The LMH ASSIST pilot trial (Acute Screening of Swallow in Stroke / TIA) - a multi disciplinary...
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Transcript of The LMH ASSIST pilot trial (Acute Screening of Swallow in Stroke / TIA) - a multi disciplinary...
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’