Dysphagia Screening: Bedside

Application and Mechanics of

Screening Tools

Jeff Edmiaston, M.S. CCC-SLP

January 31, 2012

Objectives

Screening Tool Mechanics

Specific Screening Tools
Bedside Application

Screening in Acute Stroke

+
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8

8
+ 0
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8

+
+
+
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____ ____ _____ _____ _____
8
8
8
8
8

0
1
2
4
5
+ 8 + 7 + 6 + 4 + 3
____ ____ _____ _____ _____
8
8
8
8
8

Whats in a Screen?

15 Screens Reviewed
38 different components identified
Variation in length

Most Simple-1 Item

Most Complex-16 items

Liquid Trial-93%
Level of Alertness-33%
Dysarthria-20%
Aphasia-20%
Facial Symmetry-27%
Tongue Symmetry/Fx-27%
Palatal Fx-20%
Gag-20%
Voluntary Cough-20%
Positioning-7%
Salivary Management-27%
Respiratory Fx-20%
Vocal Quality-27%
Swallowing Complaints-13%
Pulse Oximetry-7%
Stroke Location-7%
Nasal Regurgitation-7%
Eyes Reddening/Tearing-7%

Pneumonia Hx-7%
H/O Coughing with P.O.-20%
Oral Intake (Volume)-7%
Oral Intake (Rate)-7%
NPO Status-7%
Voice after Swallowing-20%
Confusion/Cognitive-7%
Solid Trial-13%
Pharyngeal Sensation-7%
Stroke Severity-7%
Cooperation-7%
Auditory Comprehension-7%
Cough Reflex-13%
Intubation/Recent Extubation-7%
Food Pocketing-7%
Suctioning Required-7%
Other-7%

Specific Screens

3 oz Water Swallow Test

Give patient 3 oz water to drink uninterrupted from a

cup
Observe for 1 minute after the swallow

Coughing
Wet/Hoarse Vocal Quality

*Depippo K, Holas M, Reding M: Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol. 1992;49:1259-1261
*Suiter D, Leder S.:Clinical utility of the 3-ounce water swallow test. Dysphagia 2008, 23: 244-250

Burke Dysphagia
Screen

Burke Dysphagia Screen

Pass/Fail
Failure on any one item results in failure

*DePippo K, Holas M, Reding M: The burke dysphagia screening test: validation of its use in patients with stroke. Arch Phys Med Rehabil 1994;
75:1284-1286

Massey
Bedside
Form

Massey Bedside Screening

Complete Pre-Assessment Form

Administer single teaspoon of water
60cc glass of water

*Massey R, Jedlicka D.: The Massey Bedside Swallowing Screen. J. Neurosci Nurs. 2002; 34(5):252-253; 257-260

Timed
Test

Timed Test

GCS >13
Able to sit up
5-10ml of water to ensure safety
100-150ml as quickly as possible
Number of swallows counted
Timed
Abnormal=outside the 95% prediction interval for age
and sex or qualitative elements of coughing during or
voice change after the test

*Hinds NP, Wiles CM: Assessment of swallowing and referral to speech and language therapists in acute stroke. QJ Med 1998; 91:829-835

Any Two

Administer following liquid bolus amounts:

5ml
10ml
20ml

Administer twice for a total of 70ml

Any Two

Presence of any two of the following indicators:

Abnormal volitional cough

Abnormal gag reflex
Dysphonia
Dysarthria
Cough after swallow
Voice changes after swallow

*Daniels S, Lindsay B, Mahoney M, Foundas A: Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients.
Arch Phys Med Rehabil 2000; 81: 1030-1033

Barnes Jewish Hospital Stroke Dysphagia

Screen (BJH-SDS)

5 items, each scored present/absent

Presence of one, screen is failed
Failed screen-NPO with speech consult
Passed screen-Regular diet

*Edmiaston J, Tabor Connor L, Loehr L, Nassief A.: Validation of a dysphagia screening tool in acute stroke patients. Am J Crit Care, 2010; 19(4): 357364.

