“Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes”

If you are considering joining or starting a head and neck cancer program, this is the read for you!

I was searching through articles this morning and found this very article stating the importance of a team approach and a systematic approach to head and neck cancer!

“Head and neck cancer guidelines recommend multidisciplinary team monitoring and early intervention.”

Prophylactic treatment for head and neck cancer has been found to increase maintenance of tongue muscle mass, preserve some taste and have an overall improved swallow.   The SLP should be right in there, from the beginning to determine baseline swallowing function and to provide education for what may happen to the swallow.

“We need patient care using a systematic approach for head and neck cancer.”

Read the research.  Keep up with the new approaches and utilize them in  your therapy.  Dysphagia assessment and treatment approaches are ever-evolving and you have to stay current to provide your patients with the best care possible.

With the multidisciplinary Approach:

  • Improved outcomes
  • Better survival rates
  • Maximize results through use of a coordinated pathway
  • Increase efficiency in care delivery
  • Reduce cost
  • Shorten the length of the hospital stay
  • Improve overall patient outcomes

Who should/may be on the multidisciplinary team:

  • Head and Neck Surgeon
  • Medical Oncologist
  • Radiation Oncologist
  • Nursing
  • Speech Language Pathologist
  • Dietician
  • Social Worker
  • Administrative Professionals (Systems Analyst, Clinical Research Coordinator)

“A significant impact of Head and Neck Cancer is typically the impact on swallowing and inadequate nutritional intake.”

The SLP plays a vital role in the assessment and treatment of swallowing.

“Prophylactic and ongoing Speech Language Pathology services can be vital by impacting swallow function, nutritional status and overall quality of life.”

We’re not just one and done.  Even though the patient may not initially have difficulty with swallowing early in their treatment doesn’t mean it will never happen.   You need to check up on the patients throughout their course of treatment and even after their treatment to continue to assess the impact on swallowing.

Collecting Data:

Patients undergo a pre-treatment MBSS (Modified Barium Swallow Study) and/or FEES (Flexible Endoscopic Evaluation of Swallowing).  Also completed with patients:

Prophylactic Exercises Included:

  • Lingual strengthening
  • Masako Maneuver
  • Effortful or Supraglottic Swallow
  • Mendelsohn Maneuver
  • Shaker
  • Therabite (incisal opening less than 40mm)
  • EMST (increase airway clearance/protection)

*Exercises completed 2x/day, 6 days/week

References:

Dance Head and Neck Clinical Pathway (D-HNCP)

Messing, B. P., Ward, E. C., Lazarus, C., Ryniak, K., Kim, M., Silinonte, J., … & Sobel, R. (2019). Establishing a multidisciplinary head and neck clinical pathway: An implementation evaluation and audit of dysphagia-related services and outcomes. Dysphagia34(1), 89-104.

 

The Medical SLP

The Patient

Being a medical Speech Language Pathologist (SLP) is quite different than working in a school.   Most people know that an SLP working with children often work on sounds that are produced in an incorrect manner or language skills.  The SLP may also help with reading and reading comprehension.

 

Did you know that an SLP can also work on social skills with students who have difficulty with appropriate interactions with others?

 

An SLP may work in a pediatric hospital and work with babies and children who have swallowing difficulties.   Many babies in the NICU require SLP services to learn to eat or suck using a bottle or even with breastfeeding.

 

As a medical SLP, I really believe the most common phrase I hear is…..”I don’t need speech therapy.  I talk just fine.”  Seriously, if I had a penny for every time I heard that, I could retire in style.

 

Our name is very misleading and barely touches on the wide array of deficits the SLP can rehabilitate.  Many SLPs have speech and language in their title, but never work with either.

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3 Reasons You Should Never “Fake it Till You Make it” in Dysphagia

I really don’t know where the phrase “fake it till you make it” came but it’s one phrase that absolutely makes me cringe in relationship to dysphagia.

Don’t get me wrong.  You should always go in confident in your skills.  How can you possibly be confident though in skills you don’t possess?

The scary part is, with dysphagia, if we don’t know what we are doing, but go in to diagnose and treat on the “fake it till you make it approach” we can play a key role in the person’s death.

