Pennsylvania Patient Safety Advisory Does Your Admission Screening Adequately Predict Aspiration Risk? ABSTRACT tools are already available to assist anesthesia provid- The National Quality Forum and the Agency for ers with aspiration prescreening criteria for patients Healthcare Research and Quality identified aspira- receiving anesthesia, but there are few such tools for tion risk assessment as a practice to reduce the risk the newly admitted hospital patient. The benefit of of harm to patients. Pennsylvania healthcare facili- adopting aspiration risk screening tools will provide ties submitted 133 nonanesthesia aspiration event organizations with the ability to promptly identify reports to the Pennsylvania Patient Safety Authority those patients who are experiencing dysphagia and from June 2004 through January 2009. Seventy-three may be at risk for aspiration. This screening may (55%) of these event reports indicated that swallow- also provide healthcare providers with baseline ing or aspiration assessments had been completed information to complete a more detailed aspiration before the event occurrence. The remaining 60 (45%) assessment to assist in the identification and treat- reports of nonanesthesia aspiration indicated patients ment of patients with aspiration, to prevent aspiration had not received aspiration risk screenings or assess- events, to provide optimal patient care, and to ensure ments before the aspirations. Thirty-eight (29%) of the accurate patient information exchange through all nonanesthesia aspiration reports describe instances levels of care. in which barriers were identified during aspiration risk screening and as aspiration precautions were imple- Pennsylvania Patient Safety Authority Reports mented. While video fluoroscopic swallow evaluation Of the 133 nonanesthesia aspiration Incidents and is considered the “gold standard” for predicting aspi- Serious Events reported to the Pennsylvania Patient ration, aspiration screening of patients on admission Safety Authority’s reporting system from June 2004 can help determine whether a more detailed aspira- through January 2009, 73 (55%) of the events indi- tion assessment and fluoroscopic swallow evaluation cated that patients had been assessed for aspiration are indicated and help to identify dysphagia and risk before the nonanesthesia aspiration event. patients at risk for aspiration. (Pa Patient Saf Advis Fifteen (11%) of the aspiration events required trans- 2009 Dec;6[4]:115-21.) fers to a higher level of care, and 7 (5%) resulted in patient death. Events that resulted in transfer to higher levels of care The Problem include the following: The National Quality Forum and the Agency for The patient began to cough, followed by vomiting, Healthcare Research and Quality (AHRQ) identi- developed worsening respiratory symptoms, and was fied the aspiration risk evaluation of each patient transferred to the ICU [intensive care unit] with upon admission and regularly thereafter as a sug- shortness of breath and aspiration. gested patient care practice.1 Patients who aspirate are at greater risk of developing serious respiratory The patient was found with cyanotic face and lips complications such as airway obstruction or aspira- upon entering the room to complete an assessment. tion pneumonia. Aspiration pneumonia is one of The rapid response team was called. The patient the most common forms of hospital-acquired pneu- began coughing up whole pieces of chicken. The monia among adults and occurs in 4 to 8 of every patient was transferred to the ICU. 1,000 admitted U.S. patients.2 Patient conditions that The patient was eating a sandwich and began to present a high risk for aspiration include stroke or choke. Heimlich attempts were unsuccessful. The food other neurologic impairment that affects swallowing, particles [were manually] removed, and the patient tracheostomy or endotracheal intubation, advanced [was transferred to the ICU] and intubated. age, changes in the oropharyngeal anatomy due to trauma, surgery complications, neoplasm, pneumo- Events that resulted in patient deaths include the nia, unexplained weight loss, or even body position.3 following: Routine bedside aspiration risk assessments are A patient vomited during the night and [the order noninvasive, typically evaluate patient symptoms, to administer the patient nothing by mouth] NPO and are designed to be administered quickly. Inva- [was written]. In the morning [the patient was] sive diagnostic procedures such as the fiberoptic found unresponsive. Despite aggressive resuscitation endoscopic evaluation of swallowing (FEES) or a [efforts], the patient ceased to breathe. Silent aspira- videofluoroscopic swallow evaluation (VSE) visualize tion is considered the cause of death. the