Volume 48 & Number 4 & August 2016 215

Nursing Interventions for Identifying and

Managing Acute Dysphagia are Effective for
Improving Patient Outcomes: A Systematic
Review Update
Sonia Hines, Kate Kynoch, Judy Munday

LITERATURE REVIEW
ABSTRACT
Background: Dysphagia, or difficulty in swallowing, is a serious and life-threatening medical condition that
affects a significant number of individuals with acute neurological impairment, largely from stroke.
Dysphagia is not generally considered a major cause of mortality; however, the complications that result
from this medical condition, namely, aspiration pneumonia and malnutrition, are among the most common
causes of death in the older adults. Methods: This is an update of an existing systematic review. The standard
systematic review methods of the Joanna Briggs Institute were used. Methods were specified in advance
in a published protocol. A wide range of databases were searched for quantitative research articles examining
the effectiveness of nursing interventions to identify and manage dysphagia in adult patients with acute
neurological dysfunction, published between 2008 and 2013. Results: Four new studies were added in this
update, for a total of 15 included studies. Strong evidence was found to show that nurse-initiated dysphagia
screening is effective for reducing chest infections in patients with dysphagia (odds ratio [OR] = 0.45, 95% CI
[0.33, 0.62], p G .00001). Nurse-initiated dysphagia screening by trained nurses may be effective for detection
of dysphagia, and training nurses in dysphagia screening improves the number and accuracy of screens
conducted. The presence of formal dysphagia guidelines in a health facility is likely to reduce inpatient
deaths (OR = 0.60, 95% CI [0.43, 0.84], p = .003) and chest infections (OR = 0.68, 95% CI [0.51, 0.90],
p = .008); however, it does not appear that formal guidelines have an effect on length of stay. Conclusions:
Nurse-initiated dysphagia screening for patients with acute neurological dysfunction is effective for a range
of important patient outcomes. The presence of formal guidelines for the identification and management
of dysphagia may have a significant effect on serious adverse outcomes such as chest infections and death.
Training nurses to conduct dysphagia screening will improve patient outcomes.

Keywords: deglutition disorders, dysphagia, nursing interventions, stroke, systematic review

Questions or comments about this article may be directed to Background

Sonia Hines, RN BN GradDipEd, MAppSc, at sonia.hines@
mater.org.au. She is a Nurse Researcher, Mater Health Services
Nursing Research Centre and The Queensland Centre for Evidence-
Based Nursing and Midwifery: a Joanna Briggs Institute Centre of
Excellence, Brisbane, Queensland.
Kate Kynoch, RN BN GradCert(ICN) MN(ICN) PhD candidate,
Director, Mater Health Services Nursing Research Centre, and The
Queensland Centre for Evidence-Based Nursing and Midwifery:
a Joanna Briggs Institute Centre of Excellence, Brisbane, Queensland.
Judy Munday, RN DipEd(Nurs) BA(Hons) PhD candidate, Clinical
Research Nurse, Mater Health Services Nursing Research Centre, and
The Queensland Centre for Evidence-Based Nursing and Midwifery:
a Joanna Briggs Institute Centre of Excellence, Brisbane, Queensland.
The authors declare no conflicts of interest.
Copyright B 2016 American Association of Neuroscience Nurses
DOI: 10.1097/JNN.0000000000000200
Dysphagia, that is, difficulty in swallowing, is a serious
and life-threatening medical condition that affects a
significant number of individuals with acute neurolog-
ical impairment, largely from stroke. It is estimated that
approximately 1 in 10 deaths worldwide are because of
stroke (Mackay & Mensah, 2004). Of those who expe-
rience a stroke, around 65% will develop neurogenic
dysphagia (Daniels, 2006). Dysphagia is not generally
considered a major cause of mortality; however, the com-
plications that result from this medical condition, namely,
aspiration pneumonia and malnutrition, are among
the most common causes of death in the older adults
(Wieseke, Bantz, Siktberg, & Dillard, 2008).
In hospitals, nurses, who are available on a 24-hour
basis, are in a prime position to undertake an initial

