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

The current study surveyed nurse practice patterns for performing swallowing screens in an academic cardiac intensive care unit (ICU). It aimed to index: training and levels of confidence in conducting dysphagia screens; screening methods employed; timing and frequency of implement; and subsequent plan of care in identified high-risk patients. Swallowing impairment (dysphagia) is common following cardiac surgery and associated with significant morbidity and mortality. Early and accurate detection of dysphagia is therefore critical to afford implementation of interventions to optimise patient care. Currently, no validated instruments or guidelines exist for nursing screening of dysphagia in this setting. An anonymous and voluntary 10-item mixed-methods online survey was conducted using Qualtrics software. Nonprobability purposive sampling was utilised to recruit nurses working in an academic 24-bed cardiac ICU. Thematic analysis using operationally defined coding, SRQR checklist and descriptive statistics were employed. Sixty-nine nurses completed the survey during a 1-month period, representing an 84% response rate. Formal training in performing swallowing screens was reported in 18.6% of nurses. In rank order, reported level of confidence was the following: "moderately" (49%); "somewhat" (35%); "not" (13%); and "very" (3%). The majority of nurses performed screens within 1 hr (40.6%) or between 1-4 hr (43.8%) of extubation. Fifteen different methods were utilised to screen swallowing function by nurses who reported a total of 31 different clinical signs indicative of dysphagia. Survey data of practicing nurses in an academic cardiac ICU revealed limited formal training in swallowing screening methodology, a high degree of variability in screening methods employed and low levels of agreement for dysphagia signs. Data highlight a knowledge gap and need for the development of formal education and validated rapid nursing dysphagia screening tools for standardised implementation in the cardiac surgery ICU setting.

Dallal York J ，Miller S ，Chapin J ，Gore S ，Jeng EI ，Plowman EK ... -  《-》

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

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.

Christensen M ，Trapl M 《-》

Nursing adherence, barriers and facilitators to conduct post-stroke dysphagia screening and assessment: A study based on theoretical domain framework.

There are an increasing number of evidence-based recommendations for managing dysphagia in post-stroke patients. However, it is unclear whether nurses adopt these recommendations in their daily nursing practices. This study aimed to explore nurses' adherence, barriers, facilitators and views on dysphagia screening and assessment of post-stroke dysphagia. In this study, multiple methods were adopted. In Phase 1, a general information questionnaire and a knowledge-attitude-practice and barriers/facilitators questionnaire for dysphagia screening and assessment were distributed in 55 hospitals online. In Phase 2, semi-structured interviews were conducted to explore nurses' views on barriers. Descriptive and one-way variance analyses were used to analyse the quantitative data, while content analysis was used to analyse the qualitative data. This study adheres to STROBE and COREQ guidelines. Nine hundred and forty-two completed questionnaires were collected. Only 36.52% of the nurses screened for swallow function in patients as a guideline. The biggest barrier was 'memory, attention and decision process', with an average score of 3.22 (.74). The different stages of implementation had various types and degrees of barriers (p < .001). Five themes were extracted after interviews, namely 'Inadequate environment and resource support', 'Increased workload', 'Professional value perception', 'Organisational culture', and 'Poor knowledge and skill'. Nurses' practice of dysphagia screening and assessment of patients with dysphagia after stroke were inadequate, and the barriers originated from patients, leadership and the nurses themselves. This research extracted five barriers of guidance adherence for post-stroke dysphagia screening and assessment and identified the different kinds and degrees of barriers in five implementation stages, providing a basis for nursing managers to break through the bottleneck of guideline implementation. The nurses recruited in this study completed validated questionnaires in the survey and suggestive answers in interviews.

Guo Y ，Guo L ，Dong X ，Yang C ，Wang M ，Gao H ，Lv P ，Ma K ... -  《-》

A bedside swallowing screen for the identification of post-extubation dysphagia on the intensive care unit - validation of the Gugging Swallowing Screen (GUSS)-ICU.

