Screening Strategies to Prevent Aspiration Screening Strategies to Prevent Aspiration Pneumonia in Acute StrokePneumonia in Acute Stroke

Jeri Lynn M. BraunlinJeri Lynn M. Braunlin

MS CNRN, CNAA, BC, RN, BCMS CNRN, CNAA, BC, RN, BC

Paula Lamb BSN RNPaula Lamb BSN RN

The Problem:The Problem:Stroke ComplicationsStroke Complications

Pneumonia occurs in 6.7-22% of hospitalized patients with Pneumonia occurs in 6.7-22% of hospitalized patients with stroke stroke Three fold increase in 30 day mortality with pneumoniaThree fold increase in 30 day mortality with pneumoniaMany pneumonia cases preventable with stroke protocols in Many pneumonia cases preventable with stroke protocols in place:place:– Swallow screeningSwallow screening– Swallow evaluationSwallow evaluation– Diet modifications Diet modifications (Katzan, Dawson, Thomas, Votruba and Cebul, 2007)(Katzan, Dawson, Thomas, Votruba and Cebul, 2007)

Pneumonia and oropharyngeal Pneumonia and oropharyngeal dysphagiadysphagia

Pneumonia thought to occur most often as Pneumonia thought to occur most often as result of oropharyngeal dysphagia with result of oropharyngeal dysphagia with secondary aspirationsecondary aspiration

42-76% patients with acute stroke develop 42-76% patients with acute stroke develop dsyphagiadsyphagia

Half will experience aspirationHalf will experience aspiration

Although not all develop pneumoniaAlthough not all develop pneumonia(Katzan, Cebul, Husak, Dawson, Baker, 2003)(Katzan, Cebul, Husak, Dawson, Baker, 2003)

Risk of pneumonia in the stroke Risk of pneumonia in the stroke population demographics:population demographics:

Older patientsOlder patients

MenMen

More likely admitted from a nursing More likely admitted from a nursing home or via the emergency roomhome or via the emergency room

More co-morbid illnessesMore co-morbid illnesses

Physiologic abnormalitiesPhysiologic abnormalities

More severe neurologic impairments More severe neurologic impairments at admissionat admission(Katsan, Dawson, Thomas, Votruba, Cebul, 2007)(Katsan, Dawson, Thomas, Votruba, Cebul, 2007)

Ramifications of Pneumonia in Ramifications of Pneumonia in StrokeStroke

Higher 30 day mortality ratesHigher 30 day mortality ratesLonger lengths of stayLonger lengths of stayDischarged alive were more likely to require Discharged alive were more likely to require extended careextended careMore likely to be readmitted to hospital within More likely to be readmitted to hospital within 30 days30 days

(Katzan,Dawson,Thomas, Votruba and Cebul, 2007)(Katzan,Dawson,Thomas, Votruba and Cebul, 2007)

(Rosenvinge and Starke, 2005)(Rosenvinge and Starke, 2005)

Strategies to prevent pneumonia after Strategies to prevent pneumonia after strokestroke

Focus: to identify at –risk patientsFocus: to identify at –risk patients

Swallow screeningSwallow screening

Modify oral intakeModify oral intake

Obtain swallow therapy to improve swallow safety Obtain swallow therapy to improve swallow safety and dsyphagiaand dsyphagia(Katsan, Dawson, Thomas, Votruba, Cebul, 2007)(Katsan, Dawson, Thomas, Votruba, Cebul, 2007)

The Joint Commission (JC) The Joint Commission (JC) Performance Measure for Dysphagia Performance Measure for Dysphagia in Acute Strokein Acute Stroke

““A swallow screen for dysphagia should be A swallow screen for dysphagia should be performed on all ischemic and hemorrhagic stroke performed on all ischemic and hemorrhagic stroke patients before being given food, fluids or patients before being given food, fluids or medications by mouth.”medications by mouth.”www.jointcommision.org

