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8/17/2019 dysphagya screening.pdf
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Dysphagia Screening: BedsideApplication and Mechanics of
Screening Tools
Jeff Edmiaston, M.S. CCC-SLP
January 31, 2012
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Objectives
Screening Tool Mechanics Specific Screening Tools
Bedside Application
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Screening in Acute Stroke
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+
_________
8
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8+ 0
_________
8
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+ + + + + ____ ____ _____ _____ _____
8 8 8 8 8
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0 1 2 4 5+ 8 + 7 + 6 + 4 + 3 ____ ____ _____ _____ _____
8 8 8 8 8
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What’s in a Screen?
15 Screens Reviewed 38 different components identified
Variation in length
Most Simple-1 Item
Most Complex-16 items
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Liquid Trial-93%
Level of Alertness-33%
Dysarthria-20%
Aphasia-20%
Facial Symmetry-27%
Tongue Symmetry/Fx-27%
Palatal Fx-20%
Gag-20%
Voluntary Cough-20%
Positioning-7%
Salivary Management-27%
Respiratory Fx-20%
Vocal Quality-27%
Swallowing Complaints-13%
Pulse Oximetry-7%
Stroke Location-7%
Nasal Regurgitation-7%
Eyes Reddening/Tearing-7%
Pneumonia Hx-7%
H/O Coughing with P.O.-20%
Oral Intake (Volume)-7%
Oral Intake (Rate)-7%
NPO Status-7%
Voice after Swallowing-20%
Confusion/Cognitive-7%
Solid Trial-13%
Pharyngeal Sensation-7%
Stroke Severity-7%
Cooperation-7%
Auditory Comprehension-7%
Cough Reflex-13%
Intubation/Recent Extubation-7%
Food Pocketing-7%
Suctioning Required-7%
Other-7%
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Specific Screens
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3 oz Water Swallow Test
Give patient 3 oz water to drink uninterrupted from acup
Observe for 1 minute after the swallow
Coughing
Wet/Hoarse Vocal Quality
*Depippo K, Holas M, Reding M: Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol. 1992;49:1259-1261
*Suiter D, Leder S.:Clinical utility of the 3-ounce water swallow test. Dysphagia 2008, 23: 244-250
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Burke Dysphagia
Screen
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Burke Dysphagia Screen
Pass/Fail Failure on any one item results in failure
*DePippo K, Holas M, Reding M: The burke dysphagia screening test: validation of its use in patients with stroke. Arch Phys Med Rehabil 1994;
75:1284-1286
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MasseyBedside
Form
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Massey Bedside Screening
Complete Pre-Assessment Form Administer single teaspoon of water
60cc glass of water
*Massey R, Jedlicka D.: The Massey Bedside Swallowing Screen. J. Neurosci Nurs. 2002; 34(5):252-253; 257-260
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Timed
Test
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Timed Test
GCS >13 Able to sit up
5-10ml of water to ensure safety
100-150ml as quickly as possible
Number of swallows counted
Timed
Abnormal=outside the 95% prediction interval for age
and sex or qualitative elements of coughing during orvoice change after the test*Hinds NP, Wiles CM: Assessment of swallowing and referral to speech and language therapists in acute stroke. QJ Med 1998; 91:829-835
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“Any Two”
Administer following liquid bolus amounts: 5ml
10ml
20ml
Administer twice for a total of 70ml
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“Any Two”
Presence of any two of the following indicators: Abnormal volitional cough
Abnormal gag reflex
Dysphonia
Dysarthria Cough after swallow
Voice changes after swallow*Daniels S, Lindsay B, Mahoney M, Foundas A: Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients.
Arch Phys Med Rehabil 2000; 81: 1030-1033
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Barnes Jewish Hospital Stroke Dysphagia
Screen (BJH-SDS)
5 items, each scored present/absent Presence of one, screen is failed
Failed screen-NPO with speech consult
Passed screen-Regular diet
*Edmiaston J, Tabor Connor L, Loehr L, Nassief A.: Validation of a dysphagia screening tool in acute stroke patients. Am J Crit Care, 2010; 19(4): 357-364.
