Implementation of a swallow screening protocol in a tertiary adult intensive care unit: A quality improvement project

Abstract

Background: Post-extubation dysphagia occurs in 3% to 62% of adults who have received invasive mechanical ventilation in an intensive care unit (ICU). A stepwise approach to identify dysphagia includes a routine swallow screening in patients who are recently extubated followed by a formal assessment by a Speech and Language Pathologist (SLP), in the event of a failed swallow screen, has been suggested. This quality improvement project aimed to implement and evaluate a new post-extubation swallow screening process.

Methods: Using the Model for Improvement framework, a new process that included the Yale Swallow Protocol (YSP) was developed, implemented, and evaluated between July and December 2022 in a 20-bed tertiary ICU. All patients with at least four hours after post-extubation were included in the project. Process development included a literature review and feedback from ICU educators, nurses, physicians, SLPs, and Registered Dietitians (RD). Education was provided to critical care nurses prior to implementation. Data on patient characteristics, process indicators, and outcomes were collected between September and December 2022 to evaluate the project implementation. Descriptive statistics were used to describe the data and bivariate analyses were used to compare data between patients who passed and failed the YSP.

Results: Fifty-four patients were extubated and evaluated using the new swallow screening process. Post-extubation dysphagia was diagnosed by an SLP in 30.0% of patients. Dysphagia was diagnosed in 90.0% of patients who failed compared to 8.6% of patients who passed the YSP (P<0.001).

Conclusion: A swallow screening process using the YSP was successfully adopted in a tertiary ICU.

Keywords: dysphagia, swallowing disorders, critical care, mechanical ventilation, quality improvement

Implications for Nursing

Consistent application of a simple, standardized swallow screening tool like the Yale Swallow Protocol can lead to collaborative team approaches to patient care, early identification of aspiration and/or dysphagia, prudent use of resources, and timely resumption of oral intake.

Critical care nurses are in a key position to screen for aspiration risk in the post-extubation population.

Significant differences in orientation to name, date, and place were found between patients who failed and those who passed the Yale Swallow Protocol indicating a possible relationship between delirium and post-extubation dysphagia.

Critical care nurses can be confident that a failed Yale Swallow Protocol is highly predictive of dysphagia; therefore, referral to a Speech and Language Pathologist for further investigation is warranted. Multidisciplinary teamwork can result in effective and efficient case management for patients admitted to the Intensive Care Unit.

Background

Post-extubation dysphagia (PED) is reported to occur in 3% to 62% of adults who have received invasive mechanical ventilation in an intensive care unit (ICU) (McIntyre, Doeltgen, Dalton, Koppa, & Chimunda, 2021; Skoretz, Flowers, & Martino, 2010). The prevalence varies due to different study inclusion criteria, dysphagia screening or diagnosis techniques, and study population (McIntyre et al., 2022; McIntyre et al., 2021; Skoretz et al., 2010). A higher prevalence of dysphagia of up to 84% can be found when the patient selection includes only those seen by a Speech and Language Pathologist (SLP) rather than all patients who have received mechanical ventilation (Macht et al., 2011; McIntyre et al., 2021). Many PED risk factors have been evaluated with 63 being reported as having a statistically significant relationship with PED including, for example, age, patient acuity, and length of intubation (McIntyre et al., 2022). PED is associated with a higher risk of developing hospital-acquired pneumonia, longer hospital length of stay, and greater hospital, 28-day, and 90-day mortality, after adjustments for age, length of mechanical ventilation, and patient acuity (Macht et al., 2011; Schefold et al., 2017).

Studies describing PED, its risk factors, and its associated outcomes have a moderate to high risk of bias and may not consider relevant confounding variables (McIntyre et al., 2022). Dysphagia is considered one consequence of ICU-acquired weakness (ICU-AW) and may co-exist with other characteristics of ICU-AW, such as decreased muscle strength, which is also associated with a longer hospital length of stay and greater mortality (Vanhorebeek, Latronico, & Van Den Berghe, 2020). Routine SLP assessment of all patients may not be a good use of resources and access to SLP resources can be limited; therefore, utility of screening tools to help guide assessment needs to become a necessity (McIntyre et al., 2021; Zuercher, Moret, Dziewas, & Schefold, 2019).

