A Decision Guide for Assessing the Recently Extubated Patient’s Readiness for Safe Oral Intake

Abstract

Background Postextubation dysphagia is a known consequence of endotracheal intubation. Several risk factors for postextubation dysphagia have been identified that could be used to help determine which patients should undergo swallowing assessment by an appropriate professional. Local Problem At the authors’ institution, critical care nurses, health care providers, and speech-language pathology professionals lacked a clear process for referring patients for swallowing assessment after extubation, resulting in inefficiency and confusion. Information to guide their decision-making in this area was needed. To address this need, a multidisciplinary group convened and developed a guide with specific indicators. Methods A review of the literature on postextubation dysphagia was conducted to determine the most appropriate indicators for the guide, which was piloted in the medical intensive care unit. The utilization rate was calculated. Referrals to speech-language pathology professionals were tabulated before and after the project. Results During the 11 months before implementation of the project, there were 994 speech-language pathology consultations for postextubation evaluation of swallowing. During the 11 months after implementation, there were 831 consultations, representing a 16.4% reduction. The decline in consultations resulted in cost savings in addition to preventing unnecessary testing before patients’ resumption of oral intake. The utilization rate for the guide during the project was 58%. Conclusion The decision guide was an effective tool to help nurses and health care providers determine which patients should be referred to speech-language pathology professionals for swallowing assessment after extubation, facilitating the appropriate use of limited health care resources.

Reducing Aspiration Risk with Validated Bedside Swallowing Screening Tools

“…Al [2] implemented a mandatory swallowing protocol using a 3-ounce water challenge for all elective surgical patients, they saw a reduction in healthcare-acquired pneumonia from 5.1% to 1.9% in six months (2023). In patients requiring intubation, a bedside swallow evaluation tool utilized by nurses resulted in a 16.4% decline in consultations to speech-language pathology services for swallowing assessment post-extubation [4].…”

“…Risk factors for acute aspiration include a known history of swallowing difficulty, weak or absent cough or gag reflex, recent extubation, extended intubation (greater than 48 hours), and decreased level of consciousness. One study found that patients with a history of head, neck, or cervical spine tumors and/or radiation experienced a "50% incidence of clinically significant dysphagia" [4]. Signs of respiratory distress such as increasing oxygen requirements, severe tachypnea, and new conversational dyspnea are important risk factors as well.…”

Perspective on dysphagia screening, assessment methods, and protocols in intensive care units: an opinion article

“…Intensive care unit (ICU) admission and related prolonged intubation has been identified as a substantial risk factor for the development of swallowing problems (aka dysphagia) (Perren et al, 2019 ; Spronk et al, 2022 ; Royals et al, 2023 ). Indeed, post-extubation dysphagia (PED) has a documented prevalence rate of 93% (Macht et al, 2013 ) and has been linked to adverse health outcomes and risks, including aspiration-related pneumonia (Barker et al, 2022 ; Freeman-Sanderson et al, 2023 ; Royals et al, 2023 ), malnutrition (Barker et al, 2022 ; Royals et al, 2023 ), dehydration (Royals et al, 2023 ), re-intubation (Muñoz-Garach et al, 2023 ; Royals et al, 2023 ), prolonged mechanical ventilation (MV) and length of ICU/hospital stay (Barker et al, 2022 ; Muñoz-Garach et al, 2023 ; Royals et al, 2023 ; Clayton et al, 2024 ). Additionally, it contributes to delayed recovery (Royals et al, 2023 ), reduced quality of life (QoL), and higher short-term (28 days) and mid-term (90 days) mortality rates (Perren et al, 2019 ; Muñoz-Garach et al, 2023 ; Clayton et al, 2024 ).…”

Strategies of Screening and Treating Post-Extubation Dysphagia: An Overview of the Situation in Greek-Cypriot ICUs

“…Despite PED’s high prevalence and significant association with negative patient outcomes, bedside screening is not routinely conducted [ 12 ]. Limited awareness and inadequate knowledge of healthcare professionals [ 19 ], especially of nurses [ 20 , 21 , 22 ] but also of physicians [ 23 ], are some of the reasons that were attributed to limited screening for PED in the intensive care units (ICUs). Additionally, although a speech and language pathologist/therapist (SLP/SLT) is helpful in the evaluation and management of dysphagia [ 24 ], dysphagia is a complex problem that requires a multi-professional targeted approach [ 22 , 25 , 26 ].…”