Copyright 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
216 Journal of Neuroscience Nursing
screening and initiate interventions for patients with
LITERATURE REVIEW swallowing difficulties (Davies, 2002). Nurses specif-
ically trained in undertaking dysphagia screening have
an important role in reducing adverse outcomes associated
with dysphagia (Yeh et al., 2011). Nurses are often in the
position of explaining and educating family members on
the patients management plan and have an important
impact on the patient and family adherence to treatment
for dysphagia (Lutz, Young, Cox, Martz, & Creasy,
2011). If nurses screen patients with an acute neuro-
logical impairment within 24 hours of admission, it may
reduce the time that patients spend without appropriate
nutrition and hydration and improve clinical outcomes
(Hines et al., 2011). Dysphagia screening by nurses does
not replace assessment by other health professionals; in-
stead, it enhances the provision of care to patients at risk
allowing for early recognition and intervention to occur.
This review is an update of a review previously
updated in 2008, using Joanna Briggs Institute (JBI)
methods, which included articles published between
1998 and 2008 (Hines et al., 2011). The original re-
view (Ramritu, Finlayson, Mitchell, & Croft, 2000)
sourced evidence from 1985 to 1998. This new update
aimed to review all available evidence from February
2008 to March 2013.
The level of evidence in the previous iteration of this
review was overall moderate to low, with only one ran-
domized controlled trial (RCT) included, with most being
of lower quality observational or descriptive designs.
This review includes stronger evidence. The objectives,
inclusion criteria, and methods of analysis for this re-
view were specified in advance and documented in a
published protocol (Hines, Kynoch, & Munday, 2013).
A version of this review with a large number of appen-
dices and supplementary materials is uploaded on the
JBI Library of Systematic Reviews and Implementation
Reports (Hines, Kynoch, & Munday, 2014).
Searches
We searched CINAHL, Medline, Cochrane CENTRAL,
Web of Science, and Embase. The search for gray liter-
ature included Mednar, OpenSIGLE, New York Acad-
emy of Medicine Library Grey Literature Report, and
ProQuest Dissertations and Theses for published and
unpublished studies. Searches were restricted to English
language only.
Initial search terms used were the following:
! dysphagia (text word and MH) or gag reflex or swallow
! problem or impair or difficult
! neurological and impair or stroke or bedside swal-
lowing assessment
! MH Brain Diseases+ or neurological and impair*
or disorder* or disease* or malfunction
Copyright 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
MH Deglutition Disorders or MH Gagging
!
or bedside swallowing assessment or swallowing
assessment
Inclusion Criteria
Participants
Participants of interest were adults over the age of
18 years with acute neurogenic dysphagia. Populations
with neurological impairment resulting from a long-
term disease process (e.g., Huntington disease) were not
included because their assessment needs are considered
different to the focus of this review and largely the
purview of speech and language professionals, not nurses.
Interventions
Interventions that focused on the nursing role in the
recognition and screening for dysphagia; any formal
observation of the ability to swallow undertaken/
documented by nurses, clinical/bedside swallowing
screening undertaken by nurses, pulse oximetry moni-
toring for the purposes of detecting aspiration, and other
interventions concerned with the nursing management
of dysphagia such as nurse education, either in com-
parison with usual care or other interventions, were
eligible for inclusion.
Exclusion Criteria
Studies focusing on diagnostic procedures ordered or
undertaken by either medical or speech-language pathol-
ogists (such as VFSS) were not of interest to this review.
Studies focusing on dysphagia without a diagnosed neuro-
logical impairment were also excluded. Any studies
with participants with dysphagia resulting from cancer,
radiotherapy, surgery, infection, or congenital abnormali-
ties were excluded, unless these participants formed the
control group.
Outcomes
This review considered studies that measured any out-
comes related to the following areas:
! Early recognition by nurses of those with difficulty
swallowing
! Clinical screening by nurses of any patient with sus-
pected swallowing difficulties
! Timely referral by nurses to speech-language pathol-
ogists for formal assessment
! Any outcome measures from interventions that aimed
to prevent aspiration, choking episodes, and/or asso-
ciated morbidity
Study Designs
Experimental and epidemiological study designs includ-
ing randomized controlled trials, nonrandomized controlled
trials, quasi-experimental studies, before-and-after studies,

