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Dysphagia Professional Issues Research

December Research Tuesday

To Eat or Not to Eat: What Information do Clinicians Use in Recommending an Oral Diet?
I LOVE the holiday season.  I love the decorations, the spirit in the air, and spending time with friends and family.  And if you are at my house, that means food – lots of food.  Our family loves to cook and eat together, and I cannot imagine a time of year when it would be more difficult to not be able to eat. Making the recommendation for oral versus nonoral feeding is pretty much the most important decision we make as swallowing therapists.  There are very few things that more dramatically change a patient’s life than taking away their PO status.  We should not take these recommendations lightly.  With great power comes great responsibility, and we should constantly be assessing why we make certain decisions.  Back in 2008, Dr. Logemann and 24 colleagues investigated this topic – they wanted to know how and why clinicians make their oral or nonoral feeding recommendations – and luckily they published this information for us to use!
Logemann, J. A. et al. (2008). What information do clinicians use in recommending oral versus nonoral feeding on oropharyngeal dysphagia patient? Dysphagia, 23. (Full Text Here)
This study was comprised of two phases.  In the initial phase, a group of 23 experienced dysphagia clinicians identified the variables they might use in making NPO vs PO decisions.  Those variables were then rated by the clinicians to determine the most important of the identified variables.  The chart below describes the 13 most influential variables identified.
chart 12142
In the second phase of the investigation, 20 modified barium swallow studies with patient histories were sent to the SLPs for analysis.  For each patient, clinicians were asked whether they would recommend an oral diet, partially oral diet, or nonoral feeding.  They were then asked what diet consistency they would recommend if they gave a partially oral feeding, whether dental status affected their decision, and if they would recommend postures or maneuvers.
The decision for a full oral feeding was made 57% of the time, whereas the decision for limited oral comprised 15% of the recommendations and nonoral 26%. A Kappa statistic was used to determine the agreement between the clinicians.  A low Kappa statistic would signify low agreement between the clinicians whereas a high Kappa statistic would signify high agreement between the clinicians.  There was a statistically substantial Kappa statistic (meaning that the agreement was above chance happening) for the full oral decision (.72) and the nonoral decision (.66).  There was little agreement amongst the clinicians on the type of oral diet recommended. A lot of data was collected – see the full text to go through it.
The Results:
The four most influential variables for the PO versus NPO decision were
  1. amount of aspiration (by far the most frequently used variable – and a very subjective variable, as well – what is ‘a lot’ of aspiration?)
  2. frequency of aspiration
  3. diagnosis
  4. history of pneumonia (best agreement amongst the clinicians)
The most frequently recommended postures/maneuvers were
  1. effortful swallow
  2. head turn
  3. chin tuck
  4. super supraglottic swallow
  5. supraglottic swallow
  6. repeat swallow
Some thoughts:
While the frequency of recommendations for full oral feeding was the same amongst clinicians, the amount of experience was found to be an important factor in determining if limited oral feeding was allowed.  Those clinicians with fewer years of clinical experience were more conservative and recommended nonoral feeding more frequently than those with more experience.  They also recommended more maneuvers than the clinicians with more years of experience.
As I have grown in my career, I have become much more liberal with my diet recommendations and learned to trust my postures/maneuvers more.  In my earlier years I was so terrified to allow a patient to leave an evaluation without a strategy (or multiple strategies) to completely eliminate all aspiration.  While this is certainly an admirable goal, I now know so many other factors determine whether a patient actually gets pneumonia (like dependence on others for feeding/oral care, pulmonary status, etc – see my July Research Tuesday post on The Most Important Aspiration Pneumonia Article Ever for more details on this!).  I have witnessed many patients who aspirate buckets who never get pneumonia, and I have seen how well certain maneuvers/postures dramatically improve the swallow.  I don’t feel the need to have the patient use a supraglottic swallow with a head turn & chin tuck – especially if a head turn will suffice.  And how do I know all this?  I have seen it.  I have completed a MBS or FEES on the patient and determined the safest swallowing situation for them by visualizing them complete the strategy or swallow the consistency.
In our practice we have spoken with many younger clinicians who rely on bedside assessments because their facility will not allow them to get an instrumental and they are too afraid to rock the boat to demand one.  We see their patients with multiple strategies and limited diets based on the best “guess” the clinician could make from the bedside.  Is that really fair to the patient – to manipulate or forbid their mealtime  based off of a guess?  Know for sure – don’t let a bean counter take away your ability to properly determine a diet.
I really appreciate Dr. Logemann and colleagues for giving us this opportunity to glance into the radiology suites of 23 skilled clinicians.  We can learn so much from our colleagues.  I hope this article gives you new insights into your own clinical decision making, and don’t forget to share this information with some newbies!
Have a very happy holiday season from the SASS family!!

