The LMH ASSIST pilot trial (Acute Screening of Swallow in Stroke / TIA)

- a multi disciplinary 'evidence into practice' partnership.

Cathi Montague, RN, MClinNsg

NMF, SA Prison Health Service

Evidence into Nursing Practice - Symposium 2011

With acknowledgement to: Linda Nimmo, Patti Holtze and Yvonne HindmanSpeech Pathologists - LMH Speech Pathology Dept.

Background

> Lyell McEwin Hospital, 2006

• 265 funded beds

• ~51000 ED presentations per year

• ~500+ patients per year with 10 CVA / TIA

• ED bed block (48+ hours)

• focus on strategies to actively manage E.D.

overcrowding.

The Problem

> E.D. bed block - delays in patient journey.

> delays to formal speech assessment

> No formal swallow screening process in E.D.

> No weekend speech pathology service

> No formal best practice clinical pathways for stroke care.

The Problem con’t

FedRISKS:

• inconsistent, cursory or no swallow screen

• aspiration / choking / inappropriate diet• unsafe discharge

• ~65% acute stroke patients• Not always assessed• Swallow clearance quality?

• Prolonged recovery• Risk of complications e.g. decubitis ulcer, falls• Length of stay

WHY?

The EBP Process in 5 easy steps!1. Ask a focused question

2. Assess the appropriate evidence

3. Appraise the evidence for validity, impact and precision

4. Apply evidence - account for patient values, preferences, clinical and policy issues.

5. Audit your practiceSchneider et al. 2007 Nursing and Midwifery Research – Methods and appraisal

for evidence based practice 3rd Edition Mosby /Elsevier, New South Wales – based on work by Sackett et al (2000) and Jackson et al (2006)

ETHICS ???

The focussed question - PICO

> Patient Population: • All patients in the E.D. with Stroke / TIA

> Intervention / Area of Interest:• Early standardised screening of swallow

> Comparison Intervention:• No screen, untrained screen or formal screen by speech pathologist

> Outcome desired:• improved swallow screening in this at-risk group.

‘What can be done in the E.D. to minimise swallow-related adverse health outcomes for patients with stroke / TIA?’

Assess and Appraise the Evidence

> Conference presentations in the Speech Pathology field on this topic.

> focus in the speech pathology and medical literature.

> 2000 onwards - development in NSW of consolidated care (bundles) under the TASC banner, including standardised EBP based swallow screen tool for stroke / TIA:

• ASSIST tool.

> Levels of evidence sufficient to implement pilot trial.

Apply the evidence : The Multi-D team

> Speech Pathology

• Director, Speech Pathology team with ED focus.

> ED CSC

• inform Nursing Director

> ED Liaison Nurses x2

> ED Medical Director

• + inform LMH Physicians

> LMH Librarian

• + SALUS

The Process

> 2 phases of the pilot trial

• First ~3months

• Second – next 9 months.

> Communication!

> ASSIST tool

> EDL Nurse education in swallow screen

• Theory and Practical

• Proof of competency

> Education of ED staff and Inpatient Medical teams.

The Audit

> Integral to process

> Provides rigour

> Database review

> Speech Pathology random audit of completed screening forms.

Phase One (First 105 days)

> Only 21% (N=26) of eligible population (n=123) screened by EDLN

> Age range 40 to 90yrs (Medium=71yrs)

> Average wait time to EDLN screen from admission= 8.09hours.

> 25% (n= 15) failed ASSIST at Step 1 (highest risk) and subsequently received Speech Pathology assessment within 24hrs of initial screen.

> Of those, 1 subsequently cleared for normal diet by Speech pathologist.

The Audit – Phase One

Collateral patient populations>Those with a secondary diagnosis of Stroke / TIA were excluded (n=176 in phase 1)

>However the audit process identified these patients who would also benefit from early speech pathology input.

Benefits

Improved profile and multidisciplinary teamwork.

Those patients were safer!

Turn problems into solutions - Ongoing problem identification and problem solving

Identified Problems

> Visibility of service

> Allowed for minor revision of ASSIST tool

> Limitations of hours of cover

> Documentation, communication and education!

> Patients fed inadvertently

> Fasting status didn’t always move with patient

> Visiting Medical staff continuing ‘adhoc’ or no screen

The Audit cont

Phase Two (next 9 months)

>Further 41 patients screened by EDLN• 27% (n=11) Pass• 73% (n=30) Fail

>A number of other patients outside of ASSIST guidelines were initially reviewed and referred for Speech Pathology.

STROKE / TIA?‘THINK SWALLOW’

Final Outcomes

> Speech Pathology and ED Leadership decided not to continue screening by EDLN.

Issues:

Cost vs benefits

Ongoing assessment of nursing competency

Hours of trained nursing staff cover limited

Concerns over role / profession overlap

Right fit?

Ongoing Benefits

> activity capture

> Collateral implementation of ED Allied Health Assessment Team

> EDLN’s as an ongoing ‘expert’ resource

> FASTING armbands

> Demonstrated sensitivity of the ASSIST tool

Take Home Messages

> Evidence into Practice uptake has to remain a focus of healthcare to benefit the patient.

> Solitary discipline approaches will limit approaches to care – whole of patient care demands a whole of team approach.

> Individual health disciplines each bring a unique focus to the table and can prompt new questions.

Take Home Messages con’t

> National standards / guidelines to support best practice.

> Improving the focus can be equally as valuable as the outcomes

> Lateral problems solved along the way also valuable!> Don’t duplicate or replicate - Use your librarians!!> Other great resources – your library, search tools, EBP

websites

QUESTIONS?

‘You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome.’

Robin Williams ‘Patch Adams’