Alternatively, a stepwise approach has been suggested by several authors, which involves routinely screening for aspiration risk of patients post-extubation followed by SLP assessment for patients who fail a swallow screen (Macht, White, & Moss, 2014; Zuercher et al., 2019). This approach has the potential to identify patients at risk of complications associated with aspiration, streamline referrals to SLP, and facilitate earlier oral diet initiation (Macht et al., 2014; Zuercher et al., 2019). While this stepwise approach has been suggested by Macht et al. (2014) and Zuercher et al. (2019), PED evaluation practices remain variable (Spronk et al., 2022), and limited literature te describes the implementation of a stepwise approach (Schefold et al., 2017). This paper describes a quality improvement project that aimed to develop, implement, and evaluate a new stepwise swallow screening process in adults who were recently extubated.

Methods

Planning

This quality improvement project occurred in a 20-bed adult tertiary ICU in British Columbia, Canada from July 2022 to December 2022 (Figure 1). This ICU admits approximately 400 patients requiring mechanical ventilation per year with medical, surgical, and trauma diagnoses. Using the Model for Improvement framework, the aims of this project were to have an oral diet started within 12 hours of a passed swallow screen, have SLP referrals entered for all patients with a failed swallow screen, and evaluate the frequency of post-extubation dysphagia using this new process.

In July 2022, a literature review was conducted by a RD and SLP who reviewed the databases of CINAHL and Medline using key words  “dysphagia,” “swallow*,” “assessment,” “evaluation,” “screening,” “critical care,” and “intensive care unit”.. All relevant full text articles on PED and validated swallow screening tools used in the ICU population were reviewed (Christensen & Trapl, 2018; Johnson et al., 2018; Lynch et al., 2017; Suiter & Leder, 2008). Four swallow screening tools, each comprised of a water swallow test (WST) with or without screening criteria, that reported validity measures were evaluated (Christensen & Trapl, 2018; Johnson et al., 2018; Lynch et al., 2017; Suiter & Leder, 2008). Considering each screening tool’s validity and study sample, a decision was made to implement the Yale Swallow Protocol (YSP) (Suiter & Leder, 2008).

The YSP is a simple aspiration screening tool that incorporates short cognitive and oral mechanism evaluations followed by a 90 ml water swallow test (WST) that must be taken by cup or straw in sequential sips without stopping and without symptoms of aspiration such as coughing (Leder et al., 2019). When evaluated against fiberoptic endoscopic evaluation of swallowing (FEES), the YSP has a sensitivity of 96.5% to predict aspiration and a specificity of 48.7% in a diverse, clinical population including ICU patients (Suiter & Leder, 2008). In ICU and step-down patients who passed the YSP, an oral diet was successfully started without any overt signs or symptoms of aspiration (Leder, Suiter, Warner, & Kaplan, 2011; Leder et al., 2019).

Implementation

Using the YSP, a new process for swallow screening and assessment in post-extubation patients was developed. All patients who were recently extubated were assessed for eligibility by the multidisciplinary ICU healthcare team for the YSP based on the YSP contraindications and timing from extubation (Table 1). Time from extubation to swallow screening varied among existing studies (Leder et al., 2019; Schefold et al., 2017; See, Peng, Phua, Sum, & Concepcion, 2016), and there may be no statistically significant difference in dysphagia prevalence when evaluated using any screening or assessment method before or after 24 hours post-extubation (McIntyre et al., 2021). As there is yet no consensus on a timeline and to consider system pressures, such as physician buy-in, nursing duties, and patient access and flow, four hours was set as the minimum duration of time from extubation to swallow screening based on the available evidence (Leder et al., 2019; Schefold et al., 2017). Leder et al. (2019) described a high YSP pass rate (87.6%) at 4 hours post-extubation in a heterogeneous ICU population (N=202) with few additional participants passing at 24 hours (91.6%). Schefold et al. (2017) also reported a high 100-ml WST pass rate at 3 hours post-extubation (80.2%) in 933 patients admitted to ICU. If the initial YSP failed, it could be repeated at 24 hours or sooner if a patient’s clinical condition, such as resolving delirium, had improved according to the bedside Registered Nurse (RN), intensivist, RD, or SLP’s clinical assessment (Leder et al., 2019), This process was reviewed and approved by critical care stakeholders, including the ICU nurse educators, SLPs, RDs, and intensivists. Two critical care RNs, an SLP, and an RD formed the implementation team that led education processes and provided support to RNs during implementation.