sass2sass

 

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons

 

Categories
Dysphagia FEES Professional Issues Research

October Research Tuesday

Ode to the Bean Counter: The Price of Dysphagia
In every medical facility there is always a bean counter, and in most, more than one.  They are the people who deny your ten thousandth request for a new Hausted chair for modified barium swallow studies because the old one “works just fine,” even when it doesn’t.  They are the folks who won’t purchase prethickened liquids because dietary can mix it up from powder, even though cups of glue keep showing up on patient trays.  And they are the ones who don’t understand why you need an instrumental exam to determine a patient’s diet status – no one has ever needed one before you came along.  So we, the ever faithful army of passionate dysphagia professionals, start collecting our own special data – we document the delayed or impossible studies, present facts about our patient’s hydration status and outline how the changes we are begging for will improve the quality of care we provide.  I’m not sure about you, but this kind of research was not covered in my graduate program…
Having been the one addressing the bean counters on many of occasions, I get waaay too excited when I find an article like this – one that speaks the bean counter’s language.  Dollars and cents!  Complex statistical analyses!  Facts and figures!  Historically speech pathologists haven’t spent a lot of time researching cost/benefit analyses and the impact on our services to hospitals, but in the last few months I have seen some promising studies coming out on this very topic (here’s looking at you, London Health Sciences Center in Ontario, Canada and the University of South Carolina).  With the changing landscape of healthcare and insurance, justification of our services will become even more crucial.  This article, which comes from our ENT colleagues at Mount Sinai School of Medicine and New York Eye & Ear, is just a small snapshot of the incidence and financial impact of dysphagia, but the information it provides could be invaluable to you the next time you have to email your bean counter.  Enjoy!
Altman KW, Yu GP, Schaefer SD. 2010. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Archives of Otolaryngology Head Neck Surgery 136(8):784-9. Full Text Here
This study looked at the National Hospital Discharge Survey (NHDS) data from 2005-2006 to identify the incidence of dysphagia and its most common comorbid medical diagnoses as well as to further quantify the length of stay, morbidity and mortality of dysphagia.
To obtain their data, the investigators searched for the dysphagia ICD-9 code (ICD-9-CM 787.2) in the first 7 diagnosis codes of each patient abstract from the 2005-2006 NHDS data (the NHDS lists the most important diagnoses first).  They then searched for dysphagia symptoms and other major accompanying disorders listed in the first 7 diagnoses.  There were 20 major diseases identified as most frequently occurring with dysphagia.  Using some very fancy software and complex statistical analysis, the authors found the mortality rates as well as the standard errors, confidence intervals and rate ratios of the disease and mortality rates among patients with and without dysphagia.
Findings:
During the years 2005-2006, there were over 77 million estimated hospital admissions and 271,983 of these were associated with dysphagia (.35% of all hospital admissions).  See the chart below for further details regarding rate of dysphagia by sex, age and race.