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BJH-SDS
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MetroHealth Dysphagia Screen
Administered in the Emergency Department Pass/Fail Criteria
No liquid or solid trials administered
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MetroHealth Dysphagia Screen
1. Is alertness level insufficient to remain awake for 10 minutes while
sitting upright?
2. Is voice weak, wet, or abnormal in any way? (If cannot speak, circle
yes)
3. Does the patient drool?
4. Is speech slurred?
5. Is the patient’s cough weak or inaudible? (If cannot cough, circle yes)
________________________________________________
One or more “yes” answers are considered a positive screen for possible
dysphagia
*Schrock J, Bernstein J, Glasenapp M, Drogell K, Hanna J.: A novel emergency department dysphagia screen for patients presenting with
acute stroke. Academic Emergency Medicine 2011; 18:584-589
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Modified Mann Assessment of Swallowing
Ability
No food trials Scoring system: 0-100
Specific task instructions
Score 95, start oral diet and progress as tolerated,
monitor first oral intake. Consult SLP if issues Score ≤ 94, NPO and consult SLP
*Antonios N, Mann G, Crary M, Miller L, Hubbard H, Hood K, Sambandam R, Xavier A, Silliman S.: Analysis of a physician tool for evaluationdysphagia on an inpatient stroke unit: The Modifed Mann Assessment of Swallowing Ability. Journal of Stroke and Cerebrovascular Diseases; 201019(1): 49-57.
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Mann Assessment of Swallowing Ability
Patient Name:_________________________Date:_________________SLP:_______________________
MASA #:_____________ Score:_______________
Alertness 2=No responseto speech
5=Difficultto rouse
8=Fluctuates 10=Alert
Cooperation 2= Nocooperation
5=Reluctant 8=Fluctuatingcooperation
10=Cooperative
AuditoryComprehension
2=No responseto speech
4=Occasionalmotor response
6=follows simpleconversationwith repetition
8=followsordinary conversationlittle difficulty
10=No deficitsnoted
Respiration 2=Chestinfection
4=Coarse basalcrepitations
6=Fine basalcrepitations
8=Sputum in upperairway
10=Chestclear
Respiratory rate
for swallow1=No independentcontrol
3=Some controluncoordinated
5=Able to controlrate for swallow
Aphasia 1=Unable toassess
2=No functionalspeech
3=Expresses selfin limited mannershort phrase/words
4=Mild difficultyfinding words orexpressing ideas
5=No deficitsnoted
Apraxia 1=Unable toassess
2=Groping/inaccurate/partialor irrelevant response
3=Speech crude.defective inaccuracy or speed
4=Speech accurateafter trial and errorMinor searchingmovements
5=No deficitsnoted
Dysarthria 1=Unable toassess
2=Speechunintelligible
3=Speech intelligible but obvious defect
4=Slow withoccasional halting
5=No deficitsnoted
Saliva 1=Gross drool 2=Some droolconsistently
3=Drooling attimes
4=Frothy/expectorated
5=No deficitsnoted
Lip seal 1=No closureunable to assess
2=Incompleteseal
3=Unilaterally weak poor maintenance
4=Mild impairmentoccasional leakage
5=No deficitsnoted
Tongue
movement
2=No movement 4=Minimalmovement
6=Incompletemovement
8=Mild impairmentin range
10=Full rangeof motion
Tonguestrength
2=Grossweakness
5=Unilateralweakness
8=Minimalweakness
10=No deficitsnoted
Tongue
coordination
2=No movementunable to assess
5=Grossincoordination
8=Mildincoordination
10=No deficitsnoted
Oral
preparation
2=Unable toassess
4=No bolusformation, no attempt
