Development and Validation of a VA Stroke Swallowing Screening Tool

描述（由申请人提供）： 急性卒中吞咽困难的早期检测至关重要，因为它允许立即干预，从而降低死亡率、发病率、住院时间和医疗费用。在出现中风症状的个体中，在给予食物、液体或药物（包括阿司匹林）之前进行吞咽筛查是美国心脏协会/美国中风协会的指导方针。根据这一指南，退伍军人健康管理局（VHA）提倡吞咽筛查是急性卒中的一项质量性能指标。此外，监察长办公室最近发布了VHA指令2006- 032，规定最初的护士评估必须包括吞咽筛查。作为对该指令的回应，许多VHA机构创建并实施了一些版本的护理吞咽筛查工具（SST），但据我们所知，没有一个使用仪器吞咽检查进行验证，也没有建立可靠性。在为卒中患者开发和建立有效且可重现的SST时，临床医生对是否需要将试验性吞咽水作为SST的一部分存在分歧。目前的观点是，由没有吞咽困难专业知识的学科进行试验吞咽会危及患者安全，因此这一步骤遭到许多语言病理学家和护士的反对。引入未经验证、不可重现的SST的谨慎性值得怀疑。本研究的主要目的是构建一个可靠和有效的SST，以确定疑似卒中患者的吞咽困难风险。这项建议的具体目标是：1）确定护士是否可以对吞咽和非吞咽特征做出可靠的评分者间判断，这些特征历史上被语言病理学家用来判断误吸，和2）确定在吞咽困难风险识别中提供最高水平灵敏度和特异性的项目组合，如通过视频荧光透视吞咽研究（VFSS）测量的在疑似中风的患者中。本研究的结果将告知执行一个多站点的可行性研究，由护士实施一个可靠和有效的SST方法：将招募疑似中风患者（N = 270）参加。个人将接受吞咽筛查和VFSS。筛选项目的选择是基于使用科克伦和QUADAS指南进行的广泛文献综述，用于确认有卒中症状的患者吞咽困难的风险。将测试8个筛选项目的有效性和评分者间可靠性：6个非吞咽特征和2个吞咽特征。所有受试者将完成每个筛选项目护理观察的可靠性。具有卒中高级实践技能并接受过筛选项目培训的执业护士将作为参考标准，与在卒中患者医院病房常规工作的注册护士进行可靠性比较。 公共卫生相关性： 中风在美国是一个主要的医疗问题，退伍军人面临着很大的风险，因为中风的最关键的风险因素，老年和相关的医疗问题，如高血压，是常见的。吞咽困难，吞咽问题，是中风后残疾的主要来源，影响生活质量，营养，水合作用和肺部状态。开发和实施一种准确一致的吞咽筛查工具来识别疑似卒中患者的吞咽困难风险至关重要，因为它允许立即干预，从而减少相关的医疗并发症、住院时间和医疗费用。然而，这种筛选工具的可用性有限。本研究的主要目的是建立一个可靠和有效的吞咽筛查工具，以确定吞咽困难的风险，在个人承认怀疑中风。

DESCRIPTION (provided by applicant): Early detection of dysphagia in acute stroke is critical as it allows for immediate intervention, thereby reducing mortality, morbidity, length of hospitalization, and healthcare costs. Screening of swallowing prior to the administration of food, liquid or medication, including aspirin, in individuals presenting with stroke symptoms is a guideline American Heart Association/American Stroke Association. In accordance with this guideline, the Veterans Health Administration (VHA) has advocated the screening of swallowing be a quality performance measure in acute stroke. Moreover, the Office of the Inspector General recently issued VHA Directive 2006- 032 mandating that the initial nurse assessment must include a screening of swallowing. In response to the directive, many VHA facilities created and implemented some version of a nursing swallowing screening tool (SST), but to our knowledge, none have been validated using an instrumental swallowing examination nor has reliability been established. In developing and establishing a valid and reproducible SST for patients with stroke, clinicians are divided on the need to include trial water swallows as part of the SST. The current notion is that administering trial swallows by disciplines without expertise in dysphagia would compromise patient safety, thus this step is opposed by many speech pathologists and nurses. The prudency of introducing non- validated, non-reproducible SSTs is questionable. The primary objective of this study is to construct a reliable and valid SST to identify risk of dysphagia in individuals admitted with suspected stroke. The specific aims of this proposal are to: 1) determine if nurses can make reliable inter-rater judgments of swallowing and nonswallowing features historically used by speech pathologists to make judgments of aspiration, and 2) identify the combination of items that provide the highest level of both sensitivity and specificity in the identification of dysphagia risk as measured by a videofluoroscopic swallow study (VFSS) in individuals admitted with suspected stroke. Outcomes of this research will inform as to the execution of a multi-site feasibility study on the implementation of a reliable and valid SST by nurses Methods: Consecutive individuals admitted with suspected stroke (N = 270) will be recruited to participate. Individuals will undergo screening of swallowing and a VFSS. Screening items selected for validation in the identification of risk of dysphagia in patients presenting with stroke symptoms were based on extensive literature review using Cochrane and QUADAS guidelines. Eight screening items will be tested for validity and inter-rater reliability: 6 nonswallowing features and 2 swallowing features. Reliability in nursing observations of each screening item will be completed in all participants. Nurse practitioners with advanced practice skills in stroke and trained in the screening items will serve as the reference standard from which to compare reliability with registered nurses who routinely work on the hospital ward with stroke patients. PUBLIC HEALTH RELEVANCE: Stroke is a major medical problem in the United States, and veterans are at significant risk given that the most critical risk factors of stroke, older age and associated medical problems such as high blood pressure, are common. Dysphagia, swallowing problems, are a major source of disability following stroke affecting quality of life, nutrition, hydration, and pulmonary status. Development and implementation of an accurate and consistent nursing swallowing screening tool to identify risk of dysphagia in individuals admitted with suspected stroke is critical as it allows for immediate intervention, thereby reducing associated medical complications, length of stay, and healthcare costs. The availability of such screening tools, however, is limited. The primary objective of this study is to construct a reliable and valid swallowing screening tool to identify risk of dysphagia in individuals admitted with suspected stroke.