JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

Evaluation of nursing dysphagia screening tools among patients with stroke: a systematic review protocol 1,2

Farzaneh Raoufi, RN, FNP-BC, CNS Kate Shade, RN, PhD

1,2

1. Department of Nursing, Samuel Merritt University, California, USA 2. University of California, San Francisco (UCSF) Medical Center, UCSF Centre for Evidence-based Patient Care Quality Improvement: an Affiliate Center of the Joanna Briggs Institute

Corresponding author: Farzaneh Raoufi

[email protected] Review question/ Objective The objective of this systematic review is to evaluate the effectiveness of two bedside screening tools used by nurses to assess for dysphagia among hospitalized adult patients with stroke. The two screening tools discussed are the Toronto Bedside Swallowing Screening Test and the 90-cc Water Swallow Test. In adult patients with acute stroke, how effective is the Toronto Bedside Swallow Screening Test compared to the 90-cc Water Swallow Screening Test in detecting dysphagia and predicting the risk of acquiring nosocomial aspiration pneumonia. Sensitivity, specificity, positive predictive value and negative predictive value will be utilized to evaluate the validity of these two dysphagia-screening tools. Reliability of the two tools will be established. Video-Fluoroscopy (VF) and Fibreoptic Endoscopic Evaluation of Swallowing (FEES) will be the gold standard to which the tools will be compared against.

Background Stroke occurs when blood flow to the brain is stopped and the brain cells do not receive enough oxygen 1

and begin to die. Once brain cells are damaged, signs and symptoms such as weakness, numbness, aphasia, dysphagia and other symptoms become apparent.

1

Risk factors for stroke include

hypertension, cardiac disease, diabetes, smoking and a history of stroke.

1

There are three types of stroke: Transient Ischemic Attack (TIA), ischemic stroke and hemorrhagic 1

stroke. TIA occurs when the blood flow to the brain is blocked for a short period of time, whereas ischemic stroke happens when blood clots or fatty deposits obstruct the blood flow to the brain and hemorrhagic stroke occurs when a blood vessel ruptures in the brain causing blood to exert pressure on the surrounding tissues.

1

doi: 10.11124/jbisrir-2014-1560

Page 61

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

2

Stroke is considered to be the primary cause of dysphagia. Dysphagia is defined as difficulty with swallowing food or fluid.

2

There are two types of dysphagia: oropharyngeal and esophageal.

2

Oropharyngeal dysphagia is defined as the inability to pass food or fluid from the mouth to the 3

esophagus. Esophageal dysphagia is defined as difficulty moving food or fluid through from the 2

esophagus to the stomach. Oropharyngeal dysphagia is the most common type of dysphagia among 2

patients with stroke. An estimated 42% to 67% of patients with stroke develop dysphagia within three 3

days post-event. Annually, the number of persons in the U.S. with stroke who experience dysphagia ranges between 160,000 and 573,000.

4

Stroke can affect normal swallowing physiology by damaging areas of the motor cortex that controls the 5

muscles involved in swallowing. An individual with a normal swallow can move the food or fluid from the mouth to the stomach in four phases, as described below: 1. Oral preparatory phase: Food is masticated, mixed with saliva and is formed into a ball or bolus.

6

2. Oral propulsive phase: The tongue helps the food to move into the oropharynx.

6

3. Pharyngeal phase: The soft palate rises, larynx and hyoid bones move upward, while the vocal cords fold to the midline and the epiglottis covers the trachea. The tongue then pushes the bolus through the pharynx.

6

4. Esophageal phase: The bolus passes through the esophagus. The squeezing motion of the throat muscles helps the bolus to move to the stomach.

