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(Stroke. 2009;40:555.)
© 2009 American Heart Association, Inc.

Original Contributions

The Toronto Bedside Swallowing Screening Test (TOR-BSST)

Development and Validation of a Dysphagia Screening Tool for Patients With Stroke

Rosemary Martino, PhD; Frank Silver, MD; Robert Teasell, MD; Mark Bayley, MD; Gordon Nicholson, MHSc; David L. Streiner, PhD Nicholas E. Diamant, MD

From the Department of Speech-Language Pathology (R.M.) and the Department of Psychiatry (D.L.S.), University of Toronto; Health Care and Outcomes Research (R.M.), Toronto Western Research Institute; the Stroke Program (F.S.), the Department of Speech-Language Pathology (G.N.), and the Department of Gastroenterology (N.E.D.), University Health Network; Department of Physical Medicine and Rehabilitation (R.T.), St. Joseph’s Health Care London; Neurology Rehabilitation Program (M.B.), Toronto Rehabilitation Institute; Kunin-Lunenfeld Applied Research Unit (D.L.S.), Baycrest; Ontario, Canada.

Correspondence to Rosemary Martino, PhD, Department of Speech-Language Pathology, University of Toronto, 160-500 University Ave, Toronto, Ontario, Canada M5G 1V7. E-mail rosemary.martino{at}utoronto.ca

Background and Purpose— Dysphagia occurs in 55% of all acute stroke patients. Early identification of dysphagia from screening can lead to earlier treatments and thereby reduce complications. We designed and validated a new bedside dysphagia screening tool—the Toronto Bedside Swallowing Screening Test (TOR-BSST) for stroke survivors in acute and rehabilitative settings.

Methods— The TOR-BSST initially contained 5 items with proven high predictive ability for dysphagia. Trained screeners administer and score the TOR-BSST in less than 10 minutes. Trained nurses from 2 acute and 2 rehabilitation facilities administered the TOR-BSST to consecutively admitted stroke inpatients. A positive screen identified patients at risk for dysphagia. Blinded repeat screenings were conducted within 24 hours. Test-retest reliability was established with the first 50 administrations at an ICC=0.92 (CI, 0.85 to 0.96). Items were eliminated if they contributed 5% to the total score and were judged clinically impractical. 20% of all enrolled patients were randomly allocated to gold standard videofluoroscopic assessment of swallowing and findings rated independently by 4 blinded experts. Adequate validity was set at sensitivity 90% and negative predictive value 90%.

Results— 311 stroke inpatients were enrolled; 103 acute and 208 rehabilitation. Screening was positive in 59.2% acute and 38.5% rehabilitation patients. The pharyngeal sensation item did not meet inclusion criteria and was eliminated. The TOR-BSST demonstrated excellent validity with sensitivity at 91.3% (CI, 71.9 to 98.7), and negative predictive values at 93.3% in acute and 89.5% in rehabilitation settings.

Conclusion— The TOR-BSST is a simple accurate tool to identify stroke patients with dysphagia regardless of severity and setting.

Key Words: dysphagia • stroke • screening • assessment scale • validation