Speech-Language Pathology and Dysphagia Nursing QUERI Paula A. Sullivan, MS, CCC-SLP, BRS-S North Florida/South Georgia Veterans Health System Gainesville, Florida

1
Speech-Language Pathology and Dysphagia
Nursing QUERIPaula A. Sullivan, MS, CCC-SLP,
BRS-SNorth Florida/South Georgia Veterans Health
SystemGainesville, Florida
2
2006 OIG Report

• There is no national guidanceand considerable
  variability in practice.
• We recommenda work group of relevant healthcare
  providers develop a comprehensive policy that
  defines multidisciplinary responsibilities for
  assessment and management, with the goal of
  improving coordinated medical care provided to
  patients with feeding and swallowing problems.

3
SLP Involvement in Dysphagia Directive

• Documentation in CPRS
• Post feeding guidelines c/w JACHO and privacy
  guidelines
• Follow national guidelines on clinical indicators
  for clinical and VFSS or other instrumental
  studies
• Follow-up with appropriate treatment and
  management
• Development of an appropriate, customized,
  patient and family centered POC
• POC contains diagnosis, functional goals,
  measurable treatment objectives, and the type,
  amount, duration, and frequency of services
• Follow-up on appropriateness of long-standing
  diet orders and monitor effectiveness
• Aware of and thoroughly trained in their role
• Clinical indicators and treatment guidelines
  located at http//vaww1.va.gov/audiospeech/

4
ASP Response to the Dysphagia Directive
Implementation

• Plans of ASP Field Advisory Committee (FAC)
  monitor and encourage compliance with the
  directive and to facilitate development of a good
  dysphagia screen
• FY09 National ASP Strategic Plan Promote
  excellence in management of patients with
  dysphagia by assisting the field to implement VHA
  Directive 2006-032.

5
Controversies

• Screen vs. assessment
• Who should do it?
• Evidence of risk factors and best practices for
  screening

6
ASHA and Screening

• ASHAs Preferred Practice Pattern on Swallowing
  Screening
• pass/fail procedure to identify individuals that
  require a comprehensive assessment of swallowing
  function or referral for other professional
  and/or medical services (ASHA, 2004)
• The screening should determine the risk or
  likelihood that the individual has dysphagia or
  may be aspirating food or liquid

7
Concerns of the SLP Working Group with Nursing
Acute Care Dysphagia Assessment

• Silent Aspiration

8
Water Swallow Test

• 3-oz water. Abnormal response coughing during
  drinking or for 1 minute after or wet-hoarse
  vocal quality
• DePippo et al (1994) compared with VFSS water
  swallow identified 76 of patients as aspirating
  who were aspirating on VFSS (specificity) and
  identified 59 of patients as not aspirating when
  they were not aspirating on VFSS (sensitivity)

9
Water Swallow Test

• Garon et al (1995) tested 100 consecutive
  patients
• Of 54 patients who aspirated, only 35 coughed at
  bedside using water swallow test
• That is, 65 would be considered silent
  aspirators and would not be identified at bedside
  using the water swallow test

10
Models for Swallow Screening

• Model A SLP trains nursing staff to conduct
  screens. Fails assessed by SLP.
• Model B Physician performs screen. Consults
  SLP if pt fails.
• Model C Model A or B followed by automatic
  referral (24-48 hours) for assessment by SLP by
  all patients regardless of screening results.
• Model D All patients are automatically referred
  to SLP for screen or assessment.

11
Does Dysphagia Screening Work?

• What are the expected outcomes?
• -Correct identification of potential dysphagia
• -Correct implementation of precautions
• -Correct triage for further assessment
• -Appropriate intervention for dysphagia
• -Improved health status outcome
• Lower incidence of dysphagia related
  complications such as AP, prolonged LOS, death.

12
5 Kinds of Swallowing Outcomes

• 1. Respiratory to prevent aspiration pneumonia
  and other aspiration sequelae
• 2. Nutritional to prevent malnutrition and
  dehydration associated with swallow inefficiency
  and weakness
• 3. Financial to limit healthcare expenditure for
  preventable consequences of dysphagia
• 4. Physiologic to restore normal swallowing
  physiology
• 5. Quality of Life to restore normal mealtime
  participation and enjoyment

13
What Does the Evidence Tell Us About Screening
Procedures?

• Literature focuses almost exclusively on correct
  identification of aspiration
• Lack of evidence that any one screening
  (assessment) procedure has good accuracy in
  detecting dysphagia (Martino, Pron, Diamant,
  2000 Perry Love, 2001)

14
Problems with Current Screening Procedures

• Cough does not necessarily indicate penetration
  or aspiration
• Cough does not necessarily indicate ejection of
  material from the airway
• Absence of cough does not necessarily rule out
  silent aspiration
• Absence of cough does not rule out other
  swallowing problems

15
Where are we with Implementationof Dysphagia
Assessment

• VHA Directive 2006-032 became effective 5/22/06
• Inquiry to National VHASLP list serve inquiry on
  12/08/08 re Nursing assessment
• -11/28 (39) contain water swallow

16
Where are we with Implementationof Dysphagia
Assessment

• What assessment is being used at your facility? -
  Nursing shift assessment 1
• - Combined risk factors and pt/family report 3
• No response or dont know 5
• Original template 6
• Pt/family report 6
• Risk factors/symptom inventory - 7

17
Where are we with Implementationof Dysphagia
Assessment

• Comments
• Our number of bad consults has been steadily
  increasing and we need something better.
• The false positive rate was about 90.
• Maybe there will be national agreement on best
  practice?
• They are waiting for the new assessment to
  come out.
• Our nursing staff is uncomfortable with the idea
  of doing a bedside water sip during their
  assessment.

18
Thoughts, Challenges and Opportunities

• There are still many unanswered questions and
  much room for improvement in dysphagia screening/
  assessment
• Given the magnitude of dysphagia, is it adequate
  to focus primarily on the identification of
  aspiration?
• VHA is a leader in dysphagia research and guiding
  practice - VHA/DoD 2003 Clinical Practice
  Guidelines for Management of Stroke endorsed by
  AHA/ASA

19
Thoughts, Challenges and Opportunities

• Opportunity for collaboration between Offices of
  Nursing and Audiology/Speech Pathology to
  identify best practices for screening and to
  develop a good swallow screen
• Who should perform the screen?
• Develop a tool that will improve patient outcomes
  
• with the goal of improving coordinated medical
  care provided to patients with feeding and
  swallowing problems (OIG, 2006).