Once stakeholder approval was obtained, the SLP and RD provided education to  critical care RNs in August and September 2022. Education strategies included short bedside education huddles that occurred over two weeks and the inclusion of the new process in the newsletter sent to all ICU staff. During this time, the YSP was incorporated into the electronic medical record to provide instructions for the YSP and to allow RNs to document the YSP results. Concurrently with education, the YSP was implemented as eligible patients were identified post-extubation. Education with staff was continued on an as-needed basis. Two weeks after the staff education was completed, data collection for the implementation evaluation was started.

Evaluation

From September to December 2022, data were collected to assess both process and outcome indicators of successful implementation. Data was collected on all patients who were extubated, except for patients classified as chronic home mechanical ventilation and those who were on terminal extubation transitioning to end-of-life measures. Pertinent data collected for quality improvement purposes included: participant demographic (age, legal sex), clinical (mechanical ventilation duration, re-intubation, ICU re-admission), nutrition (oral diet order, nasogastric feeding tube use), and dysphagia-related (dysphagia diagnosis, dysphagia assessment method) characteristics. Data collected pertaining to process measures, included: the use and timing (hours) of the YSP in relation to extubation, contraindications to the YSP (reduced alertness, dysphagia history, and tracheostomy), results of the YSP, SLP assessment characteristics and results, the timing (hours) of initiating an oral diet in relation to extubation, and frequency of and the indication for nasogastric (NG) feeding tube insertion. Orogastric feeding tubes, which are removed on extubation, are more frequently used in this ICU compared to NG tubes. As NG feeding tube placement has a risk of pulmonary placement and epistaxis and exposes patients to radiation from placement confirmation radiographic imaging (Metheny, Krieger, Healey, & Meert, 2019), reducing unnecessary nasogastric tube placement was an outcome of interest. A dysphagia diagnosis was defined as a diagnosis of oropharyngeal dysphagia on an assessment by an SLP using diagnostic swallow tools, the flexible endoscopic evaluation of swallowing (FEES) or video fluoroscopic swallow study (VFSS), or a clinical bedside exam (BSE). The selection of assessment type was determined by various factors including the patient’s mobility status, goals of care, and access or contraindications to FEES or MBS. A swallow instrumental exam, the FEES or VFSS, is the only means to visualize swallow physiology and confirm or rule out aspiration (Garand, McCullough, Crary, Arvedson, & Dodrill, 2020). As such, an instrumental exam was considered the preferred assessment type. Data collected indicating clinical outcomes included frequency of re-intubation during the primary ICU admission or ICU re-admission related to an aspiration event per physician documentation.

A post-implementation survey was provided to critical care RNs in a paper format during daytime working hours over 2 weeks in December 2022. This survey included two questions on their attitudes towards the YSP. The first question asked RNs to rate the ease of use of the YSP on a 5-point Likert scale from “very easy to use” to “very difficult to use.” The second question asked RNs to rate the clarity of the YSP on a 5-point Likert scale from “very clear” to “very unclear.”

