1. Impact of the implementation of a validated swallow screening tool for acute stroke: Modified MASA
Good afternoon,
This afternoon I’m presenting a paper looking at our implementation of a validated swallow screening tool for acute stroke
Natalie Mohr, Speech Therapist
Dr Neil Baldwin, Stroke Consultant
Paul White, Statistician
12th September 2012

2. Swallow screening in acute stroke
Studies estimate swallowing problems in 40-65% of all acute stroke patients
Formal swallow screening protocols reduce the incidence of pneumonia following stroke
Swallowing problems and pneumonia contribute to:
Increased length of hospital stay
Potential re-hospitalisation
Increased disability
Increased mortality
It’s well documented that swallowing difficulties affect a large number of acute stroke patients
And there has been research showing that hospitals with formal, rather than informal or no swallow screening protocols, have lower rates of pneumonia

3. National Guidelines
Every stroke patient should have their swallow screened and documented as soon as practically possible on admission to hospital
National Stroke Strategy for England (December 2007)
The Royal College of Physicians Intercollegiate Working Party and the National Institute for Health and Clinical Excellence (NICE) stroke clinical guidelines (July 2008)
NICE Stroke Quality Standards (June 2010)
There is clear National Guidance regarding swallow screening in acute stroke.
The latest NICE stroke quality standards suggest that swallow screening happen should happen within 4 hours of admission
However, there is a lack of clear guidance regarding which swallow screening tools are most appropriate
The RCP guidelines suggest that a ‘recognised standard screening assessment’ is done, such as a water swallow test
However, the NICE guidelines suggest that the Gugging Swallowing Screen is the best validated tool for screening swallowing problems in acute stroke

4. Water swallow tests
Depippo et al (1992 & 1994): Clinical risk factors including 3oz water swallow
Gottlieb et al (1996): 50 ml water test
Kidd et al (1993): Full swallow exam including 50ml water test
Hinds & Wiles (1998): Timed water swallow test
Lim et al (2001): 50ml water swallow and O2 saturation
Suiter & Leder (2008): 3oz water swallow
There are several potential limitations to water swallow tests:
For example the Depippo study included a water swallow test among other risk factors for swallowing problems, one of which was ‘pneumonia in the acute phase of stroke’. So it’s not a highly applicable tool for the acute stroke population, unless you want to wait until patients get pneumonia first.
Suiter & Leder’s study demonstrated excellent sensitivity, at over 95%, but poorer specificity of only about 40%, so many stroke patients who fail the water swallow test are actually safe to eat and drink
ADDITIONAL INFORMATION FOR QUESTIONS ONLY
Gottlieb
There was no standard reference test, a clinical exam was done according to general Speech Therapy principals
Kidd et al
This study involved looking at features of a full bedside assessment, which happen to include a water swallow component.
Hinds & Wiles
This paper only reported results for patients who were routinely referred to Speech Therapy for a swallowing assessment therefore biasing the study sample.
Lim et al
Subsequent research has some there to be little clinical usefulness in using pulse oximetry to help identify dysphaiga/ aspiration

5. Validated acute stroke swallow screening tools
The Gugging Swallowing Screen (GUSS) (2007)
The Toronto Bedside Swallowing Screening Test
(TOR-BSST) (2008)
The Modified Mann Assessment of Swallowing Ability (Modified MASA) (2010) N
Sens
Spec
GUSS
Specially trained nurses 30
100%
69%
TOR-BSST 24
96.3%
63.6%
Modified MASA
Two Neurologists
150
89.5%
85.25%
Currently there are three published validated swallow screening tools specifically for acute stroke
The ‘Gugging’ requires that nurses be specially trained and it has been validated on 30 acute stroke patients
ADDITIONAL INFORMATION FOR QUESTIONS ONLY
It’s not reported at what time post stroke or admission. A FFES was done within 2 hours of the swallow screen. 20 SLT also validated the ‘Gugging’.
The ‘TOR-BSST’ again can only done by nurses who have been specially trained and it has been validated 24 acute stroke patients
These patients were on average 6 days post-stroke. Furthermore, it took them 3 years to collect the data for this study as it was reported to be very difficult to get acute stroke patients to videofluoroscopy. The delay to videofluoroscopy from swallow screen was 24 hours. In total the tool has been validated on 68 patients, including rehabilitation patients seen at day 31.
The Modified MASA was validated 150 acute stroke patients. There is no specific training required. Doctors, Speech Therapists or Clinical Nurse Specialists who have experience assessing acute stroke patients, can easily complete the test
Seen on average 68 hours post stroke

