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

Speech-Language Pathology Speech-Language Pathology and and

Dysphagia Nursing QUERIDysphagia Nursing QUERI

Paula A. Sullivan, MS, CCC-SLP, BRS-SPaula A. Sullivan, MS, CCC-SLP, BRS-SNorth Florida/South Georgia Veterans Health SystemNorth Florida/South Georgia Veterans Health System

Gainesville, FloridaGainesville, Florida

2006 OIG Report2006 OIG Report ““There is There is no nationalno national guidanceguidance…and… …and…

considerable variability in practiceconsiderable variability in practice.”.” We recommend…a work group of relevant We recommend…a work group of relevant

healthcare providers develop a healthcare providers develop a comprehensive policy that defines comprehensive policy that defines multidisciplinarymultidisciplinary responsibilities for responsibilities for assessment and management, with the assessment and management, with the goal of goal of improving coordinated medical improving coordinated medical care provided to patients with feeding care provided to patients with feeding and swallowing problemsand swallowing problems.”.”

SLP Involvement in Dysphagia SLP Involvement in Dysphagia DirectiveDirective

Documentation in CPRSDocumentation in CPRS Post feeding guidelines c/w JACHO and privacy guidelinesPost feeding guidelines c/w JACHO and privacy guidelines Follow national guidelines on clinical indicators for clinical Follow national guidelines on clinical indicators for clinical

and VFSS or other instrumental studiesand VFSS or other instrumental studies Follow-up with appropriate treatment and managementFollow-up with appropriate treatment and management Development of an appropriate, customized, patient and Development of an appropriate, customized, patient and

family centered POCfamily centered POC POC contains diagnosis, functional goals, measurable POC contains diagnosis, functional goals, measurable

treatment objectives, and the type, amount, duration, and treatment objectives, and the type, amount, duration, and frequency of servicesfrequency of services

Follow-up on appropriateness of long-standing diet orders Follow-up on appropriateness of long-standing diet orders and monitor effectivenessand monitor effectiveness

Aware of and thoroughly trained in their roleAware of and thoroughly trained in their role Clinical indicators and treatment guidelines located at: Clinical indicators and treatment guidelines located at:

http://vaww1.va.gov/audiospeech/http://vaww1.va.gov/audiospeech/

ASP Response to the ASP Response to the Dysphagia Directive Dysphagia Directive

ImplementationImplementation

Plans of ASP Field Advisory Committee Plans of ASP Field Advisory Committee (FAC): monitor and encourage (FAC): monitor and encourage compliance with the directive and to compliance with the directive and to facilitate development of a good facilitate development of a good dysphagia screendysphagia screen

FY09 National ASP Strategic Plan: FY09 National ASP Strategic Plan: ““Promote excellence in management of Promote excellence in management of patients with dysphagia by assisting the patients with dysphagia by assisting the field to implement VHA Directive 2006-field to implement VHA Directive 2006-032.”032.”

ControversiesControversies

Screen vs. assessmentScreen vs. assessment Who should do it?Who should do it? Evidence of risk factors and best Evidence of risk factors and best

practices for screeningpractices for screening

ASHA and ScreeningASHA and Screening ASHA’s Preferred Practice Pattern on ASHA’s Preferred Practice Pattern on

Swallowing Swallowing ScreeningScreening: : pass/fail procedurepass/fail procedure to identify to identify

individuals that require a comprehensive individuals that require a comprehensive assessment of swallowing function or assessment of swallowing function or referral for other professional and/or referral for other professional and/or medical services (ASHA, 2004)medical services (ASHA, 2004)

The screening should determine the risk The screening should determine the risk or likelihood that the individual has or likelihood that the individual has dysphagia or may be aspirating food or dysphagia or may be aspirating food or liquidliquid

Concerns of the SLP Working Concerns of the SLP Working Group with Nursing Acute Group with Nursing Acute

Care Dysphagia AssessmentCare Dysphagia AssessmentSilent AspirationSilent Aspiration

Water Swallow TestWater Swallow Test

3-oz water. Abnormal response = 3-oz water. Abnormal response = coughing during drinking or for 1 coughing during drinking or for 1 minute after or wet-hoarse vocal qualityminute after or wet-hoarse vocal quality

DePippo et al (1994) compared with DePippo et al (1994) compared with VFSS; water swallow identified 76% of VFSS; water swallow identified 76% of patients as aspirating who were patients as aspirating who were aspirating on VFSS (specificity) and aspirating on VFSS (specificity) and identified 59% of patients as not identified 59% of patients as not aspirating when they were not aspirating when they were not aspirating on VFSS (sensitivity)aspirating on VFSS (sensitivity)

Water Swallow TestWater Swallow Test

Garon et al (1995) tested 100 Garon et al (1995) tested 100 consecutive patients consecutive patients

Of 54 patients who aspirated, only Of 54 patients who aspirated, only 35% coughed at bedside using water 35% coughed at bedside using water swallow testswallow test

That is, 65% would be considered That is, 65% would be considered silent aspirators and would not be silent aspirators and would not be identified at bedside using the water identified at bedside using the water swallow testswallow test

Models for Swallow ScreeningModels for Swallow Screening

Model AModel A: SLP trains nursing staff to : SLP trains nursing staff to conduct screens. Fails assessed by SLP.conduct screens. Fails assessed by SLP.

Model BModel B:: Physician performs screen. Physician performs screen. Consults SLP if pt fails.Consults SLP if pt fails.

Model CModel C:: Model A or B followed by Model A or B followed by automatic referral (24-48 hours) for automatic referral (24-48 hours) for assessment by SLP by all patients assessment by SLP by all patients regardless of screening results.regardless of screening results.

Model DModel D:: All patients are automatically All patients are automatically referred to SLP for screen or assessment.referred to SLP for screen or assessment.

