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Nursing swallow screens: why is testing water only not enough?


The speech-language pathologist (SLP) standardized a Nursing Bedside Swallowing Screen (NBSS) tool for all patients admitted to the hospital. The adults engaged in the NBSS before oral intake (i.e., medication included) as part of the Brain Attack Pathway for patients with neurological symptoms. If the patient failed the NBSS in the emergency department (ED), then the screen was repeated again after the patient had been admitted before the SLP dysphagia evaluation. Fifty-three male and female patients ranging from 34 to 96 years old with an initial diagnosis of stroke or transient ischemic attack (TIA) admitted during an 8-week time period from April 25, 2010, to June 19, 2010, were included in this study. There were 32 women and 17 men including 27 strokes and 22 TIAs tested. As a whole, the NBSS and SLP dysphagia evaluation results were consistent with each other for 40 of 46 patients (86.96% perfect agreement). The NBSS had 74% of sensitivity (34 of 46) with the nursing and the speech pathologist in agreement with the patients passing the swallow screen. Accurate identification of aspiration with the patients failing the NBSS was evident with the nursing and speech pathology assessment, which resulted in 83% of sensitivity (10 of 12). The positive predictive value with the corresponding identification of aspiration with the staff was 96% (44 of 46). The naturalistic observation of the patients exhibited internal consistency reliability between the two disciplines. Extraneous variables affecting the results included spontaneous resolution of stroke or TIA symptoms or the patient's decline in neurological status. Video Abstract: For more insights from the authors, see Supplemental Digital Content 1, at

Keywords: aspiration, dysphagia, nursing swallow screen


Swallowing is a basic function (Ebling, 1999). Yet, when it is interrupted because of stroke or traumatic brain injury, dysphagia usually results (Mackay, Morgan, & Bernstein, 1999; Murry, Carrau, & Eibling, 1999). Stroke is the third leading cause of death in the United States and Canada (Martino, Pron, & Diamont, 2000; Summers et al., 2009). According to the American Stroke Association, approximately 795,000 new strokes occur annually (American Stroke Association, 2011). Teasell, Foley, Martino, Bhogal, and Speechley (2009) report that dysphagia occurs in 30%-64% of patients who are in the acute phase of stroke recovery and 37%-78% of those in the general stroke population. The incidence of dysphagia in inpatient rehabilitation patients who sustained traumatic brain injuries varied from 25% to 42% (Mackay et al., 1999). Overall, dysphagia is the most common treated sequelae in patients who have had strokes and traumatic brain injuries (Mackay et al., 1999).

Because many patients are required to take medications orally and consume a meal when admitted to the hospital, many of them may be put at risk for complications associated with dysphagia such as pulmonary problems; dehydration; malnutrition; aspiration and, subsequently, aspiration pneumonia; and even mortality (Martino et al., 2009). According to Lakshminarayayan et al. (2010), "the higher pneumonia rate in unscreened patients compared with those who passed screening indicates that physicians' clinical judgment on who to screen is imperfect" (p. 2853). Early identification of those patients who are at risk for those consequences associated with dysphagia is critical before the administration of medications, food, and liquids (Cohen, 2009; Massey & Jedlicka, 2002). In addition, early detection of dysphagia will also reduce the length of stay in the hospital as well as overall health expenditures (Courtney & Flier, 2009; Mackay et al., 1999).

Who is in a better position to initially detect early symptoms associated with dysphagia than nurses? Nurses spend more time with patients than any other healthcare professionals and are in a position to detect signs associated with dysphagia early on. Because nurses are not traditionally trained to screen patients for dysphagia on admission to the hospital, many patients may have been unknowingly placed at risk for additional swallowing problems. Because dysphagia diagnosis is a multidisciplinary effort that requires the expertise of speech-language pathologists (SLPs), nurses, physicians, dietitians, and other healthcare professionals to improve the outcome in dysphagia management (Davis, 2002; Miller et al., 2010; Sullivan & Dennis, 2006; Trapl et al., 2007), a simple but effective screening tool was needed to assess patients upon admission to the hospital. The purpose of this study was to develop a bedside screening tool that nurses could be trained to use for all newly admitted patients who are exhibiting neurological impairments. Subsequently, once admitted to the facility, these patients were sent either to the neuroscience floor, intensive care unit, or intermediate care unit. To satisfy one of the measures issued by The Joint Commission (2006) for a Certified Primary Stroke Center, patients exhibiting neurological deficits are screened for dysphagia upon admission. The bedside screening tool had to include both solids and liquids because many of the previous swallowing screens only included water and were not designed to recognize those individuals who had difficulty swallowing solids. The NBSS includes an adequate amount of liquid to be tested for potential aspiration, whereas the other nursing swallow screens did not test an adequate bolus amount to effectively identify possible aspiration. The NBSS also includes an inclusive analysis of signs and symptoms of overt and silent aspiration, whereas other nursing swallow screens have not adequately acknowledged these additional parameters.

