Development of a swallowing risk screening tool and best practice recommendations for the management of oropharyngeal dysphagia following acute cervical spinal cord injury: an international multi-professional Delphi consensus

Figures & data

Table 1. Topic areas and sub-categories with statement selection by the steering group.

Topic area pre-steering group	Sub – categories	Original number of statements	Number of statements following Steering group review
1. Pre-morbid status	Age, gender	4	1 (integrated with co-morbid)
2. Co-morbid status	Level, severity, brain injury, cognitive, cervical surgery, respiratory impairment	11	11
3. Definition of dysphagia	Oromotor, laryngeal and pharyngeal, functions	15	15
4. Screening for dysphagia	Oral trials, laryngeal function, respiratory function (tracheostomy and ventilation), position, respiratory measures	17	17
5. Assessment	Diagnostic videofluoroscopy, FEES, bedside swallow assessment, position	5	5
6. Identification	Clinical signs: pyrexia, chest infection, suction, aspiration, nutritional measures	7	6
7. Management	Swallowing – NBM, food and fluid options; nutrition – NG, PEG; tracheostomy and ventilation; position – upright, supine, semi-recumbent; oral hygiene, mouth care; communication	24	23
8. Therapeutic intervention	Communication, swallowing, respiratory	7	7
	Total no. of statements	90	85

Figure 1. caption: Delphi study flow chart.

A flow chart explains the process of the Delphi study. An expert panel of 27 members was recruited, who participated in two rounds of the Delphi with controlled feedback after each round. A steering group of five members reviewed the results of each process. Ninety statements were initially generated and reviewed by the steering group and modified to 85 statements. These were distributed to the expert panel for round one. At the end of round, one 50 statements had consensus and 35 had no consensus. After steering group review 25 were submitted for round two. At the end of round two, a further 12 had consensus, six had majority agreement and seven had no consensus. After steering group review a decision was made to end the Delphi process. A total of 62 statements achieved consensus and six had majority agreement. These results formed the best practice recommendations and development of a swallow screening tool.

Table 2. Professionals invited and consented as expert panellists.

n (%)	Invited n = 55	Consented n = 27
SLT	22 (40)	8 (29.6)
PT	10 (18.2)	8 (29.6)
Doctor	13 (23.6)	6 (22.2)
Nurse	7 (12.7)	3 (11.1)
Dietitian	3 (5.4)	2 (7.4)

Table 3. Demographic details of expert panel participants.

	n = 27 (%)
Female n (%)	21 (77.8)
Experience of SCI working*
SIU	24 (88.9)
ICU	22 (81.5)
MTC	12 (44.4)
Other	7 (25.9)
Years since qualification
Mean (SD)	21.3 (9.32)
Range	6–42
Median (IQR)	18 (15–28)
Years working in SCI
Mean (SD)	13.2 (8.2)
Range	3–29
Median (IQR)	11 (6–20)
Professional role:
SLT	8 (29.6)
PT	8 (29.6)
Doctor	6 (22.2)
Nurse	3 (11.1)
Dietitian	2 (7.4)
Agreement to co-author	24 (88.9)
Country
UK	17 (63.0)
Australia	6 (22.2)
New Zealand	2 (7.4)
USA	1 (3.7)
Ireland	1 (3.7)

*More than one response selected.

Figure 2. caption: Number of statements per topic achieving consensus in Delphi round one.

A bar graph shows the results of the first Delphi round with the numbers of statements per topic with and without consensus. ‘Co-morbid status’ has seven statements with consensus and five with no consensus, ‘definition’ has nine with consensus and six with no consensus, ‘screening’ has eight with consensus and nine with no consensus, ‘assessment’ has two with consensus and three with no consensus, ‘identification’ has four with consensus and two with no consensus, ‘management’ has 13 with consensus and 10 with no consensus and ‘therapeutic management’ has seven with consensus and none with no consensus.

Table 4. Descriptive statistics and levels of consensus for round one statements.