6=Minimal chew,gravity assisted
8=Lip or tongueseal, bolus escape
10=No deficitsnoted
Gag 1=No gag 2=Absentunilaterally
3=Diminishedunilaterally
4=Diminished bilaterally
5=Hyperreflexive No deficits
Palate 2=No spreador elevation
4=Minimalmovement
6=Unilateralweakness
8=Slightasymmetry
10=No deficitsnoted
Bolus clearance 2=No clearance 5=Someclearance/residue
8=Significant clearanceminimal residue
10=Fullycleared
Oral transit 2=No movement 4=Delay >10 sec. 6=Delay >5 sec 8=Delay >1 sec 10=No deficit
Cough reflex 1=Unable to assess 3=Weak reflexivecough
5=No deficitnoted
Voluntary
cough
2=No attempt 5=Attemptinadequate
8=Attempt bovine
10=No deficitnoted
Voice 2=Aphonic, notable to assess
4=Wet/gurgling 6=Hoarse 8=Mild impairmentslight huskiness
10=No deficitnoted
Trach 1=Trach/cuffed 5=Trach/fenestrated 10=No trach
Pharyngealphase
2=No swallow 5=Pooling/gurglingIncomplete laryngeal
elevation
8=Mildly restrictedlaryngeal elevation
Slow initiation
10=Immediatelaryngeal elevation
Pharyngealresponse
1=Not coping/gurgling
5=Cough beforeduringor after swallow
10=No deficitnoted
Diet recommendations Regular Soft Selected soft Mechanical soft Puree No solid by mouth
Fluid recommendation Regular Thins only Nectar Honey No liquids by mouth
Original Mann Assessment of Swallowing Ability
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Alertness 10=Alert 8=Drowsy-fluctuating
awareness/alert level
5=Difficult to arouse
by speech or mvmt
2=Coma or
nonresponsvie
Cooperation 10=Cooperative 8=Fluctuatingcooperation 5=Reluctantcooperation 2=No cooperation/response
Respiration 10=Chest clear 8=Sputum in upper
airway
6=Fine basal
crepitations
4=Coarse basal
crepitations
2=Suspected
infections/ freq
suction/ respirator
dependent
Expressive
Dysphasia
5=No abnormality 4=Mild wording finding
difficulty
3=Expresses self in
limited manner
2=No functional
speech
1=Unable to assess
Auditory
Comprehension
10=No abnormality 8=Follows ordinary
conversation with
little difficulty
6=Follows simple
conversation
4=Occasional
response
1=No response
Dysarthria 5=No abnormality 4=Slow with
occasional hesitation
3=Speech intelligible
but defective
2=Speech unintelligible 1=Unable to assess
Saliva 5=No abnormality 4=Frothy/
expectorated in cup
3=Drooling at times 2=Some drool
consistently
1=Gross drooling
Tongue Movement 10=Full R.O.M. 8=Mild impairment 6=Incomplete mvmt 4=Minimal mvmt 2=No movement
Tongue Strength 10=No abnormality 8=Minimal weakness 5=Obvious unilateral
weakness
2=Gross weakness
Gag 5=No abnormality 4=Diminished
bilaterally
3=Diminished
unilaterally
2=Absent unilaterally 1=No gag response
Cough Reflex 10-No abnormality 8=Cough attempted
but hoarse in quality
5=Attempt inadequate 2=No attempt/unable
to perform
Palate 10=No abnormality 8=Slight asymmetry 6=Unilaterally weak 4=Minimal movement 2=No movement
Modified Mann Assessment of Swallowing Ability
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EATS
• Two Phases
Questionnaire
Food/Liquid Trials
• Must show no deficits in both phases to pass screen
Courtney B, Flier L.: RN dysphagia screening, a stepwise approach. Journal of Neuroscience Nursing 2009; 41(1):28-38
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EATS
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The Gugging Swallow Screen
Includes a semi-solid, liquid, and solid trial
Severity scoring system
Allows diet to be altered
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Figure I. GUSS.