Screening for dysphagia at the intensive care unit (ICU) soon after extubation can prevent aspiration, pneumonia, lower mortality, and shorten re-feeding interval. This study aimed to modify the Gugging Swallowing Screen (GUSS), which was developed for acute stroke patients, and to validate it for extubated patients in the ICU. In this prospective study, forty-five patients who had been intubated for at least 24 h were recruited consecutively at the earliest 24 h after extubation. The modified GUSS-ICU was performed twice by two speech and language therapists independently. Concurrently, gold standard the flexible endoscopic evaluation of swallowing (FEES) was performed by an otorhinolaryngologist. Measurements were conducted within a three-hour period; all testers were blinded to each other's results. According to FEES, 36 of 45 (80%) participants were diagnosed with dysphagia; 13 of those were severe, 12 moderate, and 11 mild. Compared to FEES, the GUSS-ICU predicted dysphagia well (area under the curve for the initial rater pair: 0.923, 95% CI 0.832-1.000 and 0.923, 95% CI 0.836 -1.000 for the second rater pair). The sensitivity was 91.7% (95% CI 77.5-98.3%) and 94.4% (95% CI 81.3-99.3%); the specificity was 88.9% (51.8-99.7%) and 66.7% (29.9-92.5%); the positive predictive values were 97.1% (83.8-99.5%) and 91.9% (81.7-96.6%), and the negative predictive values were 72.7% (46.8-89%) and 75% (41.9-92.6%) for the first and second rater pairs, respectively. Dysphagia severity classification according to FEES and GUSS-ICU correlated strongly (Spearman's rho: 0.61 for rater 1 and 0.60 for rater 2, p < 0.001). Agreement by all testers was good (Krippendorffs Alpha: 0.73). The interrater reliability showed good agreement (Cohen`s Kappa: 0.84, p < 0.001). The GUSS-ICU is a simple, reliable, and valid multi-consistency bedside swallowing screen to identify post-extubation dysphagia at the ICU. ClinicalTrials.gov Identifier: NCT04532398,31/08/2020.

Troll C ，Trapl-Grundschober M ，Teuschl Y ，Cerrito A ，Compte MG ，Siegemund M ... -  《BMC Anesthesiology》

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

Post-extubation dysphagia reportedly occurs in 3%-60% of patients and is independently associated with poor patient outcomes. The aim of this study was to investigate the frequency of post-extubation dysphagia, as diagnosed using our novel nurse-performed swallowing screening protocol, and to evaluate patient outcomes, including the frequency of discharge home, the length of the intensive care unit and hospital stays, the frequency of hospital-acquired pneumonia and death in the intensive care unit and hospital. This was a prospective cohort study. This study was conducted in a mixed intensive care unit in a critical care hospital in Japan. Between October 2016 and September 2017, the swallowing functions of 216 patients were assessed using our novel screening protocol. To investigate the correlation between dysphagia and patient outcomes, we compared a dysphagia group with a no dysphagia group. Twenty-five patients (11·6%) were diagnosed with dysphagia. The frequency of discharge home, which was the primary outcome, was significantly lower in the patients with dysphagia (60% versus 87·4%, P = 0·002). Dysphagia was also correlated with longer hospital stay and higher mortality. A binomial logistic regression analysis, including the variables of dysphagia, Acute Physiology and Chronic Health Evaluation II score and duration of ventilator use, showed that dysphagia was an independent risk factor for a lower incidence of discharge home. Among patients admitted to a mixed intensive care unit, post-extubation dysphagia was correlated with a poor prognosis. The current study emphasizes the poor prognosis of patients with dysphagia after extubation. Dysphagia developed in more than 1 in 10 patients post-extubation; therefore, monitoring for a swallowing disorder is crucial in daily nursing in the intensive care unit.

Omura K ，Komine A ，Yanagigawa M ，Chiba N ，Osada M ... -  《-》