Development of a modified swallowing screening tool to manage post‐extubation dysphagia

Abstract

Post-extubation dysphagia is a condition that is becoming a growing concern. The condition occurs in 3-62% of extubated patients and can be related to mixed aetiologies, such as neuromuscular impairment, critical illness and laryngeal damage. The risk factors for developing dysphagia in critically ill patients are under-diagnosed and perhaps underestimated. Recent studies recommend the implementation of a standardized swallowing screen to prevent aspiration and decrease pneumonia rate and mortality. The aim of this quality improvement initiative was the development of a bedside swallowing screening tool to assess effective swallowing post-endotracheal extubation. Post-extubation dysphagia can result in a delay in re-feeding, with the potential for malnutrition as well as overt and covert aspiration if swallowing is not effectively screened. It is apparent that ICU nurses commence the initial screen for swallowing in the absence of an evidence base of care. A review of current local and international practice guidelines excludes the process of an effective swallowing screen of the extubated patient. Previously, a referral to speech and language therapists would be required to assess swallowing only after an initial review by the ICU medical team. This often leads to delays if the referral is made outside normal working practice, such as weekends or evenings. The initial development of a swallowing screening tool is the first step to promoting a nurse-led/-initiated bedside swallow screening tool that will enhance patient care and patient safety. There is growing body of evidence regarding the incidence of post-extubation dysphagia. Currently, there are very few recognized bedside swallowing screening tools to identify patients at risk. The most serious complication associated with post-extubation dysphagia is aspiration pneumonia, which is the leading cause of nosocomial infection in the critically ill patient.

Frequency and outcome of post‐extubation dysphagia using nurse‐performed swallowing screening protocol

“…In contrast with post‐stroke patients, there has been little evidence of the evaluation of the screening tools in ICU patients. Because the mechanism for dysphagia can be entirely different in ICU patients, the assessments used for post‐stroke patients might not be applicable, and the development or adaptation of a recognized swallowing screening tool may be needed (Christensen and Trapl, ). In medical ICU patients, only one previous report has described a nurse‐performed screening that was safely conducted with respect to several patient‐centred outcomes (See et al, ).…”

The role of speech and language therapists in the intensive care unit

“…With early screening for dysphagia risks by nurses or SLTs, a preventative approach helps to reduce complications and poorer outcomes. 19,20 Tracheostomy weaning Both swallowing and communication are impacted by the presence of a tracheostomy through redirection of airflow and alterations to valving and pressure systems that power the muscles in normal swallowing. SLTs have specific knowledge and understanding of this physiology and make valuable contributions to MDT decision making regarding tracheostomy manipulation for weaning.…”

Swallowing screening practice patterns for nurses in the cardiac surgery intensive care unit

“…Although dysphagia is common in the cardiac ICU setting, no validated screening tools are available and formal nursing guidelines for bedside dysphagia screening are lacking (Christensen & Trapl, 2017). It is therefore unclear what practices nurses currently use in this setting.…”

“…Taken together, these findings highlight the importance of repeat screening in individuals who fail an initial swallowing screen.Survey results revealed 15 different distinct methods utilised by cardiac surgery ICU nurses for screening swallowing. The noted variability in screening methods may be related to the current lack of ICU practice guidelines and formal training programmes in this area(Christensen & Trapl, 2017). Oral trials of both ice chips and water were the most frequently reported technique, followed by the integration of food and/or liquid trials of increasing viscosity.…”