A swallowing screen is defined as a minimally invasive procedure that provides a quick determination (1) whether dysphagia exists; (2) whether the patient requires a full dysphagia evaluation by the SLP; (3) whether the patient is safe for oral intake of food, liquids, and medications; and (4) whether a referral for nutritional and dehydration needs to be made (American Speech-Language Heating Association, 2004). American Speech-Language Hearing Association's Preferred Pattern on Swallowing Screening states: "Swallowing screening is a pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services" (p. 10). Review of the literature findings suggest that one of the first evidence of a swallowing screen was reported by DePippo, Holas, and Reding (1992) at the Burke Rehabilitation Center in White Plains. They developed a 3-oz water swallow test that was utilized with patients who had strokes. Patients were asked to drink 3 oz of water from a cup without interruption. If a patient coughed during or one minute after drinking the water and presented with a wet vocal quality (wet-hoarse voice), they failed the test. Results indicated that 24 patients coughed, 12 had wet-hoarse vocal quality, and 27 bad a combination of both. Their results also showed that the 3-oz water test was useful in screening patients who may have evidence of aspiration to determine if the patients required a Modified Barium Swallow (MBS) examination. Although this screening test was successful for purposes of their facility, it only screened patients in a rehabilitation center with liquids and not solid oral intake.

Since the study of DePippo et al. (1992), there have been a number of other studies in the United States (U.S.), United Kingdom, and Australia that have designed nursing screening tools for the early detection of dysphagia. In 1997, the SLPs in Southern Derbyshire trained nurses (dysphagia training nurse [DTN]) how to screen patients for dysphagia. Nurses were required to participate in a 1.5-day training seminar on the accurate application of the screening tool. Their results revealed that, after training, the DTN and SLPs both had similar recommendations for patients. The DTNs found that the education and support that they received from the SLPs helped them be more efficient in detecting dysphagia in patients admitted to their facilities (Froud, 2002). Suiter and Leder (2009) conducted a similar study using the 3-oz water test on over 3,000 patients with various medical diagnoses who were referred for a dysphagia evaluation. Their results showed that the 3-ounce water test was a good predictor of a patient's ability to safely swallow liquids.

Westergren, Hallberg, and Ohlsson (1999) reported that their bedside screening tool was effective in detecting 77% of those patients with dysphagia, whereas Massey and Jedlicka (2002) reported that their screening tool was 100% useful in detecting dysphagia. Davis reported the benefits of the Gateshead Dysphagia Management Model at the Queen Elizabeth Hospital in Gateshead, where nurses were trained to perform basic screening for dysphagia according to the National Clinical Guidelines for Stroke. The guidelines stated that all patients should have their swallowing assessment as soon as possible by appropriately trained personnel using a simple validated bedside testing protocol. Their staff developed a screening tool that nurses could be trained to use and identify those with dysphagia. The results of using nurses to screen for dysphagia resulted in a decrease of the number of patients who were kept nothing-per-oral (NPO) unnecessarily, "reduced the number of those patients with inappropriate or no feeding restriction imposed when they were at risk of aspiration," improved the quality of patients referred for services and better utilized the specialists' skills better (Davis, 2002, p. 2).

Hinchey et al. (2005) revealed how the use of a screening tool could decrease the number of patients with stroke incidence of having pneumonia. Their results revealed that pneumonia rate at sites that had a formal dysphagia screen were 2.4% compared with 5.4% that did not have a formal dysphagia screen.

Standard five of the National Service Framework for older people in emergency assessment areas stated that all patients who have had strokes and admitted to the hospital should have a dysphagia screening within 24 hours of admission (Lees, Sharpe, & Edwards, 2006). Lees et al. conducted a retrospective study of patients who were admitted to the hospital for neurological problems to determine how long patients had to wait for the SLP to perform a swallowing assessment. The nurses, who were trained to use a swallowing screening tool, screened the patients upon admission to their units. The nurses used the same screening tool, the Gateshead Dysphagia Management Model, in addition to the documentation for the chart review. Results of the retrospective study revealed that those patients who were admitted via the emergency department (ED) had a maximum wait time of 29 hours for a dysphagia assessment by the SLR Those patients spent longer times NPO. The results of the audit also revealed that the wait time for dysphagia assessment was reduced when the nursing bedside screen was utilized during the emergency room stay. The best time for assessment was within 60 minutes upon admission, whereas the worst time was 29 hours.

Cichero, Heaton, and Bassett's (2009) swallowing screen (Royal Brisbane and Women's Hospital) consisted of phase 1, listing conditions commonly associated with dysphagia such as stroke, neurological involvement, and chronic obstructive disease and/or airways, and phase 2, including an interview with the patient or caregiver and presentation of 90 ml of water via cup. The nurse observed for coughing during or between swallows or up to one minute after the swallow, wet vocal quality after the swallow, and increased respiratory rate after the swallow. Their results revealed that the dysphagia screening tool of the Royal Brisbane and Women's Hospital was effective and an accurate dysphagia triage tool. The protocol had sensitivity of 95% and specificity of 97%.