Trapl M et al. Stroke 2007;38:2948-2952
Copyright © American Heart Association
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Figure I Continued.
Trapl M et al. Stroke 2007;38:2948-2952
Copyright © American Heart Association
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What Screen Should I Use?
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+ + + + + ____ ____ _____ _____ _____
8 8 8 8 8
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0 1 2 4 5+ 8 + 7 + 6 + 4 + 3 ____ ____ _____ _____ _____
8 8 8 8 8
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+ + + + + ____ ____ _____ _____ _____
8 8 8 8 8
Use only odd numbers to answer the question
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Use only odd numbers to answer the question
+ + _____ _____
8 8
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Use only odd numbers to answer the question
5 1+ 3 + 7
_____ _____
8 8
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Screening Purpose
Identify individuals with or at risk of swallowing
dysfunction following a stroke.
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Sensitivity vs. Specificity
Always a trade-off
Dysphagia screening is tilted towards sensitivity
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The Perfect Screen
Do you have stroke-like
symptoms?
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The Perfect Screen
100% Sensitivity to Dysphagia
0% Specificity to Dysphagia
Theoretical Result: Never a dysphagia related
complication
Bedside Result 6 out of 10 patients are angry!
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Not all bedsides are the same
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BJC Healthcare1. Alton Memorial
2. Barnes Jewish3. Barnes Jewish St. Peters
4. Barnes Jewish West County
5. Boone Hospital
6. Christian Hospital
7. Clay County Hospital8. Missouri Baptist Medical Center
9. Missouri Baptist Sullivan Hospital
10. Northwest Healthcare
11. Parkland Health Center
12. Progress West HealthCare Center13. Rehabilitation Institute of St. Louis
14. St. Louis Children’s Hospital
15. Siteman Cancer Center
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Barnes Jewish Hospital
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Stroke Fellow Neuroradiology & Neurosurgery
MRI, Angiography, PET Scanner
Dedicated Stroke Neurologists
Dedicated Stroke Nursing Unit Dedicated 20 Bed Neuro-ICU with Portable CT
Intra-operative MRI Suite
Two Stroke Nursing Coordinators
Dedicated Stroke Rehabilitation Services (PT,OT, andSpeech)
Administrative group dedicated to Neurosciences
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Clay County Hospital
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Factors that may effect screen choice
Availability of Speech Pathology
Availability of Radiology Services (i.e. Videofluoroscopy)
Volume of patients
Nursing numbers
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Fewer Resources Available
May be less tolerant of false positives
May be more comprehensive
May resemble an assessment rather than screen
Potentially more burden on nursing
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More Resources Available
May tolerate false positives
May be less comprehensive (pass/fail)
Potentially less burden on nursing
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No Perfect Screen
Perfection= 100% Sensitivity & 100% Specificity
There will be false positives
There will be false negatives
How many of each can be tolerated?
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What is a good Screen?
Valid
Reliable
Works for your setting
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Validity
External
Internal
Criterion
Content
Concurrent
Predictive
Content
Construct Face
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Reliability
Inter-rater Reliability
Test-Retest Reliability
Parallel-Forms Reliability
Internal Consistency
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What Works for You?