prospective and retrospective cohort studies, case control
studies, and cross-sectional studies were considered for
inclusion.
Critical Appraisal
Articles selected for retrieval were assessed by two in-
dependent reviewers for methodological validity before
inclusion in the review using standardized critical appraisal
instruments from the JBI Meta-Analysis of Statistics
Assessment and Review Instrument. Any disagreements
that arose between the reviewers were resolved through
the adjudication of the third reviewer.
Data Extraction and Synthesis
Data were extracted from articles included in the review
using the standardized data extraction tool from JBI Meta-
Analysis of Statistics Assessment and Review Instrument.
The data extracted included specific details about the
interventions, populations, study methods and outcomes
of significance to the review question, and specific ob-
jectives. We attempted to contact study authors where
necessary to clarify details and/or retrieve any missing data.
Quantitative data were, where possible, pooled in
statistical meta-analysis using RevMan 5.2. Effect sizes
are expressed as odds ratio (for categorical data) and
weighted mean differences (for continuous data), and
their 95% confidence intervals were calculated for analysis.
Heterogeneity was assessed statistically using the stan-
dard chi-square and I-squared tests. The small amount of
additional data from this update was combined with data
from the studies included in the previous update to enable
a more accurate view of the effect of interventions.
Characteristics of Included Studies
Initially, 38 studies were identified from the searches as
being potentially relevant. We were unable to retrieve
full-text versions of two of the studies, which were only
available as conference abstracts, and seven were dupli-
cates. Twenty-nine studies in full text were checked for
congruence to the reviews inclusion criteria, and of
these, six met the criteria and were critically appraised.
After critical appraisal, four studies meeting the inclu-
sion criteria were found to be of sufficient quality to be
included in the review (Bravata et al., 2009; Edmiaston,
Connor, Loehr, & Nassief, 2010; Martino et al., 2009;
Middleton et al., 2011). These were added to 11 studies
(Anderson et al., 2000; Chang, Pattie, & Finlayson, 2005;
Daniels, Ballo, Mahoney, & Foundas, 2000; Goulding
& Bakheit, 2000; Lees, Sharpe, & Edwards, 2006;
Nishiwaki et al., 2005; Perry, 2001a, 2001b; Perry &
McLaren, 2000, 2003; Westergren, Hallberg, & Ohlsson,
1999) from the last update of this review. Although the
previous update included 14 studies, three of these are
no longer considered to meet the inclusion criteria and
Copyright 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 48 & Number 4 & August 2016 217
have been excluded (please see the Differences Be-
LITERATURE REVIEW
tween This Update and the Previous Version section for
further details). The total number of included studies in
this review update is 15 (see Fig 1 for further details of
the search and retrieval process).
Studies included in this review update were conducted
in Australia (Anderson et al., 2000; Chang et al., 2005;
Middleton et al., 2011), Japan (Nishiwaki et al., 2005),
Sweden (Westergren et al., 1999), Canada (Martino
et al., 2009), United Kingdom (Goulding & Bakheit,
2000; Lees et al., 2006; Perry, 2001a, 2001b; Perry &
McLaren, 2000, 2003), and United States (Bravata
et al., 2009; Daniels et al., 2000; Edmiaston et al.,
2010) and had a total of 6,092 participants.
Risk of Bias
Four studies were added by this update: one RCT
(Middleton et al., 2011), two tool validation studies
using observational methods (Edmiaston et al., 2010;
Martino et al., 2009), and one retrospective pre/post
descriptive study (Bravata et al., 2009). The RCT
(Middleton et al., 2011) was found to be high quality,
with adequate randomization, concealment of allocation,
and blinding of participants; however, it was unclear if
intention-to-treat analysis was utilized. The prospective
observational tool validation study by Edmiaston et al.
(2010) was lacking in some details of the methodology
used; however, it was deemed of adequate quality to
include, as was the prospective observational study by
Martino et al. (2009), which was of similar quality. The
retrospective pre/post descriptive study to validate a tool
(Bravata et al., 2009) used high-quality methods to
minimize the risk of bias.
Results
To truly update the evidence on this question rather than
simply create a new review of the most recent evidence,
we have combined data from the previous review,
where it was possible and appropriate, to conduct meta-
analyses. Findings are grouped by types of intervention
and then further grouped by outcome as it relates to
each intervention.
Nurse-Initiated Dysphagia Screening for
Reducing Chest Infections
Five studies with 4,519 participants reported data on
this intervention and outcome. Two new studies reported
data on nurse-initiated screening for dysphagia (Bravata
et al., 2009; Middleton et al., 2011)Vdata from which
were added to three included studies (Hinchey et al.,
2005; Perry, 2001b; Perry & McLaren, 2000) and the
dichotomous data pooled (Fig 2). Nurse-initiated screen-
ing was significantly more effective than usual care
218 Journal of Neuroscience Nursing
for preventing chest infections (odds ratio = 0.45, 95%
LITERATURE REVIEW confidence interval [0.33, 0.62], p G .00001).
Nurse-Initiated Dysphagia Screening for
Reducing Days Spent Nil by Mouth
Three studies with 557 participants reported data on
this intervention and outcome. One new study (Bravata
et al., 2009) investigating nurse-initiated screening re-
ported data on days spent nil by mouth, which was added
to one included study (Perry, 2001b) that also reported
this outcome. For this comparison, there was no statis-
tically significant difference between the group receiv-
ing nurse-initiated screening and the usual care group.
Days spent without oral intake were also measured
in one additional study (Perry & McLaren, 2000). Similar
to Bravata et al. (2009) and Perry (2001b), Perry and
McLaren (2000) report a significant reduction in days
spent nil by mouth in the group receiving nurse-initiated
dysphagia screening (p G .001); however, the data were
unsuitable to be included in the analysis, introducing
significant heterogeneity (22 = 56.88, df = 2, p G
.00001, I2 = 96%) and exerting considerable effect on
FIGURE 1 Flowchart of Studies
Copyright 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
the pooled result. The considerable methodological
differences (audit vs. prospective observational study)
between these studies are likely to be the cause of the
heterogeneity. It would seem from the results of the
included studies that it remains unclear whether this is
an effective intervention for reducing the number of days
spent without oral intake (Fig 3).
Nurse-Initiated Dysphagia Screening for
Detection of Dysphagia by Trained Nurses
Six studies (Anderson et al., 2000; Edmiaston et al.,
2010; Lees et al., 2006; Perry, 2001a, 2001b; Westergren
et al., 1999) with greater than 511 instances of screening
(one study reported only percentage accuracy, not num-
ber of screens) reported data on the accuracy of dysphagia
screening conducted by nurses using screening tools for
which they had received training. A variety of tools were
employed in the studies; however, as can be seen in the
analysis, very few inaccurate screens (false positive or
false negative) were reported. Where accuracy was not
reported as a percentage, we calculated it from the re-
ported numerical data. The data and percentage of
 Volume 48 & Number 4 & August 2016 219

