Background: Rapid evaluation of dysphagia poststroke significantly lowers rates of aspiration pneumonia. Logistical barriers often significantly delay in-person dysphagia evaluation by speech language pathologists (SLPs) in remote and rural hospitals. Clinical swallow evaluations delivered via telehealth have been validated in a number of clinical contexts, yet no one has specifically validated a teleswallow evaluation for in-hospital post-stroke dysphagia assessment. Methods: A team of 6 SLPs experienced in stroke care and a telestroke neurologist designed, implemented, and tested a teleswallow evaluation for acute stroke patients, in which 100 patients across 2 affiliated, urban certified stroke centers were sequentially evaluated by a bedside and telehealth SLP. Inter-rater reliability was analyzed using percent agreement, Cohen's kappa, Kendall's tau-b, and Wilcoxon matched-pairs signed rank tests. Logistic regression models accounting for age and gender were used to test the impact of stroke severity and stroke location on agreement. Results: We found excellent agreement for both liquid (91% agreement; kappa = 0.808; Kendall's tau-b = 0.813, p < 0.001; Wilcoxon signed rank = -0.818, p = 0.417) and solid (87% agreement; kappa = 0.792; Kendall's tau-b = 0.844, p < 0.001; Wilcoxon signed rank = 0.243, p = 0.808) dietary textures. From regression modeling, there is suggestive but inconclusive evidence that higher National Institute of Health Stroke Scale (NIHSS) scores correlate with lower levels of agreement for liquid diet recommendations (OR [95% CI] 0.895 [0.793-1.01]; p = 0.07). There was no impact of NIHSS score for solid diet recommendations and no impact of stroke location on solid or liquid diet recommendations. Qualitatively, we identified professional, logistical, technical, and patient barriers to implementation, many of which resolved with experience over time. Conclusions: Dysphagia evaluation by a remote SLP via telehealth is safe and effective following stroke. We plan to implement teleswallow across our multistate telestroke network as standard practice for poststroke dysphagia evaluation.

Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R: Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 2005;36:2756-2763.
Al-Khaled M, Matthis C, Binder A, Mudter J, Schattschneider J, Pulkowski U, Strohmaier T, Niehoff T, Zybur R, Eggers J, Valdueza JM, Royl G: Dysphagia in patients with acute ischemic stroke: early dysphagia screening may reduce stroke-related pneumonia and improve stroke outcomes. Cerebrovasc Dis 2016;42:81-89.
Ward E, Crombie J, Trickey M, Hill A, Theodoros D, Russell T: Assessment of communication and swallowing post-laryngectomy: a telerehabilitation trial. J Telemed Telecare 2009;15:232-237.
Burns CL, Ward EC, Hill AJ, Malcolm K, Bassett L, Kenny LM, Greenup P: A pilot trial of a speech pathology telehealth service for head and neck cancer patients. J Telemed Telecare 2012;18:443-446.
Ward EC, Sharma S, Burns C, Theodoros D, Russell T: Validity of conducting clinical dysphagia assessments for patients with normal to mild cognitive impairment via telerehabilitation. Dysphagia 2012;27:460-472.
Ward EC, Burns CL, Theodoros DG, Russell TG: Impact of dysphagia severity on clinical decision making via telerehabilitation. Telemed J E Health 2014;20:296-303.
Kantarcigil C, Sheppard JJ, Gordon AM, Friel KM, Malandraki GA: A telehealth approach to conducting clinical swallowing evaluations in children with cerebral palsy. Res Dev Disabil 2016;55:207-217.
Sharma S, Ward EC, Burns C, Theodoros D, Russell T: Training the allied health assistant for the telerehabilitation assessment of dysphagia. J Telemed Telecare 2012;18:287-291.
Sharma S, Ward EC, Burns C, Theodoros D, Russell T: Assessing dysphagia via telerehabilitation: patient perceptions and satisfaction. Int J Speech Lang Pathol 2013;15:176-183.
Landis JR, Koch GG: The measurement of observer agreement for categorical data. Biometrics 1977;33:159-174.
Hannawi Y, Hannawi B, Rao CP, Suarez JI, Bershad EM: Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis 2013;35:430-443.
McCullough GH, Wertz RT, Rosenbek JC, Mills RH, Ross KB, Ashford JR: Inter- and intrajudge reliability of a clinical examination of swallowing in adults. Dysphagia 2000;15:58-67.
McCullough GH, Martino R: Clinical evaluation of patients with dysphagia: importance of history taking and physical exam; in Shaker R, Easterling C, Belafsky PC, Postma GN (eds): Manual of Diagnostic and Therapeutic Techniques for Disorders of Deglutition. New York, Springer-Verlag, 2013, pp 11-30.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.