The development and implementation of an evidence-based risk reduction algorithm for post-extubation dysphagia in intensive care

Abstract

Intubation and mechanical ventilation are often required to support critically ill patients. These are life-sustaining measures and when they are no longer necessary, patients need to be carefully transitioned back to breathing, eating, and talking on their own. Post-extubation dysphagia is defined as swallowing difficulty following extubation. This condition can affect up to 87% of critically ill patients and can cause serious health complications such as aspiration pneumonia, which could require re-intubation, prolonged intensive care stays and increased in-hospital mortality. Currently, many extubated patients are trialed with oral intake without dysphagia screening or kept with nothing by mouth pending speech language pathology evaluation. This is not only a source of discomfort and distress for patients, families, and staff but can lead to malnutrition and dehydration, and puts patients at risk for aspiration. Systematically screening extubated patients for dysphagia is an opportunity to improve practice by enabling nurses to advocate for the safe and timely resumption of oral intake. A novel, evidence-based algorithm, called SAPE (Swallowing Algorithm Post-Extubation) was developed by an interdisciplinary critical care team to assist nurses to identify risk factors for post extubation dysphagia and help make evidence-informed decisions regarding referral to speech-language pathology and initiation of per os intake in the absence of a water swallow test.  SAPE was implemented in four tertiary-level medical and/or surgical intensive care units. Process and outcome measures of a quality improvement initiative are discussed, and future directions proposed.

Implication for Nurses

• Discuss the etiology and incidence of post-extubation dysphagia.
• Describe the potential impact of post-extubation dysphagia on critically ill patients.
• Describe a quality improvement initiative aimed at improving nursing practice.
• Discuss the outcomes of the implementation of a post-extubation dysphagia-screening algorithm in an intensive care unit.

Over five million individuals are admitted to intensive care units (ICU) annually in North America (Barrett et al., 2015; Canadian Institute for Health Information, 2016). Invasive mechanical ventilation is one of the most common interventions provided in the ICU and is delivered to 20-40% of all critically ill patients (Barrett et al., 2015; Canadian Institute for Health Information, 2016; Wunsch et al., 2013). Recently, there has been increased attention in the literature surrounding post-extubation dysphagia (PED) as an under recognized sequela of mechanical ventilation (Brodsky et al., 2020). The pathogenesis of PED occurs through one or more of the following mechanisms: oropharyngeal and laryngeal trauma with intubation, reduced laryngeal sensation, dyssynchronous breathing and swallowing patterns, neuromuscular weakness, altered sensorium, and gastro-esophageal reflux (Brodsky et al., 2014; Macht et al., 2011; Skoretz et al., 2010).

While the true incidence of PED is unknown, previous studies have reported rates between 3% and 87% of patients who have required intubation (Brodsky et al., 2020; de Medeiros et al., 2016; Skoretz et al., 2010). This wide range of incidence may be due to the heterogeneity of patient populations studied and differences in diagnostic measures, intubation duration, and the timing of the PED assessment (Rassameehiran et al., 2015). Although PED can occur with any duration of intubation, the incidence of PED reaches 67.5% by 48 hours, particularly in trauma patients and following cardiovascular surgery (Barker et al., 2009; Leder et al., 1998; Skoretz et al., 2014).

PED is an independent predictor of mortality (Schefold et al., 2017) and is also associated with a range of negative sequalae such as malnutrition, hunger and thirst, aspiration pneumonia, prolonged mechanical ventilation, and extended ICU/hospital stays (Macht et al., 2011; Macht et al.,  2014). The presence of dysphagia, regardless of etiology, increases the length of stay for patients by five times and can cost the healthcare system approximately $94,000 USD per patient (Altman et al., 2010; Kozlow et al., 2003; Sutherland et al., 2010), making PED a clinically relevant problem in the ICU.