LITERATURE REVIEW
FIGURE 2 Occurrence of Chest Infections: Nurse Screening Versus Usual Care

accurate screens performed are shown in Table 1. Ac-
curacy of screens ranged from approximately 70% to
over 94%. Accuracy of screening was considerably
greater in studies using validated tools (Edmiaston et al.,
2010; Lees et al., 2006; Perry, 2001a, 2001b) rather than
clinical assessment (Westergren et al., 1999). Although
the accuracy reported in Anderson et al. is also high,
the actual numbers of screens was small (Anderson et al.,
2000). Screening accuracy in all studies was determined
by comparison with screens conducted by speech and
language professionals. Overall, it appears that nurse-
initiated dysphagia screening by nurses trained in the use
of a validated tool is effective for detecting dysphagia.
In addition, training nurses in the use of validated
dysphagia screening tools has been found to increase
the number of patients with acute neurological dysfunc-
tion who are screened for swallowing problems (Table 2).
Although a meta-analysis of these studies showed sig-
nificant effect (p G .00001), the heterogeneity was too
great (2 2 = 58.38, df = 2, p G .00001, I = 97%) to
include the pooled results, and this was not improved
by attempting sensitivity analysis. The high degree of
heterogeneity was likely because of the extensive clin-
ical variability between the studies.
Nurse-Initiated Dysphagia Screening for
Time to Initial Assessment
One study with 50 participants reported data on the ef-
fect of nurse-initiated dysphagia screening on the time
to swallow assessment (Lees et al., 2006). In this study
of acute stroke admissions to an acute observation unit,
the mean time to assessment by speech and language
therapists (SLTs) before the intervention was 1.53 days
(Lees et al., 2006). After a training program to give
nurses the skills to conduct dysphagia screening, there
was a considerable reduction in time to swallow assess-
ment, with patients with acute stroke admitted via the
emergency department being assessed at 5Y29 hours
after admission and most patients with acute stroke
(91%) admitted directly to the acute observation unit
assessed within the first hour after admission (Lees
et al., 2006).
Nurse-Initiated Dysphagia Screening for
Time to SLT Assessment and Referral to SLT
Four studies with 655 participants (608 patients/47 staff)
reported data on the effect of nurse-initiated dysphagia
screening on the time to SLT referral and/or SLT as-
sessment (Anderson et al., 2000; Chang et al., 2005;
Lees et al., 2006; Perry & McLaren, 2003). Nurses were
found to have made the appropriate referral to SLTs in
100% of Chang et al.s (2005) experimental group,
87.5% of cases in Lees et al.s (2006) study, and 72%
of cases in Anderson et al.s (2000) study. Perry and
McLaren (2003) report that, before introduction of
nurse-initiated dysphagia screening, 39% (n = 30) of
referrals of patients with suspected dysphagia for SLT
assessment were made within 72 hours of admission,

TABLE 1. Accuracy of Screening by Nurses Trained in Dysphagia Screening

Study Tool Accurate Inaccurate Total Screens Accuracy
Anderson et al., 2000 PFC/FT 18/19 1/0 19 95%/100%
Edmiaston et al., 2010 ASDS 238 62 300 79.3%
Lees et al., 2006 SSA 35 5 40 87.5%
Perry, 2001b SSA 64 12 76 84.2%
Perry, 2001a SSA 64 4 68 94.1%
Westergren et al., 1999 Clinical evaluation 19 8 27 70.3%

Note. ASDS = acute stroke dysphagia screen; PFC/FT = prefeeding checklist/feeding trial; SSA = standardized swallow assessment.

