Background: Early cognitive screening of stroke patients may identify unmet rehabilitative needs during stroke recovery but validated tools are lacking. We report our experience with the Six Item Screener (SIS) compared to the Montreal Cognitive Assessment (MOCA) and attempt to improve upon its shortcomings in stroke patients. Hypothesis: Low sensitivity of the SIS for cognitive impairment (CI) in stroke patients can be improved by incorporating visuoexecutive dimensions. Methods: Patients admitted with ischemic stroke (IS), transient ischemic attack (TIA), intracerebral (ICH) or subarachnoid hemorrhage (SAH) between December 2014 and June 2015 underwent inpatient screening for CI using SIS and MOCA, administered by speech-pathologists if they were alert and not aphasic. Predictive value and sensitivity/specificity cut-offs of SIS for CI (MOCA≤23) were determined. A screening tool, created by adding a clock-drawing task and dropping least important SIS components was developed. Results: Of 110 (IS/TIA: 56, ICH: 17, SAH: 26) patients who had MOCA and SIS performed at the same visit, 79 patients had CI; other patient characteristics including stroke severity, are described (Fig 1A). The AUC of SIS for CI was 0.78 and comparable across stroke types (AUC for IS: 0.81 ICH: 0.79 SAH: 0.95). SIS≤4 had 46.6% sensitivity for CI while SIS≤5 had 72.6% sensitivity and 80.6% specificity for CI. Excluding ‘year’ and ‘month’ questions of the SIS had no effect on the performance of the screening test (AUC=0.78 without). A 7-item tool (CISS) that included the clock drawing task (3 points) and omitted “year/month” SIS questions had excellent predictive power for CI (AUC=0.89) and comparable across stroke types (AUC 0.89-0.93) (Fig 1B,C). CISS≤6 had 94.5% sensitivity and 49.4% specificity for CI. Conclusions: The CISS improves upon the low sensitivity of the SIS for CI in stroke patients. A validation study using 3-month neuropsychological testing as the gold-standard is underway.

Background: Dysphagia occurs in up to 78% of stroke patients and is associated with poor patient outcomes. We have previously reported low concordance rates between dysphagia screens performed by neuroscience bedside nurses compared with Speech Language Pathologists (SLPs) using the 3oz water test. Hypothesis: A multidisciplinary intervention can improve concordance rates of dysphagia screening between bedside nurses and SLPs and reduce aspiration pneumonia rates among stroke patients. Methods: An interdisciplinary team including stroke quality nurses, clinical nurse specialists, SLPs, and nursing informatics developed a 3-step intervention including 1) modifications of the electronic dysphagia screen forms to simplify documentation and provide step-by-step instructions for nursing staff, 2) hospital-wide re-education to nurses on performing dysphagia screens and 3) adjustment of all stroke ordersets to include prechecked NPO orders to prevent diet orders prior to a dysphagia screen. Interventions were completed by August 31, 2016. All stroke patients admitted to a Comprehensive Stroke Center from March 1, 2016 to May 31, 2017 were included in this analysis to determine aspiration pneumonia rates pre- and post-intervention (N=988). To determine concordance rates in dysphagia screening, neuroscience nurses and SLPs performed the same screen on consecutive stroke patients within <24 hours of each other; concordance rates were compared before and after study intervention. Results: Overall aspiration pneumonia rates significantly declined after the intervention from 11.8% to 7.3% (p=0.03). Significant declines in aspiration pneumonia rates after intervention were seen in ischemic stroke (10.4% vs 4.3%, p=0.02) patients but not seen in intracranial hemorrhage (14.8% vs 10.1%, p=0.41) or subarachnoid hemorrhage patients (11.5% vs 10.1%, p=0.85). Concordance rates between nurses and SLPs significantly increased from 52% pre-intervention up to 73% post-intervention (p=0.04). Conclusion: Our 3-step multidisciplinary dysphagia screening intervention significantly reduced aspiration pneumonia rates among ischemic stroke patients and improved concordance rates in screening results among neuroscience nurses and SLPs.

Background: While there is recognition about the importance of dysphagia screens in stroke patients, there is limited data on the concordance rates of dysphagia screens performed by neuroscience-trained nurses and speech language pathologist (SLPs). Hypothesis: Neuroscience nurses and SLPs will have high concordance rates when assessing stroke patients with dysphagia screens. Methods: From March 1, 2016 through May 31, 2016 a random sample of stroke patients underwent a dysphagia screening by neuroscience nurses and subsequently by SLPs within 24 hours using the same tool, a 2-part screen assessing for contraindications and using the 3-ounse water swallow test. Results of the dysphagia screens were retrospectively collected to identify concordance rates. Results: During the study period, 98% of stroke patients underwent dysphagia screening prior to oral intake. Of 50 stroke patients evaluated by neuroscience nurses and SLPs, only 26 patients (52%) demonstrated concordance with pass or fail results. Of 33 patients who were administered the water test and passed the dysphagia screen based on the neuroscience nursing assessment, 20 patients (61%) were determined by SLPs evaluation to have dysphagia and 11 (33%) of these patients had had overt aspiration. Conclusions: Current metrics on dysphagia screening do not identify the efficacy of dysphagia screening among stroke patients. Stroke centers who utilize bedside nurses to perform initial dysphagia screens should evaluate concordance rates with SLPs. A multidisciplinary team including Clinical Nurse Specialists, SLPs, and Nursing IT specialists have implemented measures (hospital wide re-education of nursing staff and optimizing the electronic dysphagia screening form) to improve concordance rates among nurses and SLPs. A post-intervention follow-up study of concordance rates among neurosciences and SLPs is underway.