oct data

The authors note that the most significant findings from the demographic section of the investigation were that the percent of hospitalizations increase with age and that those with dysphagia older than 75 had twice the national average of hospital admissions than the average of all other groups.
When the authors looked at major diseases and symptoms associated with dysphagia, they noted that half of the admissions had at least one comorbid diagnosis of fluid & electrolyte disorder, disease of the esophagus, ischemic stroke, or aspiration pneumonia.  Those patients who had a diagnosis of dysphagia had an increased number of diagnoses at discharge compared to those without dysphagia – 88.9% vs 57.7% with 5 or more comorbid diagnoses, respectively.
The mortality rate of patients with dysphagia undergoing rehabilitation and those with coronary atherosclerosis was significantly elevated compared to those who did not have dysphagia.
The most notable (and bean-counter important) part of the study looked at the median number of hospital days for diseases associated with dysphagia compared to those not associated with dysphagia.  They found that the median number of hospitalization days for patients without dysphagia was 2.4 days compared to 4.04 days for those with dysphagia – that’s a 40.6% increase!!!!  Hospital stay was increased by 30% or more for patients with congestive heart failure, Parkinson disease and ischemic stroke and for patients with hemorrhagic stroke, the median hospital stay increased to 10.55 days.
To summarize their findings the author noted these three important take-aways:
  1. age older than 75 years was associated with double the risk of dysphagia associated with hospitalization
  2. the presence of dysphagia was associated with a 40% increase in length of hospital stay in all age groups
  3. patients undergoing rehabilitation had a greater than 13-fold increased risk of mortality during their hospitalization when they had dysphagia.
The aim of the study was to find statistically significant associations of variables.  The authors concede that cause and effect relationships cannot be determined from this type of data, but that important conclusions can be made.
The investigators then presented more data supporting the additional costs and the likely underestimated number of patients diagnosed with dysphagia. One of the figures was an established formula that was created to determine the actual increased cost for a one-day stay with community-acquired pneumonia.  The total daily cost was found to be $2,454 which they believe is less than the actual daily cost of a patient with dysphagia/aspiration pneumonia (alternative means of nutrition/hydration, additional diagnostic testing and more care from more providers would raise the price). They extrapolate the additional number of hospitalization days per year and the estimated additional cost per year of the extra days of hospitalization to yield an economic burden of approximately $547,307,964.
Whew.  That was a lot of math, but it is important math that helps us help the bean counters understand why we are fighting so hard to help people with dysphagia.
As a speech pathologist I most often enjoy looking at the little picture – helping the individual patient get better and eat.  While that is my mission and the joy of my heart, I must remember that the bean counter’s mission is to look at the big picture – to make sure that the hospital has enough money to stay open.  The authors conclude that the best ways to save money in dysphagia care are to identify the dysphagia early, especially in those patients with high-risk comorbid conditions such as old age, stroke, neurodegenerative disease, and pneumonia, and to provide proper intervention including evaluation, treatment and diet modification.  So, armed with all of your data, documentation, and published research, let’s work with those bean counters to get patients properly (and objectively) evaluated and treated to help improve both the big and little picture.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons

Categories
Dysphagia Professional Issues

June Research Tuesday

This month’s Research Tuesday is devoted to ethics in the provision of speech pathology services.  We encourage you all to check out Gray Matter Therapy’s article roundup on Thursday to gain insights in ethics from all areas of speech pathology – from neonates to geriatrics.

His Right to Aspirate
When I saw it happen, I gasped.  His arytenoids didn’t approximate, his larynx didn’t elevate, there was no tell-tale “white out” of the swallow, the liquid just splattered into his trachea, joining the eggs that were apparently still there from breakfast.  He was my first FEES exam to meet bailout criteria (silent aspiration on 2 trials thin, nectar and puree) and I knew the only option was to recommend alternative means of nutrition and hydration.  I sat down with him and his family to discuss my plan.  The only safe option was a feeding tube, I told him. He looked me straight in the eye, shook his head and said “absolutely not.”  It wasn’t an option for him.  I’m sure at the time I got really flustered.  I probably turned red.  I left the room and tattled on him to the doctor hoping she could talk him into it.  He never got a feeding tube.  He died a few weeks later, and I never heard if it was an advancement of his cancer or from pneumonia or from some other medical malady.  He died.  I was sad.  I knew I had handled the situation poorly, but I was new and arrogant and had to move on with my patient list.  If only I knew how many more times I would be put in that same situation, offering good advice based on the best resources available, to be met with an unemotional “no.”  Maybe I would have worked harder to learn how to handle those kinds of situations better, and maybe I could have made my patient’s experiences (and possibly last few weeks of life) a little better.
Kaizer, F.,  Spiridigliozzi, A.M., Hunt, M.R.  2012.  Promoting Shared Decision-Making in Rehabilitation: Development of a Framework for Situations When Patients with Dysphagia Refuse Diet Modification Recommended by the Treating Team.  Dysphagia.  27:81–87. (Full text here)
This article comes from Dysphagia Journal and documents the creation of a diet modification refusal protocol in a hospital in Quebec.  The full article can be accessed in the link above.  It is short and well worth the read.  Though this protocol may not suit your practice or your hospital, the framework behind it can be used for creating your own protocols.
The article begins with clarifications of the ethical terms of autonomy, informed consent & beneficence.  I have provided the authors’ paragraph on autonomy below.  If you do not read anything else in this blog post, read this (emphasis is mine).
“Autonomy is typically understood as an individual’s right and ability to make choices and practice self-determination [15]. Respect for autonomy also places a negative duty on others not to interfere in the exercise of an individual’s autonomy without compelling reasons for such interference. In health care, autonomy is closely linked to the doctrine and practice of informed consent. Informed consent is a process by which a competent patient, or the duly identified surrogate decision-maker for an incompetent patient, is provided with the opportunity to receive relevant information regarding a medical decision, ask questions, weigh options, and enact decisions that are consistent with their goals and values, and free from coercion. In a range of circumstances, respecting a competent patient’s informed refusal of an offered treatment is consistent with the principle of autonomy.”
The authors from the Jewish Rehabilitation Hospital (JRH) in Laval, Quebec developed an interdisciplinary dysphagia team to ensure proper management of patients with dysphagia.  During team meetings, it was determined that a protocol should be developed for patient refusal of diet recommendations, and an outline was created.  They had experienced the same rejections as I had, what a relief!  The outline is below.
protocol for refusal
I found it interesting that during the development process the group considered and then rejected the “quick fix” of having the patient or family sign a waiver when refusing a diet – something that has been attempted at hospitals in the past to help reduce liability.  I’m not saying that these waivers are right or wrong, but that they do not solve the problem.  With the waivers the focus is placed on the SLP/hospital, not on the patient.  It is easy to have the patient/family sign a form, discharge the patient from services, and never think about them again…until they come back, usually worse off than when you left them.  The truly difficult thing is to continue to maintain your unconditional positive regard for your patient and to provide excellent education and services, if permitted.  At SA Swallowing Services, this is called “care-planning.”  This includes a process like the one above, involving patient, family and staff.  Out of the care plan meeting comes a written document specifying the patient’s diet refusal and that everyone is aware and on the same page.  Also note that waivers may not actually hold up in court.
Numerous times in my career I have been asked to “talk” a patient into a particular diet or feeding tube.  These requests usually come from a concerned family member or caring doctor, but unfortunately I have had to remind these individuals that coercion and manipulation are not part of an effective clinical skill set.  Education and counseling are, but when a competent patient makes a decision to refuse treatment we offer to them, we must respect their decision.  Just because we do not like their choice does not mean that it is wrong.
At the 2014 Dysphagia Research Society Meeting, Dr. Paula Leslie presented a beautiful lecture on ethical considerations in dysphagia management.  One point she made that has really stuck with me was the concept of “eminence-based practice.”   This idea is common in medical professionals and occurs when a clinician tells the patient to ‘do it because I say so and because I know what is best for you.’  This patriarchal assumption that the clinician “knows best” is outdated and is not best practice.  We should be communicating with patients to best develop plans centered around the patient’s goals, not our own.
The concept of patient autonomy was a huge challenge for me as a new clinician, but I hope that as I have gained years of experience under my belt, I have become better at respecting my patient’s right to make their own choices.  I have found that the burn of refusal never really goes away, but my reverence for my patients has grown, as has my realization that my clinical practice is not about me.  Its about them.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out sasspllc.com or connect with Kelley on Twitter or LinkedIn.