BJH-SDS

MetroHealth Dysphagia Screen

Administered in the Emergency Department

Pass/Fail Criteria
No liquid or solid trials administered

MetroHealth Dysphagia Screen

1. Is alertness level insufficient to remain awake for 10 minutes while
sitting upright?
2. Is voice weak, wet, or abnormal in any way? (If cannot speak, circle
yes)
3. Does the patient drool?
4. Is speech slurred?
5. Is the patients cough weak or inaudible? (If cannot cough, circle yes)
________________________________________________

One or more yes answers are considered a positive screen for possible
dysphagia
*Schrock J, Bernstein J, Glasenapp M, Drogell K, Hanna J.: A novel emergency department dysphagia screen for patients presenting with
acute stroke. Academic Emergency Medicine 2011; 18:584-589

Modified Mann Assessment of Swallowing

Ability

No food trials
Scoring system: 0-100
Specific task instructions
Score 95, start oral diet and progress as tolerated,
monitor first oral intake. Consult SLP if issues
Score 94, NPO and consult SLP

*Antonios N, Mann G, Crary M, Miller L, Hubbard H, Hood K, Sambandam R, Xavier A, Silliman S.: Analysis of a physician tool for evaluation
dysphagia on an inpatient stroke unit: The Modifed Mann Assessment of Swallowing Ability. Journal of Stroke and Cerebrovascular Diseases; 2010
19(1): 49-57.

Original Mann Assessment of Swallowing Ability

Mann Assessment of Swallowing Ability
Alertness

2=No response
to speech

5=Difficult
to rouse

8=Fluctuates

10=Alert

Cooperation

2= No
cooperation
2=No response
to speech

5=Reluctant
4=Occasional
motor response

8=Fluctuating
cooperation
6=follows simple
conversation
with repetition

10=
Cooperative
8=follows
10=No deficits
ordinary conversation with
noted
little difficulty

Auditory
Comprehension

2=Chest
infection
1=No independent
control
1=Unable to
assess

4=Coarse basal
6=Fine basal
crepitations
crepitations
3=Some control
uncoordinated
2=No functional
3=Expresses self
speech
in limited manner
short phrase/words

8=Sputum in upper
airway
5=Able to control
rate for swallow
4=Mild difficulty
finding words or
expressing ideas

10=Chest
clear

Apraxia

1=Unable to
assess

2=Groping/
3=Speech crude.
inaccurate/partial
defective in
or irrelevant response accuracy or speed

4=Speech accurate
after trial and error
Minor searching
movements

5=No deficits
noted

Dysarthria

1=Unable to
assess

2=Speech
unintelligible

3=Speech intelligible 4=Slow with

but obvious defect
occasional halting

5=No deficits
noted

Saliva

1=Gross drool

Lip seal

1=No closure
unable to assess
2=No movement

2=Some drool
consistently
2=Incomplete
seal
4=Minimal
movement
5=Unilateral
weakness
5=Gross
incoordination

3=Drooling at
times
3=Unilaterally weak
poor maintenance
6=Incomplete
movement
8=Minimal
weakness
8=Mild
incoordination

5=No deficits
noted
5=No deficits
noted
10=Full range
of motion

Respiration
Respiratory rate
for swallow
Aphasia

Tongue
movement
Tongue
strength
Tongue
coordination
Oral
preparation
Gag
Palate
Bolus clearance
Oral transit
Cough reflex
Voluntary
cough
Voice
Trach

2=Gross
weakness
2=No movement
unable to assess

5=No deficits
noted

4=Frothy/
expectorated
4=Mild impairment
occasional leakage
8=Mild impairment
in range
10=No deficits
noted
10=No deficits
noted

2=Unable to
assess
1=No gag

4=No bolus
6=Minimal chew,
8=Lip or tongue
formation, no attempt gravity assisted
seal, bolus escape
2=Absent
3=Diminished
4=Diminished
unilaterally
unilaterally
bilaterally
2=No spread
4=Minimal
6=Unilateral
8=Slight
or elevation
movement
weakness
asymmetry
2=No clearance
5=Some
8=Significant clearance
10=Fully
clearance/residue
minimal residue
cleared
2=No movement 4=Delay >10 sec.
6=Delay >5 sec
8=Delay >1 sec
1=Unable to assess
3=Weak reflexive
5=No deficit
cough
noted

10=No deficits
noted
5=Hyperreflexive
No deficits
10=No deficits
noted

2=No attempt

10=No deficit
noted
10=No deficit
noted

5=Attempt
inadequate
4=Wet/gurgling

2=Aphonic, not
able to assess
1=Trach/cuffed

Pharyngeal
phase

2=No swallow

Pharyngeal
response

1=Not coping/
gurgling

Diet recommendations Regular

Fluid recommendation Regular

6=Hoarse

5=Trach/fenestrated
5=Pooling/gurgling
Incomplete laryngeal
elevation

Soft

5=Cough before
during
or after swallow
Selected soft

Thins only

Nectar

10=No deficit

8=Attempt
bovine
8=Mild impairment
slight huskiness
10=No trach
8=Mildly restricted
laryngeal elevation
Slow initiation