JC’s rationale for Dysphagia JC’s rationale for Dysphagia ScreeningScreening

27-50% of stroke patients develop dysphagia27-50% of stroke patients develop dysphagia43-54% of stroke patients with dysphagia will experience 43-54% of stroke patients with dysphagia will experience aspirationaspirationOf those patients, 37% will develop pneumoniaOf those patients, 37% will develop pneumoniaIf not part of a dysphagia diagnosis and treatment program, If not part of a dysphagia diagnosis and treatment program, 3.8% with pneumonia will die3.8% with pneumonia will dieOther adverse effects include malnutrition and increased Other adverse effects include malnutrition and increased length of hospital staylength of hospital stay

www.jointcommision.org

Swallow Screen Project DescriptionSwallow Screen Project Description

PurposePurpose: :

Increase Dysphagia Screening Rates in Stroke Increase Dysphagia Screening Rates in Stroke PatientsPatients

Swallow Screening DeficitSwallow Screening DeficitCause AnalysisCause Analysis Inconsistent monitoring,

documenting and interventions to promote compliance

Multiple areas and Caregivers

Turnover of Stroke Physician Champion and Stroke Educator in consecutive quarters

Swallow Screen SolutionsSwallow Screen Solutions

Development, Implementation and Revision of Development, Implementation and Revision of documentation tools. documentation tools. – Pyxis prompt for swallow screeningsPyxis prompt for swallow screenings– ED Swallow screen added to EPIC (computerized medical ED Swallow screen added to EPIC (computerized medical

record system)record system)– Neurological Assessment including swallow screen module Neurological Assessment including swallow screen module

added to EPICadded to EPIC– EPIC education r/t documentation times (default was EPIC education r/t documentation times (default was

“time=now” which was not necessarily the time when the “time=now” which was not necessarily the time when the screening was completed)screening was completed)

– Stroke order sets into EpicStroke order sets into Epic

SolutionsSolutionsPyxis prompt for swallow screensPyxis prompt for swallow screens

Emergency Department Swallow Emergency Department Swallow ScreenScreen

Neurological AssessmentNeurological Assessment

Stroke Core MeasuresStroke Core Measures

Swallow Screen Swallow Screen SolutionsSolutions Emergency and Trauma Center (ETC) Staff educationEmergency and Trauma Center (ETC) Staff education

Emergency and Trauma Center Nurse Educational FlipcardsEmergency and Trauma Center Nurse Educational Flipcards

Hiring of a new Clinical Stroke Program Manager who focuses Hiring of a new Clinical Stroke Program Manager who focuses on the Stroke Populationon the Stroke Population– Stroke collaboration between care providers - Stroke Team and othersStroke collaboration between care providers - Stroke Team and others– Revision and Revitalization of the Stroke Interdisciplinary TeamRevision and Revitalization of the Stroke Interdisciplinary Team

ETC, ICU and Neuro Unit Staff education ETC, ICU and Neuro Unit Staff education – Nursing Computer Based Training Module Nursing Computer Based Training Module – Health Stream - annual competencies)Health Stream - annual competencies)

Assignment of a Lead Hospitalist to serve as Physician Stroke Assignment of a Lead Hospitalist to serve as Physician Stroke ChampionChampion

Current SituationCurrent SituationJoint Commission Core Measure # 7 Joint Commission Core Measure # 7 Swallow screen prior to any oral medication, Swallow screen prior to any oral medication, fluids or foodfluids or food

Rate was 54% at the 2005 certification dateRate was 54% at the 2005 certification date

Rate has increased to 76% (4Rate has increased to 76% (4thth quarter 2006) quarter 2006)

Rate increased to 83% (Jan-Mar 2007)Rate increased to 83% (Jan-Mar 2007)

Rate increased to 88% (April-June 2007)Rate increased to 88% (April-June 2007)

Rate increased to 94% (July-Sept 2007)Rate increased to 94% (July-Sept 2007)

Rate 91% (Oct-Dec 2007)Rate 91% (Oct-Dec 2007)

2007 yearly average = 89%2007 yearly average = 89%

Current SituationCurrent Situation

NPO status prior to swallow screen

50%55%60%65%70%75%80%85%90%95%

100%

3Q 20

05

4Q 20

05

1Q 20

06

2Q 20

06

3Q 20

06

4Q 20

06

1Q 20

07*

2Q 20

07

3Q 20

07

4Q 20

07

StrokePhysicianChampionVacancy

Stroke EducatorV

acancy

Stroe Educator vacancy

ResultsDysphagia ScreeningDysphagia Screening rate has increased from 54% 3rate has increased from 54% 3rdrd quarter 2005 to 91% in 4quarter 2005 to 91% in 4thth quarter 2007 (average in 2007- quarter 2007 (average in 2007- 89%).89%).

