Transcript Screening Strategies to Prevent Aspiration Pneumonia in Stroke

Screening Strategies to Prevent Aspiration
Pneumonia in Acute Stroke
Jeri Lynn M. Braunlin
MS CNRN, CNAA, BC, RN, BC
Paula Lamb BSN RN
The Problem:
Stroke Complications
Pneumonia occurs in 6.7-22% of hospitalized patients with
stroke
Three fold increase in 30 day mortality with pneumonia
Many pneumonia cases preventable with stroke protocols in
place:
– Swallow screening
– Swallow evaluation
– Diet modifications
(Katzan, Dawson, Thomas, Votruba and Cebul, 2007)
Pneumonia and oropharyngeal
dysphagia
Pneumonia thought to occur most often as
result of oropharyngeal dysphagia with
secondary aspiration
42-76% patients with acute stroke develop
dsyphagia
Half will experience aspiration
Although not all develop pneumonia
(Katzan, Cebul, Husak, Dawson, Baker, 2003)
Risk of pneumonia in the stroke
population demographics:
Older patients
Men
More likely admitted from a nursing
home or via the emergency room
More co-morbid illnesses
Physiologic abnormalities
More severe neurologic impairments
at admission
(Katsan, Dawson, Thomas, Votruba, Cebul, 2007)
Ramifications of Pneumonia in
Stroke
Higher 30 day mortality rates
Longer lengths of stay
Discharged alive were more likely to require
extended care
More likely to be readmitted to hospital within
30 days
(Katzan,Dawson,Thomas, Votruba and Cebul, 2007)
(Rosenvinge and Starke, 2005)
Strategies to prevent pneumonia after
stroke
Focus: to identify at –risk patients
Swallow screening
Modify oral intake
Obtain swallow therapy to improve swallow safety
and dsyphagia
(Katsan, Dawson, Thomas, Votruba, Cebul, 2007)
The Joint Commission (JC)
Performance Measure for Dysphagia
in Acute Stroke
“A swallow screen for dysphagia should be
performed on all ischemic and hemorrhagic stroke
patients before being given food, fluids or
medications by mouth.”
www.jointcommision.org
JC’s rationale for Dysphagia
Screening
27-50% of stroke patients develop dysphagia
43-54% of stroke patients with dysphagia will experience
aspiration
Of those patients, 37% will develop pneumonia
If not part of a dysphagia diagnosis and treatment program,
3.8% with pneumonia will die
Other adverse effects include malnutrition and increased
length of hospital stay
www.jointcommision.org
Swallow Screen Project Description
Purpose:
Increase Dysphagia Screening Rates in Stroke
Patients
Swallow Screening Deficit
Cause 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 Solutions
Development, Implementation and Revision of
documentation tools.
– Pyxis prompt for swallow screenings
– ED Swallow screen added to EPIC (computerized medical
record system)
– Neurological Assessment including swallow screen module
added to EPIC
– EPIC education r/t documentation times (default was
“time=now” which was not necessarily the time when the
screening was completed)
– Stroke order sets into Epic
Solutions
Pyxis prompt for swallow screens
Emergency Department Swallow
Screen
Neurological Assessment
Stroke Core Measures
Swallow Screen Solutions
Emergency and Trauma Center (ETC) Staff education
Emergency and Trauma Center Nurse Educational Flipcards
Hiring of a new Clinical Stroke Program Manager who focuses
on the Stroke Population
– Stroke collaboration between care providers - Stroke Team and others
– Revision and Revitalization of the Stroke Interdisciplinary Team
ETC, ICU and Neuro Unit Staff education
– Nursing Computer Based Training Module
– Health Stream - annual competencies)
Assignment of a Lead Hospitalist to serve as Physician Stroke
Champion
Current Situation
Joint Commission Core Measure # 7
Swallow screen prior to any oral medication,
fluids or food
Rate was 54% at the 2005 certification date
Rate has increased to 76% (4th quarter 2006)
Rate increased to 83% (Jan-Mar 2007)
Rate increased to 88% (April-June 2007)
Rate increased to 94% (July-Sept 2007)
Rate 91% (Oct-Dec 2007)
2007 yearly average = 89%
Current Situation
NPO status prior to swallow screen
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Stroke
Physician
Champion
Vacancy
7
20
0
7
4Q
3Q
20
0
7
S
t
r
o
e
E
d
u
c
a
t
o
r
20
0
2Q
7*
20
0
6
1Q
4Q
20
0
6
3Q
20
0
6
20
0
6
2Q
1Q
20
0
5
20
0
4Q
3Q
20
0
5
Stroke
Educator
Vacancy
Results
Dysphagia Screening rate has increased from 54% 3rd
quarter 2005 to 91% in 4th quarter 2007 (average in 200789%).
Dysphagia Screening rate has increased from 56% to 91%
following Physician Champion and Stroke Educator
turnover (an issue 2nd & 3rd quarters, 2006)
Aspiration rate was 3.3% in 2006 with increased
compliance aspiration pneumonia rates have decreased to
2.5 in 2007
Standardization
Hiring Stroke Program Manager
Staff Education in ETC (Emergency department, Neuro
unit and ICU
Implemented Pyxis prompt and documentation tools
Sharing Swallow screening goals with ETC, Neuro and
ICU Units as well as their respective Collaborative
Practice Councils, the Professional Practice Council, the
Organizational Performance Improvement Committee,
Interdisciplinary Team and Stroke Team Members
Revised Stroke Physician Orders, Benchmarking
Guidelines, Patient Education Tools, and Instructions for
Care at Home.
Hospitalist Stroke Champion assignment
Future Plans
Strive for 100% Dysphagia Screening rate
Build Dysphagia Screen monitoring report into computerized
medical record
Continue to monitor pneumonia rates, especially aspiration
Share Stroke Results with Internal MVH Team Members and
Success Strategies with Other Hospitals
Questions 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.
References
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;1938-1943
Martino PhD, Rosemary, Foley, BSc, Norine, et. al.,
“Dysphagia After Stroke.” Stroke. 2005; 36;2756-2763. pg.
275
Rosenvinge, Sally K and Starke, Ian D. Improving care for
patients with dysphagia
www.jointcommision.org