anatomy and physiology of a patient’s swallowing and are frequently used when a suspected swallow- A patient had moderate to severe dysphagia [follow- ing disorder has been identified by a routine bedside ing a] stroke. Family [members] brought in solid food, aspiration screening. Many aspiration risk assessment which the patient ate and [immediately began] to Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 115 Pennsylvania Patient Safety Advisory choke. Despite immediate resuscitation efforts, the oral propulsive, pharyngeal, and esophageal phases of patient expired. swallowing.2,3,4 A patient with recent history of stroke was placed Impairment to the oral phase of swallowing may on pureed dysphagia diet after nutrition and speech result in difficulty retaining the food or liquid bolus evaluations. After being fed [a meal] by [a family in the oral cavity or chewing or moving the material member], the patient became [short of breath]. Suc- toward the oropharynx. Associated symptoms with tioning [the patient] produced the [meal] contents. impairment in the oral phase of swallowing may The patient was intubated, transferred to the cardiac include drooling, pocketing of food in the buccal cav- care unit, [and died as a result] of aspiration. ity, poor tongue movement, leakage of food or liquid The remaining 60 (45%) reports of nonanesthe- from the mouth, or difficulty initiating the swallow- sia aspiration indicated patients had not received ing process.5 aspiration risk screening or assessments before the The pharyngeal phase of swallowing is under invol- aspiration events. untary neuromuscular control and triggers the Of the 55% of reports indicating patients had been swallowing reflex as the food or liquid moves with assessed for aspiration risk before a nonanethesia a progressive contraction wave from top to bottom. aspiration event, analysis identified the following con- Impairment to the pharyngeal phase of swallow- tributing factors: ing can result in the food or liquid material being retained in the oropharynx and overflow aspiration ■ Patients received inappropriate nutrition in 28 after swallowing. Associated symptoms with impair- (38%) of the events, including delivery of incor- ment in the pharyngeal phase of swallowing include rect nutrition to patients who were NPO (nothing nasal regurgitation, coughing, choking, hoarseness, or by mouth), family members who fed patients who food sticking in the throat.5 were NPO, or missed patient bedside NPO alerts. The esophageal phase of swallowing begins after the ■ Miscommunication occurred between healthcare food or liquid passes through the upper esophageal providers and departments in the hospital in four sphincter.4,5 Impairment to the esophageal phase of (5%) of the events (e.g., NPO notification between swallowing may result in ineffective movement and patient care areas and the dietary department). retention of the bolus of food or liquid in the esopha- ■ Medication-related issues were evident in three gus. Associated symptoms with impairment in the (4%) of the events, including some patients who esophageal phase of swallowing may include burping, received unauthorized medication doses and indigestion resulting from esophageal reflux, heart- incidence of staff knowledge deficit (e.g., NPO burn, chest pain, or silent aspiration.5 clarification between prescribers and nurses when Anything that interferes or impairs with any of the patients are NPO except for medications versus normal swallowing phases is defined as dysphagia, exclusively NPO). which may cause morbidity and mortality.4 ■ Tubing insertion misplacement issues occurred in Dysphagia three (4%) of the events involving endotracheal, Dysphagia, or difficulty swallowing, may cause nasogastric, or gastrostomy tubes. problems that range from symptoms of mild throat discomfort to an inability to eat.6 Dysphagia may be The Complexity of Swallowing a symptom of one or more underlying pathologies It is important for healthcare providers to understand and may include complications related to age, struc- the complexity of normal swallowing in order to rec- ture, neurologic and neuromuscular impairment, ognize, identify, and treat patients with swallowing medication side effects, surgery, infections, iatrogenic difficulties and aspiration. Furthermore, provider conditions, and irradiation effects of the head and knowledge will assist in prevention efforts, help neck. Fifty percent of adult patients in acute care provide optimal patient care, ensure accurate commu- facilities are reported to experience dysphagia, while nication and patient information exchange through 66% of those in long-term care facilities have swal- all levels of care, and aid in educating patients and lowing difficulties.7 