Dysphagia ScreeningDysphagia Screening rate has increased from 56% to 91% rate has increased from 56% to 91% following Physician Champion and Stroke Educator following Physician Champion and Stroke Educator turnover (an issue 2turnover (an issue 2ndnd & 3 & 3rdrd quarters, 2006) quarters, 2006)

Aspiration rate was 3.3% in 2006 with increased Aspiration rate was 3.3% in 2006 with increased compliance aspiration pneumonia rates have decreased to compliance aspiration pneumonia rates have decreased to 2.5 in 20072.5 in 2007

StandardizationStandardization

Hiring Stroke Program ManagerHiring Stroke Program ManagerStaff Education in ETC (Emergency department, Neuro Staff Education in ETC (Emergency department, Neuro unit and ICUunit and ICUImplemented Pyxis prompt and documentation toolsImplemented Pyxis prompt and documentation toolsSharing Swallow screening goals with ETC, Neuro and Sharing Swallow screening goals with ETC, Neuro and ICU Units as well as their respective Collaborative ICU Units as well as their respective Collaborative Practice Councils, the Professional Practice Council, the Practice Councils, the Professional Practice Council, the Organizational Performance Improvement Committee, Organizational Performance Improvement Committee, Interdisciplinary Team and Stroke Team MembersInterdisciplinary Team and Stroke Team MembersRevised Stroke Physician Orders, Benchmarking Revised Stroke Physician Orders, Benchmarking Guidelines, Patient Education Tools, and Instructions for Guidelines, Patient Education Tools, and Instructions for Care at Home. Care at Home. Hospitalist Stroke Champion assignmentHospitalist Stroke Champion assignment

Future PlansFuture Plans

Strive for 100% Dysphagia Screening rateStrive for 100% Dysphagia Screening rate

Build Dysphagia Screen monitoring report into computerized Build Dysphagia Screen monitoring report into computerized medical recordmedical record

Continue to monitor pneumonia rates, especially aspirationContinue to monitor pneumonia rates, especially aspiration

Share Stroke Results with Internal MVH Team Members and Share Stroke Results with Internal MVH Team Members and Success Strategies with Other HospitalsSuccess Strategies with Other Hospitals

Questions and CommentsQuestions and Comments

References

Adams Jr, Harold P. et al. Guidelines for the Early Management of Adults With Ischemic Stroke. Stroke Volume 38, Number 5, May 2007, Hinchley, Judith A., Shepard, Timothy, Furie, Karen, et. al., “Formal Dysphagia Screening Protocols Prevent Pneumonia.” Stroke. 2005; 36;1972-1976.Huang, JY, Zhang, Y Yao, et. al., “Training in Swallowing Prevents Aspiration Pneumonia in Stroke Patients with Dysphagia.” The Journal of International Medical Research, 2006; 34: 303-306. Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The Effect of Pneumonia on Mortality among Patients Hospitalized for Acute Stroke. Neurology 2003; 25:620-625.

ReferencesReferences

Katzen, I. L. , Dawson, N.V., Thomas, M.E., C. L., Votruba, M.E., and Cebul, R. D. The cost of pneumonia after acute stroke. Neurology 2007;68;1938-1943Martino PhD, Rosemary, Foley, BSc, Norine, et. al., “Dysphagia After Stroke.” Stroke. 2005; 36;2756-2763. pg. 275Rosenvinge, Sally K and Starke, Ian D. Improving care for patients with dysphagiawww.jointcommision.org