6. Project Aims
To evaluate the clinical robustness of the Modified MASA when used in a UK Hospital on an Acute Stroke Unit by a range of Stroke Consultants, Specialist Registrars and Speech Therapists
To evaluate the impact of implementing the Modified MASA on key acute stroke service indicators
This project had two aims
The first was to evaluate the validity of the Modified MASA when applied in a UK teaching hospital by a range of clinicians working in acute stroke
Our second aim was to reflect on the impact of introducing a validated acute stroke swallow screening tool in a UK teaching hospital

7. The Modified MASA
For those of you who might not be familiar with the Modified MASA, it involves evaluation of 12 items with points are awarded for each item up to a total of100.
A cut off score of 95 was determined to detect the presence or absence swallowing difficulties

8. 1. Methods (to determine the robustness)
All stroke patients admitted to Frenchay Hospital had their swallowing screened using the Modified MASA from November 2009 to January 2011
The Modified MASA was administered by Consultants, Specialist Registrars and Speech Therapists working on the Acute Stroke & Medical Admissions Units
Monday-Friday 08:30-16:30 all Modified MASA tests were bleeped to a ‘Project SLT’
Patients were randomly allocated for a ‘check’ by the ‘Project SLT’
The ‘Project SLT’ was blind to the outcome of the swallow screen
All ‘checks’ were done within 2 hours of the swallow screen
The ‘check’ was a full standard clinical swallowing assessment using the Mann Assessment of Swallowing Ability (MASA)
The first part of our study involved stroke patients admitted to Frenchay hospital from November 2009 to January 2011
Consultants, Specialist Registrars and Speech Therapists screened stroke patients’ swallowing using the Modified MASA
Randomly allocated patients received a full clinical bedside swallowing evaluation using the ‘Mann Assessment of Swallowing Ability’, which has been validated to videofluoroscopy. It is the only validated comprehensive clinical swallowing examination, which has been specifically designed for stroke
All full assessment ‘checks’ were done within 2 hours of the screen
ADDITIONAL INFORMATION FOR QUESTIONS ONLY
FEES was not routinely available at Frenchay Hospital at the time of this project. VF not practical as per previous study difficulties/ our resource limitations.
Our Specialist Acute Stroke Nurse is now also using the tool.

9. Distribution of Oxford Stroke Classification Thrombolysis Treatment
1. Study population
100 patients
Average age 78.3 years
50 males & 50 females
Oxfordshire Stroke Classification
Total anterior circulation infarct 20%
Partial anterior circulation infarct 40%
Lacunar infarct 25%
Posterior circulation infarct 7%
Subdural haemorrhage 2%
Intra cerebral haemorrhage 6%
Distribution of Oxford Stroke Classification
Our study population included 100 stroke patients with an average age was 78.3 years (SD:12.5)
There were equal numbers of men and women
There was a range of stoke syndromes and 12 patients received thrombolysis
Thrombolysis Treatment

10. 1. Timing of evaluations Average time from stroke to swallow screen
54 hours 59 minutes (SD: 41 hours 27 minutes)
Average time from hospital admission to swallow screen
37 hours 54 minutes (SD: 27 hour 47 minutes)
Screening assessments were completed by
Consultant n=31
Specialist Registrars n=40
Speech Therapists n=29 (all clinical grades)
And the average time from hospital admission to swallow screening was about 38 hours
Possibly longer time from hospital admission to swallow screen than average as this data includes only patients who were seen Mon-Fri in working hours; so it does include patients who for any number of reasons waited a long time for screening.
ADDITIONAL INFORMATION FOR QUESTIONS ONLY
4 consultants did 31 swallow screens.
4 registrars did 40 swallow screens.
6 Speech Therapists did 29 swallow screens