Dysphagia makes a patient more family members about abnormal swallowing. prone to malnutrition, dehydration, aspiration, aspi- Normal Swallowing ration pneumonia, subsequent respiratory failure, and Normal swallowing is a complicated act that relies possible death.8 Normal aging has subtle effects on all on independent cognition, upper extremity mobility, four stages of swallowing.5 Presbyphagia, or normal oral mobility, taste, smell, and vision capabilities. It changes in the swallowing mechanism secondary to involves more than 26 muscles that control facial, aging, compounds the risk for aspiration.9,10 Aging palatal, suprahyoid, and pharyngeal structures, whose causes changes in the structure, motility, coordina- actions are coordinated by the cerebellum.4,5 Normal tion, and sensitivity of the swallowing process.5,9,11 swallowing also depends on the intact function of McCullough et al. used an 8-point penetration-aspira- the trigeminal, facial, glossopharyngeal, vagus, and tion scale incorporating thin liquid, puree, and solid hypoglossal cranial nerves.5 Successful swallowing and bolus sizes from 5 mL to 3 ounces in 79 normal occurs with the completion of the oral preparatory, adults ranging in age from 21 to 103 years old. This Page 116 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 Pennsylvania Patient Safety Advisory study found that laryngeal penetration is common for Overt aspiration may occur with patients who have older individuals, often resulting in retained material dysphagia. Aspiration pneumonia is the second most in the laryngeal vestibule after swallowing, which is common healthcare-acquired infection in hospital- consistent with changes in the swallowing physiol- ized patients.3,14 Patients with endotracheal tubes have ogy that occur with the aging process. Increase in the a high risk for aspiration and may also experience time to swallow has the potential to create problems, prolonged swallowing dysfunction after extubation.3 including aspiration. Penetration-aspiration was more The presence of a nasal or oral feeding tube, gas- common with older participants. Over- or under- troesophageal reflux, or those patients tube fed in managing these changes may present unnecessary the supine position may have increased swallowing restrictions on nutritional intake or negative conse- dysfunction, thereby increasing aspiration risk.3,14 The quences that affect the quality of life, even though this right lower lobe is the most frequent site of aspiration study provided some data that supports that aspiration due to its larger caliber and straighter orientation of in small quantities is normal for some older adults.11 the right mainstem bronchus. The left lung is more This makes it even more difficult for healthcare pro- difficult to suction secondary to the fact that the viders to assess aspiration risk for these patients. left bronchus is narrower, longer, and has a more horizontal angle than the right lung, making it more Common presenting symptoms of oral or pharyngeal difficult to suction the intubated patient.3 There are dysphagia include coughing or choking with swallow- also patients who may regularly experience silent ing, difficulty initiating swallowing, food sticking in aspiration when food or liquid material is inhaled the throat, drooling, unexpected weight loss, change in without a discernable gag reflex, cough, or other dietary habits, recurrent pneumonia, change in voice identifiable apparent difficulties.10,12 or speech, and nasal regurgitation. Signs of esophageal dysphagia include the sensation of food sticking in the Silent Aspiration chest, oral or pharyngeal regurgitation, food sticking Silent aspiration is the occurrence of aspiration in the throat, drooling, unexpected weight loss, change before, during, or after swallowing in the absence in dietary habits, and recurrent pneumonia.4,5,10 of cough or other apparent signs of distress.2,12,15 Patients with silent tracheobronchial aspiration have Aspiration a 13-fold increased risk for developing pneumonia.2,12 Aspiration is the passage of food or liquid through Silent aspiration cannot be diagnosed without the the true vocal cords and is often caused by impaired aid of instrumentation, since patients do not display laryngeal closure but may also occur because of the overt signs (coughing) and often deny swallowing overflow of food or liquids retained in the pharynx. difficulty; thus, silent aspiration requires a higher Cervical spine surgery increases aspiration risk by more index suspicion. As a result, the healthcare prescriber than 40%.2 Factors that influence aspiration include may elect to incorporate the assistance of a speech quantity, depth (material in the distal airways is more language pathologist (SLP) who may