6

Of the four phases of the normal swallow process, only the oral and pharyngeal phases are affected 6

when a patient experiences a stroke. Stroke patients have difficulty controlling the tongue and are unable to chew and swallow food particles as both the oral and pharyngeal phases of swallowing are 6 impaired. When stroke patients are given fluids, they have difficulty holding the liquid in the oral cavity and therefore, the liquid may enter the pharynx hastily and cause aspiration. When there is impairment 6

in the esophageal phase of swallowing, transport of food to the esophagus is affected. The food remains in the pharynx when the patient attempts to swallow, or swallows ineffectively.

6

7

An estimated 40% to 50% of stroke patients with dysphagia aspirate. Aspiration is referred to as 8

breathing in an object. Aspiration is caused by food particles or fluid droplets entering the airways and 9

lungs. Silent aspiration occurs when a patient aspirates particles without exhibiting any signs or symptoms.

10

It has been estimated that 40% to 70% of stroke patients suffer from silent aspiration.

11

One third of stroke patients exhibiting signs and symptoms of aspiration will suffer from pneumonia that 12

requires pharmacological treatment. Pneumonia that occurs during an inpatient episode and was not present on admission is considered to be “hospital-acquired pneumonia” or nosocomial pneumonia. (p.88)

13

“Hospital-acquired pneumonia” commonly results in increased hospital length of stay, with

associated costs ranging from USD $13,000 to $16,000

per episode.

3(p.3155)

The mortality rate

associated with pneumonia is three times higher in patients with dysphagia than in those without this condition.

3

Dysphagia screening is important in early recognition of patients with dysphagia, who are at risk of developing aspiration pneumonia.

14

Dysphagia screening should be performed on patients with acute 12

stroke prior to giving food, fluids or medications. The dysphagia screening is a simple “clinical bedside

doi: 10.11124/jbisrir-2014-1560

Page 62

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

exam” that determines: a) the presence of dysphagia; b) the need for a dysphagia evaluation by a speech language pathologist; c) whether the patient can receive food, fluids or medications; and d) whether a nutritional consult or intravenous fluid hydration is needed.

15(para3)

The American Speech

Language-Hearing Association recommends dysphagia screening as an initial assessment with a pass or fail outcome, to identify patients requiring further assessment and evaluation by a speech pathologist. If a patient fails the dysphagia screening, the patient cannot receive food or fluid by mouth until a speech language pathologist evaluates the patient.

15

Video-Fluoroscopy and FEES are considered to be the gold standard for identifying dysphagia and the 16

risk of aspiration.

Video-Fluoroscopy provides dynamic images of the bolus during the swallowing

16

process. The bolus can be tracked going through the alimentary tract when contrast materials such as barium sulfate are added.

16

However, expensive equipment is required and the patient is exposed to

radiation during this diagnostic test.

14

The FEES test requires “trans-nasal passage of flexible

laryngoscope into the hypo-pharynx” during the swallowing process so that the passage of food or liquids can be video-taped.” test safely.

17

16(p.478)

The individual performing this test must be capable of executing the

Although VF and FEES allow for accurate diagnosis of dysphagia and aspiration 17

pneumonia, both tests are invasive and require trained staff. Bedside dysphagia screening tests are inexpensive, quick and may be equally useful in screening for dysphagia among stroke patients.

16

Nurses have an important role in dysphagia screening; however, nurses must receive training to perform this task successfully.

16

A speech language pathologist performs the dysphagia evaluation

process that includes interview with patients/families, “observation, formulation and communication of the results and recommendations” to the physician responsible for the patient.

15 (para 4)

12

There are a number of bedside dysphagia screening tools currently in use. The effectiveness of a 12

screening tool is determined by its reliability, validity and clinical utility. Reliability is defined as the ability of the tool to provide consistent and stable results and is measured through a test-retest method.

17

Validity is measured by a tool’s sensitivity and specificity.

17

Sensitivity refers to how

successful a tool is in detecting patients with dysphagia, whereas specificity assesses how successful a tool is in detecting patients without dysphagia.

18

Positive predictive value is defined as the percentage 18

of stroke patients with positive screening tests that have dysphagia.