The gold-standard for dysphagia evaluation is a videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) (Ajemian et al., 2001; Leder et al., 1998; Martino et al., 2009), as they allow clinicians to have an objective view of all stages of swallowing. However, instrumental tests are not always available, feasible, or timely (Rassameehiran et al., 2015), so bedside swallowing evaluations (BSE) or screenings are performed by Speech-Language Pathologists (SLPs) or trained ICU nurses approximately 60% of the time (Macht et al., 2012).   

Current tools used to screen for PED use a water swallow test (e.g., 3 oz (90 mL) of water), including the Post-Extubation Dysphagia Screening tool (Johnson et al., 2018), the Yale Swallow Protocol (Suiter et al., 2014), the Modified Gugging Swallow Screen (Christensen & Trapl, 2017) and the Bernese ICU Dysphagia Algorithm (Zuercher, Dziewas, et al., 2020). While these water swallow tests provide practical and deployable tools for PED screening, they have shortcomings. They are unable to detect silent aspiration (Ferguson & Lamb, 2015) and they do not fully account for patient and procedure specific risk factors that could affect swallow function. To our knowledge, there is currently no valid and reliable screening tool for PED that does not employ a water swallow test.

We describe conceptualization, development, and implementation of an enhanced post-extubation screening algorithm. We focused on the early identification of at-risk patients and a streamlined referral to SLP for definitive evaluation and management without the need to put patients at unnecessary risk of a water swallow test. The specific aims of this project were (1) to increase critical care providers’ knowledge about PED and, (2) to develop and implement the Swallowing Algorithm Post-Extubation (SAPE) across our institution to enable systematic, timely and thorough screening of ICU patients for PED.

Method

Setting

This project took place at two adult, tertiary care hospitals (Toronto General and Toronto Western Hospitals) located within a single academic hospital network (University Health Network) in a large, urban city. Across the sites, there are four ICUs: a medical-surgical ICU (MSICU), a coronary-care ICU (CICU), a cardiovascular surgical ICU (CVICU), and a medical-surgical/neuroscience ICU (MSNICU). These ICUs range in size from eight to 32 beds and service, collectively, over 5600 patients per year. These ICUs provide care to patients with acute respiratory distress syndrome (ARDS), cardiopulmonary failure, sepsis and multiorgan failure. Additionally, specialized post-operative care is provided for patients undergoing cardiac, vascular, solid organ transplantation, orthopedic surgery, and neurosurgery.

SAPE Algorithm Development

SAPE was developed by a multidisciplinary working group consisting of three SLPs, two registered dietitians, three registered nurses (RN), and three respiratory therapists who work full time across the four critical care units. First, we performed a literature review of the Medline database (from inception to April 2017) using the following search terms: extubation, deglutition disorders and dysphagia.  Articles were limited to English language, humans, and adults (18 plus years of age).  Additional articles were sourced between April 2017 and May 2018 through manual searching of reference lists, relevant journals, and consultation with colleagues. Relevant articles were divided between members of the working group and were each read by no less than four working group members, including a representative from each profession. Data extracted were title, author, year of publication, issues addressed in the article, problem statement, research method and overall findings. Articles were summarized by each sub-group and then discussed with the full working group to make decisions regarding indicators to be included in a draft algorithm. The algorithm underwent ten iterations based on the literature review and consensus of stakeholders and experts within critical care.   A total of 27 articles were reviewed and clinical recommendations from 20 of these articles were included in SAPE (Figure 1). 

Figure 1

Swallowing Algorithm Post Extubation

Patients who are intubated for greater than 48 hours or who have a tracheostomy are kept nil per os (NPO) with enteral feeds and referred to SLP for a swallow assessment (Barker et al., 2009; Brown et al., 2011; Ding & Logemann, 2005; Elpern et al., 2000; Macht et al., 2012; Skoretz et al., 2014). Patients with multiple intubations (Macht et al., 2012; Macht et al., 2013), laryngeal edema (Dziewas et al., 2017), stroke (and failed Toronto Bedside Swallowing Screening Test^©), neurological or neuromuscular diagnosis (Clavé & Shaker, 2015; Macht et al., 2012; Martino et al., 2009; Ponfick et al., 2015), history of dysphagia (Macht et al., 2012), head and neck cancer (Macht et al., 2012; Schindler et al., 2015), thoracic abdominal aortic aneurysm repair (Ishii et al., 2004) or anterior cervical discectomy and fusion (Wolf & Meiners, 2003) are kept NPO with enteral feeds and referred to SLP for a swallow assessment post-extubation. Finally, vocal fold damage was initially added to the algorithm based on expert consensus and experience, however, was subsequently found to be supported in the literature (Zhou et al., 2019).

