Enhancing Dysphagia Assessment & Management: A Comprehensive Policy Approach

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 nationalguidance…and… considerable variability in practice.” • We recommend…a 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 • ASHA’s 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 don’t 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).”