Negative predictive value refers 18

to the percentage of stroke patients with negative screening tests that do not have dysphagia. sensitivity and specificity are inversely proportional.” lower is the value of specificity.

19

18(p.47)

“The

That is, the higher the value of sensitivity, the

Leder and colleagues assess that while there is no consensus for a

specified/defined parameter or value for sensitivity, an effective dysphagia screening tool should have a sensitivity value of 95% or greater.

19

In the late 1990s and early 2000s, there was a movement to evaluate swallow screening tests.

12

There

was also an effort to identify the significant factors associated with dysphagia and risk of aspiration (e.g. abnormal gag reflex, dysphonia, dysarthria and cough after swallow).

12

There was a mounting body of

research demonstrating the need for a dysphagia screening tool with sufficient sensitivity, specificity 12

and predictive strength, that could be administered by a frontline healthcare professional. By 2007, the American Heart Association/American Stroke Association guidelines recommended stroke patients be assessed for dysphagia prior to administering food, fluid or medication orally.

12

In 2010, the Joint

Commission (TJC) removed the dysphagia screening performance standard because the National 12

Quality Forum (NQF) did not support this measure. The lack of support from the NQF was because no

doi: 10.11124/jbisrir-2014-1560

Page 63

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

12(p.e.25)

single dysphagia screening tool was identified as being “superior”.

Therefore, studies published

from 2007–2014 will be considered for inclusion in this review. The data chosen indicate the period in which studies were being conducted to assess the validity, sensitivity and specificity of various dysphagia screening tools and identify an evidence-based dysphagia screening tool. The two dysphagia-screening tools recommended in the guidelines were the Toronto Bedside 20

Swallowing Screening Test and the 90cc Water Swallow Screening Test. The Toronto Bedside Swallowing screening test takes approximately 10 minutes to perform.

21

The test is composed of three

parts: two parts consists of oral exams and one part tests the patient’s ability to swallow 50 cc of water. The oral exam consists of pharyngeal sensation, tongue movement and dysphonia.

21

Training is

available via an online module for hospitals interested in implementing this tool and training their staff. The training takes about four hours and all nursing staff will receive training that is standardized.

21

21

The

21

test is copyrighted by the University of Toronto and there is a cost associated with its use. The 90-cc Water Swallow Test is also known as the 3-oz Water Swallow Test. The patient is instructed to drink 3 22

oz of water without disruption and passes if he/she can do so. If the patient passes this screening test, they can receive food, fluid or medication. Performing this test does not require specialized equipment therefore, this test is inexpensive.

22

The American Stroke Association and American Heart Association guidelines support the Toronto Bedside Swallowing Test, since this test has been evaluated for inter-rater reliability and predictive validity. The guidelines also support the 90-cc Water Swallow Test, since “a wet voice after swallowing is a predictor of high risk for aspiration”.

20(p.916)

Therefore, both tools are considered appropriate for 23

screening dysphagia among patients with stroke. This systematic review will examine the reliability and validity of the Toronto Bedside Swallowing Screening Test and the 90-cc Water Swallow Test.

Keywords Stroke; deglutition disorders; dysphagia bedside screening; water; point-of-care systems; Toronto dysphagia screening and deglutition

Inclusion criteria Types of participants This review will consider studies that include adult patients screened for dysphagia (aged 18 years and over), who are admitted to an inpatient unit within a general acute care hospital setting. This review will consider studies that include dysphagia assessment using the Toronto Bedside Swallow Screening Test and/or the 90-cc Water Swallow Screening Test. Studies with patients with active dysphagia and pneumonia present on admission will be excluded. Focus of the review This review will consider studies that assess oropharyngeal dysphagia in patients following an acute stroke, using the Toronto Bedside Dysphagia Screening test and/or the 90-cc Water Bedside Dysphagia Screening Test. In order to assess specificity and sensitivity, the screening tools will be compared against VF and FEES in diagnosing adults with dysphagia. Video-Fluoroscopy and FEES are the gold standard for identification of dysphagia and silent aspiration. This review will also investigate aspiration pneumonia as an adverse outcome for patients who underwent dysphagia screening tests.