Patients intubated for less than 48 hours, with no past medical history to predispose them to dysphagia, are deemed ready for oral intake if hemodynamically stable and able to follow commands (Leder et al., 2009), maintain alertness for longer than ten minutes, tolerate FiO₂ less than 60%, breathe without a face mask during oral intake, breathe without non-invasive ventilation, maintain a respiratory rate of less than 30 breaths per minute, speak louder than a whisper and sit upright (Macht et al., 2012).  A water swallow test or screening is not included in SAPE. Once oral intake is initiated, RNs monitor for coughing, choking, throat clearing, gurgling, desaturation or increased respiratory rate, food pocketing in the mouth, drooling and painful swallowing. If any of the above warning signs are present, the algorithm recommends an SLP consult.

Intervention

The primary purpose of SAPE is to guide RNs to identify risk factors for PED and make decisions regarding referral to SLP and initiation of oral intake.  Rollout of SAPE was a multi-phase process, including a pilot study, quality improvement project, dissemination, and policy development.  Details are described in the following sections following the SQUIRE 2.0 guidelines for quality improvement reporting (Davidoff et al., 2008; Ogrinc et al., 2016). 

Pilot testing of the algorithm was completed in the CVICU between June and September 2018. This unit was chosen due to its smaller size and relatively uniform patient population. To start, pre-training surveys were administered to determine the knowledge of trainees with regard to PED and current practice. Then thirty-minute training sessions provided to nursing and allied health professionals were conducted in small groups during June 2018 where the decision points in the algorithm were reviewed and then used in case study examples, tailored to specific ICU patient populations, to consolidate learning.

In September 2018, after SAPE was in use in the CVICU for two months, post-implementation surveys were conducted to assess knowledge of PED and current practice.  Changes were made to the algorithm based on feedback from the pilot and the revised algorithm was launched in CVICU in October 2018 and expanded into CICU, MSICU, and MSNICU over the next six months.

Implementation of SAPE in the MSICU was accompanied by a quality improvement project led by one of the authors (M. Davidson) in order to evaluate the knowledge translation and use of SAPE. A waiver of consent was obtained from the institutional ethics review board at the University Health Network for this quality improvement project. The MSICU was chosen to evaluate the algorithm as it is the largest ICU at our facility and has a mixed medical-surgical patient population. Initially, a needs assessment was completed to determine the impact of PED on the MSICU’s patient population and to assess the staff’s knowledge and practice around resuming oral intake after extubation. This was done via a retrospective chart review from October 2018 and a survey of the MSICU’s interprofessional staff. Information of interest during the chart review included intubation duration, presence of PED risk factors, onset of oral intake and whether an SLP referral was obtained. Staff surveys assessed practices around starting oral intake after extubation, staff confidence with starting oral intake after extubation and staff knowledge about PED risk factors. Based on these surveys, education was provided during January and February 2019.  Training was completed using 1:1 peer teaching, small group sessions, new hire orientations, and presentations at physician rounds. Staff were also engaged by using SAPE signage placed at the point-of-care, presentations at daily unit safety huddles, and email reminders. SAPE was put into practice January 2019 after an initial two weeks of staff training. Evaluation of SAPE occurred in March 2019 with a five-week chart audit and post-implementation staff survey using the same criteria as the baseline needs assessment.