Statistical Analysis

Statistical analyses were chosen to describe the patient population, YSP implementation outcomes, and differences in patients who passed and failed the YSP and based on feedback from critical care RNs, physicians, SLPs, and RDs. These analyses’ results were used to determine if the project’s aims were met and to inform the implementation of and critical care staff education for the YSP in other ICUs within the regional health care system. Patient demographic, clinical, nutrition and dysphagia-related characteristics were summarized using frequencies (n, %) or median (interquartile range). To identify if the project’s aims were achieved, the number of hours from a passed YSP to an oral diet start, frequency of SLP referrals, and frequency of a dysphagia diagnosis were described. To better understand which patients may be more likely to fail the YSP, characteristics between patients who passed and failed the YSP were compared using the chi-square test, Fisher’s exact test, or Mann-Whitney U test. To better understand how the YSP may identify dysphagia in this site’s patient population, the relationship between YSP results and a diagnosis of dysphagia by SLP was analyzed using a chi-square test. The post-implementation survey responses were described using frequencies (n, %).

All statistical analyses were conducted using IBM SPSS. This project was conducted as a quality improvement initiative and was exempt from local research ethics board approval.

Results

Fifty-four patients were extubated and evaluated using the new swallow screening process during the data collection timeframe. Patients were a median of 65.0 (51.5, 75.0) years old, and more than half were male (55.6%). Within 24 hours of extubation, 71.7% of patients (n=38) were screened using the YSP. Fifteen patients were ineligible during the first 24 hours post-extubation due to reduced alertness (n=10), history of dysphagia (n=2), and need for a tracheostomy (n=3). One patient received a different swallow screen. Patients with reduced alertness were screened once their level of consciousness improved. The median time from extubation to the first YSP attempt was 7.1 (4.0, 27.1) hours for all patients (n=46) evaluated using the YSP. On the first YSP attempt, 51.1% of patients (n=24) successfully completed the YSP. Ninety-one percent received a repeat attempt, and of these patients, a further 13 patients (61.9%) successfully completed the YSP.

Sixty-five percent of patients had an NG or nasoenteric feeding tube placed peri-extubation. Indications for a feeding tube included contraindication to the YSP at the time of extubation (n=21), unsuccessful YSP (n=8), need for ongoing medication or nutrition delivery (n=3), and unknown or no indication (n=3). Among all patients that started an oral diet (n=47), the median time from extubation to starting an oral diet was 28.9 (7.3, 92.5) hours.

All patients who failed the YSP were referred to SLP, an additional aim of this quality improvement project. An SLP swallowing assessment was completed on 21 patients after an initial failed YSP. Of these assessments, a FEES was conducted on 38.1% of patients, followed by a BSE (23.8%) and a repeat YSP (23.8%). A VFSS was done in the remaining 14.3% of patients.

Patients required mechanical ventilation for a median of 87.8 (56.0, 142.5) hours, and 7.7% required re-intubation during the primary ICU admission. One patient was re-admitted to ICU with a diagnosis of aspiration pneumonia; however, this patient never received a YSP, SLP assessment, or started an oral diet prior to re-admission.

Patients who passed the YSP were compared to patients who failed the YSP (Table 1). There were significant differences in the timing of the YSP and the YSP screening question results between groups. Patients who failed the YSP received the screen significantly later post-extubation (25.6 hours) compared to patients who passed the YSP (4.5 hours, P=0.007). Patients who failed the YSP were also less frequently alert and oriented to name, date, and place (41.7%) compared to patients who passed the YSP (71.9%, P=0.002). Patients that failed the YSP had significantly longer median durations in time from extubation to oral diet start (88.8 hours) and time from the initial YSP to oral diet start (69.1 hours) compared to those that passed the YSP (23.0 hours, P=0.003 and 3.0 hours, P=0.002, respectively). A median of 3 hours from a passed YSP to starting an oral diet was within the project aim which was  oral diet initiation within 12 hours from a passed YSP.

Dysphagia was diagnosed by SLP in 90.0% of patients that failed the YSP while dysphagia was ultimately diagnosed in 8.6% of patients that initially passed the YSP (P<0.001). The prevalence of dysphagia was 30.0% among patients who were evaluated by the YSP or by SLP (n=50) including patients with a tracheostomy and with a history of dysphagia. The remaining four patients had persistently reduced alertness during the project and were not evaluated for dysphagia.