10=Immediate
laryngeal elevation

10=No deficit
noted
Mechanical soft
Honey

Puree

No solid
by mouth
No liquids by mouth

Patient Name:_________________________Date:_________________SLP:_______________________

MASA #:_____________

Score:_______________

Modified Mann Assessment of Swallowing Ability

Alertness

10=Alert

8=Drowsy-fluctuating
awareness/alert level

5=Difficult to arouse
by speech or mvmt

2=Coma or
nonresponsvie

Cooperation

10=Cooperative

8=Fluctuating
cooperation

5=Reluctant
cooperation

2=No cooperation/
response

Respiration

10=Chest clear

8=Sputum in upper
airway

6=Fine basal
crepitations

4=Coarse basal
crepitations

2=Suspected
infections/ freq
suction/ respirator
dependent

Expressive
Dysphasia

5=No abnormality

4=Mild wording finding

difficulty

3=Expresses self in
limited manner

2=No functional
speech

1=Unable to assess

Auditory
Comprehension

10=No abnormality

8=Follows ordinary
conversation with
little difficulty

6=Follows simple
conversation

4=Occasional
response

1=No response

Dysarthria

5=No abnormality

4=Slow with
occasional hesitation

3=Speech intelligible
but defective

2=Speech unintelligible

1=Unable to assess

Saliva

5=No abnormality

4=Frothy/
expectorated in cup

3=Drooling at times

2=Some drool
consistently

1=Gross drooling

Tongue Movement

10=Full R.O.M.

8=Mild impairment

6=Incomplete mvmt

4=Minimal mvmt

2=No movement

Tongue Strength

10=No abnormality

8=Minimal weakness

5=Obvious unilateral
weakness

2=Gross weakness

Gag

5=No abnormality

4=Diminished
bilaterally

3=Diminished
unilaterally

2=Absent unilaterally

Cough Reflex

10-No abnormality

8=Cough attempted
but hoarse in quality

5=Attempt inadequate

2=No attempt/unable
to perform

Palate

10=No abnormality

8=Slight asymmetry

6=Unilaterally weak

4=Minimal movement

1=No gag response

2=No movement

EATS

Two Phases

Questionnaire
Food/Liquid Trials

Must show no deficits in both phases to pass screen

Courtney B, Flier L.: RN dysphagia screening, a stepwise approach. Journal of Neuroscience Nursing 2009; 41(1):28-38

EATS

The Gugging Swallow Screen

Includes a semi-solid, liquid, and solid trial

Severity scoring system
Allows diet to be altered

Figure I. GUSS.

Trapl M et al. Stroke 2007;38:2948-2952

Copyright American Heart Association

Figure I Continued.

Trapl M et al. Stroke 2007;38:2948-2952

Copyright American Heart Association

What Screen Should I Use?

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8
8
8
8
8

0
1
2
4
5
+ 8 + 7 + 6 + 4 + 3
____ ____ _____ _____ _____
8
8
8
8
8

Use only odd numbers to answer the question

+
+
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____ ____ _____ _____ _____
8
8
8
8
8

Use only odd numbers to answer the question

+
_____
8

+
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8

Use only odd numbers to answer the question

5
+ 3
_____
8

1
+ 7
_____
8

Screening Purpose

Identify individuals with or at risk of swallowing

dysfunction following a stroke.

Sensitivity vs. Specificity

Always a trade-off
Dysphagia screening is tilted towards sensitivity

The Perfect Screen

Do

you have stroke-like

symptoms?

The Perfect Screen

100% Sensitivity to Dysphagia

0% Specificity to Dysphagia
Theoretical Result: Never a dysphagia related
complication
Bedside Result

6 out of 10 patients are angry!

Not all bedsides are the same

BJC Healthcare
1.
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3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Alton Memorial
Barnes Jewish
Barnes Jewish St. Peters
Barnes Jewish West County
Boone Hospital
Christian Hospital
Clay County Hospital
Missouri Baptist Medical Center
Missouri Baptist Sullivan Hospital
Northwest Healthcare
Parkland Health Center
Progress West HealthCare Center
Rehabilitation Institute of St. Louis
St. Louis Childrens Hospital
Siteman Cancer Center

Barnes Jewish Hospital

Stroke Fellow
Neuroradiology & Neurosurgery
MRI, Angiography, PET Scanner
Dedicated Stroke Neurologists
Dedicated Stroke Nursing Unit
Dedicated 20 Bed Neuro-ICU with Portable CT
Intra-operative MRI Suite
Two Stroke Nursing Coordinators
Dedicated Stroke Rehabilitation Services (PT,OT, and
Speech)
Administrative group dedicated to Neurosciences

