Pulmonary Critical Care

V ALIDATION OF A
POSTEXTUBATION DYSPHAGIA
SCREENING TOOL FOR
PATIENTS AFTER PROLONGED
ENDOTRACHEAL INTUBATION
By Karen L. Johnson, RN, PhD, Lauri Speirs, RN, MSN, ACNS-BC, PCCN, CNRN,
SCRN, Anne Mitchell, RN, MSN, CCRN, CEN, ACNS-BC, Heather Przybyl, RN, DNP,
CCRN, Diane Anderson, MS, CCC-SLP, Brenda Manos, RN, BSN, Amy T. Schaenzer,
MS, CCC-SLP, and Keri Winchester, MS, CCC-SLP

Background Patients who receive prolonged endotracheal

intubation (> 48 hours) are at risk for dysphagia. Nurses
should conduct swallowing assessments after extuba-
tion because of the high likelihood of aspiration pneu-
monia developing. No valid and reliable postextubation
dysphagia screening tools are available.
Objectives To establish content validity, analyze interrater
reliability, and determine sensitivity and specificity of
an evidence-based postextubation dysphagia screening
tool developed by a multidisciplinary team.
Methods A prospective nonexperimental study was con-
ducted in 4 medical-surgical intensive care units in 4
hospitals. The study was conducted in 3 phases: (1)
establishing content validity with clinical experts who
participated in a Delphi survey, (2) establishing inter-
rater reliability by agreement with nurses who simulta-
neously and independently completed the tool, and (3)
establishing sensitivity and specificity with speech lan-
guage pathologists and nurses who independently
and blindly completed the tool for eligible patients.
Results Individual item scores were > 0.82 and the overall
content validity index was 0.93, indicating content validity.

C E 1.0 Hour Interrater reliability was established (Cohen g = 0.92). In 66

eligible patients, the prevalence of postextubation dys-
phagia was 56%, sensitivity of the postextubation dys-
This article has been designated for CE contact phagia screening tool was 81%, and specificity was 69%.
hour(s). See more CE information at the end of Conclusion The reliability and validity of a postextuba-
this article. tion dysphagia screening tool that can help nurses
determine an extubated patient’s ability to swallow after
prolonged endotracheal intubation were established.
©2018 American Association of Critical-Care Nurses
(American Journal of Critical Care. 2018;27:89-96)
doi:https://doi.org/10.4037/ajcc2018483

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 E
ndotracheal intubation (ETI) to support mechanical ventilation is often required for
critically ill patients. ETI is a life-sustaining technique; however, complications,
including dysphagia, can manifest after extubation. Postextubation dysphagia (PED)
is attributed to mechanical and cognitive factors that interfere with the ability to
execute an efficient and safe swallow. The incidence of PED in mixed populations of
medical-surgical patients is from 3% to 62%.1 Patients who receive prolonged ETI, defined as
longer than 48 hours, have the highest frequency of dysphagia compared with other diagnostic
subtypes.1 One report2 revealed that the risk of PED developing on the first day of ETI was 25%
and the risk doubled after 2 days of ETI. Studies2,3 have shown that prolonged ETI is an inde-
pendent predictor of PED.