Not necessarily that the person even chokes on something.  When we change a patient’s liquids and thicken the liquids, the person can then experience dehydration, sepsis, UTI or a multitude of other effects.

So let’s get to it.  The THREE reasons why you should never fake it till you make it in dysphagia therapy.

Reason One

It’s actually against our code of ethics provided by ASHA.

“Individuals shall not misrepresent their credentials, competence, education, training, experience, and scholarly contributions.”

When we “fake it” we are actually telling patients that we are competent in an area that we may not have a clue and misleading that patient.   Ideally, we should help that patient find a competent clinician if you do not feel that you fit that bill.

Reason Two

How can you assess and diagnose what you don’t know?

Yes, we diagnose dysphagia.  This is the reason we are Speech Language Pathologists in the US.  We are able to diagnose a range of speech and swallowing related disorders.

If you don’t understand the normal swallowing process and know the deficits, how can you possibly diagnose dysphagia?  Did you know that when a diagnose is given to a patient, that diagnosis stays with the person.

Misdiagnosis often leads to inappropriate diet changes, unnecessary therapy services and possibly secondary issues that can arise from those inappropriate diet changes.

I mean, do you really know any person that has been excited about having thickened liquids?  Have you ever had a patient comment on the amazing taste of thickened liquids?

What if you are the person responsible for the Modified Barium Swallow Study (MBSS) or Flexible Endoscopic Evaluation of Swallowing (FEES)?  Do you know how to complete the test or interpret the test.  If the answer is no, then you’ve just wasted, money, time and effort.  Accurate completion and reporting of either of these assessments is vital in diagnosing, referring or providing treatment for dysphagia.

Reason Three

Just like you can’t assess and diagnose dysphagia, how can you possibly treat dysphagia when you don’t understand it.

I mean sure, you can throw a list of exercises at a patient, you can modify the diet, but what are you doing for the patient?   What are you actually accomplishing with this patient?

This patient is relying on you to be the expert, to be honest with them and to help them with an issue that is a major roadblock in their recovery.

What can you do?

Don’t turn to social media the night before an evaluation or treatment session knowing nothing about the disease process, the assessment or the treatment protocols.

If you are interested in dysphagia but don’t feel comfortable or confident in dysphagia, find a mentor, read journal articles, shadow, read textbooks.  Learn everything you possibly can about dysphagia.

Be honest with your patient.  I am terrible with fluency.  If I have a referral for a patient with dysfluency, I will more than likely refer them out to an SLP with more experience.  It’s the right thing to do.

Hold paramount your patient’s best interest and never, ever “fake it till you make it.”

  • Tanner, D. C. (2010). Lessons from nursing home dysphagia malpractice litigation. Journal of gerontological nursing36(3), 41-46.
  • American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists performing videofluoroscopic swallowing studies.
  • American Speech-Language-Hearing Association. (2002). Knowledge and skills needed by speech-language pathologists providing services to individuals with swallowing and/or feeding disorders.
  • Boaden, E., Davies, S., Storey, L., & Watkins, C. (2006). Inter professional dysphagia framework. University of Central Lancashire, Preston.
  • McAllister, L., & Rose, M. (2000). Speech-language pathology students: Learning clinical reasoning. Clinical reasoning in the health professions, 205-213.
  • Kamal, R. M., Ward, E., & Cornwell, P. (2012). Dysphagia training for speech-language pathologists: Implications for clinical practice. International journal of speech-language pathology14(6), 569-576.
  • ASHA Code of Ethics www.asha.org

Be the Change

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Let’s face it, we’re not all leaders. Some of us are happy going to our jobs and just done at the end of the shift. Many of us tend to get on social media and complain about issues that we feel are out of our control.

The problem is that just voicing our concerns on social media does not solve the problems. We have to look beyond ASHA and our boss to make these changes.  Now don’t get me wrong, ASHA, management, your state association can be a great start.

You might be asking what are some of these gripes and complaints. Productivity is the big one. We are often asked to work billable time for the majority of our day not allowing us any break for consultation or paperwork that is required of us.  How many of us go in to work,  clock out to maintain our productivity while completing paperwork, making phone calls or some of the necessary but not billable time possible while maintaining 90% productivity or more.   Maybe the reason the productivity expectations exist and the reason that it keeps getting higher is because people are actually meeting these standards. When we give 100% the next expectation will be 110%.

