found that silent aspiration is rather frequent in acute patients so the absence of choking or coughing may not indicate that the swallow was successfull and putting your ear on the chest of the patient to listen for sounds may be helpful.

Thank you for the responses so far and the links which have had interesting literature. I work with spinal cord injury patients, so I am particularly interested in how they are screened as they often have positional problems as well as silent aspiration.

Hi. Dysphagia assessment is carried out by one of our SLT. Their main tool is the GUSS (Trapl et al.). Our stroke unit has a project to train RNs in performing the GUSS. In case of doubt we perform a FEES. Hope that helps. Greetings.

Thank you Thomas

Do we know what the size of the problem is regarding dysphagia post extubation?

Hi David, I enjoyed the debate about screening tools at UKSRG. My focus is going to be on dysphagia in spinal cord injury, which the literature puts at an incidence of around 40%. Of course these patients are managed in critical care alongside patients with different etiologies, so I'm interested to know what tools are routinely used with the generic group as dysphagia in SCI is under-recognised resulting in additional complications.

I have worked in hospitals in both the UK and the US. I have found that although NICE guidelines call for SLTs to be involved in critical care, it is less common in the NHS than in the United States. This is only based on my limited experiences, however. I know I have seen job opportunities for SLTs in critical care, but mostly in the bigger metropolitan hospitals. I know when I was working in Canterbury, it was rare for them to bring us (SLTs) in while patients were in critical care and on vents etc. Places that have specialist units in SCI for example, or trauma, may be more likely to have SLTs involved early. Even in the US I have seen wide variability in whether it is SLT/Ps or Respiratory Therapist (or Physios) who work with speaking valves for example. At the hospital in LA I worked at, our protocol was that any patient who had a tracheostomy or anterior cervical fusion required a videofluorographic swallow study because of the high likelihood of silent aspiration. We did not have FEES available. I think FEES would be really valuable with SCI populations who may have difficulty going down into Radiology suites and with positioning as you say.

I do feel there is a place for nurse screens in critical care, though, as long as they are well-trained and aware of what to look for besides overt signs. Nurses, especially critical care nurses, tend to be very good observers and are constantly making judgements about a patient's condition that inform their care.

Hi Wendy, thanks for your response. Having done three visits to the USA in the last year, I have seen a difference in approach particularly in the ICU environment. By contrast my role in our spinal outreach team, which takes me into other ICUs to support SLT practice, demonstrates our reduced involvement. I do think we have strong role to play and FEES serves as a valuable diagnostic and teaching tool, but there are issues with trying to meet the challenging competencies that we have set in our profession. I'm hoping that the first stage of my study will reveal more about current ICU practice by team members, which I plan to publish. We all need to be collecting data and have national benchmarking to demonstrate our value and add evidence.

In my masters thesis I am evaluating nurse’s knowledge of dysphagia. In our hospitals SLTs are included after nurses evaluation. Nurses have problems because we don’t have evaluating standards or protocols. We do the swallowing test; patient must sit upright at least 15 min, teeth must be cleaned. Then they are given a spoon of water and observed like Wayne described, three times. If they pass, they are given a glass of water 30-60 ml. If it is ok they are carefully feed. If not, we contact our doctor and SLT.

But there are not a lot of nurses trained in the procedure and I would like to discover where the main problems are and develop a standard to help them.

Thank you Angela for the tips and good luck to you Jackie.

Hi Bojana, thanks for your reply. I think you have a good system, but it is always the problem to get other professionals, especially nurses, to comply with these recommendations. I did a similar project for my masters on delivering good oral hygiene which required assessing the mouth and giving a score between 5 and 15 that would then determine the level of mouthcare required. Unfortunately, the tool was not used and staff continued to deliver infrequent and inadequate mouthcare. Changing the behaviour of people is a very big issue in many areas of healthcare and I am looking at different theories in order to improve adherence to new practice. I'll let you know how I get on.

O, I would really like to know that. I had a problem a few years ago as I started to teach other nurses a breather clinical practice (aspirating a patient thru nose, mouth and tubus) that I learned in the ICU. It was a long and hard way. And I still sometimes see a nurse do it the old and painful way. But I still believe that we can make our work better, we just have to gather evidence for better clinical practice and have a good communication.

I have also studied aspiration pneumonia and published guidelines for safe oral, NGS and PEG feeding. Then I have seen how many patients have dysphagia and we don’t see it. This is why now I am trying to find out where the lack of knowledge is and find a way to educate our nurses what is important to know and why.

Unfortunately I haven’t found any similar study to compare it with and so I have developed my own questioner. If you have any information about any study I would appreciate it.