recommend dangerous than aspirating material in the pharynx), performing a modified barium swallow study or FEES physical properties of the aspirate, and pulmonary to rule out silent aspiration in these at-risk patients. clearance mechanisms.4 The bedside swallowing assess- At-risk patients who have been found to silently ment provides the early identification of those patients aspirate include those with altered mental status at greatest risk for dysphagia and aspiration. The VSE and decreased awareness; decreased sensation due is the “gold standard” for predicting aspiration, and to stroke, neurological disorders, or head and neck aspiration screening of patients on admission can cancers; gastrointestinal problems; and those who are help determine whether a more detailed aspiration generally weak or deconditioned. Researchers have assessment and fluoroscopic swallow evaluation are found that very young and elderly patients are more indicated; therefore, an accurate and valid risk assess- susceptible to silent aspiration.11,12 ment tool is vital.2,4,12 This will help identify dysphagia Contraindication for use of VSE includes lethargy, and patients at risk for aspiration. absent swallow response, abnormal upper airway Sitoh et al.’s prospective study of 65 geriatric patients sounds, need for frequent oral/pharyngeal suction- used a bedside swallowing assessment that incorpo- ing, those patients unable to cooperate, tachypnea, rated criteria known to be associated with aspiration and some critically ill patients.2 Clinical identifiers risk, including cough upon swallowing, delay in swal- that may predict the need for a swallowing evaluation lowing, and drooling. The study found the simple include a new cough, sputum, fever, rigors, breath- assessment swallowing protocol was useful in helping lessness, wheezing, pleuritic chest pain, sore throat, to identify patients at risk for swallowing dysfunc- and head cold symptoms. However, classic symptoms tions and those at risk for developing chest infections. are often absent, diminished, or nonspecific in the Fourteen of the 65 patients subsequently contracted elderly and may include tachypnea, lethargy, func- hospital-acquired pneumonia; 13 of those had been tional decline, incontinence (new onset), alteration identified as having swallowing dysfunctions, based in sleep-wake cycles, loss of appetite, and increased on the bedside swallowing assessments. One limita- confusion or agitation. tion to the study was the lack of video-fluoroscopic or Due to the high incidence of silent aspiration in acute endoscopic confirmation of aspiration.13 care settings, SLPs do not rely solely on the absence Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 117 Pennsylvania Patient Safety Advisory of signs or symptoms to rule out silent aspiration. and those conditions associated with aspiration may Patients determined to be at risk, but who are without include an oral-pharyngeal swallow evaluation. Those cough or complaint, warrant further evaluation. Many patients at high risk for aspiration, with reduced level factors predispose patients to silent aspiration, includ- of consciousness, should be kept NPO until there is ing altered level of consciousness, enteral feeding, an increase in sensorium. The guidelines also sug- cerebral vascular accident, increased age, gastroparesis, gest that alert patients with medical diagnosis and gastrophageal reflux, seizure, neurologic dysfunction, conditions associated with aspiration be assessed structural lesions, psychiatric disorder, connective tis- while drinking small sips of water. If the patient sue diseases, iatrogenic causes, neurologic disorders, exhibits clinical signs of aspiration, the patient may be and medication side effects.2,3,4,10,12 Ramsey et al. referred for a detailed swallowing evaluation. These suggest that silent aspiration likely occurs in healthy guidelines suggest that those patients with dysphagia individuals during sleep and in many disease states.12 have VSE or FEES evaluation of their swallowing This make it more difficult for healthcare providers to ability to determine appropriate treatment. An aspi- assess aspiration risk for these patients. ration assessment relies on the clinician’s subjective Smithard et al.’s prospective study concluded that evaluation, while the VSE and FEES provide direct bedside assessment alone lacks the necessary sensi- visualization of the anatomy and physiology of swal- tivity to use as the sole screening tool in predicting lowing. Limited economic and staffing resources acute stroke complications such as aspiration. In make the regular use of VSE and FEES nearly impos- this study, 94 patients who had been admitted to sible on every admitted patient, so dependence on the 1 of 2 