In recent years, even before the mandates by The Joint Commission and The Veterans Administration concerning screening all patients for dysphagia, many speech-language pathologists and nurses have teamed together to develop a nursing dysphagia screening tool. The Joint Commission's Disease Specific Stroke Performance Measure 7 (DSC Stroke 7) stated that "dysphagia screening should be performed on all ischemic and hemorrhagic stroke patients before being given anything by mouth including food, fluids, or oral medications. Therefore, the patient must remain NPO until a dysphagia screen has been completed" (p. 24). Similarly, in 2006, the Department of Veterans Affairs, a VHA Directive 2006-032, indicated that one of the responsibilities of the chief nurse executive was to ensure "all patients admitted to the facility receive an initial nursing assessment, which includes an evaluation for swallowing and feeding problems" (p. 32). The assessment included an analysis of the oral hygiene status, swallowing status, and feeding status (Department of Veterans Affairs, 2006) of the patient. Furthermore, it is the Veterans Affair's policy that "all patients with potential for swallowing or feeding disorder must be appropriately assessed, referred for diagnostic evaluation (as necessary), treated, managed, monitored, and followed throughout the continuing care" (p. 32).

Many articles have been written reporting on the development challenges and implementation of a nursing dysphagia screens (Cohen, 2009; Hind, Robbins, & Priefer, 2009; Westergren et al., 1999). Poskus (2009) used the evidence by Suiter and Leder (2009) as a basis for their nurses' dysphagia screening tool. The article only reported on the challenges of developing and implementing the tool.

The need for an evidence-based screening tool was necessary to respond to the Joint Commission directive and to ensure recertification as a Certified Stroke Center. The Nursing Bedside Swallowing Screen (NBSS; Appendix A) developed at this community-based hospital had to be different than the conventional swallowing screens that only utilized water and had to show significant specificity and sensitivity (Suiter & Leder, 2009). The NBSS developed at this facility incorporated both solids and liquids in addition to identifying signs and symptoms of silent and overt aspiration.

There have been few studies that used both solids and liquids in their nursing swallowing screening tools. One of the first reports of both solids and liquids used in screening for dysphagia was in 1997 with Wood and Emick-Herring's Examine Ability To Swallow (EATS) screening tool. Their EATS box contains the following food items and protocol: a nursing assessment, one Italian ice, a 6-oz can of cranberry juice, one jar of baby food peaches, and one package of graham crackers. Although Wood and Emick-Herring (1997) did not collect data during their development and implementation of the protocol, they did report that the screening protocol did satisfy their facility's needs. Courtney and Flier (2009) also utilized the EATS box in the development of their nursing dysphagia screening tool. They reported that, based on their research evidence, the screening tool and methods were effective for their facility.

Beckstrom and Hanson (2008) also developed a nursing swallowing tool at the Park Nicollet Methodist Hospital in St. Louis Park, Minnesota, that utilizes both solids and liquids. Their tool had high specificity and sensitivity and was useful in determining whether a swallow was normal versus abnormal. Specificity of screen for solids only was 91.30 and sensitivity was 57.14. Their results also showed that the tool allowed those individuals who were deemed as having a normal swallow resume oral intake sooner than if SLP was consulted to do the evaluation.

Martino et al. created the Toronto Bedside Swallowing Screening Test. The test included five items: the Kidd water test of 50 ml, pharyngeal sensation, tongue movement, and general dysphonia (voice quality before and after the swallow). Their results revealed that the screen was an easy test that "could be administered, scored, and placed on the medical chart in approximately 10 minutes" (Martino et al., 2009, p. 556). Bravata et al.'s comparison study revealed that "the nursing dysphagia screening tool had a positive predictive value of 50% and a negative predictive value of 68% with a sensitivity of 29% and specificity of 84%" (p. 10). The use of the National Institutes of Health Stroke Scale identified dysphagia risk with a "positive predictive value of 60% and a negative predictive value of 84% and had better test characteristics in predicting dysphagia than the nursing screening tool" (Bravata et al., 2009, pp. 1127-1128).

Edmiaston, Connor, and Abdullah (2010) further reports on the development and implementation of a nursing swallowing screening tool (NST) at the Barnes Jewish Hospital. In their prospective study, approximately 300 patients who were admitted to stroke services were screened by the nurses and subsequently by the SLP using the Mann Assessment of Swallowing Ability. The results of this study showed that the NST identified dysphagia with a sensitivity of .91 and specificity of .74. It also identified aspiration risk with a sensitivity of .95 and specificity of .68. Edmiaston reports that the NST was easy to administer and was a reliable tool in identifying both dysphagia and aspiration risks in acute stroke patients.

Braislin (2009) developed an NST that also included both liquids and solids (water and applesauce). The results of this retrospective study of 146 records of inpatient rehabilitation patients indicated that 64% of patients had dysphagia. Of those, 11% were not previously identified as having dysphagia. Fifty-one percent of the patients had been prescribed diets that were modified from their regular diet consistency. Of those, 12% had diet downgrades on admission with additional speech therapy intervention, and 39% had diet upgrades on admission.