The act of swallowing is complex: It involves sen- Given the likelihood of serious medical com-
sory and motor nerves, more than 30 muscle groups, plications of PED and the associated high costs,
2 brainstem centers, occurs in 4 phases, and is vol- Skoretz et al,1 in a systematic review, recommended
untary and involuntary.4 PED can develop through that a swallowing evaluation be conducted on all
several mechanisms, including patients who have received prolonged ETI. The
injury from ETI,5 muscle weak- American Association of Critical-Care Nurses
Swallowing should ness,6 dysfunctional oropharyn- issued a Practice Alert for the prevention of aspira-
be assessed in geal or laryngeal sensation,7 tion in adults.12 One of the 7 recommendations
impaired sensorium,8 gastroesoph- made in the Practice Alert was to “consult with [a]
recently extubated ageal reflux,9 or dyssynchronous provider about obtaining a swallowing evaluation
patients who were breathing and swallowing.7 Com-
plications of PED include dehy-
before oral feedings are started for recently extu-
bated patients who had been intubated for more
intubated > 48 hours. dration, malnutrition, aspiration than 2 days.”12(pe20)
of oral secretions, and aspiration Donovan et al13 stress the importance of differen-
pneumonia.1 These consequences are associated tiating between dysphagia screening and dysphagia
with poor outcomes and high financial cost owing evaluation (clinical or instrumental). Dysphagia screen-
to longer stays in the intensive care unit and addi- ing is defined as a “pass/fail procedure to identify
tional medical costs related to the need for antibiotics individuals who require a comprehensive referral
and chest radiographs.4,10 The annual cost in the to other professional and/or medical services.”14(p10)
United States for PED is estimated to be more than Screening procedures identify patients who need a
$500 million.11 complete dysphagia evaluation, including a clinical
evaluation of swallowing mechanisms and function
that uses different food and liquid consistencies.13
About the Authors Speech language pathologists (SLPs) perform
Karen L. Johnson is research director, nursing, Banner evaluations to diagnose and manage dysphagia.
Health, Phoenix, Arizona. Lauri Speirs is stroke clinical Because SLPs may be available only during standard
nurse specialist, JPS Health Network, Fort Worth, Texas.
Anne Mitchell is a clinical nurse specialist, retired from weekday working hours, the definitive diagnosis by
Banner Baywood Medical Center, Mesa, Arizona. Heather SLPs may not be available for 24 to 48 hours after
Przybyl is a clinical education specialist; medical/surgical ETI. In these situations, nurses have to provide ini-
intensive care unit, Banner University Medical Center-
Phoenix, Phoenix, Arizona. Diane Anderson is a speech tial screening for PED. If the initial PED screening
language pathologist and rehabilitation services senior determines the patient is at risk for dysphagia, the
manager, Banner Baywood Medical Center. Brenda Manos patient is allowed nothing by mouth until the SLP
is senior clinical manager cardiac care unit/intensive care
unit, Banner Estrella Medical Center, Phoenix, Arizona. can complete a diagnostic evaluation.15 With nurses
Amy T. Schaenzer is a speech language pathologist, Ban- available 24/7, enhancing their skills in identifying
ner University Medical Center-Phoenix. Keri Winchester dysphagia is logical and necessary.16
is a speech language pathologist, Banner Gateway Med-
ical Center, Gilbert, Arizona. Evidence indicates that nurses can successfully
complete dysphagia screenings17,18 using valid and
Corresponding author: Karen L. Johnson, RN, PhD, Director,
Nursing Research, Banner Health, 901 E Willetta St, Phoenix, reliable dysphagia screening tools for patients who
AZ 85006 (email: [email protected]). have had a stroke,15,18,19 medical patients in acute

