Rita Hunsucker, DNP, Nicole Cornell, MS, Gerald Hobbs, PhD, Jorge Con, MD & Alison Wilson, MDWVU Medicine, J.W. Ruby Memorial Hospital
The authors have nothing to disclose.
Post‐extubation dysphagia (PED) is difficulty swallowing which occurs following intubation.1
PED is a significant complication experienced by 3% to 62% of patients.1
Risk factors are inconsistent.1
37% of trauma patients are silent aspirators.2
The length of time from extubation to evaluation by speech therapy is 36 hours on average.3
Decreased patient satisfaction Delay in nutritional interventions Decreased caloric intakeIncreased length of stayIncreased mortalityIncreased cost
We hypothesize that the Standardized Swallow Assessment, a bedside nursing screen, results in earlier nutritional intake and no changes in adverse outcomes in the post‐extubated adult trauma patient.
A quasi‐experimental post‐test only designPre‐implementation group, speech therapy evaluated at trauma surgeon’s discretionPost‐implementation group, every patient was screened by bedside RN using Standardized Swallow Assessment
Inclusion criteria: intubated trauma patients over 18 years of age.
Exclusion criteriamandible fractureshead and neck cancer hxNPO for medical or surgical reasons.
Already in use within the institution for strokePre‐swallow Screening Checklist must be completedWater swallow test:
With the patient alert and sitting upright, give first a teaspoonful of water. If there are no problems, repeat the process with a second and third teaspoonful. If there is still no problem evident, give half a glass of water. If there is no problem, the patient has passed the SSA.4
Time from extubation to diet order and adequate oral intake were studied using Wilcoxon/Kruskal‐Wallis Tests. Hospital and ICU length of stay (LOS) were analyzed with T‐test. Fisher’s exact was utilized to evaluate unplanned and emergent reintubation, return to higher level of care, pneumonia, and mortality.
Differences in aspiration related complications of rates of pneumonia, unplanned intubation, emergent reintubation, unplanned return to ICU, and mortality were not statistically significant
Significant differences between groups ventilator dayshistory of alcohol/drug use.
SSA groupearlier diet order (13 hours, p = 0.03) earlier adequate oral intake (16 hours, p = 0.006)shorter ICU LOS (2 days, p = 0.03) shorter hospital LOS (5 days, p= 0.02)
Cost savings of $41,797 to the patient and $8,988 to the institution.
Table 1. Patient Characteristics
Characteristic Control(n=64)
Experimental (n=28)
Difference P‐value
Age (mean in years) 51.4 44.3 ‐7.085 0.1826
Gender (M, F) 75%, 25% 82.14%, 17.86% ‐0.0191 0.6705
Ventilator Days 2.81 1.28 ‐1.5238 0.0199
Face AIS 1.452 1.143 ‐0.30876 0.0955
Head/Neck AIS 2.84 2.61 ‐0.23099 0.3960
ISS 16.2951 15.9286 ‐0.477 0.6705
GCS 14.22 14.54 +0.31696 0.2246Hx Respiratory Disease
16.39% 7.14% ‐9.25 0.3260
Hx Alcohol/Drug 14.75% 35.71% +20.96 0.0485
Table 2. Outcomes
Outcome Control (n=64)
Experimental (n=28)
Difference P‐value
Hours from Extubation to Diet Order
49.57 36.48 ‐13.09 0.028
Hours from extubation to adequate diet
47.45 31.46 ‐15.99 0.0055
Mortality Rate 7.8% 0 ‐7.8 0.318Pneumonia Rate 10.94% 10.71% ‐0.23 1.00Unplanned Intubation Rate 21.88% 7.14% ‐14.74 0.134Unplanned Return to ICU Rate
7.81% 3.57% ‐4.24 0.6632
Hospital Days 13.55 8.25 ‐5.297 0.0209ICU Days 5.172 3.25 ‐1.9219 0.0296Emergent Re‐intubation Rate 15.63% 7.14% ‐8.49 0.3333Pre‐hospital Intubation 39.34% 28.57% ‐10.77 0.3534Multi‐Intubation Rate 21.3% 10.71% ‐10.59 0.3726
Utilizing a post‐extubation dysphagia screen provides the opportunity for earlier oral intake. Implementation of the nursing dysphagia screening at our institution resulted in no increase in aspiration related events. Although our numbers are small, it appears that the nursing bedside dysphagia screen is a safe, cost effective alternative to the formal swallow evaluation performed by speech therapists.
1. Skoretz, S. A., Flowers, H. L., & Martino, R. (2010). The incidence of dysphagia following endotracheal intubation. Chest, 137(3), 665‐ 673. Retrieved from http://www.chestpubs.org
2. Kwok, A. M., Davis, J. W., Cagle, K. M., Sue, L. P., & Kaups, K. L. (2013). Post‐extubation dysphagia in trauma patients: It’s hard to swallow. The American Journal of Surgery, 206, 924‐928.
3. de Medeiros, G. C., Sassi, F. C., Mangilli, L. D., Zilberstein, B., & de Andrade, C. R. (2014). Clinical dysphagia risk predictors after prolonged orotracheal intubation. Clinics, 69(1), 8‐14. DOI: 10.6061/clinics/2014(01)02
4. Perry, L. (2001). Screening swallowing function of patients with acute stroke. Part one: Identification, implementation, and initial evaluation of a screening tool for use by nurses. Journal of Clinical Nursing, 10, 463‐473. Retrieved from http://www.wiley.com
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