The Gugging Swallowing Screen, developed by Trapl et al. (2007), was another bedside nursing screening tool that used both liquids and solids to screen patients for dysphagia. The Gugging Swallowing Screen was divided into two parts. Part I was an indirect swallowing test, and Part 2 was a direct swallowing test. Before the screening test begins, the examiner had to be sure that the patient could perceive the examiner's face, the spoon, and the textures in front of him. The patient was positioned upright at 60[degrees] for all presentations. In Part I, the patient had to be successful in saliva swallows to proceed to Part 2, the swallow test. In Part 2, the patient was given a semisolid swallowing test, a liquid swallowing test, and then, a solid swallowing test. Their results indicated that a quick protocol for dysphagia could be used to detect aspiration risk in acute stroke. Tohara, Saithoh, Mays, Kuhlemeier, and Palmer's (2003) study results revealed that a combination of both liquids and solids revealed sensitivity of 90% and specificity of 56%.


The NBSS was developed out of the need to screen all patients admitted to the ED, intensive care unit, neuroscience unit and/or neurocritical care unit and to satisfy The Joint Commission directive. Review of the literature found that most of the nursing screening dysphagia tools only presented water to patients and very few presented both liquids and solids. Although the nursing professionals are proficient in monitoring a patient's vital signs and the general condition of the acute patient in the hospital, a definite method was needed to identify a patient experiencing dysphagia, to eliminate the possibility of nonsocomial pneumonia before the speech pathologist conducts a complete dysphagia evaluation. The SLP, in keeping with The Joint Commission directive, standardized a protocol for NBSS tool for all patients admitted to the hospital. The adults engaged in the NBSS before other oral intake (i.e., medication included) as part of the Brain Attack Pathway for patients with neurological symptoms. The NBSS is a primary stroke center designated to measure requirement for The Joint Commission. If the patient failed the NBSS in the ED, then the NBSS was repeated again after the patient had been admitted to the floor.

Approval to conduct the research was granted by the institutional review board. Inservices were provided by the SLP to all nurses on the aforementioned floors to ensure competency of the NBSS before initiating the data collection. During the inservices, the nurses were provided education regarding the identification of dysphagia in addition to the identification of signs and symptoms of aspiration. The nurses were then advised to contact the clinician with any concerns or questions regarding the NBSS protocol or with any additional specific information regarding their patients with potential swallowing difficulties. The results of the NBSS were then recorded electronically by the nurses on the hospital units and collected manually in the Brain Attack Pathway packet when the screen was conducted in the ED. The nurses used a preassembled kit to conduct their screening. The NBSS kit contained food items (i.e., saltine cracker and applesauce) in addition to a cup labeled with 90 ml. The preassembled kit was utilized as a method to assess the patient's swallowing ability in an efficient and timely manner in the emergency room and in the nursing units.

The NBSS has four different parts. A brief cognitive screen and inspection of the oral cavity, dry swallows, and voluntary coughs were assessed before oral intake. If the patient failed the screening at this point, the screen was stopped, and the patient was referred for an SLP dysphagia evaluation. If the patient passed the initial portion, then administration of 90-ml water from a cup was given. If one or more selected dysphagia symptoms were shown, the screen was stopped. If the patient passed step 1 of oral intake, the patient was then given one tablespoon of applesauce in Step 2. If the patient passed step 2, the patient was given a cracker in step 3. As with all levels, if the patient exhibited any one of the selected dysphagia symptoms, the screen was stopped. If the first stage was completed, then the nurse conducted the next phase of the NBSS. At the end of the NBSS, the nurse documented if the patient passed or failed the screen and listed the date and time of the completion of the screen. The results of the swallow screen were then recorded electronically in Meditech. Nursing documented results from the NBSS were documented in the Brain Attack Packet if the screen was implemented in the ED.

After completion of the NBSS, the patient would either be placed on a diet based on the physician's recommendation or kept NPO until the SLP conducted a complete dysphagia evaluation. For each of the patients admitted with neurological symptoms, the SLP would read the NBSS results before conducting a bedside dysphagia evaluation. The nurse would also inform the clinician of any additional swallowing problems or concerns either via electronic documentation or by conversing with the SLP directly. Regardless if the patient passed or failed the nursing swallowing screen, the SLP conducted a dysphagia evaluation. Nursing, staff, and family were then informed of the SLP's decision regarding the patient's swallow status after completion of the SLP dysphagia evaluation. A visual reminder was posted bedside if an altered diet and instruction for safe oral intake was needed. If the patient had dysphagia, then a treatment plan was the developed and conducted by the SLR While treating the patient, the SLP would talk to the nurse about the patient's ability to tolerate his or her diet according to the guidelines provided. It should be noted that the screen was not intended to negate the SLP's formal swallowing evaluation but to further check for swallowing difficulties before any other oral intake and thereby protecting the patient for potential additional unrecognized aspiration. The original basis of the screen was in the hospital's computerized documentation system already, but the amount of oral intake given, symptoms of silent and overt aspiration, method of intake, and consistencies tested were added based on SLP dysphagia literature. References and extensive explanation of each step of the protocol were included in the policy of NBSS for dysphagia (Appendix B) for the nursing swallow screen, which was listed in the hospital-wide computerized policy and procedures. Nurses were hesitant to comply with the entire protocol initially because of limited knowledge regarding signs of aspiration and also because of time constraints with completion of the screen. However, after the NBSS inservices were conducted with the SLP providing information regarding the screen use and answering questions regarding aspiration issues, compliance with the screen increased. In addition, a volunteer was assigned the task of creating the premade kits, which improved compliance with use of the screen because the nurses were able to have the necessary items for the NBSS in one location. The study was initiated to prove the importance of testing patients with solid versus liquid intake for accurate identification of dysphagia.