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care,16 and patients with thermal burn injuries.20 To criteria specifically relevant to patients who are extu-
our knowledge, no valid and reliable screening tool bated after prolonged ETI.
is available for nurses to use to assess for PED. Dys- Published evidence supports assessment of respi-
phagia screening tools that have been developed ratory factors, including tachypnea, and indicates that
for a specific population of patients cannot be used inability to maintain adequate oxygen saturation
with other populations because the pathophysio- without oxygen therapy can contribute to PED.1,10,21
logical mechanisms of dysphagia are different.16 Accordingly, we modified the existing tool to include
The result is that patients who are extubated after the following: (1) ability to remain without contin-
prolonged ETI either are allowed oral intake with uous airway pressure or bilevel positive airway pres-
no dysphagia screening or are still allowed nothing sure for at least 15 minutes, (2) ability to maintain
by mouth for up to 48 hours pending SLP evaluation. oxygen saturation without a nonrebreather or Venturi
Thus, a PED screening tool for nurses is needed. mask for at least 15 minutes (oxygen saturation mea-
Using a prospective nonexperimental design, sured by pulse oximeter remains > 90% and/or does
we evaluated the validity, reliability, and value of a not decrease > 10% from baseline), and (3) patient’s
PED screening tool for nurses. The specific aims of respiratory rate is less than 30/min. If the patient does
the study were to (1) assess content validity of the not meet any one of these criteria, the nurse stops the
postextubation dysphagia screening (PEDS) tool; assessment and reassesses the patient in 24 hours
(2) analyze the interrater reliability of the PEDS or when respiratory status improves. If the answer
tool; and (3) establish accuracy and overall value is yes to all 3 questions, the nurse is directed to pro-
of the PEDS tool by determining its sensitivity, ceed to the assessments in the next sections.
specificity, positive predictive value (PPV), and In the final section, the nurse confirms that the
negative predictive value (NPV). patient has no contraindications for trial feedings.
Once that is confirmed, the nurse is directed to the
Methods oral intake trial. Note that the trial takes place only
The study was approved by the institutional if the patient has an order from the provider for oral
review board at Banner Health and conducted intake. The oral intake
according to ethical standards set forth in the Hel- trial is based on the gold Different populations of
sinki Declaration of 1975. The study took place in standard for screening:
4 medical-surgical intensive care units in 4 Banner the 3-oz (90-mL) water patients need different
Health medical centers located in Phoenix, Arizona. swallow test. This test
has been used by mem-
dysphagia screening
Development of the PEDS Tool bers of various disci- tools because the patho-
To develop our PEDS tool, we began with our
health system’s existing dysphagia screening tool
plines for screening in
more than 3000 patients,
physiological mechanisms
for patients who have had a stroke. This tool was including critically ill of dysphagia differ.
developed by a multidisciplinary team from our patients with heteroge-
system and had been in use for more than 5 years. neous diagnoses, and has been validated against
The team that developed the tool reported a sensi- fiberoptic endoscopic evaluation.22-24 The screening
tivity of 64%, specificity of 99%, PPV of 92%, and is rated as pass or fail, with a failure occurring if any
NPV of 93%. The screening tool consists of 5 sec- screening item is scored as yes. Patients who do not
tions of nursing assessments: SLP evaluation, level pass the screening are allowed nothing by mouth
of alertness, symptoms and tubes, new-onset aspira- until SLP evaluation.
tion symptoms, and contraindications for trial feed- To establish validity and reliability of our PEDS
ings. Based on those assessments, nurses are directed tool, we conducted a study in 3 phases: phase 1 estab-
to take subsequent actions. lished content validity, phase 2 established interrater
A review of the literature revealed different patho- reliability, and phase 3 established sensitivity, speci-
physiological mechanisms and risk factors for dys- ficity, PPV, and NPV.
phasia after ETI versus after stroke. Therefore, we
modified 2 sections of the stroke dysphagia screen- Phase 1: Establish Content Validity
ing tool to reflect risk factors for dysphagia after ETI. We recruited 16 clinical experts within our
We replaced new-onset aspiration symptoms with a system who provide care regularly for patients with
section titled “Assessment of respiratory status” and PED to serve as content experts. Experts included
modified the tubes and symptoms section to reflect intensive care unit nurses, stroke coordinators,