Statement no.	Topic	Category	Subcategory	Mean rank	Median	Mode	Consensus %
1	Co-morbid status	Age	Over 60 yrs	3.19	3	3^a	41.4%
2		Co-morbidities	Brain injury	3.96	4	4	81.5%
3		Co-morbidities	Tetraplegia	3.78	4	4	70.4%
4		Co-morbidities	Cognitive impairment	3.67	4	4	74.1%
5		Spinal cord level	C1 to C4 injury	4.56	5	5	92.6%
6		Spinal cord level	C5 to C7 injury	4.04	4	4	76.0%
7		Spinal cord level	Thoracic level injury	2.62	3	2^a	45.0%
8		Spinal cord severity	Complete ASIA A	3.56	4	4	62.9%
9		Spinal cord severity	Incomplete ASIA B-D	3.4	4	4	31.6%
10		Spinal surgery	Anterior cervical spinal surgery	4.52	5	5	92.6%
11		Spinal surgery	Posterior cervical spinal surgery	3.33	3	3^a	47.6%
12		Respiratory	Respiratory impairments	4.07	4	5	77.7%
13	Definition	Dysphagia	Oromotor function – facial weakness	1.93	2	2	85.2%
14		Dysphagia	Oromotor function – lip weakness	1.96	2	2	77.7%
15		Dysphagia	Oromotor function – tongue weakness	2.59	2	2	51.7%
16		Dysphagia	Oromotor function – velopharyngeal (soft palate) weakness	2.89	3	3	37.9%
17		Dysphagia	Laryngeal function – weak voice	3.63	4	4	63.0%
18		Dysphagia	Laryngeal function – wet sounding voice.	3.89	4	4	77.8%
19		Dysphagia	Laryngeal function – coughing after drinking or eating	3.63	4	4	66.6%
20		Dysphagia	Laryngeal function – food or fluid coming out of the tracheostomy tube after eating	3.77	4	4	69.3%
21		Dysphagia	Laryngeal function – food or fluid being aspirated into the lungs	4.41	4	4	96.3%
22		Dysphagia	Pharyngeal function – difficulty of food or fluid passing from the mouth to the oesophagus	4.04	4	4	88.9%
23		Dysphagia	Pharyngeal function – delayed swallow initiation.	3.7	4	4	66.7%
24		Dysphagia	Laryngeal function – reduced laryngeal elevation.	4.15	4	4	88.9%
25		Dysphagia	Laryngeal function – impaired laryngeal sensation.	4.26	4	4	92.6%
26		Dysphagia	Laryngeal function – ineffective cough	4.41	5	5	88.9%
27		Dysphagia	Laryngeal function – absent cough reflex	3.7	4	4	74.1%
28	Screening for risk	Spinal cord injury	Prolonged intubation (>48 h)	3.89	4	4	77.8%
29		Spinal cord injury	Tracheostomy in situ	3.93	4	4	77.8%
30		Spinal cord injury	Invasive ventilation	4.07	4	4	84.6%
31		Spinal cord injury	Non-invasive ventilation	2.93	3	2^a	38.0%
32		Spinal cord injury	Tracheostomy cuff inflated	4.15	4	4	81.5%
33		Screening	Supine position	3.48	4	4	63.0%
34		Screening	Oral-motor function	3.12	3	4	33.3%
35		Screening	Laryngeal function – laryngeal elevation	3.68	4	4	72.0%
36		Screening	Laryngeal function – laryngeal sensation	3.76	4	4	72.0%
37		Screening	Laryngeal function – voice volume	2.88	3	2	36.8%
38		Screening	Saliva management	3.93	4	4	85.2%
39		Screening	Oral trial – water	2.93	3	4	42.8%
40		Screening	Oral trial – yoghurt	2.59	2	2	38.1%
41		Screening	Oral trial – blue dye	2.44	2	2	62.9%
42		Screening	Respiratory function	4.27	4	4	92.3%
43		Screening	Respiratory measure – forced vital capacity (FVC)	3.33	3	2	38.1%
44		Screening	Respiratory measure – Forced Expiratory Volume in 1 s (FEV1)	3.22	3	4	38.1%
45	Assessment	Instrumental	Diagnostic – videofluoroscopy	3.15	3	2a	46.4%
46		Instrumental	Diagnostic – Flexible nasendoscopy	3.63	4	4	66.6%
47		Instrumental	Clinical bedside evaluation	2.26	2	2	70.3%
48		Position	Sitting upright	3.22	4	4	52.3%
49		Clinical sign	Evidence of aspiration	1.78	2	2	92.6%
50	Identification	Clinical sign	Suctioning of food/fluids	4.04	4	4	88.9%
51		Clinical sign	Spiking pyrexia	3.63	4	4	70.4%
52		Clinical sign	Chest infection	3.81	4	4	85.2%
53		Clinical sign	Increased oral suction	3.59	4	4	74.1%
54		Clinical sign	Nutritional measure – serum albumin	3.04	3	3	58.6%
55		Clinical sign	Nutritional measure – serum pre-albumin	3.07	3	3	62.0%
56	Management	Swallowing	Proceed to eating	2.19	2	1	65.0%
57		Swallowing	Keep NBM	3.41	4	4	58.6%
58		Swallowing	Proceed to drinking	2.56	2	2	55.2%
59		Swallowing	Diet modification – thickened fluids	2.35	2	2	65.0%
60		Swallowing	Consistent cough	3.58	4	4	60.7%
61		Nutrition	NG feeding	4.48	4	4	100.0%
62		Nutrition	PEG feeding	3.92	4	4	80.7%
63		Tracheostomy	Cuff deflation when eating	3.69	4	5	69.2%
64		Ventilation	NBM if ventilated	2.04	2	2	80.8%
65		Ventilation	Eat when self-ventilating	2.04	2	2	85.2%
66		Ventilation	Ventilator weaning	1.78	1	1	85.2%
67		Ventilation	Use speaking valve	1.85	2	2	81.4%
68		Position	Eat in supine position	2.89	3	2	51.7%
69		Position	Eat in semi-recumbent position	3.7	4	4	74.1%
70		Position	Eat in upright position	2.44	2	2	70.4%
71		Oral hygiene	VAP risk – supine	3.37	4	4	58.6%
72		Oral hygiene	VAP risk – oral hygiene	4.35	5	5	88.4%
73		Mouthcare	Dry mouth – medication	4.08	4	4	80.0%
74		Mouthcare	Oral moisturizing	4.19	4	4	85.2%
75		Mouthcare	Hydrate with water	3.15	3	3	37.9%
76		Communication	Alternative communication aids	3.52	4	4	55.2%
77		Communication	Use own voice	4.07	4	4	77.7%
78		Gastrointestinal	NBM – paralytic ileus	3.96	4	4	70.3%
79	Therapeutic intervention	Swallowing	Eating/drinking goal	4.56	5	5	88.9%
80		Communication	Communicate through talking goal	4.44	5	5	88.9%
81		Swallowing	Daily swallow therapy goal	4.2	4	4^a	80.0%
82		Swallowing	Tracheostomy cuff inflated goal	1.96	2	1	77.7%
83		Swallowing	Keep NBM goal	1.74	1	1	81.5%
84		Respiratory	Self-ventilation goal	4	4	5	77.7%
85		Swallowing	Permanent dysphagia status	1.37	1	1	100.0%