doi: 10.11124/jbisrir-2014-1560

Page 64

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

Outcomes Studies will be included that provide information about the diagnostic accuracy of the Toronto Bedside Dysphagia and 90-cc Water Bedside Dysphagia Screening tests to correctly identify dysphagia in adults following stroke. Outcomes include reliability (test re-test), validity (specificity and sensitivity), as well as Positive Predictive Values (PPV) and Negative Predictive Values (NPV). Types of studies This review will consider any experimental study design including randomized controlled trials, non-randomized controlled trials, quasi-experimental, cohort studies, cross-sectional studies, case-controlled studies and observational studies, in which reliability and/or validity of the Toronto Bedside Swallowing Screening Test and the 90-cc Water Swallow is provided.

Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial search of MEDLINE and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English or translated into English will be considered for inclusion in this review. Studies published from 2007–2014 will be considered for inclusion in this review. The date chosen indicates the period in which studies were being conducted to assess the reliability, validity and clinical utility of various tools in order to identify a single evidence-based dysphagia-screening tool that could be used by frontline staff at the bedside. The databases to be searched include: PubMed, CINAHL and Cochrane Library The search for unpublished studies will include: ProQuest (Dissertations and Theses), ProQuest (Nursing & Allied Health Source), The Centers for Disease Control and Prevention (CDC), American Heart Association (AHA), American Stroke Association (ASA), American Speech-Language-Hearing Association (ASHA) and Agency for Healthcare Research and Quality (AHRQ). Initial keywords to be used will be: Stroke, Deglutition disorders, Dysphagia, Screening, Deglutition, Assessment, Toronto Bedside Swallow Screening Test, Cerebrovascular Accident (CVA), 90-cc Water Swallow Test, Aspiration, Pneumonia, Respiratory Aspiration, Reliability, Validity, Sensitivity, Specificity, Accuracy, Predictive Value, 3-oz Water Swallow Screening Test, Diagnostic Test, Screening Test, Video-Fluoroscopy (VF), and Fibreoptic Endoscopic Evaluation of Swallowing (FEES).

doi: 10.11124/jbisrir-2014-1560

Page 65

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist (Appendix I). Any disagreements that arise between reviewers will be resolved through discussion, or with a third reviewer.

Data collection Data will be extracted from papers included in the review using the standardized Standards for Reporting of Diagnostic Accuracy (STARD) checklist (Appendix II). The data extraction will summarize key information from each study including information related to the participants’ age and diagnosis, the settings, sample size and diagnostic intervention. The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. In situations where relevant study features are not provided within the study paper, the reviewer will contact the author to attempt to source additional information.

Data synthesis Reliability and validity, including sensitivity, specificity, positive predictive value and negative predictive value will be extracted directly from the source papers. If this is not possible, values will be calculated from the data provided. Positive and negative likelihood ratios, diagnostic odds ratios and 95% confidence intervals will be calculated. The data will be displayed on Forest and ROC plots. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. When synthesizing diagnostic outcomes, it is essential to plot sensitivity-specificity pairs for each included study. The relationship between the sensitivity-specificity pair depicts how significant heterogeneity differences exist and helps define the appropriate approach to synthesizing outcomes. When statistical pooling is not possible, the findings will be presented in a narrative form including tables and figures to aid in data presentation where appropriate. If meta-analysis is possible, sensitivity and specificity scores will be pooled. Rev Man 5.3 (Cochrane Collaboration) will be used as appropriate software to generate outcome measures and ROC plots.

Conflicts of interest There is no external funding for this review. This systematic review will contribute to the primary reviewer’s degree in the Doctor of Nursing Practice (DNP) from Samuel Merritt University in Oakland, California.