Copyright 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
220 Journal of Neuroscience Nursing

TABLE 2.
LITERATURE REVIEW Nurse Dysphagia Screen Training for Number of Patients Screened
No Training Training
Study Tool Screens N Screens N Significance
Chang et al., 2005 SSA 0 80 33 61 p = .002
Middleton et al., 2011 ASSIST 24 350 242 522 p G .0001
Perry & McLaren, 2003 SSA 106 200 123 200 p G .001

Note. SSA = standardized swallow assessment.

which rose to 56% (n = 42) once nurses were con-
ducting dysphagia screening; however, the difference
was not statistically significant (Perry & McLaren,
2003). Similarly, the time to SLT assessment also rose
slightly from 64% (n = 49) before nurse dysphagia
screening to 68% (n = 51) after nurse dysphagia screen-
ing, which was also statistically insignificant (Perry &
McLaren, 2003). It is interesting to note that, in Chang
et al.s study, the number of SLT referrals decreased in
the group that had received dysphagia screening with
no difference in the appropriateness of those referrals.
Formal Dysphagia Guidelines for Screening
Within 24 Hours, Chest Infections, Death,
and Length of Stay
Four studies (Hinchey et al., 2005; Middleton et al.,
2011; Perry & McLaren, 2000, 2003) with 4,528 par-
ticipants reported data on the effectiveness of formal
dysphagia guidelines within an organization in com-
parison with no guidelines or informal guidelines for a
variety of outcomes including screening within 24 hours,
rates of chest infections, death, and length of stay. The
presence of formal dysphagia guidelines has been found
to be effective, in all studies reporting this outcome, for
increasing the number of patients screened for dysphagia
within 24 hours of admission, as shown by the results
from the two studies in Table 3 below. We attempted to
meta-analyze these results; however, heterogeneity was
very high (22 = 44.9, df = 1, p G .00001, I2 = 98%),
which is likely because of the methodological dissim-
ilarity between the studies.
For chest infections such as pneumonia, both Hinchey
et al. (2005) and Perry and McLaren (2003) report
significant decreases in the presence of formal dyspha-
gia management guidelines (p = .001 and p G .003,
respectively); however, Middleton et al. (2011) report
no significant difference in chest infection incidence
between sites with and without formal guidelines (p =
.36). When these results are meta-analyzed, a significant
effect is seen ( p G .008; Fig 4). The moderate het-
erogeneity seen (I2 = 57%) is likely because of meth-
odological dissimilarities between the studies.
Death rates between hospital sites with and without
formal guidelines were reported by two studies with
differing results (Hinchey et al., 2005; Middleton et al.,
2011). Middleton et al. (2011) report no difference in
death rates at sites with or without formal dysphagia
guidelines (p = .36), whereas Hinchey et al. (2005)
report a significantly greater number of patients dis-
charged alive (p = .013) from sites with formal dysphagia
guidelines. When these study results are pooled, a
statistically significant effect is seen, with fewer deaths
seen in sites with formal dysphagia guidelines in place
(p = .003; Fig 5). It should be emphasized, however,
that Middleton et al.s study examined a bundle of
stroke care interventions that included dysphagia screen-
ing, not dysphagia screening alone, and so the effect on
mortality may be because of several factors (Middleton
et al., 2011).
Length of stay data were reported by three studies
(Hinchey et al., 2005; Middleton et al., 2011; Perry,
2001b). Middleton et al. (2011) report no significant
difference in length of stay between sites with or with-
out formal dysphagia guidelines (p = .144), whereas
Hinchey et al. (2005) state a median length of stay of
4 days for sites with dysphagia guidelines and 5 days

FIGURE 3 Days Spent Nil by Mouth: Nurse Screening Versus Usual Care,
Sensitivity Analysis