11. 1. Findings
47% (95% CI: ) incidence of dysphagia identified on full clinical swallowing assessment using the MASA
15% severe dysphagia
19% moderate dysphagia
13% mild dysphagia
Good internal reliability for Modified MASA swallow screening test (Cronbach’s alpha 0.873) and the full MASA clinical swallowing assessment (Chronbach’s alpha 0.916)
So what did we find…
47% of our population were dysphagic, which is in keeping with what would be expected
For anyone who might be interested, we reviewed the Speech Therapy notes for these 47 dysphagic patients and looked at the impact of each Speech Therapy contact on feeding management and final feeding outcome, the results of this work are on display here…..
There was good internal reliability for both the Modified MASA and full MASA. That is, both tests detect swallowing difficulties in acute stroke patients.
No one item on either test was particularly sensitive
ADDITIONAL INFORMATION FOR QUESTIONS ONLY
Dysphagia was defined as a score of less than 178 on the Mann Assessment of swallowing Ability, our full clinical exam and reference test.
Severe dysphagia score ≤138
Moderate dysphagia
Mild dysphagia

12. 1. Correlation
Significant correlation between the Modified MASA and MASA
(r = 0.770, df = 99, p < .001)
Significant agreement between Modified MASA and MASA outcomes
(k = 0.514, p < .001)
There was some disagreement in outcomes but this was not biased in any direction
(p = 0.152)
Modified MASA Total Score
This scatter plot and the Pearson’s correlation coefficient show that the Modified MASA was significantly correlated with the MASA
Analysis using kappa statistics shows statistically significant agreement between the final scores on the Modified MASA and full MASA
There was some disagreement but statistically, there was no greater chance of false negative or false positives
ADDITIONAL INFO FOR QUESTIONS ONLY
In the sample 47 patients have a score of 178 on the MASA = dysphagic. Of these 47 patients have a score of 31 patients have a score of less than 95 on Modified MASA= dysphagia
In the sample 53 patients have a score of greater or equal to 178 on the MASA = no dysphagia. Of these 53 patients 45 have a score of greater or equal to 95 on the Modified MASA = no dysphagia.
r = two tailed Pearson correlation
k = kappa value
Direction of bias measured by McNemar’s test
Mann Assessment of Swallowing Ability (MASA) Total Score
Correlation between Modified MASA
and MASA total scores

13. 1. Setting the PASS/ FAIL pointN
Sensitivity
Specificity
Neurologists (n=2)
<95 or ≥95
150
89.5%
85.25%
Frenchay MDT
(Dr n=71 & SLT n=29)
100
67.0%
85.0%
<97 or ≥97
72.3%
79.2%
Frenchay SLT (n=100)
100.0%
67.9%
Frenchay SLT
<91 or ≥91
85.4%
88.5%
We didn’t exactly replicate the previous research findings (point to top two lines)
But, determining the optimal clinical PASS / FAIL point of any screening tool depends on balancing risk…
The acute team at Frenchay Hospital had 16 out of 100 patients (point to sensitivity of 67%) who were screened as safe to eat and drink at a cut off of 95, but who actually weren’t safe and failed the full assessment. But, most patients who were screened as able to eat and drink were safe to do so (point to specificity 85.0%). Statistically the optimal cut-off pass/fail point for this data set would be a score of 97 (point to sensitivity/ specificity line 72.3% and 79.2%)
However, we were able to pretend that Speech Therapists were doing all 100 swallow screens, this is because the items on the screening test are replicated on the full assessment. If Speech Therapists were screening for swallowing problems in acute stroke patients admitted to hospital, although no patient would pass the screen who wasn’t safe (point to sensitivity 100%), 17 patients who would be safe to eat and drink would fail the screen at a cut off of 95, which is a considerable number of patients who would be referred for further swallowing assessment (point to specificity 67.9%). Statistically the optimal cut-off pass/fail point for Speech Therapists would be a much lower screening score of 91 (point to sensitivity/ specificity line 85.4% and 88.5%)
These results are probably consistent with clinical practice in this area, and what some previous research has shown, and that is that doctors are possibly a bit more ‘relaxed’ in their assessment of swallowing and risk & that Speech Therapists are probably ‘over cautious’
Sensitivity reflects those patients who failed the swallow screen and were not safe to eat and drink when they had a full formal swallow assessment
Specificity reflects those patients who passed the swallow screen and were also safe to eat and drink on full formal swallow assessment

14. Pneumonia rates 2008 Sentinel Stroke Audit (pre-Modified MASA)
16% of patients nationally developed pneumonia
12% of patients in NBT developed pneumonia
2010 Sentinel Stroke Audit (post- Modified MASA)
13% of patients nationally developed pneumonia
3% of patients in NBT developed pneumonia
For the project cohort 5% of patients developed pneumonia
However, what’s probably more interesting to know is does it matter where the pass/ fail point is set on the Modified MASA?
What we found that although our use of the Modified MASA isn’t perfect we had a 75% reduction in the incidence of aspiration pneumonia
This can be skipped over if run out of time 14