The new stepwise swallow screening process using the YSP was well received by the critical care RNs. In the post-implementation survey (N=18), 100% of RNs reported that the YSP was moderately- to very easy to use and that the YSP was moderately- to very clear.

Discussion

We have described the implementation of a stepwise swallow screening process using the YSP for all recently extubated patients. Few studies and implementation projects to date have been published that describe the use of a swallow screening tool in clinical practice and explore variables that may assist with clinical decision-making and implementation in other ICUs (Schefold et al., 2017).

The aims of the quality improvement project were successfully achieved, and the stepwise swallow screening process using the YSP was well-accepted by critical care RNs who administered the YSP in recently extubated patients. This project has led to the permanent adoption of this stepwise swallow screening process in this ICU. The results informed further local critical care RN education about how the YSP may be repeated and how the YSP screening questions may alert RNs to patients that are more likely to fail the YSP. In addition, further work has been undertaken to expand the use of the YSP to other ICUs in the regional healthcare system.

The prevalence of dysphagia in this project’s sample is within the previously reported range of 3% to 62% although less than the reported weighted mean of 41% (McIntyre et al., 2021). This may be related to the inclusion of all patients receiving mechanical ventilation in the ICU for this project rather than limiting to patients with a length of mechanical ventilation of more than 48 hours or excluding patients based on other criteria such as a neurological diagnosis. Identifying a 30.0% dysphagia prevalence in this site’s ICU population highlighted the need to have a formal, stepwise process to identify dysphagia in a timely manner while facilitating an oral diet initiation in patients without dysphagia.

In this quality improvement project, the use of the YSP was highly predictive of a dysphagia diagnosis with 90.0% of patients who failed the YSP subsequently being diagnosed (by FEES or VFSS) with dysphagia or deemed highly suspicious following BSE. This result is limited by the small sample size, quality improvement design, and variable timelines for instrumental dysphagia evaluation, but it suggests that a stepwise approach to identifying PED may identify patients that benefit from an SLP swallowing assessment. These results are consistent with other studies that use a pragmatic WST in patients who were recently extubated (Mukdad et al., 2019; Schefold et al., 2017). Mukdad et al (2019) reported that 90% of post-operative liver transplant patients who failed a WST post-extubation were diagnosed with dysphagia using FEES. In a prospective observational study in mixed adult ICU patients, dysphagia was confirmed by a specialist in 87.3% of patients who failed a WST (Schefold et al., 2017). This approach may effectively use hospital resources while minimizing risks associated with PED and warrants further investigation with experimental study designs.

While few studies have described PED as a barrier to starting oral intake or adequacy of oral intake (Chapple et al., 2016; Moisey et al., 2021; Peterson et al., 2010; Ridley et al., 2019), even fewer have described how quickly an oral diet is started post-extubation (Leder, Suiter, Warner, et al., 2011). While Leder et al (2011) reported that patients who passed the YSP were consuming an oral diet within 12 to 24 hours, we confirmed that patients who passed the YSP were able to start an oral diet a median of 3.0 hours after passing the YSP and a median of 23.0 hours post-extubation. This reflects the use of repeated YSP for some patients as the first YSP attempt was done at a median of 4.5 hours post-extubation for patients who passed. In comparison to patients that passed the YSP, patients that failed the YSP were screened significantly later post-extubation and started an oral diet significantly later. This finding corroborates that PED is a barrier to oral diet initiation post-extubation and these patients should receive an alternative nutrition support therapy, such as enteral nutrition, to ensure adequate intake post-extubation. This stepwise approach to post-extubation nutrition support decision-making has been suggested by Massanet et al (2015). These authors suggested using nutrition support in patients with a contraindication to oral intake or who failed a WST, but otherwise attempting to maximize oral intake prior to implementing supplemental nutrition support.

