Development of UWH Stroke Dysphagia Screening Tool
Stroke is the fifth leading cause of death and leading cause of disability (CDC, 2015). Nearly 50% of
stroke patients may experience deficits related to dysphagia (Massey & Jedlicka, 2002). Early
identification of dysphagia and aspiration risk is critical to avoid complications including, pneumonia,
nutritional decline, reduced ability to participate in rehabilitation and death; however, keeping patients
NPO for a formal swallow evaluation is not satisfactory and presents other risks to the patient’s health.
(Donovan et al., 2013).
A swallow screening, as defined by the American Speech-Language-Hearing Association, is a pass/fail
procedure to identify individuals who require a comprehensive assessment of swallowing functions or
referral to another professional. Screening does not define the nature of a problem, but identifies those
at risk for dysphagia and/or aspiration, and needing further diagnostic testing (Logemann, Veis, &
Colangelo, 1999). The goal of any dysphagia tool is to screen stroke patients for symptoms of dysphagia
and aspiration and refer the patient to a speech and language pathologist for more formal testing.
The UWH Stroke Dysphagia Screening tool was developed in collaboration with Speech and Language
Pathologist (SLP) and nursing experts. Members of this committee included SLP experts: Molly Knigge
and Susan Thibeault; nursing experts: Nicole Bennett, Chris Whelley, Pat Chesmore and Ellie Burgenske
and physician champion Justin Sattin. The group reviewed existing tools for content and ability to meet
the needs of the organization. The screening needed to be objective, efficient, and low risk to the
patient. Additionally, required clinical features included assessment of alertness, dysarthria, dysphonia
and a water swallow test. Previously published tools did not meet these standards, thus a novel tool was
In developing the UWH Stroke Dysphagia Screen, each clinical feature selected for inclusion had
established research evidence for sensitivity and specificity in detecting dysphagia and aspiration in the
Alertness/Level of Consciousness
Level of alertness is a common requirement for swallow screens, as the patient needs to
cooperate with the clinician’s directions such as repeating words. Daniels & Anderson (2012)
stated, “the ability to maintain alertness for a sustained period should be a prerequisite for
attempting a swallow screen.” In addition, Martino and colleagues (2009) considered patients
with reduced alertness to have dysphagia and thus inappropriate for further screening.
Any History of Swallowing Problems
This was an exclusion for most studies related to swallow screens. Patients experiencing a
stroke can have an anamnestic response, causing reappearance of previous swallowing
problems or have a long standing special diet related to deficits from a previous stroke. The
committee felt it prudent to have patients with a previous swallowing problem be formally
evaluated by a Speech and Language Pathologist.
Dysarthria, as defined by the American Speech Language Hearing Association, is a motor speech
disorder, resulting in impaired movement of the muscles used for speech production, including
the lips, tongue, vocal folds, and/or diaphragm. Logemann and colleagues (1999) found “the
best single predictor of the presence or absence of an oral stage problem was dysarthria”, with
a sensitivity of 64%. Likewise, McCullough, Wertz, & Rosenbek, (2001) and Daniels et al., (1998)
found similar results.
Dysphonia, or impairment of the speaking voice, is detected by the UWH Stroke Dysphagia
screening tool by having the patient repeat a sentence. Positive findings, including abnormal,
weak or wet voice quality, would prompt a formal SLP evaluation. McCullough et al. (2001)
found decreased speech intelligibility and ability to manage secretions noteworthy, with
sensitivity for dysphonia at 1.0; specificity 28%. Likewise, Daniels et al., (1998) found 76%
specificity for dysphonia; specificity 53%.
Water Bolus Test
The water bolus for the UWH Stroke Dysphagia Screen is only performed if all other elements of
the screen are negative. The water boluses are administered in 2 steps, first with a small 5mL
amount and then 90mL. After each water bolus, the administrator listens for any cough and wet
voice quality when speaking. In their study, Logemann et al., (1999) found that the “single best
predictor of aspiration was a throat clear or cough during trial swallows” with a sensitivity of
78%. Likewise, Daniels and colleagues (2012) and McCullough and colleagues (2001) found
cough and wet voice after swallow to be predictors of aspiration. Moreover, screening with
multiple, increasing water volumes appears to be both more robust and safe. (Daniels et al.,
After piloting the UWH Dysphagia Screening tool between March and September of 2015, a
retrospective chart audit was completed for patients with stroke-like symptoms who had been
administered the screening tool. Of the 98 patients screened, 5 were referred to a Speech and
Language Pathologist for comprehensive swallow evaluation. Of these, one patient was found to have
evidence of dysphagia upon further testing. No patients screened developed evidence of aspiration
pneumonia. The tool and results of the chart audits were taken to the Patient Assessment Tool
Committee, who found the tool to be an acceptable addition to the electronic medical record.
Daniels, S. K., Anderson, J. A., & Willson, P. C. (2012). Valid items for screening dysphagia risk in patients
with stroke: a systematic review. Stroke (00392499), 43(3), 892-897.
Daniels, S. K., Ballo, L. A., Mahoney, M., & Foundas, A. L. (2000). Clinical predictors of dysphagia and
aspiration risk: outcome measures in acute stroke patients. Archives of Physical Medicine &
Rehabilitation, 81(8), 1030-1033.
Daniels, S. K., Brailey, K., Priestly, D. H., Herrington, L. R., Weisberg, L. A., & Foundas, A. L. (1998).
Aspiration in patients with acute stroke. Archives of Physical Medicine & Rehabilitation, 79(1),
Donovan, N. J., Daniels, S. K., Edmiaston, J., Weinhardt, J., Summers, D., & Mitchell, P. H. (2013).
Dysphagia Screening: State of the Art: Invitational Conference Proceeding From the State-of-
the-Art Nursing Symposium, International Stroke Conference 2012. Stroke, 44(4), e24-31.
Edmiaston, J., Connor, L. T., Steger-May, K., & Ford, A. L. (2014). A Simple Bedside Stroke Dysphagia
Screen, Validated against Videofluoroscopy, Detects Dysphagia and Aspiration with High
Sensitivity. Journal of Stroke & Cerebrovascular Diseases, 23(4), 712-716.
Hind, J. A., Robbins, J., & Priefer, B. (2009). Development of a multidisciplinary evidence-based
dysphagia screen for all acute care admissions. Perspectives on Swallowing & Swallowing
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Logemann, J. A., Veis, S., & Colangelo, L. (1999). A screening procedure for oropharyngeal dysphagia.
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Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D. L., & Diamant, 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(2), 555-561.
Massey, R., & Jedlicka, D. (2002). The Massey Bedside Swallowing Screen. Journal of Neuroscience
Nursing, 34(5), 252-260.
McCullough, G. H., Wertz, R. T., & Rosenbek, J. C. (2001). Sensitivity and specificity of clinical/bedside
examination signs for detecting aspiration in adults subsequent to stroke. Journal of
Communication Disorders, 34(1/2), 55-186.
Schepp, S. K., Tirschwell, D. L., Miller, R. M., & Longstreth, W. T., Jr. (2012). Swallowing screens after
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Trapl, M., Enderle, P., Nowotny, M., Teuschl, Y., Matz, K., Dachenhausen, A., & Brainin, M. (2007).
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