Process and Outcome Measures

The aim of the quality improvement project was to implement SAPE in the MSICU to achieve a 60% adherence with this algorithm within five weeks of implementation. Process measures included the percentage of staff trained to use SAPE and the improvement in staff knowledge about PED. Outcome measures were the percentage of MSICU extubated patients screened using SAPE, and the percentage of at-risk patients referred to SLP.

To evaluate the process measures above, the percentage of staff trained was calculated at the end of the training period as a percentage of the total number of interdisciplinary staff employed in the MSICU. Pre- and post- implementation surveys were used to assess the change in staff knowledge about PED. The quantitative outcome measures were evaluated and analyzed using a run chart analysis from five pre- and post- SAPE implementation weeks based on data from the chart reviews.

Results

Staff Training

A total of 174 (62%) of the MSICU’s interprofessional staff were trained during the months of January and February 2019. Specifically, 135 RNs (68%), 20 respiratory therapists (40%), 14 physicians (56%), one registered dietitian (50%), and four physiotherapists (100%) were trained.

Due to high unit strain during the training period, in-service educational sessions were difficult for staff to attend, so the majority of the training was completed with individuals or small groups at the bedside. This brought forward personal narratives and improved staff engagement in the training materials.

Post-Extubation Dysphagia Knowledge

Prior to implementation of the algorithm, 43% of nurses reported that they regularly screened for dysphagia prior to initiating oral intake. Most of their screening methods were informal, involving a trial of water or ice chips and watching for any signs of difficulty (i.e., cough). The results of the post-survey for MSICU staff indicated that 74% of staff could now identify risk factors for PED and that 64% felt comfortable starting oral intake using SAPE. Additionally, 84% of staff now said that they would consider an SLP consult after extubating their patient. Each of these three metrics saw improvements of over 100% from baseline (Table 1).  The MSICU staff felt there needed to be a standard of practice for starting oral intake after extubation, and 90% of survey respondents felt that SAPE met this need. Staff commented that it was a helpful tool both for their own practice, and for educating families about starting oral intake safely.

Table 1

MSICU pre- and post- training results of interdisciplinary staff (N=174)

 Note. PED = Post-Extubation Dysphagia

SAPE Utilization and SLP Referrals

A one-month retrospective chart review from October 2018 revealed that 60% of patients were not referred to SLP despite being intubated for greater than 48 hours or having pre-existing conditions that predisposed them to PED. After SAPE was implemented in the MSICU, an average of 81% of MSICU extubated patients were screened using SAPE, which exceeded the initial project goal of 60% (Figure 2).

Figure 2

Percentage of patients screened over the 5-week SAPE evaluation period in the MSICU

Screening rates rose concurrently with staff training rates, and by the final week of the evaluation period, 100% of extubated patients were screened with SAPE. Fifteen percent of eligible patients were not referred to SLP, despite being identified for referral through SAPE, representing an opportunity for further improvement.          

The implementation of systematic PED screening with SAPE increased the number of patients receiving an SLP consultation to 60%, from only 20% in October 2018 as demonstrated in the run chart in Figure 3. With one run across the midline, occurring from the training period through the post-implementation evaluation period, a non-random pattern is seen. This indicates that the introduction of SAPE influenced an increase in the number of SLP referrals.

Figure 3

Run chart of percentage of extubated patients at risk for PED who received an SLP consultation

This run chart also depicts a reduction in SLP consultations in the final week of evaluation. This decrease may have been due to the miscalculation of the duration of intubation by some staff; wherein, total intubation time was determined by the time of the patient’s arrival in the ICU and excluded intubation for the duration of surgery.

Discussion

SAPE is a decision-making guideline that was developed for use with critically ill patients to help identify risk for PED. It was developed by a multidisciplinary working group representing staff from four diverse ICUs, incorporating elements derived from best evidence in the literature. Creating an algorithm that captured specific considerations for each of these four ICUs made the task more complex due to the heterogeneity of their patient populations. To address this heterogeneity, specific disease states were included based on consensus and available literature. The successful implementation and use of SAPE across multiple critical care units with broadly varying disease etiologies, demonstrates the utility and benefit of such a tool in identification of PED.