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 intensivists, and SLPs. The experts were sent an email because content validity of the PEDS tool was estab-
invitation to complete 2 rounds of Delphi surveys. lished (see Figure).
The survey asked them to rate the relevance of each
section of the PEDS tool on a 4-point scale, as fol- Phase 2: Establish Interrater Reliability
lows: 4 (very relevant with no revision needed), 3 To establish interrater reliability, a nurse mem-
(relevant with minor revision needed), 2 (unable ber of the research team and a clinical nurse simul-
to assess relevance without revision), and 1 (not rele- taneously and independently assessed an eligible
vant). They were asked if patient (Table 1) for dysphagia using the PEDS tool.
each section was clearly writ- Interrater reliability was verified by agreement between
The PEDS tool has a ten and, if it was not, were these 2 nurses who independently and simultane-
sensitivity of 81% and asked to provide suggestions ously (within 5 minutes) completed the PEDS tool.
to improve the clarity. They The Cohen g statistic was used to measure interrater
a specificity of 69%. were asked, “Are there any agreement for categorical items (ie, dysphagia pres-
additional items you think ent or not present).
are relevant to include for the next round?” Expert
panelist responses, statistics, and summaries were Phase 3: Establish Sensitivity, Specificity, PPV,
distributed to the panelists after each round. Each and NPV
round was open for 2 weeks. After suggestions were A clinical nurse and SLP member of the research
incorporated into the PEDS tool, the modified tool team independently completed a dysphagia assess-
was sent to experts for additional review. ment on eligible patients within 24 hours of extuba-
Based on consensus, items were retained or mod- tion (Table 1). They were blind to the results of each
ified. We analyzed the relevance of items using means other’s independent assessments. The SLP dysphagia
and percentage agreement. Consensus for retaining an evaluation was performed by certified SLPs within
item was satisfied by a percentage agreement greater 16 hours of the nurse’s assessment, using a standard-
than 70% (ie, ratings of 3 or 4) or a mean response ized swallowing evaluation including a physical
of at least 3.0. A content validity index (CVI), as out- assessment with cognitive screening, a complete oral
lined by Lynn,25 was calculated for each item and for motor examination, and an assessment of oral and
the whole scale with a goal of attaining a CVI of 0.80. pharyngeal muscle function. Initial swallowing trials
Respondents (n = 11) to round 1 of the Delphi were performed using water and crackers to allow
survey were 3 intensive care unit clinical nurses, 4 for assessment of airway safety during feeding and
intensivists, 3 nurse stroke coordinators, and 1 SLP. success of strategies in feeding.
There was high agreement that A 2 = 2 contingency table was used to calculate
all items were highly relevant sensitivity, specificity, PPV, and NPV.
The PEDS tool for clinical nurses to screen for
reduces the risk of a PED. The overall content valid- Results
ity index in round 1 was 0.92. Interrater Reliability
patient starting oral Based on the respondents’ feed- A nurse member of the research team and a
intake inappropriately back, 2 items were modified to
provide greater clarity: “Patient
clinical nurse simultaneously and independently
assessed 25 eligible patients for PED using the
or unsafely after pro- is awake, alert, and able to fol- PEDS tool. The Cohen g was +0.92.
low commands” was changed
longed intubation. to “Patient is awake, alert, and Sensitivity, Specificity, PPV, and NPV
able to follow simple com- A total of 66 patients were evaluated by a clinical
mands.” And “Patient has a feeding tube” was nurse and an SLP for dysphagia. Most of the patients
changed to “Patient has an oral-gastric, nasal-gastric, in the sample were male (73%), with a mean age of
and/or surgically placed tube (including percutane- 59.4 (SD, 14.8; range, 26-87) years. More than half
ous endoscopic gastrostomy).” of the patients (52%) had a primary diagnosis of acute
The 7 experts who responded to round 2 of the respiratory failure, followed by sepsis or septic shock
Delphi survey included 2 intensive care unit clinical (15%; Table 2). More than half of the sample (56%;
nurses, 2 intensivists, 2 stroke coordinators, and 1 n = 37) had dysphagia.
SLP. Item CVIs with expert ratings of 3 to 4 were all The 2 = 2 contingency table (Table 3) revealed
greater than 0.82, with an overall CVI of 0.93. No a sensitivity of 81%, specificity of 69%, PPV of 77%,
additional Delphi survey rounds were conducted, and NPV of 74%.

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 Section A: Evaluation
Patient has been evaluated by speech language pathologist.
Yes No
If “Yes,” stop here. Follow speech language pathologist’s recommendations. If patient is to be kept NPO, notify physician to address
medications and nutrition needs.

Section B: Level of alertness

Patient is awake and alert and able to follow commands.
Yes No
If “No,” make patient NPO. Obtain physician’s order for speech therapy consultation with message “Unable to participate in Swallow
Screen.” Notify physician to address medication and nutritional needs.
If “Yes,” go to Section C.

Section C: Respiratory status

T Patient is able to remain off CPAP or BiPAP for more than 15 mintues.
T Maintains saturation without support of nonrebreather or Ventimask for more than 15 minutes.
T Respiratory rate is less than 30 breaths per minute. (SpO2 > 90% and does not decrease > 10% from baseline.)
Yes No
If “No” to one or more statements above—stop here. Reassess in 24 hours or when respiratory status is stable.
If “Yes” to all statements above—go to Section D.