hospitals with a diagnosis of stroke underwent bedside aspiration assessment alone becomes essential video-fluoroscopy, medical bedside assessments by when determining aspiration risk.2 physicians, and bedside assessments by SLPs. Twenty The guidelines also suggest that the management patients were identified to be aspirating on video- of patients with dysphagia be the responsibility of fluoroscopy. Twenty-one percent of these patients had an organized multidisciplinary team, including a not been recognized as actively aspirating from their physician, nurse, an SLP, dietitian, and physical medical bedside assessments. The medical bedside and occupational therapist. The goals of this team assessment sensitivity was 70% compared to the SLPs’ include focusing on aspiration reduction, improving bedside assessment of 47%. VSE is considered the swallowing ability in order to optimize the patient’s gold standard in identifying aspiration risk, and the nutritional status and quality of life, determining video-fluoroscopy is one portion of this assessment compensatory strategies for those at high risk for but may be cost prohibitive for predicting acute stroke aspiration patients to enable safe swallowing, and pro- complications such as aspiration. The study results viding dietary recommendations.2 suggest that the hospitals involved revise and simplify their aspiration bedside assessments to adequately pre- Mitigation Strategies dict aspiration risk following acute stroke diagnosis.16 The development of mitigation strategies continues Guidelines to be a priority when identifying patients with swal- In 2006, the American College of Chest Physi- lowing difficulties and those at risk for aspiration cians (ACCP) developed 15 evidence-based clinical and silent aspiration upon admission. These strate- practice guidelines for cough and aspiration of food gies may include bedside swallowing screening and and liquid due to oral-pharyngeal dysphagia.2 These assessment, radiologic swallowing assessment, indi- guidelines address conditions that have a high risk vidualized swallowing treatment plan, and assessment for aspiration and silent aspiration. The conditions for medications that affect swallowing. include neurologic impairment (e.g., cerebrovascular Bedside Swallowing Screening and Assessment disease, head trauma, cervical spine injury, anoxia, Aspiration screening and assessment are two distinct seizure disorder, Parkinson’s disease, Alzheimer’s dis- procedures, conducted at separate times by differ- ease); surgery related (e.g., vocal fold paralysis, brain ent healthcare providers. The preliminary aspiration surgery, coronary artery bypass grafting, cervical spine screening is typically performed by a nurse during the surgery); structural (e.g., glossectomy); gastrointestinal patient admission assessment. The full bedside swal- problems; pulmonary problems (e.g., bronchitis); lowing assessment is typically conducted by the SLP intubation for greater than 48 hours; ventilated after the preliminary screening identified the patient patients; and medication side effects (e.g., sedatives, as high risk for aspiration.15,17 There are various types neuroleptics).2 of full bedside swallowing assessments in the clinical The guidelines suggest that those patients with high- literature, but the literature reports very few prelimi- risk conditions be referred for an oral-pharyngeal nary bedside screening tools. Many of the preliminary swallowing evaluation. Patients experiencing cough bedside swallowing screening tools do not contain should be questioned regarding their perception of the sensitivity and specificity to identify dysphagia or choking or fear of choking while eating or drinking aspiration.7,10,15,18 A preliminary swallowing screening and a chest x-ray, and a speech assessment may be performed at the admission assessment can be an considered to rule out aspiration. The evaluation of effective tool to determine whether additional swal- those patients with oral-pharyngeal dysphagia, cough, lowing evaluations are warranted.10 Page 118 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 Pennsylvania Patient Safety Advisory Hinchey et al. conducted a prospective study of Several forms of full bedside swallowing assessments 15 acute care hospitals in which 6 of the hospitals may be used to evaluate patients at high risk for aspi- had formal dysphagia screening protocols. The hos- ration or for those who have swallowing difficulties. pitals’ adherence rate to the screening protocols rate Full bedside swallowing assessments typically involve was 78% compared with 57% for the other 11 acute a questionnaire that includes care history informa- care facilities that lacked formal dysphagia screening. tion; review of auditory, visual, and