a Multiple modes exist, smallest value is shown.

Bold values indicate >70% consensus.

Figure 3. caption: Number of statements per topic achieving consensus, majority agreement in Delphi round two.

A bar graph shows the results of the second Delphi round with the numbers of statements per topic with consensus, majority agreement or no consensus. ‘Co-morbid status’ has two statements with consensus, one with majority agreement and two with no consensus, ‘definition’ has four statements with consensus, none with majority agreement and two with no consensus, ‘screening’ has two with consensus, two with majority agreement and none with no consensus, ‘assessment’ has one with consensus, one with majority agreement and none with no consensus, ‘identification’ has none with consensus and one with no consensus, ‘management’ has three with consensus, two with majority agreement and two with no consensus and ‘therapeutic management’ has no statements in this round.

Table 5. Descriptive statistics for round 2 statements.

Round 2 sub-category of statements n = 25	Median (IQR)	Mode	% consensus
>70% consensus
Voice weakness	4 (4–4)	4	100
Incomplete SCI (AIS levels B to D) dependent on treatment or surgery	4 (4–4)	4	100
Oral hygiene helps reduce VAP	5 (4–5)	5	.
Variety of food trials for assessment	4 (4–5)	4	88
Coughing at mealtimes	4 (4–5)	4	88.4
Coughing after drinking or eating.	4 (4–4)	4	80.8
Food or fluid from the tracheostomy tube	4 (4–5)	4	80.8
Upright position	4 (3.75–4)	4	76.9
Complete spinal cord injury (AIS A)	5 (3.75–5)	5	76.9
Non-invasive ventilation	4 (3.75–4)	4	76.9
Swallow initiation.	4 (3.75–4)	4	76.9
Allowed to eat rather than being kept NBM	2 (2–3)	2	76.9 (disagree)
>55% majority agreement
Posterior cervical spinal surgery	4 (2.75–4)	4	69.2
Tracheostomy cuff deflated	4 (3–5)	5	68
FEES better than VFS	4 (3–5)	4	65.4
Oral-motor assessment	4 (3–4.25)	4	65.4
Sequential fall in FVC	4 (3–4.25)	4	65.4
Eat and drink in their usual position	4 (3–4)	3	56
No consensus
Tongue weakness	4 (3–4)	4	53.9
Advanced age	4 (2.75–4)	4	53.8
Artificial saliva gels	4 (3–4)	4	53.8
Thickened fluids	2.5 (2–4)	2	50
Thoracic level injury	3.5 (3–4)	4	50
Velopharyngeal (soft palate) weakness	3 (3–4)	4	48
Serum albumin	3 (2–4)	3	38.5

Table 6. Descriptive statistics for change in non-consensus statements between round 1 and round 2.