Fifty-three male and female patients ranging in age from 34 to 96 years participated in this study. These individuals were admitted to a 197-bed community hospital for either a stroke or transient ischemic attack (TIA) during an 8-week time period from April 25, 2010, to June 19, 2010. There were 32 women and 17 men including 27 strokes and 22 TIAs tested within this time period.

Forty-six of the patients received a swallow evaluation after the initial NBSS as part of the facility's protocol with the Brain Attack Pathway. Any patient admitted into the facility with neurological symptoms had standing orders to have a swallow screen and then a speech therapy (SLP) evaluation for dysphagia and communication. There was one patient who did not receive an SLP dysphagia evaluation because the patient had a TIA and the doctor stated that her symptoms had already resolved. There were three patients who were immediately intubated upon admission. One patient was readmitted with the same diagnosis during the predetermined time frame, and three patients were discharged from the facility before ST dysphagia evaluation was conducted. Overall, 49 strokes/TIAs were admitted with 46 completed NBSS and SLP swallow evaluations. There was one patient who experienced a TIA with no SLP order because of the doctor not following the traditional protocol, one TIA with no documentation of screen completed, and one patient who the doctor discharged before SLP evaluation. No immediate MBS was conducted after the initial SLP dysphagia evaluation because the MBS was not medically necessary at that time. An MBS was conducted later if needed after dysphagia therapy intervention. It was noted that none of the patients returned to the hospital with a suspected aspiration pneumonia within the selected time frame elected for the study. After the SLP assessment was completed, the therapist would then inform the nurse of the assessment results and then hang an aspiration precaution sheet at bedside with the safe swallowing maneuvers and diet modification listed.

Data Analysis

Of the 46 NBSS and SLP dysphagia evaluations, 34 of the patients passed the NBSS and were deemed to be appropriate for oral intake by the speech pathologist. The NBSS had 74% of sensitivity (34 of 46) with the nursing and the speech pathologist in agreement with the patients passing the swallow screen. Six of the patients failed the NBSS and also failed the SLP's dysphagia evaluation with the need to remain NPO. Four of the patients failed the NBSS, but the SLP placed them on an oral diet. For two of the patients, they had passed the NBSS, but the SLP had placed them on a strict NPO status. Of the six patients who ailed the nursing swallow screen, one patient was not alert enough to engage, one patient tolerated thin liquid and applesauce but not a cracker, two patients did not pass the liquid intake portion, and two patients were not able to follow the commands successfully for potential oral intake. With the four patients who failed the NBSS initially, their neurological symptoms had improved by the time the SLP conducted her evaluation on the floor after the patient had been admitted to the facility. For the one patient who passed the NBSS but not the SLP dysphagia evaluation, the SLP had witnessed the patient having another neurological episode during the dysphagia evaluation. With the NBSS, accurate identification of aspiration with the patients failing the screen was evident with the nursing and speech pathology assessment, resulting in 83% of sensitivity (10 of 12). The positive predictive value with corresponding identification of aspiration with the staff was 96% (44 of 46). The dysphagia evaluation consisted of an oral motor examination and assessment of the patient's swallow function based on presentations of oral intake trials with various consistencies, posturing, and safe swallowing maneuvers needed for adequate airway protection for potential diet approval by the licensed clinician.


Because of the initiation of the NBSS, the nursing staff was more aware of identifying signs and symptoms of aspiration and recognizing that patients swallow liquids and solids differently. Overall, the nursing swallow screen was only a cursory assessment to determine if the patient was safe or not for oral intake. The SLP dysphagia evaluation was a more in-depth analysis of the patient's swallowing ability with specific recommendations for follow-through. As a whole, the NBSS and SLP dysphagia evaluation results were consistent with each other for 40 of 46 patients (89.6% of positive correlation). The naturalistic observation of the patients exhibited internal consistency reliability between the two disciplines. Extraneous variables affecting the results of the testing methods included the patient's status improving (i.e., spontaneous resolution of stroke or TIA symptoms) or declining throughout the course of their hospitalization (i.e., continuation of neurological impairment). Overall, there were no any true-or false-negative results from the NBSS because the two discrepancies in the outcomes from the nursing versus the speech pathologist's analysis were because of changes in the patient's neurological status and not a variation in the recognition of dysphagia.


Patients who present to a hospital with neurological deficits potentially experience difficulty swallowing and may experience aspiration pneumonia. One of the recent core measure requirements with The Joint Commission was the need for a nursing swallow screen to be conducted before any oral intake being given to a stroke/TIA patient. The goal of this measure was to safely protect and care for those patients who are compromised. The community hospital included in the study has opted to have 90% compliance with use of the screen. The national standard goal is 85% compliance. The Joint Commission retired the dysphagia screen measure in the spring of 2010 because no standard, validated NBSS was available. However, the NBSS is still a guideline that is observed with The Joint Commission standards for a Certified Primary Stroke Center. This particular facility has been Stroke Certified since 2004.