Does Dysphagia Screening Does Dysphagia Screening Work?Work?

What are the expected outcomes?What are the expected outcomes?--Correct identification of potential Correct identification of potential dysphagiadysphagia

-Correct implementation of precautions-Correct implementation of precautions

-Correct triage for further assessment-Correct triage for further assessment

-Appropriate intervention for dysphagia-Appropriate intervention for dysphagia

-Improved health status outcome-Improved health status outcome*Lower incidence of dysphagia related complications *Lower incidence of dysphagia related complications

such as AP, prolonged LOS, such as AP, prolonged LOS, death.death.

5 Kinds of Swallowing 5 Kinds of Swallowing OutcomesOutcomes

1. 1. RespiratoryRespiratory: to prevent “aspiration : to prevent “aspiration pneumonia” and other aspiration sequelaepneumonia” and other aspiration sequelae

2. 2. NutritionalNutritional: to prevent malnutrition and : to prevent malnutrition and dehydration associated with swallow inefficiency dehydration associated with swallow inefficiency and weaknessand weakness

3. 3. FinancialFinancial: to limit healthcare expenditure for : to limit healthcare expenditure for preventable consequences of dysphagiapreventable consequences of dysphagia

4. 4. PhysiologicPhysiologic: to restore normal swallowing : to restore normal swallowing physiologyphysiology

5. 5. Quality of LifeQuality of Life: to restore normal mealtime : to restore normal mealtime participation and enjoymentparticipation and enjoyment

What Does the Evidence Tell What Does the Evidence Tell Us About Screening Us About Screening

Procedures?Procedures? Literature focuses almost Literature focuses almost

exclusively on correct exclusively on correct identification of aspirationidentification of aspiration

Lack of evidence that any one Lack of evidence that any one screening (assessment) screening (assessment) procedure has good accuracy in procedure has good accuracy in detecting dysphagia detecting dysphagia (Martino, Pron, (Martino, Pron, & Diamant, 2000; Perry & Love, 2001)& Diamant, 2000; Perry & Love, 2001)

Problems with Current Problems with Current Screening ProceduresScreening Procedures

Cough does not necessarily indicate Cough does not necessarily indicate penetration or aspirationpenetration or aspiration

Cough does not necessarily indicate Cough does not necessarily indicate ejection of material from the airwayejection of material from the airway

Absence of cough does not Absence of cough does not necessarily rule out silent aspirationnecessarily rule out silent aspiration

Absence of cough Absence of cough does not rule out does not rule out other swallowing problemsother swallowing problems

Where are we with Where are we with ImplementationImplementation

of Dysphagia Assessmentof Dysphagia Assessment

VHA Directive 2006-032 became VHA Directive 2006-032 became effective 5/22/06effective 5/22/06

Inquiry to National VHASLP list serve Inquiry to National VHASLP list serve inquiry on 12/08/08 re: Nursing inquiry on 12/08/08 re: Nursing assessmentassessment-11/28 (39%) contain water swallow-11/28 (39%) contain water swallow

Where are we with Where are we with ImplementationImplementation

of Dysphagia Assessmentof Dysphagia Assessment What assessment is being used at your What assessment is being used at your

facility?facility? - Nursing shift assessment – 1- Nursing shift assessment – 1

- Combined risk factors and pt/family - Combined risk factors and pt/family report – 3report – 3

- No response or don’t know – 5No response or don’t know – 5- Original template – 6 Original template – 6 - Pt/family report – 6Pt/family report – 6- Risk factors/symptom inventory - 7Risk factors/symptom inventory - 7

Where are we with Where are we with ImplementationImplementation

of Dysphagia Assessmentof Dysphagia Assessment Comments:Comments:

- ““Our number of “bad” consults has been steadily Our number of “bad” consults has been steadily increasing and we need something better.”increasing and we need something better.”

- ““The false positive rate was about 90%.”The false positive rate was about 90%.”- ““Maybe there will be national agreement on best Maybe there will be national agreement on best

practice?”practice?”- ““They are waiting for the ‘new’ assessment to They are waiting for the ‘new’ assessment to

come out.”come out.”- ““Our nursing staff is uncomfortable with the Our nursing staff is uncomfortable with the

idea of doing a bedside water sip during their idea of doing a bedside water sip during their assessment.”assessment.”

Thoughts, Challenges and Thoughts, Challenges and OpportunitiesOpportunities

There are still many unanswered questions There are still many unanswered questions and much room for improvement in and much room for improvement in dysphagia screening/ assessmentdysphagia screening/ assessment

Given the magnitude of dysphagia, is it Given the magnitude of dysphagia, is it adequate to focus primarily on the adequate to focus primarily on the identification of aspiration?identification of aspiration?

VHA is a leader in dysphagia research and VHA is a leader in dysphagia research and guiding practice - VHA/DoD 2003 Clinical guiding practice - VHA/DoD 2003 Clinical Practice Guidelines for Management of Practice Guidelines for Management of Stroke endorsed by AHA/ASAStroke endorsed by AHA/ASA

Thoughts, Challenges and Thoughts, Challenges and OpportunitiesOpportunities

Opportunity for collaboration between Offices Opportunity for collaboration between Offices of Nursing and Audiology/Speech Pathology of Nursing and Audiology/Speech Pathology to identify best practices for screening and to to identify best practices for screening and to develop a good swallow screendevelop a good swallow screen

Who should perform the screen?Who should perform the screen? Develop a tool that will improve patient Develop a tool that will improve patient

outcomes outcomes “…“…with the goal of improving coordinated with the goal of improving coordinated

medical care provided to patients with medical care provided to patients with feeding and swallowing problems (OIG, feeding and swallowing problems (OIG, 2006).”2006).”