Bedside test screens for swallowing disorder

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Canadian Stroke Network researchers have developed a bedside test that will enable health professionals to quickly determine whether a stroke patient is having trouble swallowing and may be at risk of choking, pneumonia or malnutrition.

The Toronto Bedside Swallowing Screening Test (Tor-BSST©), presented in February at the 2007 International Stroke Conference, is a state-of-the-art tool to screen patients for dysphagia, or swallowing problems.

Neurological damage causes swallowing difficulties in as many as 55 per cent of stroke patients. “Swallowing is a subconscious act until it goes wrong,” says Canadian Stroke Network (CSN) researcher Dr. Rosemary Martino, Assistant Professor in the Department of Speech Language Pathology at the University of Toronto, who led the development of the test. Of those patients affected by dysphagia, as many as half do not recover to a normal swallow by six months post-stroke.

Screening for swallowing problems is among 24 recommendations of the Canadian Stroke Best Practice Recommendations, released in December by the Canadian Stroke Strategy, a joint initiative of the CSN and the Heart and Stroke Foundation. It calls for the screening of all stroke patients before they are given fluids, food or oral medications.

Patients who ‘fail’ the screening would receive a full bedside assessment by a speech language pathologist, and may require fluids by intravenous, feeding assistance or mealtime supervision. Patients who ‘pass’ the screening would be advanced to an oral diet. “This test is introducing efficiency in an area that is a big concern for people and it will have an impact,” says Dr. Martino.

The Tor-BSST© involves evaluating patients for alertness, participation in the test, oral motor function, and the presence of a cough. Small amounts of water are administered using a preset protocol and the patient is monitored for signs of impaired swallowing. “Coughing during and for up to one minute after completion of the test, and a ‘wet’ or hoarse voice, suggest that there is an abnormal swallow.”

A four-hour training course on Tor-BSST© (pronounced Tor-Best) will be available on CD and may be ordered through the Canadian Stroke Strategy Web site (www.canadianstrokestrategy.ca).

The course accredits speech language pathologists to train frontline nursing staff, dietitians, physical therapists and occupational therapists on use of the screening tool, which Dr. Martino describes as “easy to use, easy to administer and proven to detect dysphagia . . . There is a huge international interest in this.”

“This is a wonderful example of how CSN research is helping to improve the quality of care that stroke patients receive,” says Dr. Antoine Hakim, CEO and Scientific Director of the Canadian Stroke Network. “The availability of the Tor-BSST test will make it possible to meet the goal of screening all stroke patients for dysphagia.”

Dr. Martino says that “patients with severe dysphagia are 11 times more likely to develop pneumonia” and they are also “at increased risk of becoming dehydrated, malnourished, anxious and depressed.” Screening for dysphagia has already been shown to decrease pneumonia rates. “If you identify dysphagia early, you can avoid a lot of problems later on.”

Patients with dysphagia are also more likely to die in the first 90 days post-stroke, Dr. Martino says, which is why it is so important that people are screened and treated early for this condition.