Acknowledgements Dr. Michelle DeCoux Hampton, RN, MS, PhD – Associate Professor and Director of the Doctor of Nursing Practice (DNP) Program at Samuel Merritt University Dr. Elizabeth Scruth, RN, CNS, PhD - Kaiser Permanente Northern California, Practice Site Facilitator Dr. Kate Shade, RN, PhD - Assistant Professor at Samuel Merritt University

doi: 10.11124/jbisrir-2014-1560

Page 66

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

Dr. Daphne Stannard, RN, CCRN, PhD – Director of UCSF Center for Evidence-Based Patient Care Quality Improvement, an Affiliate Center of the Joanna Briggs Institute

doi: 10.11124/jbisrir-2014-1560

Page 67

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

References 1. Centers for Disease Control and Prevention (2013, December). About Stroke (2013). Retrieved from http://www.cdc.gov/stroke/about.htm 2. National Stroke Association (2012, August). Dysphagia Retrieved from http://www.stroke.org/site/PageServer?pagename=dysphagia 3. Titsworth WL, Abram J, Fullerton A, Hester J, Guin P, Waters MF, et al. Prospective quality initiative to maximize dysphagia screening reduces hospital-acquired pneumonia prevalence in patients with stroke. Stroke. 2013;44(11):3154-3160. 4. Tippett DC. Clinical challenges in the evaluation and treatment of individuals with post-stroke dysphagia. Top Stroke Rehabil. 2011;18(2):120-133. 5. Hamdy S. Role of cerebral cortex in the control of swallowing. GI Motilityonline. 2006. doi.10.1038/gimo8. 6. Palmer JB, Drennan JC, Baba M. Evaluation and treatment of swallowing impairments. Am Fam Physician. 2000; 61(8): 2453-2462. 7. Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest. 2003;124(1):328-336. 8. National Library of Medicine, National Institutes of Health (November, 2012). Aspiration. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/002216.htm 9. Singh S, Hamdy S. Dysphagia in stroke patients. Postgrad Med J. 2006;82(968):383-391. 10. Matsuo K, Palmer JB. Anatomy and physiology of feeding and swallowing – Normal and abnormal. Phys Med Rehabil Clin N Am. 2008;19(4):691-707. 11. Daniels SK. Neurological disorders affecting oral, pharyngeal swallowing. GI Motility online. 2006.doi: 10.1038/gimo34. 12. Donovan NJ, Daniels SK, Edmiaston, J, Weinhardt, J, Summers D, Mitchell, PH. Dysphagia screening: State of the art conference: Invitational conference proceeding from the state-of-the-art nursing symposium, international stroke conference 2012. Stroke. 2013;44(4):e24-31. 13. Armstrong JR, Mosher BD. Aspiration pneumonia after stroke: Intervention and Prevention. Neurohospitalist. 2011;1(2):85-93 14. Ramsey DJC, Smithhard DG, Kalra L. Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke. 2003; 34(5):1252-1257. 15. Swigert NB, Steele C, Riquelme LF. Dysphagia screening for patients with stroke challenges in implementing a Joint Commission Guideline. The ASHA Leader. 2007. Retrieved from http://www.asha.org/Publications/leader/2007/070306/070306c.htm 16. Bours GJJW, Speyer R, Lemmens J, Limburg M, De Wit R. Bedside screening tests vs. video-fluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: Systematic review. Journal of Advanced Nursing. 2008;65(3):477-493. 17. Stroke engine assess. Glossary of terms(n.d). Retrieved from http://strokengine.ca/assess/definitions-en.html 18. Parikh R, Mathai A, Parikh S, Sekhar GC, Thomas R. Understanding and using sensitivity and predictive values. Indian J Ophthalmol. 2008;56(1):45-50. 19. Leder SB, Espinosa JF. Aspiration risk after acute stroke: comparison of clinical examination and fibreoptic endoscopic evaluation of swallowing. Dysphagia. 2002;17(3):214–218. 20. Jauch EC, Saver JL, Adams HP, Bruno A, Conners JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947. 21. Martino R, Silver F, Teasell R, Bayley M, Nicholson G, Streiner DL. The Toronto bedside swallowing screening test (TOR-BSST). Development and validation of a dysphagia screening tool for patients with stroke. Stroke. 2009;40(2):555-561.