So maybe we can sit and stew about the fact that I’m working on my own time or maybe I can join my state association or ASHA and help bring about change to that productivity.

Another frequent complaint is the lack of instrumental assessment.  Some facilities will not allow instrumental assessment,  however have you presented the cost associated with an pneumonia or with any re-hospitalization compared to the cost of an instrumental assessment?  How can you possibly build an accurate plan of care for your patient when you can’t assess your patient?

When we actually think outside the box that’s when we can get things done.

Continue to educated yourself.  Stop being so complacent with your job.  Stop using non-evidenced based practice and the same oral motor exercises that have been used for 25 years.  Keep up with new practices.  Be a champion and advocate for yourself and for the profession you hopefully love.

When you start standing up for yourself and demonstrating efficiency and competence in your job is when we can show other medical professionals the value in the Speech Language Pathologist in the area of dysphagia.

Stop just posting to gripe on social media and make a change!!

Why Won’t They Do What I Say??

I mean, let’s face it.  When we go through all that work of assessing a patient and making these phenomenal recommendations, we get a little testy when they are not followed by the patient, nursing staff or family.

Do we ever ask WHY these recommendations are not being followed?

Let’s face it.  We really don’t need a comprehensive study to determine that thickened liquids are not as tasty as regular liquids and pureed hot dogs just don’t cut it at a baseball game.

Colodny in 2005 found that 40% of patients with dysphagia that are capable of independent feeding choose to NOT follow the recommendations of the SLP.

Why would that even be a question?

Think about these factors:

  • Fear
  • Denial
  • Loss of independence
  • Loss of pleasure
  • Depression
  • Family pressure
  • Financial concerns
  • Lack of information
  • Religious/spiritual belief
  • Previous experience

These factors were all found to contribute to non-compliance.  How many patients or family members have ever said to you…..”I never knew that swallowing could be affected.”

There is such a lack of understanding of dysphagia, among the medical field, patients and lay people.

How do we bridge this gap?

Seriously, nursing staff should be compliant with my recommendations, right?

Not always.  And why would that be?

Another study by Colodny in 2001 looked at why nursing staff does not follow SLP recommendations.  Barriers to following recommendations:

  • Hassle
  • Knowledge
  • Disagreement

Nursing staff found that it was a hassle and time consuming to thicken liquids and to prepare food to meet patient needs.  They maybe lacked knowledge of feeding techniques, why the recommendations were made or even WHO needs to have the diet modifications.  Nursing staff also may disagree with our recommendations.  They may see Patient Joe that is chugging away at a glass of water.  He never coughs.  Nope, he’s a silent aspirator.  He won’t cough.   The problem is, the nurse doesn’t see any overt clinical symptoms that are expected with aspiration.

So, don’t go getting mad at your patients, families or staff.  Maybe they just don’t understand.  It’s amazing what a little education can do to bridge the gap.  Now, this isn’t always the case, but it’s always worth the effort.

  • Colodny, N. (2001). Construction and validation of the mealtime and dysphagia questionnaire: An instrument designed to assess nursing staff reasons for noncompliance with SLP dysphagia and feeding recommendations. Dysphagia16(4), 263-271.
  • Colodny, N. (2005). Dysphagic independent feeders’ justifications for noncompliance with recommendations by a speech-language pathologist. American Journal of Speech-Language Pathology14(1), 61-70.
  • King, J. M., & Ligman, K. (2011). Patient noncompliance with swallowing recommendations: reports from speech-language pathologists. Contemporary Issues in Communication Science and Disorders38, 53.
  • Morris, L. S., & Schulz, R. M. (1992). Patient compliance—an overview. Journal of clinical pharmacy and therapeutics17(5), 283-295.
  • Ekberg, O., Hamdy, S., Woisard, V., Wuttge–Hannig, A., & Ortega, P. (2002). Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia17(2), 139-146.

My Top Five Continuing Education Courses in Dysphagia


We all have to do it.  Some of us love it more than others.  Continuing Education.  Since six years of school just wasn’t enough!

