Development and Pilot Test of a Clinical Swallowing Examination (CSE) Protocol for Telerehabilitaion Delivery of SLP Services

目的：这项研究的首要目标是改善临床上及时吞咽的机会 退伍军人卒中患者的CSE检查及吞咽困难治疗。这项研究的目的 是建立一个可用于语音-语言病理学(SLP)的CSE协议(CSEP) 远程康复服务，意义：及时的CSE对预防相关的吞咽困难至关重要 死亡率、发病率、住院时间延长和医疗费用增加。延误 在SLP服务中，当中风患者在营业时间以外、周末或 在节假日。SLP服务的远程康复具有消除所有机会的巨大潜力 卒中幸存者吞咽困难评估和处理的障碍。具体目标： 研究将涉及3个具体目标：1)开发/完善用于远程SLP实践的CSEP，使用 曼恩吞咽能力评估(MASA)，由一个多学科团队提供 SLP、卒中病房护士和远程卒中顾问；2)建立初步的评分者 远程SLP管理和通过mHealth技术对MASA进行评分之间的可靠性 床边护士便利化与现场SLP同时独立评分 MASA；以及3)在退伍军人管理局NTSP设施内试行Tele-SLP CSEP，以改进mHealth的提供 并确定可行性、可接受性、征聘战略和成果 衡量“CSE服务的及时性”。方法：这是一项探索性研究，使用两种方法 定性与定量相结合的研究方法。这项研究将在退伍军人事务部迈克尔·E·德巴基进行 医疗中心，与退伍军人事务部国家远程中风计划设施的虚拟合作伙伴在 田纳西州默弗里斯伯勒。参加者将包括SLP(N=3)、注册护士(N=20)和 退伍军人(N=55)因中风入院。数据收集/分析程序：用于电信的CSEP- SLP实践将使用MASA开发，MASA是唯一经过验证的、标准化的中风CSE 病人。将采用迭代模拟和汇报方法来建立和记录 为每个MASA项目提供mHealth的最佳技术。基本内容分析将是 适用于代码汇报会议的说明和意见。一次Tele-SLP实践的CSEP是 建立，一个远程SLP和一个护士辅导员，在病人的床边，将完成CSEP 入院治疗中风退伍军人(N=50)。现场SLP也将在床边，并将 对所有患者的反应做出同步但独立的临床判断 使用MASA提供的操作定义的MASA问题/任务。初步 将在远程SLP管理和MASA评分之间建立评分员之间的可靠性 通过具有床边护士便利的mHealth技术和现场SLP同时进行 独立为Masa打分。将为每个Masa计算Cohen的加权kappa 项目包括吞咽困难风险、吸入风险，以及饮食和 工具性评估。CSEP的迭代完善将继续实现适度到 对Masa的所有项目都有强烈的一致意见。在确定初步可靠性的同时 在CSEP中，将反复开发和改进mHealth交付流程。在……里面 为更大规模的实施研究做准备，CSEP将在退伍军人中进行试点测试(N=5) 因中风入院接受退伍军人管理局NTSP治疗。CSEP的可行性/可接受性将是 采用半结构化访谈/问卷的方式，在SLP、护士和病人之间建立。 将记录成功的招聘战略，并及时衡量Tele-SLP 服务将通过图表审查来确定。

Purpose: The overarching goal of this study is to improve access to timely clinical swallowing examination (CSE) and dysphagia treatment in veterans with stroke. The purpose of this study is to establish a CSE protocol (CSEP) that can be used for speech-language pathology (SLP) telerehabilitation services, Significance: A timely CSE is critical to prevent dysphagia related mortality, morbidity, prolonged length of hospitalization, and increased healthcare costs. Delays in SLP services will occur when stroke patients present after business hours, on weekends or during holidays. Telerehabilitation for SLP services has great potential to eliminate all access barriers in dysphagia assessment and management for stroke survivors. Specific Aims: The study will address 3 specific aims: 1) Develop/refine a CSEP for tele-SLP practice using the Mann Assessment of Swallowing Ability (MASA) with input from a multidisciplinary team of SLPs, stroke ward nurses, and telestroke consultants; 2) Establish preliminary inter-rater reliability between a tele-SLP administering and scoring the MASA via mHealth technology with bedside nurse facilitation, versus an on-site SLP simultaneously and independently scoring the MASA; and 3) Pilot the tele-SLP CSEP within a VA NTSP facility to refine mHealth delivery processes and to establish feasibility, acceptability, recruitment strategies and outcome measurements for ‘timely CSE services. Methods: This is an exploratory study using both qualitative and quantitative methods. The study will be conducted at the Michael E. DeBakey VA Medical Center, with virtual partners at the VA National TeleStroke Program facility in Murfreesboro, Tennessee. Participant will include SLPs (N=3), registered nurses (N=20) and veterans (N=55) admitted with stroke. Data Collection/Analysis Procedures: The CSEP for tele- SLP practice will be developed using the MASA, the only validated, standardized CSE for stroke patients. Iterative simulation and debrief methods will be applied to establish and document optimal techniques for mHealth delivery of each MASA item. Basic content analysis will be applied to code debrief session notes and observations. Once a CSEP for tele-SLP practice is established, a tele-SLP and a nurse facilitator, at the patient’s bedside, will complete the CSEP on veterans admitted with stroke (N=50). An on-site SLP will also be at the bedside and will make simultaneous but independent clinical judgements concerning patient responses to all MASA questions/tasks using the operational definitions provided by the MASA. Preliminary inter-rater reliability will be established between a tele-SLP administering and scoring the MASA via mHealth technology with bedside nurse facilitation and an on-site SLP simultaneously and independently scoring the MASA. Cohen’s weighted kappa will be calculated for each MASA item including dysphagia risk, aspiration risk, as well as recommendations for diet and instrumental assessment. Iterative refinement of the CSEP will continue to achieve moderate to strong agreement for all items of the MASA. Simultaneous to establishing preliminary reliability of the CSEP, mHealth delivery processes will be iteratively developed and refined. In preparation for a larger implementation study, the CSEP will be pilot tested in veterans (N=5) admitted with stroke in a VA NTSP facility. Feasibility/acceptability of the CSEP will be established among SLPs, nurses and patients using semi-structured interviews/questionnaires. Successful recruitment strategies will be documented and measurement of timely tele-SLP services will be determined via chart review.