No numeric value to derive this
Dependent on multiple factors
Specific to a given institution
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Making a Decision
Expert Opinion
Data Driven-Dependent on quality of data
Group Consensus
Kepner-Tregoe Decision Matrix
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Kepner-Tregoe Decision Matrix
Timed Up
and Go
Timed Up
and Go (R)
Get Up and
Go
BJC Get Up
and GoEasily
Administered
Valid
Reliable
Easily
Documented
Sensitivity/Spec
ificity (5)
Evidence Based
(10)
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Kepner-Tregoe Decision Matrix
Timed Up
and Go
Timed Up
and Go (R)
Get Up and
Go
BJC Get Up
and GoEasily
Administered
x x x
Valid x x X X
Reliable x x
Easily
Documented
x x x x
Sensitivity/Spec
ificity (5)
5 5 5
Evidence Based
(10)
10 10 10 10
K T Analysis of Swallow Screens
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3 oz
water
Massey Timed
Test
Burke
Screen
Metro
Health
Any
Two
EATS Mini
MASA
GUSS BJH
SDS
Sensitivity>90%
Face Validity
Easy to
administer
Reliable
Concurrent
Validity
Scoring
Severity
Easy to learn
Specificity
>50%
K-T Analysis of Swallow Screens
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Barnes Jewish Hospital- KT Matrix
3 M Ti d B k M t A EATS Mi i GUSS BJH
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3 oz
water
Massey Timed
Test
Burke
Screen
Metro
Health
Any
Two
EATS Mini
MASA
GUSS BJH
SDS
Sensitivity
>90%
Face Validity
Easy to
administer
Reliable
Concurrent
Validity (8)
Scoring
Severity (1)
Easy to
learn (10)
Specificity
>50% (5)
3 M Ti d B k M t A EATS Mi i GUSS BJH
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3 oz
water
Massey Timed
Test
Burke
Screen
Metro
Health
Any
Two
EATS Mini
MASA
GUSS BJH
SDS
Sensitivity
>90% X X X X X X X X X X
Face ValidityX X X X X X X X
Easy to
administer X X X X X X X
ReliableX X X X X X X X X X
Concurrent
Validity (8)
Scoring
Severity (1)
Easy to learn
(10)
Specificity
>50% (5)
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Massey Timed TestBurke
ScreenAny Two BJH SDS
Sensitivity >90%X X X X X
Face ValidityX X X X X
Easy to administer X X X X X
ReliableX X X X X
Concurrent
Validity with
MBS/FEES (8)0 0 0 8 8
Scoring Severity
(1) 0 0 0 0 0
Easy to learn (10) 10 10 10 10 10
Specificity
>50% (5) 5 5 0 5 5
TOTAL 15 15 10 23 23
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Clay County Hospital-KT Matrix
3 oz Massey Timed Burke Metro Any EATS Mini GUSS BJH
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3 oz
water
Massey Timed
Test
Burke
Screen
Metro
Health
Any
Two
EATS Mini
MASA
GUSS BJH
SDS
Sensitivity
>90%
FaceValidity
Easy to
learn
Specificity
>50%
Reliable
Concurren
t Validity
Scoring
Severity
Easy to
administer
3 oz Massey Timed Burke Metro Any EATS Mini GUSS BJH
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3 oz
water
Massey Timed
Test
Burke
Screen
Metro
Health
Any
Two
EATS Mini
MASA
GUSS BJH
SDS
Sensitivity
>90% X X X X X X X X X
Face ValidityX X X X X X X X X X
Easy to learnX X X X X X X X X X
Specificity
>50% X X X X X X X
Reliable
Concurrent
Validity
Scoring
Severity
Easy to
administer
Ti d M t A Mi i BJH
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MasseyTimed
Test
Metro
Health
Any
Two
Mini
MASAGUSS
BJH
SDS
Sensitivity >90%X X X X X X X
Face ValidityX X X X X X X
Easy to learnX X X X X X X
Specificity
>50% X X X X X X X
Reliable (2)2 2 2 2 2 2 2
Concurrent Validity
with MBS/FEES (10) 0 0 10 10 10 10 10
Scoring Severity (8)
0 0 0 0 0 8 0Easy to administer
(4) 4 4 4 4 4 0 4
TOTAL 6 6 16 16 16 20 16
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Conclusion
Much research has been done
Many screens, most are pretty good
When choosing a screen, be objective and systematic
There is no “best” screen
The best screen is the one that is best for your institution