15. 2. Methods (to determine stroke service impact)
April 2009 and April 2012 records for all stroke patients admitted to Frenchay Hospital were retrospectively audited
Key national targets were audited including:
Time to swallow screen
Time to formal Speech Therapy swallow assessment
Time to NG feeding
Incidence of aspiration pneumonia
The second part of this project evaluated the impact of implementing the Modified MASA on key national stroke targets

16. 2. Stroke service
April 2009
20 dedicated acute stroke beds for local admissions on 1 medical ward
1.0 WTE SLT per 10 acute stroke beds
Audited 52 sets of notes
28 strokes referred to SLT
8 strokes not referred to SLT
16 non-strokes referred to SLT as strokes
Males=25 Females=27
Average age 79 years
April 2012
16 acute stroke beds for local and regional admissions spread across 2 neurology wards
1.0 WTE SLT per 10 hyper-acute, acute and rehabilitation stroke beds
Audited 47 sets of notes
29 strokes referred to SLT
16 strokes not referred to SLT
2 non-strokes referred to SLT as strokes
Males=23 Females=22
Average age 75 years
In 2009 we had 20 acute stroke beds on one medical ward, and in 2012 we had 16 ‘stroke’ beds over two neurology wards, including hyper-acute, acute and some rehabilitation patients

17. 2. Swallow screening April 2009
79% of acute strokes appropriate for swallow screening
22% of patients had a swallow screen
Average time to swallow screen: 14 hrs 18 min
Validated swallow screening tool used: 0%
Swallow screen in 4 hours: 22%
Swallow screen in 24 hours: 77%
April 2012
64% of acute strokes appropriate for swallow screening
83% of patients had a swallow screen
Average time to swallow screen: 11 hrs 11 min
Validated swallow screening tool used: 83%
Swallow screen in 4 hours: 58%
Swallow screen in 24 hours: 96%
There was an expected increase in swallow screening following the introduction of the Modified MASA (point to 22% versus 83%)
There was also an expected increase in the use of a validated tool (point to 0% versus 83%)
Similarly, because our admitting Stroke Consultants and Specialist Registrars screen all stroke patients’ swallowing on admission, patients are having their swallows screened much quicker (point to 96% compliance in 24 hours)

18. 2. Formal swallow assessment
April 2009
38 patients referred to SLT for formal swallow assessment
Formal swallow assessment appropriate for 32 patients
84% of patients referred to SLT required assessment
Average time to formal swallow assessment: 32 hours
Formal swallow assessment in 24 hours: 56% of stroke patients
Formal swallow assessment in 72 hours: 94% of patients
April 2012
32 patients referred to SLT for formal swallow assessment
Formal swallow assessment appropriate for 8 patients
25% of patients referred to SLT required assessment
Average time to formal swallow assessment: 54 hours
Formal swallow assessment in 24 hours: 0% of stroke patients
Formal swallow assessment in 72 hours: 60% of patients
Similar number of patients are being referred to Speech Therapy for a specialist swallow assessment, but far fewer of the patients who are referred actually need seeing. Mostly we don’t need to see patients because they have passed their swallow screen (point to 25%)
We suspect that this probably reflects a lag in ward culture to only refer those patients who have failed their swallow screen
Interestingly, the time to specialist Speech Therapy swallow assessment has increased (point to 32 hours versus 54 hours), despite us needing to see far fewer patients (point to 8 versus 32)
We wonder if this reflects a change in our culture, that is we don’t rush to see patients for their first swallowing assessment because we know that they will have had a swallow screen.
And I wonder if it is probably quite appropriate not to see patients on the same day they have failed their swallow screen (point to 0%), but we probably need to be more aware of the need to see patients within 72 hours (point to 60%)

