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Nurse training in dysphagia screening: an innovative online training approach

Logan Hospital. Rachel Lovaszy (1) , Nicola Hall (2) , Jo Farrell (3) , Marnie Seabrook (1) , Maria Schwarz (1,4) , Inger Kwiecien (1) (1) Allied Health, Logan Hospital, Metro South Hospital and Health Service

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Nurse training in dysphagia screening: an innovative online training approach

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  1. Logan Hospital Rachel Lovaszy(1) , Nicola Hall (2) , Jo Farrell (3) , Marnie Seabrook(1) , Maria Schwarz(1,4) , Inger Kwiecien (1) (1) Allied Health, Logan Hospital, Metro South Hospital and Health Service (2) Division of Medicine, Logan Hospital, Metro South Hospital and Health Service (3) Emergency Department, Logan Hospital, Metro South Hospital and Health Service (4) The University of Queensland Nurse training in dysphagia screening: an innovative online training approach

  2. Overview of today’s presentation Clinical issue: Low rate of dysphagia screening for stroke/TIA patients admitted to Logan Hospital Emergency Innovative online approach to clinical training MDT collaboration + Joint nursing and speech pathology-led study investigating: • Nurses’ perceptions of online dysphagia screening training • Nurses’ confidence in dysphagia screening after online training • Clinical outcomes – dysphagia screening rates

  3. RBWH Dysphagia Screening Tool • 5-minute, validated screener for dysphagia • Screens for valid indicators of dysphagia/aspiration e.g. water test, abnormal cough, dysarthria, dysphonia (Daniels et al., 2012) • High degree of accuracy in reporter rating (Cichero et al., 2009) • Reduces risk of pneumonia three-fold • Leads to quick, safer medication administration • Reduces malnutrition, unneeded NGT Screener only – does not replace need for comprehensive swallow assessment by Speech Pathologist

  4. Why is dysphagia screening important in acute stroke care? • Dysphagia is common complication of stroke: • 27 to 78% prevalence of dysphagia post stroke (Guyomard et al., 2009) • High as 80% in brainstem lesions (Meng et al., 2000) • Leads to poorer outcomes for patients • Increased risk of infection (Langdon et al., 2008) • Distress, malnutrition and dehydration (Foley et al.,, 2009) • Higher mortality rate • Higher rate of disability 3 months post discharge (Westergren et al., 2001) • Negative impact on health service delivery: • Longer length of stay – 40.6% increase (Altman et al., 2010; Bonilha et al., 2014) • Financial costs of more complex care provision

  5. Key drivers to improve dysphagia screening “People with acute stroke should have their swallowing screened within four hours of arrival at hospital and before being given any oral food, fluid or medication.” The Australian Clinical Guidelines for Stroke Management: • People with acute stroke should have their swallowing screened, using a validated screening tool, by a trained healthcare professional • Gag reflex is not a validated screening tool • All stroke patients who fail swallow screening or who deteriorate should be assessed by a speech pathologist.

  6. Logan Hospital • 436 bed hospital, non-tertiary • Servicing one of the fastest growing, most culturally diverse regions in Queensland • One of the busiest emergency departments in Queensland • 89,844 emergency presentations annually (2017-2018)

  7. 2017: Low rate of dysphagia screening at Logan Hospital • Only 17.8% of patients screened with nurse-led DST • 59% of stroke/TIA patients administered oral medicationsbefore dysphagia screen /assessment • 37.4%givendiet / fluids before dysphagia screen/ assessment Swallow screen or assessment prior to oral intake: by hospital Logan Hospital vs other hospitals 2017 data Source: AuSCR

  8. Our response to this clinical care issue 2017 ......................................... From May 2018

  9. Online Royal Brisbane Women’s Hospital (RBWH) DST e-learning resource Theory component Online video Online 20-question quiz

  10. New online, collaborative model of DST training • Blended training model – online training + supplementary informal face to face education and written resources • Online • 15-20 minutes • Theory • Watch a video of DST administered • Answer 20 questions • Guide to accessing DST on iEMR • Extra support • Joint nursing and speech pathology education sessions • Voluntary attendance • Logan Hospital-specific FAQs, case studies

  11. Study aims and methodology Did we increase rate of DST training ? DST screening ? What did nurses think about online training? Did nurses feel confident administering a DST after online training? • Prospective survey and observational study design • Online and hardcopy 31-question survey (July 2019) of nursing staff and 22 question online survey of speech pathologists to assess confidence levels in dysphagia screening post training • Monitoring DST training completion rates • A retrospective observational design: • Chart audits to evaluate accuracy of dysphagia screening by nursing staff and compliance with the Stroke Foundation dysphagia management guidelines

  12. Nurses’ perceptions of online DST training

  13. Survey respondents • 82 nurses • Exclusion criteria: did not complete DST training (n =58) • 91% female, 9% male • 75% RNs, 22% CN/CNCs, 3% ENs • 74% in ED, 20% in acute stroke ward, 6% in medical assessment planning unit/demand reliever

  14. Nurse perceptions: training content was relevant 96% of nurses strongly agreed or agreed that the e-learning training content was relevant Source: Survey of nurses perceptions of dysphagia screening e-learning resource

