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We’re afraid to admit when we’re wrong.

We’re afraid to admit that we don’t know everything.

And we’re afraid to admit that another direction might exist and be better.

Yes folks, this post is going to ruffle some feathers, but hopefully open some eyeballs. So get yourself some wine or whatever other self-soothing poison you pick, because it’s honesty hour.

“I don’t even send my patients for MBSS anymore because the reports are so poorly written, I can just see better at the bedside.”

“My administrator said no when I asked one time last year, so I just use my best judgement.”

“I’ve been practicing so long that my clinical skills are really sharp.”

Literally. Exact. Comments. Taken. From. Facebook.

No, you literally just can’t. You can not assess physiology and silent aspiration at the bedside. You really just cant.

(If you disagree with me, I’m terribly sorry but this is my post with plenty of published work to support. Please write your own post, with your own cited published work, if you beg to differ. Thank you.)

According to McCullough et al., (2003), “The Subcommittee on the CSE reported, based on over 150 articles that while data supported with some dissent, the use of CSE measures to detect aspiration post-stroke, no data existed to support the use of the CSE to evaluate any of the physiologic measures deemed necessary for complete examination of swallowing function.” 

So if you read that whole blurb, that’s 154 studies at the time of this report which was in 2003, which is almost 15 years ago.

That’s 154 studies over 15 years ago that found NO data to support using the CSE to evaluate swallowing physiology. Where have you been all these years?

With the advancement in technology, it is absolutely a no brainer that you should be using instrumental swallowing assessments to evaluate the physiology of swallowing disorders. (Limited access to imaging? We’ll get to that.)

So where does ASHA stand on this? Well why do we even care what ASHA says?

Well let’s back this truck up with Speech Pathology 101 and the ASHA Code of Ethics, and specifically: “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.”

Ok, so what are the Best Practice Guidelines?

Note: This section is taken directly from the “Clinical Indicators for Instrumental Assessment of Dysphagia” site. These guidelines are an official statement of the American Speech-Language-Hearing Association (ASHA):

A    An instrumental examination is indicated for making the diagnosis and/or planning effective management and treatment in patients with suspected, or who are at high risk for, oropharyngeal dysphagia based on the clinical examination when: 

• The patient’s signs and symptoms are inconsistent with findings on the clinical examination.
• There is a need to confirm a suspected medical diagnosis and/or assist in the determination of a differential medical diagnosis.
• Confirmation and/or differential diagnosis of the dysphagia is needed. 
• There is either nutritional or pulmonary compromise and a question of whether the oropharyngeal dysphagia is contributing to these conditions.
• The safety and efficiency of the swallow remains a concern.
• The patient is identified as a swallow rehabilitation candidate and specific information is needed to guide management and treatment.

    B    An instrumental examination may be indicated [*] for making the diagnosis and/or planning effective treatment in patients with suspected dysphagia based on the clinical examination and the presence of one or more of the following: 

• The patient has a medical condition or diagnosis associated with a high risk for dysphagia, including but not limited to neurologic, pulmonary or cardiopulmonary, gastrointestinal problems; immune system compromise; surgery and/or radiotherapy to the head and neck; and craniofacial abnormalities.
• The patient has a previously diagnosed dysphagia and a change in swallow function is suspected.
• The patient has a condition such as cognitive or communication deficits that preclude completion of a valid clinical examination.
•  The patient has a chronic degenerative disease or a disease with a known progression, or is in a stable or recovering condition for which oropharyngeal function may require further definition for management.

“Ok, so that’s what ASHA says, big deal, I don’t have my CCCS, I’m not bound by their code of ethics. I’ll just keep sticking with my trusty clinical swallow exam.”

Do you know how “trusty” your clinical skills are at the bedside?

They are so sharp that 70% of the time, you are over diagnosing your patients with dysphagia. (Leder, 2002)

At the bedside, without any sort of instrumental, 70% of the time you are using clinical signs and symptoms to create a diagnosis that doesn’t exist. Runny nose? Nope, not correlated. (Raphael, 1989) O2 stats? Nope, not correlated. (Wang, 2005) And what usually goes along with over diagnosing dysphagia? Overly restrictive diets and the excessive overuse of thickened liquids.

