How much should students swallow

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How much should students swallow?
Elizabeth Boaden Head of Adult Speech and
Language Therapy Services Central Lancashire NHS
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Format

• RCSLT Student knowledge skills
• Presentation of dysphagia frameworks
• Bedside Swallow Screening Tool (BESST)
• Ethical and legal issues
• Summary

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RCSLT Pre-registration Dysphagia Knowledge

• Anatomy, physiology neurology of swallowing
• Normal swallowing
• Aetiology of dysphagia
• Glossary
• Referral process and case history
• Legal and ethical decision making
• Risk management
• Awareness of complex client needs

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RCSLT Pre-registration Dysphagia Assessment Skills

• Oropharyngeal assessment
• - Palpation
• Assessments
• - trial of food consistencies
• Role of instrumental assessments
• - VFES, FEES

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RCSLT Pre-registration Dysphagia Management Skills

• Compensatory techniques
• Positioning
• Food consistencies
• Service delivery (MDT, caseload management)
• Prognostic indicators
• Environmental factors and role of carers
• Non-oral feeding options

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Students role expectations in your clinical
placement

• 1. Observation of assessment and treatment
• 2. Practice with normal subjects
• 3. Assess non-complex patient to detect the
  presence or absence of dysphagia -
  oropharyngeal examination
• - dry swallow
• - trial of food consistencies
• 4. Assist with treatment
• 5. Recommendations for management
• 6. Consult MDT including supervisor
  
• (Advanced Studies
  Committee1999)

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• Perhaps the most dangerous assumption in the
  professions is that being qualified implies that
  one is competent.
• (Eraut Learning in Health and Social Care
  2003)

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As a Newly Qualified Therapist (NQT) employers
vs. your expectations

• Basic assessment management of dysphagia
• Expect in-house/formal courses
• Transition to independent practitioner
• Aware of when to seek advise support from an
  experienced practitioner
• SIG membership
• CPD

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Dysphagia competence frameworks

• A number of frameworks had been developed
• using a range of approaches
• Local - to meet local need
• National - to meet government guidelines
• Profession specific competencies
• Staff (grades/groups) specific

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Dysphagia Competence Frameworks

• Kings College Dysphagia Competencies for
  Students/Newly Qualified Speech and Language
  Therapists
• RCSLT Dysphagia Competency Framework
• Inter-professional Dysphagia Framework (IDF)

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Kings College Dysphagia competencies

• Stage 1 Observation and information
  gathering
• Stage 2 Active involvement under
  supervision
• Stage 3 Hands on dysphagia management
• Stage 4 Hands on with distant supervision
• Stage 5 Independent

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RCSLT Dysphagia Competency Framework

• Basic expertise and competence to work
  independently at post-registration (CQ3 2006)
• SLT at graduate level will have basic management
  skills for eating and drinking difficulties but
  will require supervision and support to develop
  enhanced specialist knowledge and skills related
  to certain areas i.e. craniofacial conditions,
  prematurity and tracheostomy (CQ3 2006)
• Reference Framework Underpinning competence to
  practise (RCSLT Competencies Project Sept 2003)

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Inter-Professional Dysphagia Framework -IDF
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Patient group example

• 1997 NMC (formally UKCC)
• 1998 RCSLT Dysphagia Policy Review Forum
  Report on the Issues of Management of the
  Dysphagic Patient
• 2000 IWP Clinical Guidelines for Stroke
• 2002 NSF for Older People
• (Standard 5 Stroke)
• 2004 IWP Clinical Guidelines for Stroke
• (2nd Edition)

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IDF Phases of development

• Phase 1 Review of literature
• Phase 2 20 semi-structured interviews
• Phase 3 Staff User Survey Instrument (SUSI)
• Phase 4 Developed draft SfH competences (NOS)
• Phase 5 Consultation Stage (76 charities, expert
  advisors)
• Phase 6 Modified competencies
• Phase 7 Developed IDF role descriptors
• Phase 8 Field Testing (competencies SfH/ IDF)
• Phase 9 Professional endorsement

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IDF Role Descriptors

• Awareness Aware of the presenting signs and
  symptoms of dysphagia
• Assistant Contributes to the
  implementation monitoring of dysphagia
  management plan
• Foundation Implements
  protocol-guided assessment and management
• Specialist Undertakes comprehensive
  assessment and management
• Consultant Undertakes expert assessment and
  management of complex or co-existing difficulties
  with a responsibility for policy development
  and/or consultative opinions

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• Role of the NQT
• Foundation-Specialist
• Role of the Nurse
• Awareness
• Assistant
• Foundation
• Specialist

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Screening tools

• Identify risk of aspiration
• Variable sensitivity correctly identify the
  dysphagia if present (0.86)
• Variable specificity correctly identify
  patients in whom dysphagia is not present
  (0.09)
• Need for formal swallow assessment
• Safety of oral intake

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3oz water swallow test

• 3oz water swallow test widely used to screen for
  dysphagia
• Teaspoons of water followed by 3oz (90cc) water
• Fail if coughing or wet voice during or within 1
  min post completion of test
• Patient maintained NBM with referral to SLT OR
  normal diet and fluids

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Clinical Utility of the 3oz Water Swallow Test
(Suiter DM and Leder SB Dysphagia in Press)

• 1.Does the 3oz water swallow test identify
  patients who aspirate on thin fluids?
• 2.Does a fail identify patients who are unsafe
  for oral intake (according to FEES)?
• 3.Does a passed test allow diet without further
  assessment?

