Abstract 46: An Innovative Approach to the Bedside Nursing Swallow Screening Tool: Can Be Used as a Trigger for an Inpatient Cognitive Evaluation to Improve Timeliness of Post-Discharge Cognitive Therapy Referrals

Background: According to the American Heart Association, a formal assessment of cognitive dysfunction caused by stroke is a level I recommendation. However, cognitive evaluation is often missed or overlooked in the inpatient setting. When and who performs the assessment is not well-defined. Stroke nurses can corroborate with clinicians in completing the Montreal Cognitive Assessment (MoCA) 8.1, a validated tool for assessing cognitive function in stroke patients. Purpose: The purpose of this study was to evaluate the process of using the bedside nursing swallow screen (NSS) as a trigger for an inpatient cognitive evaluation by the Speech Therapist (ST). This study was also used to determine if post-discharge cognitive therapy referrals were placed based on the MoCA scores. Methods: All STs completed the required MoCA certification. The new process was implemented in October 2019. Data were analyzed from October 2019 through March 2020. NSS was performed on newly admitted stroke patients. If failed, an ST consult was ordered for a dysphagia evaluation. However, if passed, a cognitive evaluation consult was triggered by the RN. MoCA was completed within 24 hours. The total possible score is 30; a score of 26 or above is considered normal. A MoCA score of 25 or less, prompted a post-discharge cognitive therapy referral. Results: 229 patients were assessed, all of whom had an NSS completed. 120 (52.4%) passed the NSS, of which 85 (71%) completed a MoCA evaluation. 42 (49.4%) scored 25 or less, of which 35 (83.3%) were referred for a post-discharge cognitive therapy. 7 (17%) had no referral, of which 4 (57%) were discharged home to self-care; 2 (29%) discharged to other healthcare facility; and 1 (14%) left against medical advice. Conclusions: Repurposing the NSS as a standardized tool to trigger an inpatient MoCA evaluation was innovative, practical and efficient. Timely post-discharge cognitive therapy referrals were also evident on MoCA scores of 25 or less.

254 An Audit of the Frequency of Early Swallow Screens Performed in Patients Diagnosed with a Stroke

Background The National Stroke Audit 2015 showed that Ireland had made great advances in stroke care but one notable area of deficiency was in access to early swallow screening (within 4 hours). An early swallow screen is recommended by the Royal College of Physicians Stroke Guidelines (2016) to minimise the risk of aspiration pneumonia. The National Guideline for Swallow Screening in Stroke was released in May 2017 and outlines the need to have staff who are trained in swallow screening available 24/7. This audit aimed to evaluate the percentage of stroke patients in our hospital who received a documented swallow screen within 4 hours of admission. Methods Data relating to swallow screens/assessments and the time in which they were performed was extracted from our hospital’s HIPE database. The sample size included all confirmed strokes seen by the stroke service in our hospital in the first 6 months of 2018 (1/1/2018- 30/06/2018 inclusive). This amounted to 78 patients. Results In our hospital >90% of patients diagnosed with stroke get admitted to our stroke unit. Of the 78 patients, 38 (48.1%) had a documented swallow screen/assessment during admission, 27 did not have a documented swallow screen/assessment (34.2%) and for 14 patients (17.7%) it was unclear whether they had one during admission. Of the 38 patients who had documented swallow screens/assessments during admission 5 (13.2%) of these occurred within 4 hours of admission. Conclusion In summary while our hospital is succeeding in getting the vast majority of diagnosed strokes into our stroke unit we are not currently meeting the UK target for early swallow screening. We aim to roll out an education and training programme targeting nurses and doctors in our stroke unit regarding early swallow screening and re-audit this in 6-12 month’s time.

297 Re-audit of Swallow Assessment in Acute Stroke Patients Following Introduction of a Full-time Speech Specialist

Background The National Clinical Guidelines and Recommendations for the Care of People with Stroke recommend that if an initial screen of a patient with an acute stroke indicates swallowing difficulties, the patient should have a specialist swallow assessment within 24 hours of admission and not more than 72 hours afterwards. The aim of this audit was to reassess the rate of specialist assessment in this patient group following the introduction of a full-time speech specialist in an acute hospital. Methods This was a clinical audit where all patients who presented with acute stroke, where initial swallow screening indicated problems were reviewed. Data was collected from medical records over a twelve week period from January 2019-April 2019. Results Twenty patients presented with an acute stroke, with initial assessment indicating swallow problems; 12 male, 8 female. Mean age was 72 years (ranging from 41 to 96). Eight of these were seen by a speech and language therapist (SALT) within 72 hours; 7 were assessed by SALT <24 hours and 1 was assessed within the 48-72-hour window. Of those seen by SALT; -2 were placed on a normal diet, 2 nil by mouth (NPO), 4 were placed on a modified diet. Two patients were reassessed (3 and 2 times respectively). Of the patients assessed by SALT, 1 passed away and 7 were discharged home (2 referred to community SALT follow-up). When compared with a previous audit in 2018, swallow assessment by SALT < 72 hours has increased from 14% to 40%. The National Stroke Audit has recorded rates of 37%. Conclusion Introduction of a full-time speech and language specialist has increased the rates of swallow assessment in line with the national average. The overall rates of SALT interventions in dietary regimens highlights the need to increase overall assessment rates in patients with acute stroke.

268 Can the Swallow Screening Component of a Frailty Assessment be Used to Reliably Direct Clinical Dysphagia Assessment Referrals?

Background The prevalence of dysphagia rises with age. It is associated with increased dependency and mortality (Smithard, 2016). The Irish Association of Speech & Language Therapists (IASLT) only supports swallow screening by trained nursing staff post stroke in acute care settings. Further research is required to establish its use with other clinical populations (IASLT, 2016). This study was performed to evaluate the use of a swallow screening tool by an interdisciplinary integrated team to identify frail older patients who require a clinical dysphagia assessment. Methods This was a prospective cohort study (N=177) of patients admitted through an acute hospital emergency department, between November 2018 and February 2019, 70 years or older, in an acute setting, who were identified as frail based on the Variable Indicative of Placement. The number of patients referred to SLT due to a positive swallow screen on CGA, conducted by a trained interdisciplinary team was compared with the number referred by the patient’s primary team. The criteria for dysphagia positive score was to answer yes to any of the swallow screen questions, which were based on risk factors for dysphagia. Results Of 177 patients, 47 (26%) screened positive for risk of dysphagia by the interdisciplinary team. Eight, who screened negative for risk of dysphagia, were referred by the patient’s primary team. One out of eight who screened negative, required a diet modification based on an SLT assessment. Conclusion A trained interdisciplinary frailty team can reliably screen for and identify risk of dysphagia. This indicates a potential for use of more standardised swallow screening protocols beyond the post stroke population into a broader cohort of patients.