Background: After stroke, up to 65 percent of stroke patients suffer dysphagia, with increased risk of aspiration pneumonia and disability. Aspiration risk is reduced by swallow assessment on every acute ischemic stroke (AIS) prior to medication or food intake. Annually, about 88,000 patients enter the Cedars-Sinai Emergency Department (ED). Although only 1% of these patients are AIS, 100% of these patients require a swallow screen. In busy EDs where stroke is infrequent, swallow screens are missed. Jointly with our ED Educator and our Electronic Information Systems (EIS) application specialist we created a user-friendly, reliable solution to improve swallow screen compliance in the ED.
Purpose: To implement a valid swallow screening tool and optimize nurse awareness and compliance in a busy, urban ED.
Method: We emphasized educating and listening to staff concerns and requests and collaboration with EIS. The Barnes Jewish Hospital stroke screening tool is a validated, evidence based screening tool for assessing swallowing. We defined “fall outs” as patients who received anything by mouth prior to a swallow assessment. EIS created an electronic alert linked to chief complaints that fired in response to a wide range of stroke symptoms. The alert was also linked to the medication administration record.
Result: Prior to deployment, fall outs ranged from 40 to 65% of cases. Following deployment of the alert fall out numbers decreased (see graph) significantly (Chi-Square p<0.001 for trend), despite an overall increase in AIS volumes. While education was somewhat successful, linking the alert to the MAR prompted the nurse to complete the swallow screen prior to administering oral medications.
Conclusion: We successfully improved ED compliance with swallow screening in a busy urban ED in which AIS represents less than 1% of the annual volume. A similar strategy should work well in a variety of other hospitals and medical centers.