Nursing students have many opportunities to change practice. As a registered nurse working in the neurosurgical intensive care unit (NICU), I returned to school to complete my bachelor of science in nursing degree. During my evidence-based practice (EBP) class, I was able to make a change on my own unit by developing and implementing a Nursing Bedside Swallow Screen for acute stroke patients by using the Iowa Model of Evidence-Based Practice to Promote Quality Care. Here is my experience, which I hope will help others who wish to implement change.

Getting started

From the list of clinical placements offered on the first day of EBP class, I chose the clinical nurse specialist (CNS) in the NICU where I worked. My classmate and I met with the CNS, who emphasized that patients with neurological dysfunction such as stroke are at risk for aspiration due to alteration in swallowing function. She expressed the need for a swallow screening tool for nurses to identify patients at risk for dysphagia.

The swallow screen is a minimally invasive, pass/fail tool for quick identification of patients who require a formal evaluation of swallowing by a speech language pathologist (SLP). An effective tool is designed to identify swallow dysfunction, not necessarily aspiration. Implementing a swallowing screening protocol has been shown to significantly reduce the risk of pneumonia. The CNS said that there are currently dysphagia screens in use at other institutions, so part of our task would be to explore best practice.

After leaving the CNS’s office, I felt overwhelmed. All my years of nursing had not prepared me for this type of assignment. My anxiety quickly resolved when the professor introduced the tools and resources that we would use to aid in our progress and decision making: The Iowa Model of EBP and The Evidence-Based Practice Manual for Nurses.

The Iowa Model of EBP guided us throughout the project. It incorporates the entire infrastructure of patient care, including the patient, provider, and institution. The model starts with triggers that nurses must identify as knowledge-based or problem-focused. It also incorporates feedback loops to help nurses make decisions based on their findings. As we progressed through each step of the Iowa Model, The Evidence-Based Practice Manual for Nurses provided additional details and clarification. The manual describes each step of EBP, from forming a research question to prioritizing the hierarchy of information. Here is a closer look at each step.

1. Identify triggers

What triggers affected our need for a nursing bedside swallow screen? Several questions were proposed:

1. What are the reasons for dysphagia among stroke patients?

2. What is the national incidence of dysphagia among stroke patients?

At our institution, we asked:

3. Are there problems with delay of medications?

4. Are there problems with getting a swallow study?

5. What is the incidence of pneumonia?

6. Do the nurses feel the need for a dysphagia screening protocol?

To answer the first two questions, we searched the literature. We learned that dysphagia, which occurs in 28% to 45% of stroke patients, can be a serious complication, resulting in malnutrition, dehydration, and pneumonia. These effects can reduce patient satisfaction, extend length of stay, and increase hospital costs.

Patients with stroke are at a high risk for dysphagia because they often have decreased level of consciousness and lower cranial nerve dysfunction resulting in facial and oropharyngeal muscle weakness. However, clinical signs and symptoms of dysphagia aren’t always overt. And the presence of an intact gag reflex doesn’t necessarily rule out the possibility of aspiration.

Reducing morbidity from aspiration pneumonia is an initiative shared by national stroke quality improvement programs such as those from the Joint Commission, Centers for Disease Control and Prevention, and the American Heart Association. All three recommend the following:

• Acute stroke patients must receive nothing by mouth (NPO), including food, fluid, and oral medications, until a dysphagia screen has been done.
• All patients, except those with a known history of dysphagia, should have a dysphagia screen before any oral intake.
• An evidence-based bedside testing protocol approved by the hospital is acceptable.
• A competent staff member (defined by each institution) should complete the dysphagia screen—abnormal results should be referred to the SLP for a complete assessment.

Now that we had answers to the first two questions, we were ready to informally ask the NICU nurses about questions 3, 4, 5, and 6. Overwhelmingly, they said they needed a swallow screen that they could use at the bedside. Too often they were admitting patients from the emergency department with orders that read “NPO except medication until swallow evaluation by speech therapy.” This was frustrating because patients were still at risk for aspirating the medicine. Also, some patients often remained NPO for an unnecessarily long amount of time.

Using the Iowa Model, we identified whether the triggers were knowledge-based or problem-focused.

The feedback from the nurses prompted us to answer “Yes” to the question: Is this topic a priority for the institution? This meant we were ready for the next step in the Iowa Model.

2. Form a team

In addition to me, our team included my classmate, our NICU’s CNS, the nurse practitioner (NP) from our hospital’s neurology stroke department, and the SLP who works with our stroke patients. We scheduled weekly meetings with our professor and CNS, and meetings with the NP and SLP were scheduled as needed.

3. Assemble relevant research and related literature

Before starting our literature search, we used the PICO formula to develop our question:

Population: Describe a group of patients similar to yours.

Intervention: Describe what it is you’re trying to do or what has happened to the patient.<br/
Comparison: Describe an alternative, if any.<br/
Outcome: Define what you’re hoping to accomplish.

Our question was: In neurological patients at risk for dysphagia, what is a sensitive specific screening protocol that can be carried out at the bedside by nurses?

We began our literature search with two objectives in mind—investigate if there is evidence that a dysphagia screening tool is effective, and search for current dysphagia tools that other institutions have implemented. We searched for research and theoretical articles that included systematic reviews, articles on dysphagia and pneumonia, and swallow assessment tools.