motor status; The dysphagia screening was defined as a checklist screening of cognitive/communications skills; a non- that assessed patients for previous and current risk invasive oral-pharyngeal exam that includes the oral factors for aspiration, based on clinical findings. If cavity; evaluation of oral motor skills and laryngeal the patient passed the initial screening, a water chal- function for phonation; observation of respiratory lenge followed, and the patient was observed. If the function; and functional swallowing trials.16,18 Vari- patient failed the initial screening, an NPO order ous acceptable methods are included in a full bedside was initiated, followed by further evaluation by an swallowing assessment, including a simple standard SLP. Dysphagia screens were performed before any bedside swallowing assessment and formal evalua- oral intake by the patient. The results for pneumonia tion by an SLP.17 The Joint Commission excludes rates at the hospitals with a formal dysphagia screen the National Institutes of Health Stroke Scale rating were 2.4% versus 5.4% for the hospitals that did not and the documentation of a gag reflex or positive gag have formal dysphagia screening. Patients who expe- as the full evaluation for screening dysphagia. The rienced a stroke and had received a formal screening dysphagia screening may include the minimum of a that were used to treat the patient were found to have formal bedside swallowing assessment.18,20 Patients significantly decreased odds (three-fold) of developing who are waiting for the completion of the full bedside pneumonia after consideration for stroke severity.19 swallowing assessments are typically kept NPO until the testing is conducted so an individualized patient A preliminary bedside swallowing screening tool may treatment plan may be developed. Full bedside assess- be in checklist or algorithm formats, which may be ments may also include the patient’s health history, easily conducted with the patient admission assess- nutritional status, medications, physical examination, ment.10,18 The Massey bedside swallowing screen and diagnostic evaluation.6 A diagnostic evaluation is an example of such a tool (a reprinted copy is may be conducted through the VSE. available online from the Authority at http://www. Radiologic Swallowing Assessment patientsafetyauthority.org). This particular tool has ACCP practice guidelines identify VSE screening as content that has been shown to have predictive valid- beneficial for those patients with medical conditions ity and interrater reliability. Sensitivity and specificity or diagnosed as being at high risk for developing were determined by retrospective chart analysis to aspiration or those with silent aspiration. Penetra- determine postscreening evidence of dysphagia.8 All tion occurs when food or liquid material enters the preliminary bedside tools screen a patient’s swal- laryngeal area to the level of the true vocal cords. lowing abilities through a series of questions, the Aspiration occurs when the food or liquid material presence of a variety of symptoms, and the use of moves below the true vocal chords and enters the clinical indexes to identify patients with dysphagia, trachea.3 Silent aspiration is often not recognized and at risk of aspiration, or who have no prior history of therefore is not treated. dysphagia but meet the criteria for a full bedside swal- lowing assessment.4,8,13,17-19 A FEES is used by the SLP for the functional evalu- ation of the oropharyngeal stage of swallowing. The While AHRQ identified a suggested patient care FEES does not replace the fiberoptic examination practice to include the evaluation of each patient for performed by an otolaryngologist, which assesses the aspiration risk upon admission and regularly thereaf- integrity of the laryngeal and pharyngeal structures. ter, the use of preliminary bedside screening tools can The FEES is a comprehensive assessment of swallow- provide facilities the minimum requirements and key ing and includes the following components: elements needed to identify patients with dysphagia ■ Observation of the anatomy involved in the oro- and those at greater risk for developing aspiration. pharyngeal stage of swallowing While AHRQ has not recommended any single screening tool, the agency suggests a formal dysphagia ■ Observation of the movement and sensation of screening protocol may decrease the risk of pneumo- critical structures within the hypopharynx nia by three-fold.19 The Joint Commission dysphagia ■ Observation of secretions screening requires that patients who have experienced ■ Direct assessment of swallowing function for food a stroke be assessed for dysphagia before any food, and liquid fluids, or medications are administered orally. A