Swallowing Screening

Swallowing screening is a minimally invasive procedure that enable quick determination of

• the likelihood that dysphagia exists,
• whether the patient requires referral for further swallowing assessment, and
• whether the patient requires referral for nutritional or hydrational support.

Swallowing screening procedures indicate the presence of clinical signs and symptoms that may be indicators of dysphagia, with a focus on identifying overt signs of aspiration.

It is important to note that, currently, no bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several tools have demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols have not been established (O’Horo et al., 2015).

There is no preferred dysphagia screening procedure. Screening procedures are usually used to determine the possible presence of dysphagia and the need for further investigation.

Screening Procedures

Screening procedures may include the following:

• Questionnaires or interviews with the patient and/or caregiver to ask whether they are aware of any past or current swallowing difficulties (Mari et al., 1997).
• Medical history review for etiological risk categories (Mari et al., 1997).
• Observation of patient’s level of alertness.
• Assessment of volitional cough and assessment of secretion management.
• Evaluation of gag reflex or pharyngeal sensation (Kidd et al., 1993).
• Observation for overt signs of cough or other difficulty during planned trial swallows (e.g., water) or routine oral intake (Kidd et al., 1993).
• Observation of the patient for combinations of specific clinical signs from oral motor and speech motor examinations, as well as trial swallows with water (Daniels et al., 2000; Logemann et al., 1999).
• Use of decision-making algorithms considering several factors (Runions et al., 2004).
• Observation of occurrence of cough during or following water swallows (DePippo, Holas, & Reding, 1994; Kidd et al., 1993). Water swallow tests may be one of the following standardized protocols:
  • Burke Dysphagia Screening Test (DePippo, Holas, Reding, Mandel, & Lesser, 1994)
  • Yale Swallow Protocol (Leder & Suiter, 2014) including 3 oz. water swallow test
  • Timed Water Swallow Test (Hughes & Wiles, 1996)
• Observation of changes in voice quality post swallow as a potential marker for aspiration (Ryu et al., 2004; Warms & Richards, 2000).
• Assessment of the patient’s laryngeal cough reflex; in this assessment, the SLP looks for a cough response to inhalation of tartaric acid as a marker of the integrity of laryngeal sensation (Addington et al., 1999).
• Swallowing screening protocols such as these:
  • Toronto Bedside Swallowing Screening Test (TOR-BSST; Martino et al., 2009)
  • Simple Standardized Bedside Swallowing Assessment (SSA; Perry, 2001)

For further information regarding screening procedures for patients with stroke, see Summary of the Systematic Review in the ASHA Evidence Maps.

If there is an indication of increased risk of dysphagia, then the screening procedure is typically terminated and a referral to speech-language pathology is initiated for comprehensive swallowing assessment. It is common for precautions (e.g., dietary precautions, no oral intake) to be put into place while the patient is waiting for further assessment.

Potential Models of Swallowing Screening

There are several potential models for swallowing screening, many of which involve collaboration with other members of the clinical team. Some approaches include the following: 

• The SLP trains nursing staff to conduct swallowing screenings. Nursing staff performs swallowing screenings and refers patients with swallowing problems to an SLP for a comprehensive swallowing assessment. For a specific example of this model, see Steele (2002).
• The physician performs swallowing screening during a regular medical evaluation and requests that the SLP conduct further swallowing assessment upon noting signs of swallowing difficulty.
• Either the nursing staff or the physician completes swallowing screening, followed by automatic referral within a specific timeframe (e.g., 24–48 hours) for SLP assessment. This swallowing screening
  • may be used for a specific diagnosis (e.g., used in acute stroke unit),
  • may include an ongoing training module for nurses, and
  • may include various in-services presented to the clinical team.
• All patients are automatically referred to an SLP for assessment.
• Nursing staff contacts the SLP, as needed, to screen patients at risk for dysphagia.

Considerations on Screening/Documentation

Trained medical professionals should be available 24 hours a day, 7 days a week to complete screenings. A delay in screening the patient for safety of oral intake can delay administration of oral medications. The emergency department physician, admitting physician, or nursing staff might be selected to complete the screening. If the speech-language pathology staff are selected to perform the screening, procedures will have to be established to ensure timeliness. Policies and procedures for documenting the results of swallowing screening should be established by the facility.

Training

Training other professionals refers to educating non-SLP clinical staff (e.g., nursing) to conduct swallowing screening. Such education could lead to earlier identification of dysphagia and referrals for further SLP evaluation. If the SLP is to conduct the initial swallowing screening, then expertise in the area of dysphagia and familiarity with current literature should suffice in order to conduct a competent swallowing screening at bedside. If the screening is to be conducted by other health care personnel (e.g., nurse, physician), training requirements will vary by facility. A competency evaluation should be included in the training process. The SLP’s involvement might include monitoring quality outcomes for the screening program. If the SLP is to be the primary trainer, then the content of the training will depend on the model or protocol that will be employed. A basic description of the anatomy and physiology of deglutition—as well as a list of the signs and symptoms of dysphagia—are usually included in any training program.

Cross-training refers to specific training provided to service providers (e.g., SLPs) in a department or capacity in which they do not typically work.

Role of the SLP

SLPs should be involved in establishing dysphagia screening programs, as the SLP is the preferred provider of dysphagia treatment and diagnosis. SLPs should make evidence-based decisions as they work with a facility to design a screening program.

