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

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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.