pre- liminary bedside swallowing screening will promptly ■ Response to therapeutic maneuvers and interven- identify those patients at high risk for dysphagia, tions to improve swallowing developing aspiration, or those experiencing silent The FEES frequently guides prescribers regarding aspiration, so a timely full bedside swallowing assess- the adequacy of the swallow, the advisability of oral ment can be provided.1 feeding, and the use of appropriate interventions to Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 119 Pennsylvania Patient Safety Advisory exhibit aspiration symptoms (see “Medications That Medications That Increase Aspiration Risk Increase Aspiration Risk”). The medication review ■ Benzodiazepines should also include any over-the-counter, supple- mental, and herbal formulations the patient may be ■ Neuroleptics taking.2,4,5,6,10 ■ Anticonvulsants Individualized Treatment Plan ■ Corticosteroids Development of an individualized patient treatment ■ Lipid-lowering drugs plan occurs following the bedside and radiologic ■ Anticholinergics assessments so the patient can receive safe and ade- ■ Antihistamines quate nutrition. This treatment plan is developed by an interdisciplinary team and may include the physi- ■ Antipsychotics cian, SLP, individual nurse and nurse manager for the ■ Narcotics patient care area, clinical nurse specialist, dietitian, ■ Anticonvulsants respiratory therapist, physical therapist, pharmacist, ■ Antiparkinson agents patient, and family who determine patient-specific interventions.2,5 These interventions may include ■ Antineoplastics exercises, indirect therapy (strengthening exercises for ■ Antidepressants swallowing muscles), and direct therapy (exercises to ■ Anxiolytics perform effects of swallowing difficulties).2,10 These interventions may also consist of rehabilitative mea- ■ Muscle relaxants sures that incorporate swallow therapy, compensatory ■ Diuretics strategies for patients to implement while swallowing, ■ Antibiotics and dietary modifications that are directly related to ■ Iron preparations the patient’s swallowing capabilities.2,4 ■ Quinidine Conclusion ■ Nonsteroidal anti-inflammatory drugs There continues to be a need to optimize a prelimi- ■ Potassium nary bedside aspiration screening that accurately ■ Anticholinergics predicts patients who need further testing to diagno- sis dysphagia, aspiration, and/or silent aspiration.16,17 ■ Calcium channel blockers The need for organizations to have more standardized ■ Theophylline aspiration screening and assessments continues to be ■ Corticosteroids a priority when identifying patients with swallowing Sources: difficulties and those at risk for aspiration and silent aspiration upon admission.5,15,19 Palmer JB, Drennan JC, Baba M. Evaluation and treat- ment of swallowing impairments. Am Fam Physician Notes 2000 Apr 15;61(8):2453-62. 1. Agency for Healthcare Research and Quality. 30 safe Robbins J, Kays S, Mccallum S. Team management practices for better health care [fact sheet online]. 2005 of dysphagia in the institutional setting. J Nutr Elder Mar [cited 2009 Feb 13]. Available from Internet: 2007;26(3-4):59-104. http://www.ahrq.gov/qual/30safe.pdf. Wieseke A, Bantz D, Siktberg L, et al. Assessment and early diagnosis of dysphagia. Geriatric Nurs 2008 2. Smith Hammond CA, Goldstein LB. Cough and Nov-Dec;29(6):376-83. aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guide- lines. Chest 2006;129(1 Suppl):154S-68S. 3. Delegge MH. Aspiration pneumonia: incidence, mortal- facilitate safe and efficient swallowing. The obser- ity, and at-risk populations. JPEN J Parenter Enteral Nutr vations of structure or function of the larynx and 2002 Nov-Dec;26(6 Suppl):S19-25. pharynx through a fiberoptic examination may suggest the possibility of an undiagnosed medical 4. Palmer JB, Drennan JC, Baba M. Evaluation and treat- ment of swallowing impairments. Am Fam Physician 2000 condition.18,21 Apr 15;61(8):2453-62. Medications Affecting Swallowing 5. Wieseke A, Bantz D, Siktberg L, et al. Assessment and The review of the patient’s current medication list early diagnosis of dysphagia. Geriatric Nurs 2008 Nov- may reveal some drugs that can exacerbate dysphagia Dec;29(6):376-83. and aspiration. Some of these side effects include cen- tral nervous system depression, increased salivation, 6. Werner H. The benefits of the dysphagia clinical nurse drooling, myopathy, poor tongue movement, xero- specialist role. J Neurosci Nurs 2005 Aug;37(4):212-5. stomia, inability to initiate the swallowing process, 7. Ramsey DJ, Smithard DG, Kalra L. Can pulse oximetry coughing, burping, and esophageal sphincter dysfunc- or a bedside swallowing assessment be used to detect tion. These side effects may predispose a patient to aspiration after stroke? Stroke 2006 Dec;37(12):2984-8. Page 120 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 Pennsylvania Patient Safety Advisory 8. Massey R, Jedlicka D. The Massey Bedside Swallowing 16. Smithard DG, O’Neill PA, Park C, et al. Can bedside Screen. J Neurosci Nurs 2002 Oct;34(5):252-9. assessment reliably exclude aspiration following acute 9. Leslie P, Drinnan MJ, Ford GA, et al. Swallow respira- stroke? Age Ageing 1998 Mar;27(2):99-106. tory patterns and aging: presbyphgia or dysphagia? 