Copyright 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

TABLE 3. Dysphagia Guidelines for Dysphagia Screening Within 24 Hours
No Guidelines
Screened Within
Study 24 Hours
Middleton et al., 2011 24
Perry & McLaren, 2000 106
for those without and report no further statistical data
for this outcome. Conversely, Perrys (2001b) audit of
standardized swallow assessment use found a signif-
icantly shorter length of stay in the group receiving
standardized swallow assessment screening by nurses
(p = .04).
Strategies for Nursing Management
of Dysphagia
In addition to the above evidence on the effectiveness of
nurse-initiated dysphagia screening and formal dyspha-
gia guidelines, three studies provide additional guid-
ance on strategies for nursing management of dysphagia
for three different aspects of practice. Chang et al. (2005)
examined strategies to improve nurses knowledge about
dysphagia, Bravata et al. (2009) looked at ways to im-
prove nursing admission processes for people with acute
stroke and dysphagia, and the benefits of monitoring
fluid thickness were evaluated by Goulding and Bakheit
(2000).
Goulding and Bakheits (2000) RCT examined the
effectiveness of thickening fluids for preventing aspi-
ration in patients with dysphagia, using pulse oximetry
to detect aspiration, with the aim of addressing the
problem of patients with dysphagia being prescribed
thickened fluids of different consistencies based on
subjective assessment only. Using fluids thickened to
either yoghurt or syrup consistency, the study was well as a significant decrease in the number of nutri-
unable to find any significant difference between
aspirators and nonaspirators and concluded that in-
creasing fluid thickness may not be an effective
intervention to prevent aspiration and in fact may lead
patients to decrease their fluid intake to a harmful
FIGURE 4 Formal Dysphagia Guidelines for Chest Infections
Copyright 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 48 & Number 4 & August 2016 221
LITERATURE REVIEW
With Guidelines
Screened Within
N 24 Hours N p Value
350 242 522 p G .0001
185 123 185 p G .001
degree (Goulding & Bakheit, 2000). Ten (43%)
patients in the study group and nine (39.1%) control
subjects showed evidence of pulmonary aspiration,
and the total frequency of observed aspiration was 12
and 10 times, respectively. The difference between the
two groups was not statistically significant (p = .7).
Improving nurses knowledge about dysphagia can
lead to significant improvements in dysphagia manage-
ment at the ward level (Chang et al., 2005). In two 1-hour
sessions, Chang et al. (2005) delivered an educational
program, developed by a speech pathologist, to nurses
caring for patients with acute neurological dysfunction
with the aim of increasing the number of dysphagia
screens done by nurses. Median results on the knowl-
edge questionnaire administered to participants improved
significantly between the pretest and posttest measures
(p G .001) and between nurses who received the edu-
cational intervention and those in a control ward who
did not (p = .006), which led to a significantly greater
number of dysphagia screens being conducted by nurses
who had received education (p = .002; Chang et al., 2005).
Adding nurse-initiated dysphagia screening to admis-
sion processes has also been found to be effective (Bravata
et al., 2009). After the introduction of nurse-initiated
dysphagia screening, Bravata et al. (2009) found a
significant decrease in the number of patients transferred
to skilled nursing facilities postdischarge (p G .001) as
tionist consultations performed (p = .05). It should be
noted, however, that no significant improvements were
made in a number of key outcomes such as rates of
chest infection, days spent nil by mouth, or inpatient
death (Bravata et al., 2009).
222 Journal of Neuroscience Nursing
LITERATURE REVIEW FIGURE 5 Formal Guidelines Versus Informal or No Guidelines for Inpatient Death
Conclusions
It is important that formal dysphagia screening guide-
lines are in place in healthcare organizations and that
the guidelines include recommendations that patients
are screened for dysphagia with a validated tool within
24 hours of admission. If nurses are trained to use a
dysphagia screening tool, the number of accurate
screens performed will increase. Dysphagia screen-
ing may reduce the rates of death, chest infections, and
days spent nil by mouth; however, the latter requires
more evidence. Dysphagia screening by nurses does
not replace screening by other health professionals
but is a necessary addition and is in the best interests
of patients.
Implications for Practice
