Screening Strategies to Prevent Aspiration Pneumonia in Acute Stroke

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 ProblemStroke 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)
  

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)
  
• (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
JCs 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

• 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

• Purpose
• Increase Dysphagia Screening Rates in Stroke
  Patients

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Swallow Screening DeficitCause Analysis

• Inconsistent monitoring, documenting and
  interventions to promote compliance
  
• Multiple areas and Caregivers
• Turnover of Stroke Physician Champion and Stroke
  Educator in consecutive quarters
  

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Swallow Screen Solutions

• 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

• 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 timenow which was not necessarily
  the time when the screening was completed)
  
• Stroke order sets into Epic

12
Solutions

• 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

• Pyxis prompt for swallow screens

13
Emergency Department Swallow Screen
14
Neurological Assessment
15
Stroke Core Measures
16
Swallow Screen Solutions

• 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

• 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

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Current SituationJoint Commission Core Measure
7 Swallow screen prior to any oral medication,
fluids or food

• 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

• 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

18
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 EducatorVacancy
Stroe Educator vacancy
19
Results

• Dysphagia Screening rate has increased from 54
  3rd quarter 2005 to 91 in 4th quarter 2007
  (average in 2007- 89).
  
• 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

20
Standardization

• 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

• 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

21
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
  361972-1976.
• 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 25620-625.

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
  2007681938-1943
• Martino PhD, Rosemary, Foley, BSc, Norine, et.
  al., Dysphagia After Stroke. Stroke. 2005
  362756-2763. pg. 275
  
• Rosenvinge, Sally K and Starke, Ian D. Improving
  care for patients with dysphagia
  
• www.jointcommision.org