19. 2. Time to NG feeding April 2012 April 2009
NG feeding suggested for 18% of acute stroke patients
NG feeding in place in 24 hours for 25% of acute stroke patients
Wait to NG feeding due to pending swallow assessment in 12.5% of patients
Time to first swallow contact (screen or formal assessment) average: 11 hours 11 minutes
April 2009
NG feeding suggested for 44% of acute stroke patients
NG feeding in place in 24 hours for 18% of acute stroke patients
Wait to NG feeding due to pending swallow assessment in 59% of patients
Time to first swallow contact (screen or formal assessment) average: 29 hours 8 minutes
Previously the main reason patients waited for an NG tube was the time it took to swallow assessment (point to 59%)
Despite needing fewer NG tubes (point to 44% versus 18%) and being much quicker in ensuring patients swallows are evaluated (point to 29 hours versus 11 hours)
Most patients are still waiting longer than suggested 24 hours to have NG tubes placed for feeding (point to 18% and 25%)

20. 2. Aspiration pneumonia
2008 Sentinel Stroke Audit (pre- Modified MASA)
12% of patients in NBT developed pneumonia
April 2009
3.8% of patients developed aspiration pneumonia
2 patients, both with low GCS
2010 Sentinel Stroke Audit (post- Modified MASA)
3% of patients in NBT developed pneumonia
April 2012
13.3% of patients developed aspiration pneumonia
6 patients, 5 with low GCS
Despite initially having a very encouraging reduction in our aspiration pneumonia rate (point to 12% versus 3%)
This audit comparing April 2009 and April 2012, with a small number of patients, shows an increase in our aspiration pneumonia rate (point to 3.8% compared to 13.3%)
Most patients who developed aspiration pneumonia had a low GCS as would be expected
So it may be that we incidentally had more patients with a low GCS in April 2012, or it may be that we’re not caring for patients with a low GCS as well in 2012 as we were in 2009

21. 1. Conclusions
The Modified MASA is a robust screening tool for detecting swallowing difficulties in acute stroke patients
Setting the cut-off point can be considered
The Modified MASA is quick to use
Administering the Modified MASA doesn’t require any training for stroke clinicians
Considering clinical practice this work adds to previous research findings demonstrating that the Modified MASA is a robust tool for screening swallowing difficulties in acute stroke
The Modified MASA is a quick and simple tool to use as it incorporates components of a general medical neurological examination.
It adds less than 5 minutes to the assessment of a stroke patient when done by a Consultant or Specialist Registrar who are seeing the patient
Importantly from a Speech Therapy point of view a significant advantage of the Modified MASA is that it does not require any special training from us

22. 2. Conclusions Improving swallow screening improves swallow screening
Improving swallow screening practice may not be sufficient to change other related aspects of the stroke pathway
The whole stroke pathway needs to be considered
Other changes in health care and service provision can influence outcomes
We expected that working to improve swallow screening would not only improve swallow screening, but also other closely related aspects of the acute stroke pathway
However, and I’m not sure if this is surprising or not, we essentially found that working towards improving swallow screening, improves swallow screening!
Our audit shows that work to improve other aspects of the stroke pathway still needs to be done
We, as I’m sure many services, are experiencing changes in resources and this possibly also had an impact on some of our audit findings

23. Future directions…
What is the benefit of using validated tools to assess for swallowing difficulties in acute stroke?
What is the optimal time for evaluating swallowing in acute stroke care?
What other factors, such as stroke type, could we be considering when assessing swallowing in acute stroke patients?
In considering how this project might inspire further research into clinical practice in the area swallowing problems in acute stroke
I wonder if considering the value of using validated tools to assess for swallowing problems might improve Speech Therapy practice?
I also wonder if the national guidelines we all work so hard to achieve do actually reflect best care? Why does a specialist Speech Therapy assessment of swallowing have to be done in hours?
This leads me to think if there might be an opportunity to consider if stroke type might be an important factor in optimising when we see patients?
As always more questions than answers….

24. Acknowledgements
Dr Neil Baldwin (Stroke Consultant Physician), Dr Benito (Stroke Consultant Physician), Ruth Cemlyn (SLT), Dr Phil Clatworthy (Neurology Specialist Registrar), Natalie Cole (SLT), Dr Jon Ho (Acute Medical Consultant Physician), Suzy Imeson (SLT), Dr Jess Kubie (Specialist Registrar), Dr Veronica Lyell (Care of the Elderly Specialist Registrar), Dr Fenella Maggs (Acute Medical Specialist Registrar), Karen Moore (SLT), Dr Sam Patel (Acute Medical Consultant Physician), Mike Richards (SLT), Katie Thomas (SLT), Jo Upton (Acute Stroke Coordinator) & Pippa Wiseman (SLT)
Special thanks to ‘The PAT Fund’