Picture from: http://www.autismafter16.com/article/01-18-2013/always-advocating
If you are on Facebook in any of the SLP medical-based groups, you know the word of everyday is advocacy. There are too many stories of Speech Language Pathologists not able to get instrumental examinations for their patients with dysphagia because of the cost. People are losing their jobs for not maintaining 90% productivity. People are losing their jobs because of PDPM or PDGM. SLPs are burnt out because they always get the closet office or are the last discipline to get supplies and often those include a mirror and some tongue depressors.
We all talk about advocating for the needs of our patients. At the end of the day, the patient is the one who is not receiving the service they were promised. At the end of the day it’s the patient’s life that we’re playing with. However, what can you do for the patient if you’re not advocating for yourself or for our profession?
“You’re just speech.”
How many times have you been in a facility and heard “Oh, you’re just speech.” I have. Yes, I’m the Speech Pathologist. Yes, I have a very important job of determining if there is a diagnosis of dysphagia and what is causing the dysphagia, rehabilitating the patient’s swallow to make them safe with the consistency they desire, setting up a cognitive program so that person can function as independently as possible, making sure oral care is complete and appropriate to reduce the risk of pneumonia. Just because I’m not the person that is going to come in and put your patient back into the bed doesn’t mean my job is not important.
Advocating for Instrumental Assessment
It is true. We do need to advocate for instrumental assessment. Otherwise it’s a guessing game. At ASHA 2015, there was a great session on instrumental assessment vs. bedside assessment by Coyle, Leder and McCaullaugh. One of my take-away messages: “Once the mouth is closed, everything is inferred.” “The clinical bedside exam is a series of pass-fail screens.” “We need more than a cough to determine that a patient might aspirate.” “No part of bolus flow or the pharyngeal phase can be assessed without instrumentation.”
I wish that every professional with which I work could have attended this course. I feel like 80% of my job in the acute care hospital is education. I take many opportunities to educate staff that I, in fact, cannot determine if the patient is aspirating or has aspiration pneumonia during a clinical assessment. I may have a good idea that they are, but there is no way to say for sure.
Too many people state that instrumental assessment is not available or that the building “won’t allow it.” It’s time to change that narrative. Change your approach. Become a researcher and show how much money the facility is spending on hospital readmission, on thickened liquids, on O2 equipment for patients with repeated pneumonia. Change the way you ask. Research Mobile FEES or Mobile MBSS. THEY COME TO YOU!
Educate staff that a chin tuck, may indeed be the contributing factor to aspiration and may not help the patient after all. Instrumentation is required to determine if the chin tuck may or may not be an appropriate strategy for the patient. The same can be said with a head turn, Mendelsohn Maneuver or an Effortful Swallow.
Educate staff that the gag reflex is NOT present in every person and that it is not a reliable predictor of the ability or inability to swallow. Yes, this is still utilized as a determining factor in swallowing in some places.
The Equipment is Just Sitting There Collecting Dust
Sometimes we advocate just for the use of instrumentation. My friend Shareka lives in Barbados. She had the equipment available for a modified barium swallow study, however she had to advocate to use it and FINALLY was able to complete her first MBSS.
Here in the United States many of us advocate for FEES assessments with and without success. We have to prove outcomes, cost effectiveness, etc while sometimes our therapy counterparts are able to purchase large equipment without the same hassle.
We have to stand up at some point and let other medical professionals know that what we do matters. We’re not “just the speech therapist” and that we’re more than a few service-based codes. This will not change if we all sit back and hope ASHA or our state organizations do this for us.
Do you need some inspiration in advocating for instrumental assessment? This post was put together by Vince Clark and Kate Krival and approved by members of the Dysphagia Therapy Group Advisory Board.
“Often SLPs comment on this page about how testing (both Modified Barium Swallow Studies – MBSS and Flexible Endoscopic Examination of Swallowing – FEES) is openly discouraged or “not permitted” by administration. While this occurs in all settings, it seems that skilled nursing facilities tend to be the setting where this occurs most often. The topic comes up so frequently that the admins on this board feel we need to address it. It is worrying that this trend seems to be so prevalent throughout our work environments and it is particularly troubling when it is discussed here that the leadership often encouraging “no testing” or making inaccurate claims about what ASHA considers “best practices” are SLPs themselves. In order to give those in the field easy access to ASHA policies and guidelines, we present the following statement and resources.
Speech-language pathologists (SLPs) practicing in all the United States settings are obliged to follow American Speech-Language-Hearing Association (ASHA) guidelines for best practice . SLPs are mandated to perform all clinical tasks competently , which requires them to develop and maintain the knowledge and skills consistent with prevailing scientific information regarding clinical practice. Best practice for SLPs engaged in the diagnosis and determination of management approaches for adults with oropharyngeal dysphagia requires consideration of both clinical and instrumental examinations where needed [2, 3]. The American Speech Language Hearing Association (ASHA)  recommends that clinical evaluation of patients presenting with probable swallowing difficulty include an interview, medical chart review, observation of eating and drinking, and oral mechanism examination . Instrumental visualization should be added to the clinical exam in order to identify anatomical and physiological aspects of swallowing that cannot otherwise be discerned .
1. American Speech-Language Hearing Association. Code of ethics [Ethics]. 2015.
2.Splaingard, M.L., et al., Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil, 1988. 69(8): p. 637-40.
3. American Speech-Language Hearing Association. Preferred practice patterns for the profession of speech-language pathology [Preferred Practice Patterns]. 2004.
While all patients are not appropriate for testing, the vast majority of them are appropriate for testing. Consider what you are doing when you recommend diets, compensatory strategies, exercises or maneuvers WITHOUT testing. Evidence based practice would indicate that we are most likely doing inappropriate things and ultimately causing harm when we treat without the use of MBSS or FEES.
Best of luck as we all try to change the system in a positive manner.
Sincerely, The Admins of The Dysphagia Therapy Professional Page”
May begins Better Hearing and Speech Month. Although most of the pre-made promotional materials cover communication and are aimed at pediatrics, we can still take the month and plan some educational activities at our facilities. Some ideas?
- 1.) Pass out educational material on dysphagia and what we as SLPs do to help. Make sure there is evidence to support us.
- 2.) Create a quiz for others to complete with a gift card as a prize. Even a $5 gift card is worth the effort!
- 3.) Plan a 5-10 minute in-service for staff to let them know what we do and why we do it.
- 4.) Work with companies to host a luncheon and invite your patients with dysphagia. Success stories are always a great boost. (I did this with my VitalStim representative.) Invite your rehab managers or any of the top-dogs at your company.
- 5.) Create a bulletin board to stay up for the entire month.
- 6.) Write a story for your local newspaper.
Do you have any other ideas? Get out and let people know what we do and why we matter!!! We are more than “just the speech person!!”