1. Screening Strategies to Prevent Aspiration Pneumonia in Acute Stroke Jeri Lynn M. Braunlin MS CNRN, CNAA, BC, RN, BC Paula Lamb BSN RN

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

3. 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)

4. 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)

5. 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) (Katzan,Dawson,Thomas, Votruba and Cebul, 2007) (Rosenvinge and Starke, 2005) (Rosenvinge and Starke, 2005)

6. 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)

7. 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

8. 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

9. Swallow Screen Project Description Swallow Screen Project Description Purpose: Increase Dysphagia Screening Rates in Stroke Patients Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click “Create from File” Locate File name in “File” box Make sure “Display as Icon” is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click “Object Action” and select “Edit” Click OK

10. 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

11. Swallow Screen Solutions 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 Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click “Create from File” Locate File name in “File” box Make sure “Display as Icon” is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click “Object Action” and select “Edit” Click OK

12. Solutions Solutions Pyxis prompt for swallow screens Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click “Create from File” Locate File name in “File” box Make sure “Display as Icon” is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click “Object Action” and select “Edit” Click OK

13. Emergency Department Swallow Screen

14. Neurological Assessment

15. Stroke Core Measures

16. Swallow Screen Solutions 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 Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click “Create from File” Locate File name in “File” box Make sure “Display as Icon” is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click “Object Action” and select “Edit” Click OK

17. Current Situation Joint Commission Core Measure # 7 Swallow screen prior to any oral medication, fluids or food 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% (4 th 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% Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click “Create from File” Locate File name in “File” box Make sure “Display as Icon” is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click “Object Action” and select “Edit” Click OK

18. Current Situation Current Situation Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click “Create from File” Locate File name in “File” box Make sure “Display as Icon” is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click “Object Action” and select “Edit” Click OK Stroke Physician Champion Vacancy Stroke EducatorV acancy Stroe Educator vacancyStroe Educator vacancy

19. Results Dysphagia Screening rate has increased from 54% 3 rd quarter 2005 to 91% in 4 th quarter 2007 (average in 2007- 89%). Dysphagia Screening rate has increased from 56% to 91% following Physician Champion and Stroke Educator turnover (an issue 2 nd & 3 rd quarters, 2006) Aspiration rate was 3.3% in 2006 with increased compliance aspiration pneumonia rates have decreased to 2.5 in 2007

20. Standardization 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 Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click “Create from File” Locate File name in “File” box Make sure “Display as Icon” is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click “Object Action” and select “Edit” Click OK

21. Future Plans 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

22. Questions and Comments

23. 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.

24. 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