Unfortunately, because there is no universal standard swallow screen for dysphagia patients in most facilities, the nurses only give the patients a sip of water to determine whether the patient has swallowing issues. Therefore, as a result, stroke/TIA patients were not being identified as having dysphagia, thus compromising the safe care of the patient. Hospital-acquired pneumonia is a real potential threat to patients with stroke/TIA. The patient's respiratory issues may be treated, but the dysphagia component was not addressed as the etiology of this condition. The purpose of this study was to prove that the NBSS created for this study is a useful indicator for the identification of dysphagia. Although the sample size was small for this particular study, the screen was proven to be a viable tool. This NBSS would be a worthwhile tool to be utilized by other medical facilities as well.

Nursing Bedside Swallow Screen

Is patient   [] Yes, continue screen.
alert?       [] No, STOP screen.

Patient      [] Clear oral cavity
has/can      [] Dry swallow upon command
             [] Voluntary cough 2x
             [] Swallow secretions

If ALL items in the second section above are checked, continue with screen. If not, STOP swallow screen, keep patient strict nothing-by-mouth, notify MD, and request dysphagia evaluation order.
STEP 1:   Have patient sip         [] No signs or
          90-ml water from cup        symptoms of
          [] Audible chest         [] Inability to cough/
             congestion               clear secretions
          [] Audible pharyngeal    [] Complains of
             congestion               swallowing
          [] Increased                difficulty
             respiratory rate      [] Decrease in OZ
          [] Multiple swallows        saturation
             needed                [] Decreased
          [] Temperature spike        respiratory rate
          [] Throat clearing       [] Delayed cough
          [] Wet or gurgly voice   [] Heavy, labored

STEP 2:   Have patient eat         [] No signs or symptoms
          one tablespoon           of aspiration
          of applesauce

          [] Audible chest         [] Inability to cough/
             congestion               clear secretions
          [] Audible pharyngeal    [] Complains of
             congestion               swallowing difficulty
          [] Increased respiratory [] Decrease in [O.sub.2]
             rate                     saturation
          [] Multiple swallows     [] Decreased respiratory
             needed                   rate
          [] Temperature spike     [] Delayed cough
          [] Throat clearing       [] Heavy, labored breathing
          [] Wet or gurgly voice

If one or more of the above signs and symptoms are checked, STOP swallow screen and notify MD as above.
STEP 3:   Have patient eat a       [] No signs or symptoms
          cracker                     of aspiration
          [] Audible chest         [] Inability to cough/clear
             congestion               secretions
          [] Audible pharyngeal    [] Complains of
             congestion               swallowing difficulty
          [] Increased             [] Decrease in [O.sub.2]
             respiratory rate         saturation
          [] Multiple swallows     [] Decreased respiratory
             needed                   rate
          [] Temperature spike     [] Delayed cough
          [] Throat clearing       [] Heavy, labored breathing
          [] Wet or gurgly voice

If one or more of the above signs and symptoms are checked, STOP swallow screen and notify MD as above.
Nursing   [] PASS   DATE:
Bedside             --
Screen    [] FAIL   TIME:

RN's signature: --


Policy for the Nursing Bedside Swallow Screen for Dysphagia

Complete screen on all patients at risk for aspiration before oral intake.

Examples of patients at risk for aspiration include the following:

* Decreased level of consciousness

* Stroke or TIA

* Multiple sclerosis

* Tracheostomy/ventilated patients

* Head/neck cancer

* Traumatic brain injury

* Pneumonia patients

* Dementia

* Other neurological problems such as ALS, Parkinson's, brain stem pathology, and extubated patients



* Elderly

Swallow Screen:

1. Sit the patient upright at 90[degrees] with head aligned in neutral position (not extended).

2. Check the patient's oral cavity for any excessive secretions or residue from previous oral intake.

3. Ask the patient to perform a dry swallow while assessing laryngeal elevation per palpation.

4. If the patient is unable to follow commands or is not alert, discontinue swallow screen and go to no. 11.

5. Have the patient drink 3 oz. (90 ml) of water from a medicine cup. Do not use straws or syringes during a bedside screening.

6. Observe the patient for any of the following warning signs:

* coughing, choking, strangling in relation to swallowing

* excessive secretions, drooling from one corner of the mouth

* gurgly voice quality

* repetitive throat clearing

* pocketing or holding food/fluid through the mouth

* spitting food out of the mouth or tongue thrusting

* regurgitation of food/fluid through the nose, mouth, or tracheostomy tube

* red facial color or watery eyes

* excessive runny nose during oral intake

7. Observe for signs of silent aspiration:

* throat clearing

* temperature spike

* decrease in [O.sub.2] saturation

* wet or gurgly voice

* increased respiratory rate (i.e., heavy labored breathing)

* delayed cough

* audible pharyngeal and/or chest congestion

* inability to cough/clear secretions

* decreased respiratory rate

8. Repeat above with one tablespoon of applesauce and then with a cracker.

9. If patient report of swallowing difficulty and/or multiple swallows only and does not exhibit ANY of the aforementioned concerns, inform the MD and recommend the patient on a puree/pudding thick via spoon diet with crushed medication. Request ST evaluation.

