Abstract
There is a clear need for improved clinical identification of all acutely ill hospitalized patients at risk for aspiration. In 2016, a 1,100-bed quaternary-care facility found an upward trend in mortality rates with diagnoses of aspiration from years 2013 to 2015. An aspiration risk screening process was implemented to increase timely involvement of a dysphagia therapist. Current mortality data indicates that this change increases patient safety by timely involvement of dysphagia therapists.
Primary Author and Speaker: Gina Pifer
Additional Authors and Speakers: Janelle Hatlevig
Contributing Authors: Tina Wangen, Kirsten Vitale
Dysphagia and aspiration are major nosocomial complications in which dysphagia represents a predisposing factor for aspiration; there is a clear need for improved clinical identification of all acutely ill hospitalized patients at risk for aspiration, not just patients with neurologic conditions (Festic et al., 2016). Aspiration pneumonia related to dysphagia is a major nosocomial complication that can have vast negative health care implications on patients, caregivers, staff, and the hospital system. The National Quality Forum and the Agency for Healthcare Research and Quality suggests an aspiration risk evaluation upon admission and regularly thereafter of each patient (Pennsylvania Patient Safety Advisory, 2009).
In 2016, a 1,100 bed Midwestern quaternary care facility found an increasing trend in mortality rates with acquired diagnoses of aspiration from years 2013-2015. A multidisciplinary group which included occupational therapists was formed to analyze this trend through quasi-experimental design and to make clinical changes from the results to reduce these rates. The safest and most cost-effective solutions were to identify those at risk and implement a valid screening tool for the nursing staff. Upon extensive review of bedside screening tools, the Massey Bedside Swallow Screening (MBSS) tool was selected for use. An aspiration risk screening process that combined the American College of Chest Physicians (ACCP) practice guidelines with the institution’s internal mortality data findings was completed prior to use of the MBSS to increase early identification of patients at risk for aspirating.
The purpose of this study was to investigate if enhanced screening procedures would decrease aspiration rates within an acute care hospital. The intervention, or screening for aspiration using the MBSS, was performed in two steps. The first step assesses for risk using a risk list in the electronic medical record (EMR) and documenting the patient’s risk. It includes a screening process that combined the ACCP practice guidelines and the institution’s internal mortality data findings. This intervention was performed on all adult direct admissions to General Care Units, Progressive Care Units, and Intensive Care Units (ICU), but excluded patients in the Emergency Department (ED) and AM admission areas of surgical and same day surgery patients. This screening process was embedded in the nursing EMR for aspiration screening with the MBSS. If a patient meets one or more of the criteria, the registered nurse (RN) would proceed to the second step of screening and perform the MBSS. This screening process triggered timelier and more medically necessary dysphagia interventions from occupational and speech therapists. Data was collected through the EMR, occupational and speech referral rates, and hospital mortality data.
After implementation of the MBSS throughout the hospital, the institution’s mortality data reported zero deaths attributed to aspiration in 2016 and into 2017. These results prove promising that the identification process through implementation of the screening tool and timelier interventions from dysphagia therapists are effective solutions to reducing mortality rates related to aspiration pneumonia in acute care hospitals, which is one of the quality indicators of our national health care system.
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