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9 December 2014

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 December 9, 2014
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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

 

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