American Academy of Nursing

View all recommendations from this society

March 21, 2017

Don’t order “formal” swallow evaluation in stroke patients unless they fail their initial swallow screen.

Dysphagia (difficulty swallowing) is a common disorder in patients who have suffered a stroke, occurring in 50–60% of acute stroke patients. It is associated with an increased risk of aspiration, pneumonia, prolonged hospital stay, disability, and death. Swallow screening is critical in the rapid identification of risk of aspiration in patients presenting with acute stroke symptoms. Because formal swallowing evaluation is not warranted in all patients with acute stroke, the purpose of a swallowing screen is to identify those who do not need a formal evaluation and who can safely take food and medication by mouth. Formal swallowing evaluations can be done in patients who don’t pass the initial screening.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a health professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician or nurse.

How The List Was Created

The American Academy of Nursing has convened a Task Force of member fellows who are leaders of professional nursing organizations representing a broad range of clinical expertise, practice settings and patient populations. The Task Force collaboratively identifies nursing/interdisciplinary interventions commonly used in clinical practice that do not contribute to improved patient outcomes or provide high value. An extensive literature search and review of practice guidelines is conducted for each new proposed recommendation for the list. The supporting evidence is then reviewed by the respective nursing organization(s) with the most relevant expertise to each recommendation. The Academy Task Force narrows the recommendations through consensus, based on established criteria. The final recommendations are presented to the American Academy of Nursing’s Board of Directors for approval to be added to the Choosing Wisely list created by the Academy. Once approved by the Academy’s Board of Directors, the recommended statements are sent to the ABIM Foundation for an external review by physician(s) and nurse(s) and final approval for consistency with the ABIM Foundation principles.

Recommendations were developed in partnership with the following organizations: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), recommendations 1, 11, 12, & 13; Academy’s Expert Panel on Aging, recommendations 2, 3, 14, 15, & 24; American Association of Critical- Care Nurses (AACN), recommendations 4 & 5; Oncology Nursing Society (ONS), recommendations 6, 7, 8, 9, & 10; American Association of Neuroscience Nurses (AANN), recommendations 16, 17, 18, 19, & 20; Academy’s Expert Panel on Acute & Critical Care, recommendation 21; Society of Pediatric Nurses (SPN), recommendation 22; American Pediatric Surgical Nurses Association, Inc. (APSNA), and the American Pediatric Surgical Association (APSA), recommendation 23; and the Association of periOperative Registered Nurses (AORN), American Association of Nurse Anesthetists (AANA), and the American Association of Neuroscience Nurses (AANN), recommendation 25.

The American Academy of Nursing’s conflict of interests and disclosures policy can be found at


Jauch, E., Saver, J., Adams, H., Bruno, A., Connors, J., Demaerschalk, B., Khatri, P., et al.( 2013) AHA / ASA guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association / American Stroke Association. Stroke. 44, 870-947.

Kenmuir, C., Hammer, M., Tudor, J., Reddy, V., Wechsler, L., Jadhav, A., (2015). Predictors of outcome in patients presenting with acute ischemic stroke and mild stroke scale scores. Journal of Stroke and Cerebrovascular Disease. 24(7) 1685-1689.

Martino, R., Maki, E., Diamant, N. (2014) Identification of dysphagia using the Toronto Bedside Swallowing Screening Test (TOR-BSST): Are 10 teaspoons of water necessary? International Journal of Speech-Language Pathology. 16 (3): 193-198.

Schepp, S., Tirschewll, D., Miller, R., Longstreth, W. (2012) Swallowing screens after acute stroke: A systematic review. Stroke. 43, 869-871.

Summers, D. Leonard, A., Wentworth, D., Saver, J., Simpson, J., Spilker, J., Hock, N…et al. (2009). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient. A scientific statement from the American Heart Association. Stroke. 40, 1-35.