The following are rated using JBI grades of recom-
mendation (JBI, 2013):
! Nurse-initiated dysphagia screening is effective for
reducing chest infections in patients with dysphagia
(Grade A).
! Nurse-initiated dysphagia screening may be effec-
tive for reducing days spent nil by mouth, but more
evidence is needed (Grade B).
! Nurse-initiated dysphagia screening by trained nur-
ses is effective for detection of dysphagia (Grade A).
! Training nurses in dysphagia screening improves the
number and accuracy of screens conducted (Grade A).
! Nurse-initiated dysphagia screening may reduce time
to initial dysphagia assessment (Grade B).
! It is unclear whether nurse-initiated dysphagia screen-
ing has an effect on time to SLT assessment; however,
training nurses in dysphagia screening may improve
the appropriateness of their referrals of patients to SLT
(Grade B).
! Formal dysphagia guidelines are likely to reduce in-
patient deaths and chest infections; however, it does
not appear that formal guidelines have an effect on
length of stay (Grade A).
! Formal dysphagia guidelines are effective for increas-
ing the number of patients screened for dysphagia
within 24 hours (Grade A).
Copyright 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
! It is important to use a validated dysphagia screening
tool that is both sensitive and specific to dysphagia, such
as the standardized swallow assessment (Grade A).
! Cough during swallowing and voice change after
swallowing are the clinical signs most likely to in-
dicate the presence of dysphagia (Grade A).
! There is little evidence to suggest that greater thick-
ness of fluids decreases aspiration (Grade B).
! Dysphagia education is likely to improve nurses
dysphagia practices (Grade A).
! Nurse-initiated dysphagia screening at admission may
have an effect on patient outcomes such as discharge
destination, but more evidence is needed (Grade B).
Implications for Research
A considerable body of research now exists on this
subject; however, some gaps still remain. High-quality
research is needed to provide evidence about the effect
of nurse-initiated dysphagia screening on the number of
days patients spend nil by mouth, the time patients wait
for SLT assessment, and the effect of nurse-initiated
dysphagia screening on length of stay and discharge
destination.
Differences Between This Update and the
Previous Version
The studies by McCullough et al. (2005), Terr2 and
Mearin (2006), and Smith, Lee, ONeill, and Connolly
(2000) that were included in the previous update, on
further consideration, have been excluded from this ver-
sion because the outcome of interest in these studies
was detection of aspiration in patients diagnosed with
dysphagia and not detection of dysphagia. Therefore,
the studies were beyond the scope of this review.
References
Anderson, A., Byers, S., Luscombe, V., McDougall, J.,
Reeves, L., Russell, K., I Wilson, H. (2000). Dysphagia
Screening Project: A descriptive quality assurance project.
Australasian Journal of Neuroscience, 13(4), 10Y24.
Bravata, D. M., Daggett, V. S., Woodward-Hagg, H., Damush, T.,
Plue, L., Russell, S., I Chumbler, N. R. (2009). Compar-
ison 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), 1127Y1134.
Chang, A., Pattie, M., & Finlayson, K. (2005). Early detection
of swallowing problems in patients with neurological condi-
tions (p. 32). Brisbane, Queensland: QUT.
Daniels, S. K. (2006). Neurological disorders affecting oral,
pharyngeal swallowing. GI Motility Online. doi:10.1038/
gimo34. Retrieved from http://www.nature.com/gimo/
contents/pt1/full/gimo34.html. Accessed May 18, 2008.
Daniels, S. K., Ballo, L. A., Mahoney, M. C., & Foundas, A. L.
(2000). Clinical predictors of dysphagia and aspiration risk:
Outcome measures in acute stroke patients. Archives of
Physical Medicine and Rehabilitation, 81(8), 1030Y1033.
Davies, S. (2002). An interdisciplinary approach to the man-
agement of dysphagia. Professional Nurse, 18(1), 22Y25.
Edmiaston, J., Connor, L. T., Loehr, L., & Nassief, A. (2010).
Validation of a dysphagia screening tool in acute stroke
patients. American Journal of Critical Care, 19(4), 357Y364.
Goulding, R., & Bakheit, A. M. (2000). Evaluation of the
benefits of monitoring fluid thickness in the dietary man-
agement of dysphagic stroke patients. Clinical Rehabilitation,
14(2), 119Y124.
Hinchey, J. A., Shephard, T., Furie, K., Smith, D., Wang, D.,
Tonn, S.; & Stroke Practice Improvement Network In-
vestigators. (2005). Formal dysphagia screening protocols
prevent pneumonia. Stroke, 36(9), 1972Y1976.
Hines, S., Kynoch, K., & Munday, J. (2013). Identification
and nursing management of dysphagia in individuals with