Subcategory	Mean		Median (IQR)			Mode			Consensus
	R1	R2	R1		R2	R1		R2
>55% majority agreement
Posterior cervical spinal surgery	3.33	3.54	3 (3–4)	4 (2.75–4)		3	4		69.2%
Tracheostomy cuff deflation	3.69	3.8	4 (2.75–5)	4 (3–5)		5	5		68%
FEES	3.63	3.81	4 (3–4)	4 (3–5)		4	4		65.4%
Oral-motor assessment	3.12	3.65	3 (2–4)	4 (3–4.25)		4	4		65.4%
FVC	3.33	3.81	3 (2–4)	4 (3–4.25)		2	4		65.4%
Eat/drink in usual position	2.44	3.44	2 (2–3)	4 (3–4)		2	3		56%
No consensus
Tongue weakness	2.59	3.46	2 (2–4)	4 (3–4)		2	4		53.9%
Artificial saliva	3.15	3.58	3 (2–4)	4 (3–4)		3	4		53.8%
Advanced age	3.19	3.31	3 (2–4)	3.5 (2.75–4)		3	4		50%
Thickened fluids	2.35	2.81	2 (1.75–3)	2.5 (2–4)		2	2		50%
Thoracic level injury	2.62	3.38	3 (2–3)	3.5 (3–4)		3	4		50%
Velopharyngeal weakness	2.89	3.4	3 (2–4)	3 (3–4)		3	4		48%
Serum albumin	3.04	2.96	3 (3–3)	3 (2–4)		3	3		37% (neutral)

Table 7. Best practice recommendations for acute cSCI management of dysphagia and associated complications.

Key areas	Best practice recommendations
Swallowing	Early screening by a team for dysphagia risk factors and symptoms. Specialist SLT assessment for those with risks or symptoms, especially those requiring tracheostomy and ventilation. Access to instrumental assessments including Fibreoptic Endoscopic Evaluation of Swallowing (FEES), to help evaluate pharyngeal and laryngeal functions. Avoid routine use of thickened fluids and blue dye without SLT assessment. Do not restrict oral intake based on position or ventilation status alone.
Respiratory	Nationally agreed weaning guidance should be used routinely, aiming for self-ventilation where possible. Tracheostomy cuff deflation trials can help speech and improve swallowing ability and should be planned as part of an MDT. Use vital capacity as an outcome measure as part of weaning. Specialist training is required for all staff undertaking respiratory rehabilitation.
Communication	Early options for communication are vital to support patient involvement in decision-making. Options for natural speech should be considered including tracheostomy cuff deflation and use of one-way (speaking) valves. For those people who are unable to speak, a variety of communication aids should be trialled as alternative options
Nutrition	Early nasogastric tube feeding for high cervical SCI ensures consistent and adequate nutrition to aid recovery If dysphagia persists, gastrostomy tube feeding should be considered in consultation with Dietitians and SLT. This can be reversed when eating resumes Avoid prolonged nil by mouth status as this can decondition the swallowing and speech muscles, SLT advice should be sought
Oral care	Mouthcare should routinely be provided at least twice a day to reduce the risk of ventilator-associated pneumonia Staff need to pay attention to dry mouth due to medication Additional oral moisturisation will be required (link to local mouthcare policy)

Table 8. Domains, category and sub-category of swallow risk screening tool.

Domains	Category	Sub-category
Injury risk	Co-Morbid	Brain injury/cognitive deficit
	Level of injury	Cervical SCI C1-C7
	Severity of injury	Complete/incomplete injury
	C-spine surgery	Anterior or posterior cervical spine surgery
Clinical risk	Intubation	>48 h
	Tracheostomy	Cuffed or uncuffed tube
	Ventilation	Requiring up to 24 h ventilation
	Nutrition	Reduced nutritional intake
Urgency	Chest infection	Recent chest infection
	Pyrexia	Spiking pyrexia
	Oral hygiene	Increased need for oral care
	Suction	Increased need for suction

Data availability statement

All research data are stored securely in the Research Innovation Centre at the Royal National Orthopaedic Hospital ([email protected]).