17. Perry L. Screening swallowing function of patients with J Gerontol A Biol Scie Med Sci 2005 Mar;60(3):391-5. acute stroke. Part two: Detailed evaluation of the tool by 10. Robbins J, Kays S, Mccallum S. Team management nurses. J Clin Nurs 2001 Jul;10:474-81. of dysphagia in the institutional setting. J Nutr Elder 18. Swigert NB. Update on current assessment practices 2007;26(3-4):59-104. for dysphagia. Topics Geriatr Rehab 2007 Jul-Sep;23(3): 11. McCullough GH, Rosenbek JC, Wertz RT, et al. 185-96. Defining swallowing function by age: promises and 19. Hinchey JA, Shephard T, Furie K, et al. Formal dyspha- pitfalls of pigeonholing. Topics Geriatr Rehab 2007 Oct- gia screening protocols prevent pneumonia. Stroke 2005 Dec;23(4):290-307. Sep;36(9):1972-6. 12. Ramsey D, Smithard D, Kalra L. Silent aspiration: what do we know? Dysphagia 2005 Summer;20(3):218-25. 20. The Joint Commission. Dysphagia screen data element [online]. 2008 Aug 18 [cited 2009 May 27]. Available 13. Sitoh YY Lee A, Phua SY, et al. Bedside assessment of from Internet: http://manual.jointcommission.org/bin/ ? swallowing: a useful tool for dysphagia in an acute geriat- view/Manual/DataElem0205. ric ward. Singapore Med J 2000 Aug;41(8):376-81. 21. American Speech-Language-Hearing Association. The 14. Metheny NA. Risk factors for aspiration. JPEN J Parenter role of the speech-language pathologist in the perfor- Enteral Nutr 2002 Nov-Dec;26(6 Suppl):S26-33. mance and interpretation of endoscopic evaluation of 15. Ramsey DJ, Smithard DG, Kalra L. 2003. Early assess- swallowing: technical report [online]. 2005 [cited 2009 ments of dysphagia and aspiration risk in acute stroke Jul 1]. Available from Internet: http://www.asha.org/ patients. Stroke 2003 May;34(5):1252-7. docs/html/TR2005-00155.html. ? Self-Assessment Questions The following questions about this article may be useful for internal education and assessment. You may use the following 4. The goals of the multidisciplinary team that manages patients with dysphagia include all of the following EXCEPT: examples or come up with your own. a. Optimize the patient’s quality of life. 1. Risk reduction strategies to prevent aspiration include all b. Eliminate any movement deficit caused by stroke. of the following EXCEPT: c. Determine compensatory strategies to ensure safe a. Perform strengthening exercises for swallowing muscles. swallowing. b. Implement dietary modifications related to swallowing d. Reduce aspiration risk. capabilities. 5. A previously healthy 78-year-old female is admitted to c. Perform videofluoroscopic swallowing evaluation the hospital with unexplained shortness of breath. Upon upon admission. examination, she is found to be lethargic and wheezing d. Review medication list that includes all over-the- with a pulse oximetry of 86%. Examination of her chest counter and supplemental drugs. radiograph reveals right lower lobe infiltrates. There is 2. Clinical manifestations of silent aspiration include all of no previous history of any respiratory problems, chronic the following EXCEPT: obstructive pulmonary disease, or asthma. The patient is a nonsmoker. Her caregiver reports that she is drowsy and a. Altered mental status and decreased awareness confused while awake. b. Gastrointestinal problems c. Rib fractures Select the intervention that is appropriate for this patient upon admission. d. Generalized weakness or deconditioning a. Obtain a formal evaluation by a speech-language 3. Which of the following should not be implemented when pathologist. aspiration is suspected based on the admission screening? b. Restrict dietary intake until there is an increase in a. The physician limits the patient to a full-liquid diet. sensorium. b. The speech-language pathologist conducts a formal c. Develop an individualized swallowing treatment plan. evaluation. d. Perform videofluoroscopic swallowing evaluation. c. The dietitian performs a comprehensive nutritional assessment. d. The pharmacist assesses the patient for medications that affect swallowing. Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 121 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 4—December 2009. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2009 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.