acute neurological impairment (new update protocol). The
JBI Database of Systematic Reviews and Implementation
Reports, 11(7), 312Y323.
Hines, S., Kynoch, K., & Munday, J. (2014). Identification
and nursing management of dysphagia in individuals with
acute neurological impairment: A systematic review (new
update). JBI Database of Systematic Reviews and Imple-
mentation Reports, 12(5), 195Y236.
Hines, S., Wallace, K., Crowe, L., Finlayson, K., Chang, A., &
Pattie, M. (2011). Identification and nursing management
of dysphagia in individuals with acute neurological impair-
ment (update). International Journal of Evidence-Based
Healthcare, 9(2), 148Y150.
Joanna Briggs Institute. (2013). Grades of recommendation.
Retrieved from http://joannabriggs.org/jbi-approach
.html#tabbed-nav=Grades-of-Recommendation
Lees, L., Sharpe, L., & Edwards, A. (2006). Nurse-led dysphagia
screening in acute stroke patients. Nursing Standard, 21(6),
35Y42.
Lutz, B. J., Young, M. E., Cox, K. J., Martz, C., & Creasy, K. R.
(2011). The crisis of stroke: Experiences of patients and
their family caregivers. Topics in Stroke Rehabilitation,
18(6), 786Y797.
Mackay, J., & Mensah, G. (2004). The atlas of heart disease
and stroke. Geneva, Switzerland: World Health Organization.
Retrieved from http://www.who.int/cardiovascular_diseases/
en/cvd_atlas_15_burden_stroke.pdf
Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G.,
Streiner, D. L., & Diamant, N. E. (2009). The Toronto bed-
side swallowing screening test (TOR-BSST): Development
Copyright 2016 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 48 & Number 4 & August 2016 223
and validation of a dysphagia screening tool for patients with
LITERATURE REVIEW
stroke. Stroke, 40(2), 555Y561.
McCullough, G. H., Rosenbek, J. C., Wertz, R. T., McCoy, S.,
Mann, G., & McCullough, K. (2005). Utility of clinical
swallowing examination measures for detecting aspiration
post-stroke. Journal of Speech, Language, and Hearing Re-
search, 48(6), 1280Y1293.
Middleton, S., McElduff, P., Ward, J., Grimshaw, J. M., Dale, S.,
DEste, C., I. QASC Trialists Group. (2011). Implementa-
tion of evidence-based treatment protocols to manage fever,
hyperglycaemia, and swallowing dysfunction in acute stroke
(QASC): A cluster randomised controlled trial. Lancet,
378(9804), 1699Y1706.
Nishiwaki, K., Tsuji, T., Liu, M., Hase, K., Tanaka, N., &
Fujiwara, T. (2005). Identification of a simple screening
tool for dysphagia in patients with stroke using factor analysis
of multiple dysphagia variables. Journal of Rehabilitation
Medicine, 37(4), 247Y251.
Perry, L. (2001a). Screening swallowing function of patients
with acute stroke. Part one: Identification, implementation
and initial evaluation of a screening tool for use by nurses.
Journal of Clinical Nursing, 10(4), 463Y473.
Perry, L. (2001b). Screening swallowing function of patients
with acute stroke. Part two: Detailed evaluation of the tool
used by nurses. Journal of Clinical Nursing, 10(4), 474Y481.
Perry, L., & McLaren, S. (2000). An evaluation of implementa-
tion of evidence-based guidelines for dysphagia screening
and assessment following acute stroke: phase 2 of an
evidence-based practice project. Journal of Clinical Excellence,
2(3), 147Y156.
Perry, L., & McLaren, S. (2003). Nutritional support in acute
stroke: The impact of evidence-based guidelines. Clinical
Nutrition, 22(3), 283Y293.
Ramritu, P., Finlayson, K., Mitchell, A., & Croft, G. (2000).
Identification and nursing management of dysphagia in
individuals with neurological impairment: A systematic review.
The JBI Database of Systematic Reviews and Implementation
Reports, 3(1), 1Y87.
Smith, H. A., Lee, S. H., ONeill, P. A., & Connolly, M. J.
(2000). The combination of bedside swallowing assessment
and oxygen saturation monitoring of swallowing in acute
stroke: A safe and humane screening tool. Age and Ageing,
29(6), 495Y499.
Terr2, R., & Mearin, F. (2006). Oropharyngeal dysphagia after
the acute phase of stroke: Predictors of aspiration. Neuro-
gastroenterology and Motility, 18(3), 200Y205.
Westergren, A., Hallberg, I. R., & Ohlsson, O. (1999). Nurs-
ing assessment of dysphagia among patients with stroke.
Scandinavian Journal of Caring Sciences, 13(4), 274Y282.
Wieseke, A., Bantz, D., Siktberg, L., & Dillard, N. (2008).
Assessment and early diagnosis of dysphagia. Geriatric
Nursing, 29(6), 376Y383. http://dx.doi.org/10.1016/j.gerinurse.
2007.12.001
Yeh, S. J., Huang, K. Y., Wang, T. G., Chen, Y. C., Chen, C. H.,
Tang, S. C., I Jeng, J. S. (2011). Dysphagia screening
decreases pneumonia in acute stroke patients admitted to
the stroke intensive care unit. Journal of the Neurological
Sciences, 306(1Y2), 38Y41.