Unfortunately my article is in Slovenian language, but findings from my masters will also be in English.

Hi,

For screening, you could use V-VST, which was a validate tool for dysphagia screening. Vigilance, cough and saliva swallowing have to be evaluated before starting evaluation.

http://www.ncbi.nlm.nih.gov/pubmed/23051998

Hi, thanks for that, I shall,have a look at it.

Many thanks for that information.

Jackie

V-VST is more of an assessment tool rather than a screening tool. It appears to me that the majority of screening tools are based upon the Bedside Swallow Assessment published in 1997.

The issue with many screening tools, is the focus on motor function. In my experience, many of my cervical spinal cord injury patients have laryngeal sensory problems, so they silently aspirate, which compromises their already vulnerable respiratory function. My DAISY project aims to develop a screening tool for this patient group, to be used by staff working in ICU. National staff survey has just been completed. For more information see my powerpoint presentation in my publications list.

Who will be conduct the patient screening - SLTs or nurses? Are there any guidelines to help determine the SLT role in the ICU?

 Julie, it is a good question - the gatekeepers are often the Drs or nurses and they make the first decision about whether a patient needs a referral to SLT, which is usually based on their own 'screen' or after a period of oral intake that then results in a chest infection/aspiration pneumonia. So I am wanting to develop something that will be utilised by the people making those first decisions - be it SLT, Dr, PT or nurse.  

You're second point about the SLT role is also very pertinent because I would say that this is a relatively new area for the profession. As technology changes and life support improves survival, SLTs are trying to make the right decisions for different patients. Some SLTs demand that a patient is able to sit upright, be vent free and cognitively intact before considering a swallow assessment. This leaves many NBM and has disadvantaged many of my SCI patients. There is no evidence to suggest you cannot swallow safely in supine/side lying and whilst ventilated, IF YOU DO THE RIGHT ASSESSMENT. I use FEES which gives very valuable information about laryngeal function in response to a range of scenarios, which we use to create a therapy plan. 

Our professional body has developed clinical guidelines for our role in critical care, which is a step in the right direction.

 Hi Ella, thanks for the information on aspiration. I think it is interesting that there is great focus on motor responses in bedside swallow assessments. I regularly see patients who have been told they pass the test but go onto develop signs of aspiration and on instrumental assessment (FEES) are silently aspirating with no overt signs. I saw a woman last week, who has yo-yoed between oral intake and NBM because she kept passing the test, so no one bothered to test further. My assessment found she had a completely insensate larynx which caused a dramatic silent aspiration for fluids, although less so with semi-solids.

I also think that aspiration should not be the only focus of our assessments, I like to know what is leading to the aspiration, in order to provide therapy to remediate it. I see many therapists recommending thickened fluids but this is not a therapy just symptom management.  We need to use our skills to help to normalise the swallow where possible.

Para mim o paciente que esteve entubado por mais de 48 horas antes da reintroducao oral ou o paciente critico deveria realizar a videoendoscopia da deglutiçao com controle de volume e consistencia de alimento controlado, esta avaluaçao objetiva a beira do leito nos dará informaçoes objetivas sobre estase de alimento, penetraçao e aspiraçao laringea, como tambem nos auxilia sobre a forçA da deglutiçao, sensibilidade laringea, e com estas informaçoes a fonoaudioliga poderá trabalhar mais segura. Se o exame vier com risco de broncoaspirar poderemos realizar algumas manobras durante o exame e a restriçao de alimento consistencia e volume poderã ser parcial, as x sendo permitido liberar alguma consistencia por exemplo restricao para liquidio e libera - se pastoso mas isto será individualizado, acredito tambem que este instrumento objetivo de avaliação poderá ser repetido para reavaliar o desempenho pos fonoterapia diminuindo com isto a restriçao generalizada para todos pacientes como tambem a reintroduçao segura da dieta  oral naqueles pacientes com risco de broncoaspirar.  frente está avaluacao objetiva haverá mais compreensao quanto a indicaçao da alumentaçao por via alternativa ( sonda nasoenteral)  tanto por parte do paciente , familuares e equipe multidisciplinar pois todos vendo os sinais de riscos contribuiram com as medidas preventivas e terapeuticas ( fonoterapia , higiene oral, controle de sialirreia, posicionamento, e nao oferta oral)

While screening individuals in ICU, the first thing i check for before actually carrying out a dysphagia assessment is the cognitive functioning of the patients and the comprehension levels. A detailed oral peripheral mechanism gives an elaborate idea regarding the anatomical and physiological functioning of the oral cavity. 

If the patient is able to follow this adequately, i proceed with dry swallow and water test.