10. If the patient does not exhibit ANY aspiration signs with puree/thin via cup, inform the MD and recommend the order for this diet. Request ST evaluation for follow-up.

11. If any of the symptoms above are noted, report this to the physician:

a. Recommend the patient to be strict NPO including ice chips and crushed medications unless the aforementioned scenarios in number 9/10 occurred.

b. Ask if speech therapy consultation for full dysphagia evaluation should be ordered.

c. Ask for appropriate diet, medications, and iv orders until dysphagia evaluation has been completed by speech therapist.

d. If medications must be given orally despite the patient failing the swallow screen; per physician order, give the patient medication crushed with puree, with chin tuck, and cued multiple swallows.

e. Head of bed should be elevated more than 30[degrees] at all times. Position the patient at 90[degrees] for at least 30 minutes after intake including medications and sips of [H.sub.2]O.

12. If patient fails the swallow screen, reconduct the screen if the patient's health status improves.

13. If the patient passes the screen, continue to monitor the patient during oral intake. If aforementioned symptoms are noted, request an order for ST.

14. Inform patient and family of the results of the screen and purpose of the recommendations as indicated above.

Aspiration Prevention Guidelines

For patients receiving enteral feedings:

* Check feeding tube placement every shift.

* Monitor residuals every 4 hours.

* Turn off tube feeding at least 3 minutes before lying patient flat.


Beckstrom, L., Hanson, S. K., & Park, N. (2007). Comparison of nursing swallow screenings and speech swallow evaluations on an acute stroke unit (unpublished).

Suiter, D. M., & Leder, B. B. (2008). Clinical utility of the 3-ounce water swallow test Dysphagia, 23(3), 244-250.

Summers, D., Leonard, A., Wentworth, D., Saver, J. L., Simpson, J., Spilker, J. A., ... Mitchell, P. H.; American Heart Association Council on Cardiovascular Nursing and the Stroke Council. (2009). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: A scientific statement from the American Heart Association. Stroke: Journal of the American Heart Association, 40, 2911-2944.


The authors thank Shelley Nichols, MSN RN-BC, for her assistance in literature review, data collection, and nursing implementation of the screening tool and Dr. C. Van Morris for his influence toward the initial creation of a succinct swallow screen.


American Speech-Language Hearing Association. (2004). Preferred practice patterns for the profession of speech-language pathology. Retrieved from

American Stroke Association. (2011). Impact of stroke. Retrieved from

Beckstrom, L., & Hanson, S. K. (2008). Comparison of nursing screen and speech swallow evaluations on an acute stroke unit. Stroke, 39, 731-773. doi:10.1161/STROKEHA. 107.200002

Braislin, M. (2009). Dysphagia screening. Making it work. A how to "for harmonious implementation." Retrieved from

Bravata, D. M., Daggett, V., Woodward-Hagg, H., Damush, T., Pine, L., & Russell, S. (2009). Comparison of two approaches to screen for dysphagia among acute ischemic stroke patients: Nursing admission screening tool versus National Institutes of Health Stroke Scale. Journal of Rehabilitation Research and Development, 46(9). doi:10.1682/JRRD.2008.12.0169

Cichero, J., Heaton, S., & Bassett, L. (2009). Triaging dysphagia: Nurse screening for dysphagia in acute hospital. Journal of Clinical Nursing, 18, 1649-1659. doi:10.1111/j.1365-2702 .2009.02797.x

Cohen, A. K. (2009). Creating a swallow screening program at Mass General Hospital: A model for development and implementation. Perspectives on Swallowing and Swallowing Disorders, 18, 123-128.

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

Davis, S. (2002). An interdisciplinary approach to the management of dysphagia. Retrieved from

Department of Veterans Affairs. (2006). VHA Directive 2006-032, Veteran Health Administration. Washington, D.C.: Author. Retrieved from Publication.asp?pub_ID=1422

DePippo, K. L., Holas, M. A., & Reding, M. J. (1992). Validation of the 3-oz water swallow test for aspiration following stroke. Archives of Neurology, 49, 1259-1261.

Ebling, D. E. (1999). Organs of swallowing. In L. C. Ricardo & M. Thomas (Eds.), Comprehensive management of swallowing disorders. (pp. 11-21). San Diego, CA: Singular Publishing Group.