I have been through A LOT of continuing education courses.  I’m sure you’re thinking, yea, so have I.  I really honestly do take a lot of courses.  In fact, I’m working on my 12th ACE award.

I will definitely say that I’ve enjoyed some courses and thoroughly detested some courses.  I have walked out of courses, vowed to never listen to certain speakers again and also vowed to see people any opportunity I have.

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We Can’t Treat What We Don’t Know

Call it what you like, a bedside swallowing evaluation, a bedside swallow, a clinical swallow evaluation. No matter what you call it it’s never the same. At a recent ASHA convention there was a session by Leder, Coyle and McCullough which addressed the clinical swallow evaluation versus instrumental evaluation. Dr. Coyle stated that the bedside evaluation is merely a series of pass and fail screens. You can visit many facilities whether they be hospital skilled nursing acute rehab or home health and rarely will you see two SLP’s complete the clinical bedside evaluation the same.

McCullough also has an interesting article on the ASHA website with various resources titles To See or Not to See.

There are always various views.

“A Modified Barium Swallow Study is just a moment in time.”

“I can assess a patient without an instrumental using palpation, observation and clinical judgment.”

“You can’t accurately assess a patient without doing an instrumental.”

One of the main problems with all of our assessments are they are not standardized, whether it’s a Clinical Exam or Instrumental.

The work of Bonnie Martin Harris has started the standardization process for the Modified Barium Swallow Study through the MBSImP (Modified Barium Swallow Impairment Profile), however not everyone has to take this course to complete the MBSS. Not only does the MBSImP have an aim to standardize the MBSS, it also addresses identifying and reporting functional deficits or physiological impairments rather than commenting on what happens with every consistency.  The goal of the MBSImP is to find impairment through trials of a set of consistencies rather than to identify every consistency which is difficult for the patient.  Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia, 23(4), 392-405.

FEES has had tools to help standardize interpretation, including interpretation of the residue amount through the Yale Pharyngeal Residue Scale.   There are numerous courses available to teach the anatomy and physiology of the pharynx as viewed through the endoscope.

The American Speech Language and Hearing Association (ASHA) has given us guidelines for “best practice”.   Within the ASHA Rules of Ethics, it states:  “Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.”

ASHA provides us with guidelines for SLPs performing MBSS which you can find here.   There are also guidelines for those performing FEES which you can find here.

So why do we need instrumentation?  What’s the big deal?

There are many areas that we can and cannot view with a Clinical Dysphagia Examination.

You can’t see the epiglottis.  In fact, you can’t see anything in the pharynx.  It’s always difficult to assess movement and physiology of an area you can’t see.  I recently had a patient for an MBSS that told me that during the Clinical Evaluation they were told that their epiglottis is not moving.  During the MBSS, the epiglottis moved just as it should.  You can’t just assume by a symptom such as coughing that it is an airway protection deficit.

You can’t assess bolus flow.  If you have attended the Critical Thinking in Dysphagia Management course you know that assessment is broken down in 2 main areas.  Bolus flow and Airway Protection.  If you haven’t yet attended the CTDM course, it is highly suggested you do!  There is even an online version.   The point is though, once the mouth is closed, you just can’t see where the food or drink is going and how it reaches it’s final destination.

You can’t assess airway protection.  Have you ever assessed a patient at bedside and after palpation of the larynx feel pretty confident that the larynx is moving?  Then you start trying to figure out why the patient has a wet cough later in the day.  You take the patient downstairs for a swallow study and low and behold, there is no laryngeal elevation.  What you felt was the tongue moving trying to initiate a swallow.  Go ahead, put your fingers on your larynx and move your tongue.  What do you feel?

Compensatory Strategies.  My friends Theresa wrote a blog post about compensatory strategies that is definitely worth a look.  How do we know for sure that a compensatory strategy is effective or that the patient is actually able to do the strategy in the correct way?  You might remember a post I wrote earlier about the chin tuck.   There was also a great post on SwallowStudy.com about the chin tuck.


Remember that by not providing our patients with best practice in assessment we may be putting them at higher risk for:

  • dehydration
  • aspiration pneumonia
  • malnutrition
  • increased length of stay
  • re-admission

Our patients deserve the best.  instrumentals aren’t always necessary for all, but they do answer many questions beyond did the person aspirate.