(Image courtesy of Stuart Miles / FreeDigitalPhotos.net)

Categories
Professional Issues

Tennessee Professional Privilege Tax

Tennessee Professional Privilege Tax
What would you do with an additional $400 a month? Pay off student loans? Pay off your car? Start saving to buy a house or put your kids through college?
Well, as an SLP or AuD in the state of Tennessee, you get to take $400 every year and pay it as a tax to the state government as a “privilege” to practice here. You heard me right. Some of us are paying 1% of our total (sometimes household) income for the privilege to practice in the state of Tennessee. That is on top of our annual state licensure renewal fees ($80), ASHA dues ($225) and, if we so choose, membership fees for the Tennessee Association of Audiologists and Speech-Language Pathologists (TAASLP – $85). That’s almost $1,000 a year just to call ourselves a licensed SLP or AuD in the state, and with our median income at around $57,700, we think this is a hardship that we can no longer bear.
 TAASLP has a wonderful summary of the tax here, but I will summarize the good stuff for you.
-What was the initial purpose of the tax? The tax was enacted in 1998 instead of an income tax and instead of having professionals collect taxes on the services they rendered.
-Who pays this tax? The tax is paid by a variety of professionals such as lawyers, doctors, dentists, engineers, architects, optometrists, veterinarians, and even professional athletes.
-Who doesn’t pay this tax? (This is where my jaw dropped – prepare your heart) Physical therapists, occupational therapists, nurses, dietitians, respiratory therapists.
The tax isn’t scaled based upon how much money you make or how much service you render – if you have a license, you have to pay. For our new graduates and those who work in schools, this is an especially big burden. And with most of us heavily in debt from earning our degrees for the right to practice, adding this extra cost of maintenance is just salt in our wound.
So what do we do? We do what we were trained to do – we talk! And listen! And argue our point with those who care about what we think – the politicians WE ELECTED to represent us. On March 15, 2014 TAASLP and passionate SLPs & AuDs across the state joined together for a “Day on the Hill” to talk to our leaders about why we think this tax is an undue burden…and it made a difference!  So join us in contacting your representatives on the Hill and join TAASLP to help communicate our needs.