doi: 10.11124/jbisrir-2014-1560

Page 68

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

22. Leder SB, Suiter DM, Warner HL, Acton LM, Swainson BA. Success of recommendation oral diets in acute stroke patients based on passing a 90-cc water swallow challenge protocol. Top Stroke Rehabil. 2012;19(1):40-44.

doi: 10.11124/jbisrir-2014-1560

Page 69

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

Appendix I QUADAS checklist

Insert page break

doi: 10.11124/jbisrir-2014-1560

Page 70

JBI Database of Systematic Reviews & Implementation Reports

2014;12(10) 61 - 72

Appendix II STARD checklist STARD checklist for reporting of studies of diagnostic accuracy (version January 2003) Section and Topic TITLE/ABSTRACT/ KEYWORDS INTRODUCTION METHODS Participants

Item # 1 2

3 4

5

6

Test methods

7 8

9 10 11

Statistical methods

12

13 RESULTS Participants

14 15 16

Test results

17 18 19

20

doi: 10.11124/jbisrir-2014-1560

On page # Identify the article as a study of diagnostic accuracy (recommend MeSH heading 'sensitivity and specificity'). State the research questions or study aims, such as estimating diagnostic accuracy or comparing accuracy between tests or across participant groups. The study population: The inclusion and exclusion criteria, setting and locations where data were collected. Participant recruitment: Was recruitment based on presenting symptoms, results from previous tests, or the fact that the participants had received the index tests or the reference standard? Participant sampling: Was the study population a consecutive series of participants defined by the selection criteria in item 3 and 4? If not, specify how participants were further selected. Data collection: Was data collection planned before the index test and reference standard were performed (prospective study) or after (retrospective study)? The reference standard and its rationale. Technical specifications of material and methods involved including how and when measurements were taken, and/or cite references for index tests and reference standard. Definition of and rationale for the units, cut-offs and/or categories of the results of the index tests and the reference standard. The number, training and expertise of the persons executing and reading the index tests and the reference standard. Whether or not the readers of the index tests and reference standard were blind (masked) to the results of the other test and describe any other clinical information available to the readers. Methods for calculating or comparing measures of diagnostic accuracy, and the statistical methods used to quantify uncertainty (e.g. 95% confidence intervals). Methods for calculating test reproducibility, if done. When study was performed, including beginning and end dates of recruitment. Clinical and demographic characteristics of the study population (at least information on age, gender, spectrum of presenting symptoms). The number of participants satisfying the criteria for inclusion who did or did not undergo the index tests and/or the reference standard; describe why participants failed to undergo either test (a flow diagram is strongly recommended). Time-interval between the index tests and the reference standard, and any treatment administered in between. Distribution of severity of disease (define criteria) in those with the target condition; other diagnoses in participants without the target condition. A cross tabulation of the results of the index tests (including indeterminate and missing results) by the results of the reference standard; for continuous results, the distribution of the test results by the results of the reference standard. Any adverse events from performing the index tests or the reference standard.

Page 71

JBI Database of Systematic Reviews & Implementation Reports

Estimates

21 22 23

DISCUSSION

24 25

doi: 10.11124/jbisrir-2014-1560

2014;12(10) 61 - 72

Estimates of diagnostic accuracy and measures of statistical uncertainty (e.g. 95% confidence intervals). How indeterminate results, missing data and outliers of the index tests were handled. Estimates of variability of diagnostic accuracy between subgroups of participants, readers or centers, if done. Estimates of test reproducibility, if done. Discuss the clinical applicability of the study findings.

Page 72