  15. Nurses’ perceptions of online training Top 3 factors that made the DST online training easy to complete • Able to complete online • Time taken to complete (average time 15-20 mins) • Could complete in own time Top 3 factors that made the DST online training difficult to complete • Lack of time during clinical shifts • Difficulty logging on / accessing training • Access to computers Source: Survey of nurses perceptions of dysphagia screening e-learning resource

  16. Nurses’ confidence administering DST after online training

  17. Nurses: Confidence levels administering the DST 75% of nurses surveyed strongly agreed/agreed that they feel confident administering the DST after completing the online training Source: Survey of nurses perceptions of dysphagia screening e-learning resource

  18. Nurses: Highest confidence areas Source: Survey of nurses perceptions of dysphagia screening e-learning resource

  19. Nurses: Least confident areas Source: Survey of nurses perceptions of dysphagia screening e-learning resource

  20. Factors that could improve nursing confidence in DST training • Nurses identified the top five factors that could further improve their confidence administering the DST: • More experience administering the DST with patients • Face to face support • Additional information about the DST specific to Logan Hospital • Watching another nurse administer the DST • Troubleshooting FAQs

  21. Clinical outcomes – did dysphagia screening increase after nurse training?

  22. Clinical outcomes – Increase in dysphagia screening • 124 nurses have completed online dysphagia training since May 2018 Source: AuSCR

  23. Clinical outcomes – Increase in dysphagia screening • 124 nurses have completed online dysphagia training since May 2018 Source: AuSCR

  24. Summary and Next steps Through MDT collaboration and shift to online training: • Increased DST nurse training with flow on increase in DST administered • Online training overcome key barriers e.g. limited time • Nurses feel confident administering DST with ongoing support in specialist areas Next steps • Embedding dysphagia screening – nurse champions and experts • Expansion to other clinical populations • Supplementary face to face education on specialised areas of dysphagia management e.g. thrombolysis • Continued goal towards exceeding benchmark standards

  25. Acknowledgements • Research team, co-investigators and collaborators • Nicola Hall, Clinical Nurse Consultant, Stroke, Logan Hospital • Jo Farrell, Clinical Nurse Consultant, Emergency, Logan Hospital • Murieann Wynne, Clinical Nurse Consultant, Emergency, Logan Hospital • Marnie Seabrook, Speech Pathology, Logan Hospital • Inger Kwiecien, Speech Pathology, Logan Hospital • Maria Schwarz, Speech Pathology, Logan Hospital Contact; Rachel.Lovaszy@health.qld.gov.au • Royal Brisbane Women’s Hospital (RBWH) Dysphagia Screening Tool and e-learning resource • LEAPOnline • Ethics approval HREC/2019/QMS/47989

  26. References Altman, K. W., Yu, G. P., & Schaefer, S. D. (2010). Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Archives of Otolaryngology–Head & Neck Surgery, 136(8), 784-789. AuSCR / AuSDaT Registry for Logan Hospital (2018, 2017). Bonilha, H. S., Simpson, A. N., Ellis, C., Mauldin, P., Martin-Harris, B., & Simpson, K. (2014). The one-year attributable cost of post-stroke dysphagia. Dysphagia, 29(5), 545-552. Bray, B. D., Smith, C. J., Cloud, G. C., Enderby, P., James, M., Paley, L., ... & Rudd, A. G. (2016). The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia. J Neurol Neurosurg Psychiatry, jnnp-2016. Cichero, J. A., Heaton, S., & Bassett, L. (2009). Triaging dysphagia: nurse screening for dysphagia in an acute hospital. Journal of clinical nursing, 18(11), 1649-1659. Daniels, S. K., Anderson, J. A., & Willson, P. C. (2012). Valid items for screening dysphagia risk in patients with stroke: a systematic review. Stroke, 43(3), 892-897. Foley, N. C., Martin, R. E., Salter, K. L., & Teasell, R. W. (2009). A review of the relationship between dysphagia and malnutrition following stroke. Journal of Rehabilitation Medicine, 41(9), 707-713. Guyomard, V., Fulcher, R. A., Redmayne, O., Metcalf, A. K., Potter, J. F., & Myint, P. K. (2009). Effect of dysphasia and dysphagia on inpatient mortality and hospital length of stay: a database study. Journal of the American Geriatrics Society, 57(11), 2101-2106. Meng, N. H., Wang, T. G., & Lien, I. N. (2000). Dysphagia in patients with brainstem stroke: incidence and outcome. American journal of physical medicine & rehabilitation, 79(2), 170-175.

  27. References Langdon, P. C., Lee, A. H., & Binns, C. W. (2007). Dysphagia in acute ischaemic stroke: severity, recovery and relationship to stroke subtype. Journal of Clinical Neuroscience, 14(7), 630-634. Queensland Health (2018). Metro South Hospital and Health Service Annual Report 2017-2018. Sourced online: https://metrosouth.health.qld.gov.au/sites/default/files/msh-annual-report-17-18.pdf Hinchey, J. A., Shephard, T., Furie, K., Smith, D., Wang, D., & Tonn, S. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke, 36(9), 1972-1976. The Stroke Foundation (Australia). (2017). Clinical guidelines for Stroke Management 2017. The Stroke Foundation. Westergren, A., Ohlsson, O., & Hallberg, I. R. (2001). Eating difficulties, complications and nursing interventions during a period of three months after a stroke. Journal of advanced nursing, 35(3), 416-426.

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