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

目的：本研究的总体目标是改善及时临床吞咽的机会 中风退伍军人的检查（CSE）和吞咽困难治疗。本研究的目的 是建立一个可用于言语病理学（SLP）的CSE协议（CSEP） 远程康复服务，意义：及时的 CSE 对于预防吞咽困难相关的至关重要 死亡率、发病率、住院时间延长以及医疗费用增加。延误 当中风患者在工作时间外、周末或在 SLP 服务中出现时 假期期间。 SLP 服务的远程康复具有消除所有访问的巨大潜力 中风幸存者吞咽困难评估和管理的障碍。具体目标： 研究将解决 3 个具体目标： 1) 使用以下方法开发/完善用于远程 SLP 实践的 CSEP 曼恩吞咽能力评估 (MASA)，由多学科团队提供意见 SLP、中风病房护士和远程中风顾问； 2) 建立初步的内部评估者 远程 SLP 通过 mHealth 技术对 MASA 进行管理和评分之间的可靠性 床边护士协助，与现场 SLP 同时独立评分 玛萨； 3) 在 VA NTSP 设施内试点远程 SLP CSEP，以完善移动医疗服务 流程并建立可行性、可接受性、招聘策略和结果 “及时的 CSE 服务”的测量。方法：这是一项探索性研究，使用了 定性和定量方法。该研究将在弗吉尼亚州迈克尔·E·德贝基 (Michael E. DeBakey) 研究所进行 医疗中心，与位于 VA 国家 TeleStroke 计划设施的虚拟合作伙伴 田纳西州默弗里斯伯勒。参与者将包括 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：用于远程的 CSEP SLP 实践将使用 MASA 进行开发，MASA 是唯一经过验证的标准化中风 CSE 患者。将应用迭代模拟和汇报方法来建立和记录 每个 MASA 项目的 mHealth 交付的最佳技术。基本内容分析将 适用于代码汇报会议笔记和观察。一旦用于远程 SLP 实践的 CSEP 一旦建立，远程 SLP 和护士协调员将在患者床边完成 CSEP 因中风入院的退伍军人 (N=50)。现场 SLP 也将位于床边，并将 对患者对所有药物的反应做出同时但独立的临床判断 MASA 使用 MASA 提供的操作定义提出问题/任务。初步 将在远程 SLP 管理和评分 MASA 之间建立评估者间的可靠性 通过 mHealth 技术，同时提供床边护士协助和现场 SLP， 独立评分 MASA。将为每个 MASA 计算 Cohen 加权 kappa 项目包括吞咽困难风险、误吸风险以及饮食和建议 仪器评估。 CSEP的迭代细化将继续实现中等到 对 MASA 的所有项目都达成了强有力的协议。建立初步可靠性的同时 在 CSEP 的基础上，移动医疗交付流程将得到迭代开发和完善。在 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) 因中风入住 VA NTSP 机构。 CSEP 的可行性/可接受性将 使用半结构化访谈/问卷调查在 SLP、护士和患者之间建立。 将记录成功的招聘策略并及时衡量远程 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.