Clay County Hospital

Factors that may effect screen choice

Availability of Speech Pathology

Availability of Radiology Services (i.e. Videofluoroscopy)
Volume of patients
Nursing numbers

Fewer Resources Available

May be less tolerant of false positives

May be more comprehensive
May resemble an assessment rather than screen
Potentially more burden on nursing

More Resources Available

May tolerate false positives

May be less comprehensive (pass/fail)
Potentially less burden on nursing

No Perfect Screen

Perfection= 100% Sensitivity & 100% Specificity

There will be false positives
There will be false negatives
How many of each can be tolerated?

What is a good Screen?

Valid
Reliable
Works for your setting

Validity

External
Internal
Criterion
Content
Concurrent
Predictive
Content
Construct
Face

Reliability

Inter-rater Reliability
Test-Retest Reliability
Parallel-Forms Reliability
Internal Consistency

What Works for You?

No numeric value to derive this

Dependent on multiple factors
Specific to a given institution

Making a Decision

Expert Opinion
Data Driven-Dependent on quality of data
Group Consensus
Kepner-Tregoe Decision Matrix

Kepner-Tregoe Decision Matrix

Timed Up
and Go
Easily
Administered
Valid
Reliable
Easily
Documented
Sensitivity/Spec
ificity (5)
Evidence Based
(10)

Timed Up
and Go (R)

Get Up and
Go

BJC Get Up
and Go

Kepner-Tregoe Decision Matrix

Timed Up
and Go
Easily
Administered

Timed Up
and Go (R)

Get Up and
Go

BJC Get Up
and Go

X
x

Valid

Reliable

Easily
Documented

Sensitivity/Spec
ificity (5)

Evidence Based
(10)

10

10

10

10

K-T Analysis of Swallow Screens

3 oz
water
Sensitivity
>90%
Face Validity
Easy to
administer
Reliable
Concurrent
Validity
Scoring
Severity
Easy to learn

Specificity
>50%

Massey

Timed
Test

Burke
Screen

Metro
Health

Any
Two

EATS

Mini
MASA

GUSS

BJH
SDS

Barnes Jewish Hospital- KT Matrix

3 oz
water
Sensitivity
>90%
Face Validity

Easy to
administer
Reliable
Concurrent
Validity (8)
Scoring
Severity (1)
Easy to
learn (10)
Specificity
>50% (5)

Massey

Timed
Test

Burke
Screen

Metro
Health

Any
Two

EATS

Mini
MASA

GUSS

BJH
SDS

Sensitivity
>90%

3 oz
water

Massey

Timed
Test

Burke
Screen

Metro
Health

Face Validity

Easy to
administer
Reliable
Concurrent
Validity (8)
Scoring
Severity (1)
Easy to learn
(10)
Specificity
>50% (5)

Any
Two

EATS

Mini
MASA

GUSS

BJH
SDS

X
X

Massey

Timed Test

Burke
Screen

Any Two

BJH SDS

Concurrent
Validity with
MBS/FEES (8)

Scoring Severity
(1)

10

10

10

10

10

15

15

10

23

23

Sensitivity >90%
Face Validity

Easy to administer
Reliable

Easy to learn (10)

Specificity
>50% (5)
TOTAL

Clay County Hospital-KT Matrix

3 oz
water
Sensitivity
>90%
Face
Validity

Easy to
learn
Specificity
>50%
Reliable
Concurren
t Validity
Scoring
Severity
Easy to
administer

Massey

Timed
Test

Burke
Screen

Metro
Health

Any
Two

EATS

Mini
MASA

GUSS

BJH
SDS

Sensitivity
>90%
Face Validity

Easy to learn
Specificity
>50%
Reliable
Concurrent
Validity
Scoring
Severity
Easy to
administer

3 oz
water

Massey

Timed
Test

Burke
Screen

Metro
Health

Any
Two

EATS

Mini
MASA

GUSS

BJH
SDS

Sensitivity >90%
Face Validity

Easy to learn
Specificity
>50%
Reliable (2)
Concurrent Validity
with MBS/FEES (10)
Scoring Severity (8)
Easy to administer
(4)
TOTAL

Massey

Timed
Test

Metro
Health

Any
Two

Mini
MASA

GUSS

BJH
SDS

10

10

10

10

10

16

16

16

20

16

Conclusion

Much research has been done

Many screens, most are pretty good
When choosing a screen, be objective and systematic
There is no best screen
The best screen is the one that is best for your institution