Section D: Symptoms and tubes

Patient has one or more of the following (check all that apply):
T Patient has an oral-gastric, nasal-gastric, and/or surgically placed feeding tube (including percutaneous gastrostomy)
T History of dysphagia
T Adverse changes in lung sounds
T Wet or gurgling vocal quality
T History of head/neck trauma
T No voice, is nonverbal or mute
T Poor volume of voice
T Complaints of swallowing problems
T Cannot produce a voluntary cough or clear throat
T Unexplained history of weight loss or dehydration
T History of head or neck cancers or surgery
T History of stroke, Parkinson disease, multiple sclerosis, or chronic obstructive pulmonary disease
If “Yes,” stop here. Make patient NPO until speech language pathologist evaluates the patient. Notify physician to address medication
and nutritional needs.
If “No,” go to Section E.

Section E: Verification to proceed for trial feedings

Verify patient has diet orders from physician.
Above assessment complete. Proceed to oral intake trial.
Date: _____________________ Signature: ______________________________________

Figure Postextubation dysphagia screening tool.

Abbreviations: BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; NPO, nothing by mouth; SpO2, oxygen saturation as
shown by pulse oximetry; Ventimask (Flexicare Medical).

Discussion dysphagia screening tool used by nurses to assess

This study was designed to evaluate a screen- patients after a stroke. The modified tool includes
ing tool for nurses to assess patients at risk for PED evidence-based assessment criteria specifically
after prolonged ETI (defined as longer than 48 hours). relevant to patients who are extubated after pro-
A multidisciplinary team modified an existing longed ETI.

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 Table 1
Patient eligibility criteria

Inclusion criteria Exclusion criteria difference between observed agreement and expected
agreement, standardized to a -1 to +1 scale, where
Age older than 18 years Existing or new neurological diagnosis
perfect agreement is 1; 0 is what would be expected
(ie, stroke, Parkinson disease, multi-
Medical or surgical patients in by chance, and negative values indicate less than
ple sclerosis, Guillain-Barré syndrome,
intensive care unit chance.27 Values greater than 0.75 represent very
neurosurgical procedure)
Intubated more than 48 hours good agreement.28
Patient had head or neck surgery
Extubated within past 24 hours In phase 3 of this study, the prevalence of dys-
Patient has head or neck trauma
phagia was 56%. This prevalence is within the range
Awake, alert, able to follow
Patient has tracheostomy reported by others in mixed medical-surgical patient
commands
Patient is receiving end-of-life care, populations (3%-62%).1 These results provide addi-
comfort measures, hospice, and/or tional evidence that patients who have received pro-
palliative care longed ETI for more than 48 hours are at risk of
Patients who cannot be seen by speech having PED develop.
language pathologist within 16 hours Sensitivity and specificity are important criteria
of screening to evaluate screening tools. The PEDS tool identified
the majority of patients who were determined by
the SLP evaluation to have PED and identified the
Table 2
Patients’ diagnoses majority of patients who did not have PED. The
necessity for more extensive evaluations and their
Diagnosis Percentage of sample associated costs can be avoided in patients with
negative findings.29
Respiratory failure 52
Sensitivity is the ability of a tool to identify a
Sepsis or septic shock 15 case correctly; in this study, this meant to screen
Chronic renal failure 7 “in” PED when PED actually existed. Sensitivity
Cardiac arrest 5 measures “true positives,” or the proportion of those
patients who screened positive for PED by the nurse
Heart failure 5
and who later had PED diagnosed by the SLP. It is
Other (hypoglycemia, cardiogenic shock, 16 important for screening instruments to have a high
gastrointestinal bleeding, seizures, cancer)
sensitivity so patients with PED are not missed by
the nursing assessment. The sensitivity of the PEDS
tool is consistent with the sensitivity of other dyspha-
Table 3
2 x 2 Contingency table gia screening tools reported in the literature (29%-
90%) that were validated in other populations of
Speech language patients.13,15,16,18-20,30,31
pathologist’s evaluation
Specificity is the ability of a screening tool to
Positive for Negative for screen out those patients who do not have the con-
Nurse’s assessment dysphagia dysphagia Total dition (ie, the “true negatives”). In our study, this
Positive for dysphagia 30 9 39 was the proportion of patients who screened nega-
7
tive for PED by the nurse and who were later evalu-
Negative for dysphagia 20 27
ated by the SLP and found not to have dysphagia.
Total 37 29 66
The specificity of the PEDS tool is consistent with
the specificity of other dysphagia screening tools
Content validity was established in 2 rounds of reported in the literature (52%-90%) that were vali-
a Delphi survey with content experts. The number dated in other populations of patients.13,15,16,18-20,30,31
of rounds in the modified Delphi method can be as Emphasis for dysphagia screening tools should
few as 2 if the experts achieve consensus.26 For a scale be on high sensitivity, not high specificity; specificity
to be judged as having excellent content validity, ranging from 50% to 90% is acceptable.16 A good
Lynn25 recommended it should be composed of items screening tool needs to have a high sensitivity and a
that have item CVIs greater than 0.78, with an overall high negative predictive value.32 The PEDS tool meets
average CVI greater than 0.90. The PEDS tool item CVIs these criteria with a sensitivity of 81% and an NPV
were all greater than 0.82, and overall CVI was 0.93. of 74%, which are consistent with published data
Interrater reliability was established with a from other studies on dysphagia screening tools for
Cohen g of +0.92. Cohen g is a measure of the patients after stroke.13,15,16,18-20,30,31 High sensitivity is