Edmiaston, J., Connor, L. T., & Abdullah, N. (2010). Validation of a dysphagia screening tool in acute stroke patients. American Journal of Critical Care, 19(4), 357-364. doi:10.4037/ajcc 2009961

Froud, H. (2002). Dysphagia trained nurse project in Southern Derbyshire. Retrieved from final_report_project1

Hinchey, J.A., Shepard, T., Furie, K., Smith, D., Wang, D., & Tonn, S. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke. 36, 1972. doi: 10.1161/01.STR .0000177529.86868.8d

Hind, J. A., Robbins, J., & Priefer, B. (2009). Development of multidisciplinary evidence based-dysphagia screen for all acute care admissions. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 18, 134-139. doi: 10.1044/ sasd18.4.134

Lakshminarayayan, K., Tsai, A. W., Tong, X., Vazquez, G., Peacock, J. M., George, M. G., & Anderson, D. C. (2010). Utility of dysphagia screening results in predicting post stroke pneumonia. Stroke, 41, 2849-2854. doi:10.1161/ STROKEAHA. 110.597039

Lees, L., Sharpe, L., & Edwards, A. (2006). Nurse-led dysphagia screening in acute stroke patients. Nursing Standard. 21(6), 35-42.

Mackay, L. E., Morgan, A. S., & Bernstein, B. A. (1999). Factors affecting oral feeding with severe traumatic brain injury. Journal of Head Trauma Rehabilitation. 14(5), 435-447.

Martino, R., Pron, G., & Diamont, N. (2000). Screening for oropharyngeal dysphagia in stroke: Insufficient evidence for guidelines. Dysphagia, 15, 19-30. doi:10.1007/s004559910006

Martino, R., Silver, F, Teasell, R., Bayley, M., Nicholson, G, Streiner, D. L., & Diamont, N. E. (2009). The Toronto bedside swallowing screening test (TOR-BSST). Development and validation of a dysphagia screening tool for patients with stroke. Stroke, 40, 555-561. doi:10.1161/STROKEAHA.107.510370

Massey, R., & Jedlicka, D. (2002). The Massey bedside swallowing screen. Journal of Neuroscience Nursing, 34(5), 252-253, 257-260.

Miller, E. L., Murray, L., Richards, L., Zorowitz, R. D., Bakas, T., Clark, P., & Billinger, S. A. (2010). Comprehensive overview of nursing and interdisciplinary rehab center of the stroke patient: A scientific statement from the American Heart Association. doi: 10.1161/STR.06013e3181e7512b

Murry, T., Carrau, R. L., & Eibling, D. E. (1999). Epidemiology of swallowing disorders. In R. L. Carrau & T. Murry (Eds.), Comprehensive management of swallowing Disorders. (pp. 3-7). San Diego, CA: Singular Publishing Group.

Poskus, K. (2009). Triumphs and challenges of implementing a nursing bedside swallow screening tool: A stroke coordinators perspective. Perspectives on Swallowing and Swallowing Disorders. doi: 10.1044/sasd18.4.129

Suiter, D. M., & Leder, S. B. (2009). 3 ounces is all you need. Perspectives in Swallowing Swallowing Disorders (Dysphagia). 18(4), 111-116. doi:10.1044/sasd18.4.110

Sullivan, P., & Dennis, K. (2006). Dysphagia care is a "major clinical focus" at the Veterans Health Administration. Asha Leader. 12, 10859586.

Summers, D., Leonard, A., Wentworth, D., Saver, J. L., Simpson, J., Spilker, J. A., & Mitchell, P. (2009). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: A scientific statement from the American Heart Association. Stroke, 40, 2911-2944. doi:10.1661/STROKEAHA.109.192362

Teasell, R., Foley, N., Martino, R., Bhogal, S., & Spechley, M. (2009). Dysphagia and aspiration post stroke. Retrieved from

The Joint Commission. (2006). Primary stroke centers: Stroke performance measurement implementation guide (pp. 4-24). Retrieved from primary_stroke_centers.aspx

Tohara, H., Saithoh, E., Mays, K. A., Kuhlemeier, K., & Palmer, B. J. (2003). Three tests for predicting aspiration without videoflurorography. Dysphagia, 18, 126-134.

Trapl, M., Enderle, P., Nowontny, M., Teuschl, Y., Matz, K., Dachenhausen, A., & Vrainin, M. (2007). Dysphagia bedside screening for acute-stroke patients. The Gugging Swallowing Screen. Stroke, 38, 2948-2952. doi:10.116l/ STROKEAHA. 107.483933

Westergren, A., Hallberg, I. R., & Ohlsson, O. (1999). Nursing assessment of dysphagia among patients with stroke. Scandinavian Journal of Caring Science, 13(4), 274-282.

Wood, P., & Emick-Herring, B. (1997). Dysphagia: A screening tool for stroke patients. Journal of Neuroscience Nursing, 29(5), 325-329.

Questions or comments about this article may be directed to Allison Loftiss Ellis, MSEd CCC-SLP, at She is a Speech-Language Pathologist at United Home Care of Greensboro, Greensboro, GA.

Ruth Renee Hannibal, PhD CCC-SLP, is an Associate Professor at the Department of Communication Sciences and Disorders, Valdosta State University, Valdosta, GA.

The authors declare no conflicts of interest.

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DOI: 10.1097/JNN.0b013e31829d8b5b
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Author:Ellis, Allison Loftiss; Hannibal, Ruth Renee
Publication:Journal of Neuroscience Nursing
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2013
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