4. Critique and synthesize research for use in practice

After our literature search, we needed to critique and evaluate each article for use in practice by asking three key questions:

1. Are the findings applicable in my setting?

2. Is the quality of the study good enough to use the results?

3. What do the results mean for my patients?

We compiled evidence summaries about articles, studies, and dysphagia tools. These were useful to dissect each study and screen for its applicability for our use. We asked: Where did each item fit on the hierarchy of evidence? What were the design, sample size, results, and limitations?

For example, the article “The Massey Bedside Swallow Screen” explained a prospective, one-group nonexperiment study. It was a two-phase study to establish inter-rater reliability and content validity. The results showed high reliability with sensitivity and specificity 100%. These results looked impressive, but the study had some limitations. It was a very small sample size of only 25 participants and was done at only one location.

We found a systematic review of literature that addressed three questions:

• What are the incidence and outcomes of dysphagia in acute stroke?
• What tools are available to detect dysphagia and how effective are they?
• What effect has screening swallow function on patient outcomes?

The goal of this review was to seek current best evidence for dysphagia screening for acute stroke patients. We found that the incidence of dysphagia is higher during the first 72 hours of stroke.

Six screening tests were compared. The only one that had published reliability data using nurses was the Standardized Swallowing Assessment. Overall results showed that patients who have abnormal screening tests are at increased risk for pneumonia and nutrition problems compared to patients who have normal screening tests.

5. Is there a sufficient research base?

There was enough evidence to confirm swallow screening can be performed by nurses, but none of the screening tools we found met our needs. We wanted the tool to be short and easy to follow: a one-page screen that incorporated all the validated dysphagia screening criteria. It would not include any food or thickened liquids. We made some formatting modifications to the tools that were currently in the literature to create our own tool. See the end of this article for the tool.

6. Is change appropriate for adoption in practice?

We answered, “Yes,” so the next step was to implement the change.

7. Institute the change in practice

My classmate and I developed a poster for staff nurses that outlined the practice change and the supporting evidence. We presented the tool to our neurology physicians and explained their role in ordering the screen. It was added to the physician’s preprinted admission orders and included in the nurses’ stroke admission packet.

We also developed a competency check-off form to confirm nurses’ ability to carry out the bedside screen. The form included knowing the signs and symptoms of aspiration, how to use the swallow screen tool effectively, and when it’s appropriate to refer cases to the SLP. We anticipated some resistance to change but surprisingly received very little. The nurses were eager to have a simple dysphagia screen for use at the bedside.

8. Monitor and analyze structure, process, and outcomes data

We audited patients’ medical records and found an almost immediate improvement in documentation of dysphagia screening. But then documentation of screenings began to plateau and fluctuate. We continued to reinforce the need for screening before any oral intake to current and new staff and added the nursing competency to the orientation manual. Screening and documentation subsequently improved.

SLPs report that the swallowing screening tool has improved the quality of referrals they receive. Nurses and physicians report that the tool is fast and easy to use. The tool is now part of our electronic charting system, and we continue to track compliance and monitor patient outcomes.

Clinical Swallow Screening Tool

Marget Smallwood is a staff nurse on the neurosurgical intensive care unit at the University of Michigan Health System in Ann Arbor.

Selected references

American Heart Association. Get with the guidelines: Stroke. http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStroke/Get-With-The-Guidelines-Stroke-Home-Page_UCM_306098_SubHomePage.jsp. Accessed June 14, 2012.

Craig J, Smyth R. The Evidence-Based Practice Manual for Nurses. London: Churchill Livingstone; 2002.

Daniels SK, Ballo LA, Mahoney MC. Foundas AL. Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. Arch Phys Med Rehabil. 2000;81(8):1030-1033

Davies S, Taylor H, MacDonald A, Barer D. An inter-disciplinary approach to swallowing problems in acute stroke. Int J Lang Commun Disord. 2001;36(supp 1):357-362.

Exley C. Pulse oximetry as a screening tool in detecting aspiration. Age Aging. 2000;29:475-476.

Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36:1972-1976.

The Joint Commission. Specifications Manual for Joint Commission National Quality Core Measures. http://www.jointcommission.org/specifications_manual_joint_commission_national_quality_core_measures.aspx. Accessed June 14, 2012.

Marik P, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest. 2003;124(1):328-336.

Massey R, Jedlicka D. The Massey Bedside Swallowing Screen. J Neurosci Nurs. 2002;34(5):252-258.

McHale J, Phipps M, Horvath K, Schmelz J. Expert nursing knowledge in the care of patients at risk of impaired swallowing. Image J Nurs Sch. 1998;30(2):137-141.

Perry L. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia. 2001;16(1):7-18.

Perry L. Screening swallowing function of patients with acute strokes. Part one: identification, implementation and initial evaluation of a screening tool for use by nurses. J Clin Nurs. 2001;10:463-473.

J Clin Nurs. 2001;10:474-481.

Smith H, Connolly M. Evaluation and treatment of dysphagia following stroke. Top Geriatr Rehabil. 2003;19(1):43-59.

Smithard DG, O’Neill PA, England RE, et al. The natural history of dysphagia following a stroke. Dysphagia. 1997;12(4):188-193

Titler MG, Kleiber C, Steelman V, et al. The Iowa Model of Evidence-Based Practice to Promote Quality Care. http://www.hinursing.org/pdf/IowaModel.pdf. Accessed June 14, 2012.

Titler MG, Kleiber C, Steelman V, et al. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. http://www.ncbi.nlm.nih.gov/pubmed/11778337. Accessed June 14, 2012.

Wood P, Emic-Herring B. Dysphagia: a screening tool for stroke patients. J Neurosci Nurs. 1997;29(5):325-329.