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especially important in conditions such as dyspha- Conclusion
gia in which the risk of being undetected can lead This study established the content validity and
to the serious consequences of pneumonia, malnu- interrater reliability of the PEDS tool. Its high sensi-
trition, and death.29 tivity combined with the high negative predictive
Donovan et al13 identified criteria that consti- value demonstrate that the PEDS tool is a valid
tute a good dysphagia screening tool: (1) The tool screening tool for nurses to use to assess for PED in
should evaluate dysphagia risk, suitability for oral patients who have received prolonged ETI.
feedings, and the need for further evaluation by an
SLP (content validity); (2) various people should ACKNOWLEDGMENTS
be able to administer the screening with similar results This study was performed at Banner University Medical
Center – Phoenix, Arizona; Banner Estrella Medical Center,
(interrater reliability); (3) the screening tool should Phoenix, Arizona; Banner Baywood Medical Center Mesa,
identify patients at risk of dysphagia (sensitivity); and Arizona; and Banner Desert Medical Center, Mesa, Arizona.
(4) the tool should rule out patients who are not at We thank members of the research team: Robechard
Halaghay, RN, MSN (Banner Estrella Medical Center); Sara
risk for dysphagia (specificity). The PEDS tool met Nichols, MS, CCC-SLP, Barbara Janine Crandall-Litvak, RN, BSN,
these criteria. RD, CCRN, OCN, Amy Merril, RN, CCRN (Banner Desert Medical
Center); Timothy Jackson, RN, BSN, Lorena Bachelier, RN, BSN
(Banner Baywood Medical Center); and Casey Thompson,
Implications RN, BA, BSN, CCRN, Christine M. Meyer, MS, CCC-SLP, and Jaclyn
The information that nurses need to complete Knoll, MS, CCC-SLP (Banner University Medical Center
the PEDS tool is gathered quickly, allowing swift iden- Phoenix).
tification of PED and timely referral to SLP care. One
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24. Leder S, Suiter D, Warner H, Kaplan L. Initiating safe oral Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050
feeding in critically ill intensive care unit and step down (ext 532); fax, (949) 362-2049; email, [email protected].

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Validation of a Postextubation Dysphagia Screening Tool for Patients After Prolonged
Endotracheal Intubation
Karen L. Johnson, Lauri Speirs, Anne Mitchell, Heather Przybyl, Diane Anderson, Brenda Manos, Amy T.
Schaenzer and Keri Winchester
Am J Crit Care 2018;27 89-96 10.4037/ajcc2018483
©2018 American Association of Critical-Care Nurses
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