Can I advance the diet in a rule out stroke patient with a negative CT scan and bedside swallow screen?

Diet Advancement in Rule-Out Stroke Patients with Negative CT and Bedside Swallow Screen

Yes, you can advance the diet in a rule-out stroke patient once both the CT scan is negative and a validated bedside swallow screen has been passed. 1, 2

Dysphagia Screening Protocol

1. Initial Assessment Requirements:

   • Swallowing function must be evaluated before any oral intake (including medications, food, or liquids) 2, 1
   • Screening should be performed as soon as the patient is alert 1
   • Ideally within the first few hours of hospital admission 1

2. Validated Screening Tools:

   • Use a validated screening tool rather than unvalidated methods 1
   • Recommended validated tools include:
     • Gugging Swallowing Screen (GUSS) - 97% sensitivity, 67% specificity 1, 3
     • Volume-Viscosity Swallow Test (V-VST) 1
     • 3-oz water swallow test (accurate for predicting ability to tolerate thin liquids) 2, 1

3. Screening Results Interpretation:

   • Passed Screen: Diet can be advanced based on the specific screening tool recommendations 2, 1
   • Failed Screen: Patient should remain NPO and be referred for comprehensive assessment by a speech-language pathologist 2, 1

Diet Advancement Protocol

1. When CT is Negative and Swallow Screen is Passed:

   • Advance diet according to the specific recommendations from the swallow screening tool 2
   • Begin with the safest consistency as indicated by the screening tool (often starting with semi-solid foods rather than thin liquids) 1, 3

2. Monitoring After Diet Advancement:

   • Observe for signs of dysphagia during meals 2
   • Look for: choking, coughing, wet voice, delay in initiating swallow, uncoordinated chewing/swallowing, extended time eating/drinking 2
   • Monitor nutritional intake and weight 2, 4

Important Considerations and Cautions

1. Risk of Silent Aspiration:

   • Approximately 50% of aspirations due to dysphagia are "silent" with no obvious clinical signs 2
   • Even with a passed bedside screen, maintain vigilance for subtle signs of aspiration 5

2. Limitations of Bedside Screening:

   • Bedside assessments have limited sensitivity (47-75%) for detecting aspiration 5
   • A negative CT does not rule out all stroke types that might affect swallowing 2

3. Nutritional Impact:

   • Early appropriate nutritional intervention improves outcomes 2, 4
   • Malnutrition affects up to 50% of stroke patients by 2-3 weeks post-stroke 2
   • Nutritional intervention should occur no later than 3-4 days after diagnosis of dysphagia 2

Special Situations

1. If Uncertain About Swallow Safety:

   • Consider referral for instrumental assessment (videofluoroscopy or fiberoptic endoscopic evaluation) 2, 1
   • When in doubt, maintain NPO status until a more comprehensive assessment can be performed 2

2. For Patients with Higher Risk Factors:

   • Age >70 years and male sex are independent predictors of swallowing impairment at 6 months 6
   • Consider more cautious advancement in these populations 6

By following this evidence-based protocol, you can safely advance diet in rule-out stroke patients with negative CT and passed bedside swallow screens while minimizing the risk of aspiration and its complications.