Early Dysphagia Screening in Mater Emergency Department

Aim

The overarching objective of this project was to improve the process and timeliness of dysphagia identification and management in Mater Emergency settings. It was anticipated that earlier dysphagia diagnosis would expedite the establishment of safe plans for nutrition, hydration, and medication administration and in turn facilitate improved patient outcomes and flow.

Outcomes

Data indicated that patients most at risk of dysphagia were those aged over 65 who presented with falls; respiratory infection/COPD; delirium; back pain; dizziness/syncope and stroke. Using these criteria, dysphagia prevalence at Mater was in line with the literature, with 34% of patients diagnosed with the condition. Roughly half of the patients (48%) were discharged from the SP service after initial input in ED. The remaining patients were admitted to wards with safe feeding plans earlier. The patients admitted after a dysphagia screen had a shorter length of stay by 3.23 days when compared to historical unscreened patient data. Within 0.5FTE, the Senior SP was able to screen 67% of eligible patients. This data was used to obtain ongoing funding for an HP4 0.8FTE clinical senior speech pathologist in Emergency. SP led dysphagia screening is now embedded within Mater ED.

Funding for an HP4 0.8FTE clinical senior speech pathologist in ED was approved to continue to assess patients over 65 with the above conditions for dysphagia. The position is now operating in a business-as-usual model and is an embedded part of the ED service. The profile of dysphagia has increased and is reflected in the significant increase in referrals generated by the ED team with an average of 25 referrals per month received.

Background

Dysphagia (difficulty swallowing) is a serious condition impacting approximately 30% of adults presenting to Emergency Departments (ED). Speech pathologists have a critical role in the assessment and management of oropharyngeal dysphagia across the lifespan and continuum of care. It is often under-diagnosed which results in adverse health outcomes for patients (e.g. aspiration pneumonia) and healthcare costs (e.g. increased length of stay). Mater Speech Pathologists (SP) received only two referrals for dysphagia in a six-month period. Just 13% of stroke patients received a swallow screen on presentation to Mater, despite strong recommendations for this in the Stroke Guidelines.

Discussion

In response to the under referral/detection of patients with dysphagia, an 18-month trial was commenced in Mater Emergency wards. Various models of early dysphagia screening were trialed in a three-phase project to design the best model of care for early dysphagia identification and management at Mater.

Outcomes for dysphagic patients in ED in Phase 3:

• 36% discharged from SP without follow up after one intervention including education, diet modification or strategies
• 12% discharged after one intervention with community SP follow up organised
• 52% of patients required ongoing SP follow up on the ward.

Comparison length of stay (LOS) data for 30 patients screened for dysphagia and admitted in 2023 versus 30 high risk patients admitted through ED without dysphagia screening in 2021:

• patients screened in 2023 - LOS 4.3 days
• patients NOT screened in 2021 - LOS 7.5 days
• difference (~ 3 days) = ~ $1M bed-days.

Lessons learnt

• Dysphagia is invisible and building awareness of this condition is critical to changing management
• Building relationships is essential in creating a new and embedded service
  • Augment existing models of care/processes in place
• Contribute specialist knowledge in relation to the objectives of ward/service
• Develop processes for supporting patients to eat and drink with acknowledged risk (EDAR) to support patient care and flow