The development and implementation of an evidence-based risk reduction algorithm for post-extubation dysphagia in intensive care

Intubation and mechanical ventilation are often required to support critically ill patients. These are life-sustaining measures and when they are no longer necessary, patients need to be carefully transitioned back to breathing, eating and talking on their own. Post-extubation dysphagia is defined as swallowing difficulty following extubation. This condition can affect up to 87% of critically ill patients and can cause serious health complications such as aspiration pneumonia, which could require re-intubation, prolonged intensive care stays and increased in-hospital mortality. Currently, many extubated patients are trialed with oral intake without dysphagia screening or kept with nothing by mouth pending speech language pathology evaluation. This is not only a source of discomfort and distress for patients, families, and staff, but also can lead to malnutrition and dehydration, and put patients at risk for aspiration. Systematically screening extubated patients for dysphagia is an opportunity to improve practice by enabling nurses to advocate for the safe and timely resumption of oral intake. A novel, evidence-based algorithm, called SAPE (Swallowing Algorithm Post-Extubation) was developed by an interdisciplinary critical care team to assist nurses to identify risk factors for post-extubation dysphagia and help make evidence-informed decisions regarding referral to speech-language pathology and initiation of per os intake in the absence of a water swallow test. SAPE was implemented in four tertiary-level medical and/ or surgical intensive care units. Process and outcome measures of a quality improvement initiative are discussed, and future directions proposed.