There is considerable variability in the awareness, screening, and diagnosis of PED (Marian et al., 2018), despite the fact that systematic screening for PED in the ICU is increasingly supported in the literature (American Association of Critical-Care, 2016; Brodsky et al., 2020; Mandell & Niederman, 2019; Zuercher, Dziewas, et al., 2020; Zuercher, Schenk, et al., 2020). A recent survey of Dutch ICU staff found that 84% of respondents felt that dysphagia was relevant and contributed to increased length of hospital stays and ICU re-admission rates; however, they significantly underestimated the incidence of PED at fewer than 25% of patients (van Snippenburg et al., 2019). Standardized protocols to guide the screening for dysphagia existed in only 22% of hospitals in the Netherlands (van Snippenburg et al., 2019), and only 29 % of American hospitals have clear guidelines on when to involve SLPs in the care of recently extubated patients (Macht et al., 2012). ICUs where guidelines and algorithms for SLPs existed experienced a twofold increase in the number of patients assessed for dysphagia after extubation (Macht et al., 2012).

To date, one validated screening tool for identification of PED exists in a non-homogenous, stable patient population (Johnson et al., 2018). This screening tool, called the Post-Extubation Dysphagia Screening (PEDS) tool, leads nursing staff through decision points similar to our own algorithm. Where these two algorithms differ, however, is that SAPE uses a defined period of prolonged intubation (48 hours) to trigger a referral for SLP assessment whereas PEDS relies on a water swallow screening. SAPE requires mandatory referral to SLP for a formal swallow assessment due to the high incidence of dysphagia in patients intubated greater than 48 hours (Skoretz et al., 2014).

One non-validated tool designed to manage PED in the ICU is the modified Gugging Swallow Screen (GuSS-ICU) (Christensen & Trapl, 2017), which applies to patients intubated greater than 72 hours. The patient must pass ten elements on phase one of the tool and wait 24 hours post-extubation before being considered for swallowing screening. In contrast to this, SAPE allows for consideration for oral intake two hours post-extubation. This is in line with recent research (Marvin et al., 2019) revealing that resumption of oral intake is safe within 2-4 hours post extubation. Therefore, a 24-hour waiting period is unnecessary. Earlier access to oral intake and swallowing rehabilitation has the potential to improve quality of life for patients in the ICU.

Another algorithm used to detect aspiration in critically ill patients has been developed by Moss et al. (2020) based on results of SLP bedside swallow exams (BSE) compared to FEES in patients with acute respiratory failure (defined as patients requiring intubation for greater than 48 hours). Patients with pre-existing neuromuscular disorders, history of dysphagia, diagnosis of head and neck cancer or a related surgery or with a burn injury were excluded. In this study, the majority of participants did not have a BSE until one day after extubation. The resultant algorithm includes five factors: length of intubation, a 2-oz (60 mL) water swallow, APACHE II score, voice quality and patient diagnosis. Moss et al. (2020) identify 200 hours of intubation as the threshold for concern. As it stands, the algorithm does not appear to be intended for use by nurses to screen patients for PED. Rather, the algorithm would guide SLPs as to whether or not a BSE would be sufficient to determine aspiration risk in this patient population.

Compared to these screening tools and algorithms above, SAPE has many benefits for patients and clinicians. SAPE can be applied broadly, by bedside clinicians, to all extubated patients, regardless of diagnosis. It establishes a specific trigger point (48 hours of intubation) after which patients are automatically deemed high risk for dysphagia and are assessed by SLP. It requires a waiting period of two hours only post-extubation. Further, SAPE does not include a water swallow test, as there is poor evidence in the literature that a water swallow screen is effective in capturing aspiration in unstable, critically ill patients with varying underlying diagnoses. Finally, as a result of SAPE training and implementation, nurses reported feeling more confident having clear guidelines for resumption of oral intake for those patients who met criteria. Nurses’ ability to identify risk factors for PED improved and referral rates to SLP for a formal swallow assessment increased. SAPE has also been formally adopted as an official policy in critical care at University Health Network.