One of the main barriers to using the YSP within 24 hours of extubation was reduced alertness. We also identified patients who failed the YSP were screened after a longer duration post-extubation compared to patients who passed the YSP suggesting that reduced alertness persisted for longer in the patients who failed the YSP. This data, together with lower levels of orientation to name, date, and place in patients who failed the YSP, suggests that a variable such as delirium may play a larger role in dysphagia prevalence post-extubation. While this quality improvement project was not designed to evaluate this relationship, delirium is prevalent in the ICU and may be a risk factor for PED (Bode et al. 2020, Kotfis et al., 2022). This has resulted in a heightened awareness and further discussion among critical care RNs, physicians, SLPs, and RDs in this ICU and the local health care region about how delirium and PED may be related. As highlighted in a recent ICU research agenda on ICU-AW, the relationship between delirium, duration of mechanical ventilation, and ICU-AW (including dysphagia) has not been well explored (Latronico et al., 2017).

One limitation of this project is the limited validation and reliability measures for any PED evaluation process or aspiration screening tools. While the decision to use the YSP was based on its high sensitivity across a heterogeneous population and its documented use in the ICU population (Leder, Suiter, Warner, et al., 2011; Leder et al., 2019; Suiter & Leder, 2008), the YSP requires further validation in the post-extubation population, particularly at longer durations of mechanical ventilation. The possibility of silent aspiration among patients that passed the YSP is another potential limitation. Silent aspiration may occur in 36% of patients with PED (McIntyre et al., 2021); however, it is suggested that silent aspiration is volume dependent and that patients who silently aspirate on small volumes will trigger symptoms of aspiration with larger water volumes (Leder, Suiter, & Green, 2011). This is a strength of the YSP which requires patients to drink the 90 ml WST without stopping, and this may reduce the risk of not identifying patients who aspirate (Leder, Suiter, & Green, 2011). This project’s results are also limited by the small sample at a single tertiary ICU as they may not be generalizable to all patients admitted to ICU.

Conclusions

A stepwise swallow screening process using the YSP was adopted successfully in a tertiary ICU and resulted in the timely identification of PED risk, referral to SLP, and oral diet initiation. Reduced alertness and disorientation may be a barrier to swallow screening and risk factors for PED, although this finding is limited by this project’s quality improvement design and warrants further research. This suggests a relationship between post-extubation delirium and dysphagia which should be explored in future research. Future research should continue to evaluate the validity of swallow screening tools, including the YSP, in the ICU population post-extubation and identify the optimal PED identification, treatment, and monitoring process.

Author Notes:

Courtney Wedemire, MS, RD, Abbotsford Regional Hospital, Abbotsford, BC.

Lara Sas, MA, RSLP, Abbotsford Regional Hospital, Abbotsford, BC.

Sarah Russell, BSc, RN, Abbotsford Regional Hospital, Abbotsford, BC.

Corresponding Author:

Courtney Wedemire, Abbotsford Regional Hospital, Abbotsford, BC.  Email:  courtney.wedemire@fraserhealth.ca.

Funding and Conflict of Interest:

The authors have no funding to declare, and no competing, relevant financial, and non-financial interests to disclose.

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Figure 1

Implementation and Evaluation Timeline of a Stepwise Swallow Screening Process in a Tertiary Intensive Care Unit

Notes. EMR, electronic medical record; RN, Registered Nurse; YSP, Yale Swallow Protocol
Table 1

Exclusion Criteria for Using the Yale Swallow Protocol in Patients Recently Extubated

Table 2

Characteristics and outcomes of adult patients who completed the Yale Swallow Protocol post-extubation 

^a with a diagnosis of aspiration pneumonia

BSE, bedside swallow examination; FEES, fiberoptic endoscopic evaluation of swallowing; ICU, intensive care unit; IQR, interquartile range (expressed as Q1, Q3); MV, mechanical ventilation; NG, nasogastric; SLP, Speech and Language Pathologist; VFSS, videofluoroscopic swallow study; YSP, Yale Swallow Protocol

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