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Methods

• 1. All patients required to swallow spontaneously
• 3 boluses puree
• 3 boluses liquid
• 2. After FEES drink 3oz water without interruption

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Results

• 1. Does the 3oz water swallow test identify
  patients who aspirate on thin fluids?
• 1,151/3,000 (38.4) passed
• 1,849/3,000 (61.6) failed
• When compared with FEES
• Sensitivity 96.5
• Specificity 48.7
• False positive 51.3

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2. Does a fail identify patients who are
unsafe for oral intake (according to FEES)?

• Of those 1,849 who failed
• 1,029/1,849 (55.7) thin liquids
• 254/ 1,849 (13.7) modified (thickened
  liquid)
• 565/1,849 (30.6) actually failed thin fluids
• 1,304/1,849 (70.5)- tolerated some type of
  diet

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3. Does the 3oz water swallow test predict
patients ability to tolerate food?

• Of the 1,151 who passed
• - 648/ 1,151 (56) - regular diet
• - 149/ 1,151 (13) - soft diet
• - 45/ 1,151 (4) - chopped diet
• - 289/ 1,151 (25) - puree diet
• - 3/ 1,151 (1.5) - liquid diet

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Bedside Swallow Screening Tool (BESST)

• Aim
• Devise a traffic light tool to offer a third
  management option of a modified diet such as
  thickened fluids and puree.
• This would allow the patient oral intake in the
  intervening period between referral and a more
  detailed assessment, avoiding unnecessary NBM.

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Methods

• Consecutive stroke patients admitted to an acute
  stroke unit in a large teaching hospital over a
  seven month period.
• A researcher obtained informed written consent,
  witnessed consent or, for those patients who were
  unable to consent, relative assent.
• All patients were considered for inclusion in the
  study. Patients were excluded if they were
  transferred to a rehabilitation unit or home
  prior to contact with the researcher.
• If a patient was included in the study, their
  usual clinical care was not affected.

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Methods

• Patient assessed on 2 consecutive days by 3
  raters
• Specialist SLT whose assessment was considered as
  the gold standard (GS)
• Nurse from the wards (N1)
• Research nurse (N2)
• No training offered to determine if instructions
  on how to use the tool were sufficient.
• Neither nurse had experience of patients with
  neurological problems raters were required to
  follow the BESST without drawing on previous
  experience.

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Methods

• BESST took 10mins to administer
• Contiguous but independent swallow screens took
  approx. 30 mins.
• Order of assessment randomized to minimise the
  effects of swallow fatigue.
• All raters were blind to each others ratings.

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BESST

• Pre-assessment
• Conscious level
• (unconscious stuporosed rousable alert)
• Trunk control
• (no trunk control supported upright has
  trunk control)
• Head control
• (no head control can be supported has head
  control)
• Voice quality
• (wet gargly voice normal voice)
• Voluntary cough reflex
• Patients who are at high risk of aspiration nil
  by mouth (NBM) and referred for a specialist
  dysphagia assessment.
• Patients who have a pre-admission history of
  recurrent chest infections referred for a
  specialist assessment

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BESST

• BESST
• 50mls water from an un-spouted beaker
• 100mls of water, thickened to a puree consistency
  (one 9g sachet to 80mls water) from a teaspoon.
• The sachets were used to
• Ensure consistency never varied on different days
  or between raters
• Avoid contamination of the thickener
• Clinical determinants of aspiration
• absent swallow
• cough/throat clearing
• wet voice
• weak up and forward movement of the larynx
  (determined by palpation)
• multiple swallows (more than three swallows per
  teaspoon of pureed water)
• wet breath sounds

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Results

• Day 1
• 83 agreement with N1 GS
• Kw0.63, CI0.48 to 0.78
• 76 agreement with N2 GS
• Kw0.50, CI0.36 to 0.64
• Inter-rater reliability
• 81 agreement with N1 N2
• Kw0.61, CI0.45 to 0.77
• We selected patients who were rated the same on
  both days by the GS (medically stable)
• Intra-rater reliability
• 87 agreement for N1
• Kw0.70, CI0.49 to 0.91
• 86 agreement for N2
• Kw0.71, CI0.51 to 0.91

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Results

• BESST indicated that
• 38/70 (54) patients placed NBM on the 3oz water
  swallow test could have had a modified diet
  rather than to be placed NBM.
• 35/38 (92) could safely have been placed on
  modified diet according to GS
• 3oz water swallow test used by nurses can be
  modified to allow nurses to manage patients with
  a third option of modified diet whilst awaiting
  more specialist assessment

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Conclusion

• In line with IDF framework
• Allows others to undertake specialist assessments
  and a comprehensive management strategy

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Ethics Legal Issues

• Professional Issues
• Job description
• Access support from more experienced clinicians
• Ethical Issues
• Decision making
• (General Medical Council 2002, NICE Guidelines
  eg. Dementia 2007, Palliative care, pain relief
  and care at the end of life)
• Legal ssues
• Consent
• Capacity
• Risk
• (Mental Capacity Act 2005)

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Summary

• Be aware of
• different professional frameworks
• local assessments used
• own role/those of others within each location
• ethical legal frameworks
• own limitations
• support how to access it
• ongoing training professional development CPD
  etc

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A comprehensive effective Health Service

• Demonstrate team working
• Transcend professional and organisational
  boundaries
• Flexible working
• Streamline workforce planning
• Ensure development that stems form the needs of
  patients not just professionals
• Maximise contribution of all staff to patient
  care, doing away with boundaries
• Modernise education and training
• Develop new more flexible careers for staff
• Expand workforce to meet future demands

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