Development and Validation of a VA Stroke Swallowing Screening Tool

描述(由申请人提供)： 早期发现急性卒中的吞咽困难至关重要，因为它允许立即进行干预，从而降低死亡率、发病率、住院时间和医疗成本。美国心脏协会/美国中风协会的指导方针是，在服用食物、液体或药物(包括阿司匹林)之前对出现中风症状的人进行吞咽筛查。根据这一指导方针，退伍军人健康管理局(VHA)倡导将吞咽筛查作为急性卒中的一项高质量表现衡量标准。此外，监察长办公室最近发布了VHA指令2006-032，要求最初的护士评估必须包括对吞咽的筛查。为了响应这一指令，许多VHA机构创建并实施了某种版本的护理吞咽筛查工具(SST)，但据我们所知，尚未使用仪器吞咽检查进行验证，也没有建立可靠性。在为中风患者开发和建立有效和可重复的SST的过程中，临床医生对是否需要将水燕试验作为SST的一部分存在分歧。目前的观点是，在没有吞咽困难专业知识的情况下，由学科进行试验吞咽会危及患者的安全，因此这一步骤遭到许多言语病理学家和护士的反对。引入未经验证、不可复制的SST的审慎程度值得怀疑。这项研究的主要目的是建立一个可靠和有效的SST来确定可疑中风患者吞咽困难的风险。这项建议的具体目的是：1)确定护士是否可以在评价员之间对吞咽和非吞咽特征做出可靠的判断，语言病理学家历来使用这些特征来判断吸入；以及2)确定在通过视频透视吞咽研究(VFSS)对入院的疑似中风患者进行吞咽困难风险识别时提供最高灵敏度和特异度的项目组合。这项研究的结果将为护士实施可靠和有效的SST的多地点可行性研究提供参考。方法：将招募连续的疑似中风患者(N=270)参与。个人将接受吞咽和VFSS的筛查。根据Cochrane和QUADAS指南进行的广泛文献回顾，筛选出用于确认有中风症状的患者吞咽困难风险的有效项目。将测试8个筛选项目的有效性和评分者之间的可靠性：6个非吞咽功能和2个吞咽功能。每个筛查项目的护理观察的可靠性将在所有参与者中完成。具有先进的中风实践技能并接受过筛查项目培训的护士从业者将作为参考标准，将其与经常在医院病房为中风患者工作的注册护士的可靠性进行比较。

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.