The SLP may initially contact nursing administration to discuss the role of nursing staff in designing a screening program. The process may also be initiated as a joint/interdisciplinary performance improvement project. The SLP may also contact the medical education office and identify which physicians or specialists might be appropriate for a discussion of this nature. In some instances, the most appropriate party may be a senior medical resident or the chair of the neurology service. It is important for the SLP to contact key players among nursing and physician staff. Initial calls and/or meetings may serve to further guide the process of development and/or implementation.

The SLP department might analyze patient data to determine the following data points:

• How many patients who survived a cerebrovascular accident (CVA) were admitted?
• How many patients were kept NPO until screened for dysphagia?
  • What was the average duration of time between admission and dysphagia screening?
• How many patients were referred to speech-language pathology for a complete swallowing evaluation?
  • How much time elapsed between referral generation and SLP evaluation?
• How many patients were referred for instrumental assessment following their initial screening or bedside evaluation?
  • Of those who received instrumental assessment, in how many cases did the instrumental assessment contradict or change (a) the findings and/or (b) the recommendations from the initial screening and/or bedside assessment?
• How many patients experienced specific complications related to dysphagia (e.g., aspiration pneumonia)? Of those,
  • how many were kept NPO until screening and
  • how many were evaluated by the department?

References

Addington, W. R., Stephens, R. E., & Gilliland, K. A. (1999). Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: An interhospital comparison. Stroke, 30(6), 1203–1207. https://doi.org/10.1161/01.str.30.6.1203

Daniels, S. K., Ballo, L. A., Mahoney, M. C., & Foundas, A. L. (2000). Clinical predictors of dysphagia and aspiration risk: Outcome measures in acute stroke patients. Archives of Physical Medicine and Rehabilitation, 81(8), https://doi.org/1030-1033.10.1053/apmr.2000.6301

DePippo, K. L., Holas, M. A., & Reding, M. J. (1994). The Burke dysphagia screening test: Validation of its use in patients with stroke. Archives of Physical Medicine and Rehabilitation, 75(12), 1284–1286.

DePippo, K. L., Holas, M. A., Reding, M. J., Mandel, F. S., & Lesser, M. L. (1994). Dysphagia therapy following stroke: A controlled trial. Neurology, 44(9), 1655–1660. https://doi.org/10.1212/wnl.44.9.1655

Hughes, T. A. T., & Wiles, C. M. (1996). Clinical measurement of swallowing in health and in neurogenic dysphagia. Quarterly Journal of Medicine, 89(2), 109–116. https://doi.org/10.1093/qjmed/89.2.109

Kidd, D., Lawson, J., Nesbitt, R., & MacMahon, J. (1993). Aspiration in acute stroke: A clinical study with videofluoroscopy. Quarterly Journal of Medicine, 86(12), 825–829.

Leder, S. B., & Suiter, D. M. (2014). The Yale Swallow Protocol: An evidence-based approach to decision making. Springer.

Logemann, J. A., Veis, S., & Colangelo, L. (1999). A screening procedure for oropharyngeal dysphagia. Dysphagia, 14(1), 44–51. https://doi.org/10.1007/PL00009583

Mari, F., Matei, M., Ceravolo, M. G., Pisani, A., Montesi, A., & Provinciali, L. (1997). Predictive value of clinical indices in detecting aspiration in patients with neurological disorders. Journal of Neurology, Neurosurgery, and Psychiatry, 63(4), 456–460.

Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D. L., & Diamant, N. E. (2009). The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and validation of a dysphagia screening tool for patients with stroke. Stroke, 40(2), 555–561. https://doi.org/10.1161/STROKEAHA.107.510370

O’Horo, J. C., Rogus-Pulia, N., Garcia-Arguello, L., Robbins, J. A., & Safdar, N. (2015). Bedside diagnosis of dysphagia: A systematic review. Journal of Hospital Medicine, 10(4), 256–265. https://doi.org/10.1002/jhm.2313

Perry, L. (2001). Screening swallowing function of patients with acute stroke. Part two: Detailed evaluation of the tool used by nurses. Journal of Clinical Nursing, 10(4), 474–481. https://doi.org/10.1046/j.1365-2702.2001.00502.x

Runions, S., Rodrigue, N., & White, C. (2004). Practice on an acute stroke unit after implementation of a decision-making algorithm for dietary management of dysphagia. Journal of Neuroscience Nursing, 36(4), 200–207. https://doi.org/10.1097/01376517-200408000-00006

Ryu, J. S., Park, S. R., & Choi, K. H. (2004). Prediction of laryngeal aspiration using voice analysis. American Journal of Physical Medicine and Rehabilitation, 83(10), 753–757. https://doi.org/10.1097/01.phm.0000140798.97706.a5

Steele, C. M. (2002, Summer). Emergency room assessment and intervention for dysphagia: A pilot project. Journal of Speech-Language Pathology & Audiology, 26(2), 100–110. https://tspace.library.utoronto.ca/handle/1807/17524

Warms, T., & Richards, J. (2000). “Wet voice” as a predictor of penetration and aspiration in oropharyngeal dysphagia. Dysphagia, 15(2), 84–88. https://doi.org/10.1007/s004550010005