Limitations and Future Work

Limitations to our work included the inability to train all staff, as well as variance in how that training was rolled out in the different critical care areas. Training was administered in three of the four ICUs by the unit SLP during the course of the regular workday. Dedicated non-clinical time to provide a more structured and consistent approach to team education was not possible due to resource constraints. As a result of this, not all training outcome data points were collected in a consistent manner across all ICUs. Ensuring that all staff received training was difficult due to the nature of shift work and sick leave, and the regular turnover of fellows and residents in our teaching hospitals. Post implementation data was collected from MSICU RNs, not all of whom may have received the formal SAPE training. As a result, only 64% confidence in initiating oral intake was achieved. Recognizing the importance of detecting PED, SAPE training is now included during the initial orientation of all new critical care nursing staff.  It will need to be incorporated into orientation for other healthcare professionals.

Next steps include research to determine whether the use of SAPE accurately identifies presence or absence of PED, and subsequently reduces incidence of aspiration pneumonia, reintubation, and ICU length of stay. Qualitatively, it should be determined whether the use of SAPE impacts patient/caregiver satisfaction post-extubation. Prospective validation of the algorithm in a heterogeneous critical care population is required.

Conclusion

The Swallowing Algorithm Post-Extubation (SAPE) was developed based on best evidence to identify patients at risk of PED. It has been implemented in four ICUs at two hospital sites within a single tertiary level academic healthcare network. We have determined that, when staff have been trained in the use of this algorithm, nursing awareness of risk factors for PED and confidence in initiating oral intake improve. Moreover, the implementation of SAPE increased rates of referral to SLP and more bedside swallow assessments were performed, with the goal of reducing unnecessary risk when starting oral intake for patients at risk of PED.

Author Notes

Jennifer Barker, Department of Speech Language Pathology, University Health Network; Department of Speech Language Pathology, University of Toronto; Peter Munk Cardiac Centre, University Health Network 

Morgan Davidson, Medical-Surgical Intensive Care Unit, University Health Network; Institute of Health Policy, Management and Evaluation, University of Toronto 

Eddy Fan, Medical-Surgical Intensive Care Unit, University Health Network; Institute of Health Policy, Management and Evaluation, University of Toronto; Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto; Department of Medicine, University Health Network and Sinai Health System 

Shauna Hellen, Department of Speech Language Pathology, University Health Network; Department of Speech Language Pathology, University of Toronto; Medical-Surgical- Neuroscience Intensive Care Unit, University Health Network 

Trish Williams, Department of Speech Language Pathology, University Health Network; Department of Speech Language Pathology, University of Toronto; Medical-Surgical Intensive Care Unit, University Health Network 

This paper features a quality improvement project and ethics approval was waived by the Research Ethics Board of the University Health Network (Waiver 18-0270), based on the ARECCI (A pRoject Ethics Community Consensus Initiative) screening tool. Our quality improvement project follows the SQUIRE 2.0 reporting guidelines (Davidoff et al., 2008; Ogrinc et al., 2016).

Acknowledgements

The authors acknowledge the generous funding of the Sprott Department of Surgery at Toronto General Hospital for its funding of the quality improvement project as a part of the 2018 Collaborative Academic Practice Fellowship Program at the University Health Network. We would also like to thank the ICU nurses and the interdisciplinary members of the working group at University Health Network (UHN) who were involved in this project. We would particularly like to acknowledge the contribution of Clare Fielding, MN, RN, CNCC(C).

Address for Correspondence

Trish Williams, Medical Surgical Intensive Care Unit, Toronto General Hospital, 4EB-316, 200 Elizabeth St, Toronto, ON, M5G 2C4.  Email:  Trish.williams@uhn.ca

Funding and Conflict of Interest

Funding for this project was provided by the Sprott Department of Surgery at Toronto General Hospital as a part of the 2018 Collaborative Academic Practice Fellowship Program at the University Health Network.  The authors have no conflicts of interest to disclose.

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