“Well who cares? It’s just a little cornstarch added to their drinks! It doesn’t really do anything different.” It does a lot, and can lead to dehydration and decreased quality of life. 

Let me explain, the thickener itself does not directly cause dehydration, however, according to Daniels and Huckabee (2014),  patients have a tendency to find thickened liquids not as palatable, therefore drinking much less than if it were a thin consistency.

Well what happens when you don’t drink enough fluids? The patient is at increased risk for dehydration, malnutrition, electrolyte imbalance, sepsis, and/or a UTI.

Ok, those are all no biggies, so whats the hype? Well the hype is that all 5 of those conditions equate for 78% of all 30 day re-hospitalizations. (Mor et. al, 2010)

Ok, I still don’t get it. Well each time a patient is re-hospitalized from a SNF within 30 days of their previous discharge, the SNF is responsible for footing the bill. So those 5 conditions can potentially cost a facility an extra $30,000. Each of those conditions have all been deemed as potentially avoidable with careful monitoring of and adherence to patient fluid and nutrient intake, and by following appropriate positioning of residents with swallowing difficulties to avoid aspiration that could potentially lead to pneumonia.

So maybe you’ll reconsider putting the gentleman that has recurrent UTI’s back on the honey thick liquids without an instrumental now? No? Still not convinced?

Do you know exactly how much thickener costs in your facility? (Pssst, the Dietary Manager might know!) As I joked above, no it’s not just cornstarch, although I have seen some facilities purchase buckets of cornstarch to keep costs down, but there are quite a few different companies now, and guess what? They charge a price!

The cost to keep 1 resident on thickened liquids for 1 year can cost a facility between $2,000-$7,000.

It really does not seem like “a huge deal” to downgrade someone to nectar thick liquids, but when you consider the cost for the entire year (because you may just discharge them on that consistency and never re-evaluate them again), and also consider the increased risk of various medical conditions that can turn in to a re-hospitalization, then getting an instrumental first just to be sure that they do in fact need the thickened liquids really is the way to go. Otherwise, you could be costing your facility more money in the long run, hurting your patient, not helping, and with a 70% chance that you are over-diagnosing at the bedside? That’s a pretty high likelihood.

(And as I’ve stated in the posts here, here, and here, I am by no means against thickened liquids. I’m all for using them as they are intended to be used, just not as a catch-all solution.)

Now, let’s not get started on the cost of PEG tubes.

The cost of managing a patient with a feeding tube, which for many has been the primary treatment option for dysphagia is reported to average over $31,000 per patient per year. (Hwang et al., 2014).

So if you think you’re hearing aspiration at the bedside and you recommend NPO with alternate means of nutrition and don’t think you need an instrumental to confirm that that is definitely the case, then again, you can be an extremely costly liability to that facility and harming that patient. In fact, in 2007, there were over 188,000 PEG tubes placed in patients, with over 70% of patients reporting serious complications. (Enteral Nutrition Policy, 2010) I wonder how many of them were ACTUALLY confirmed via instrumental?

So now not only are you soooo good at over-diagnosing dysphagia, you are also pretty consistently missing SILENT aspiration at the bedside as well, as in 14% of the time. (Leder, 2002) So 1.4 out of the 10 patients that you saw today are silently aspirating and you think life is rainbows and butterflies and instrumentals aren’t necessary.

Why should it matter if we miss silent aspiration? Well for starters, aspiration pneumonia is the leading cause of deaths in SNFs, and residents that are diagnosed with aspiration pneumonia have a mortality rate three times higher than the other residents. (Oh et al., 2004)

As we discussed above with the other 5 conditions, a re-hospitalization due to aspiration pneumonia costs about $30,000 as well.

In patient’s with tracheostomies, silent aspiration occurs in 75-92% of cases, (Dettlebach, 1985) and in acute stroke patients, silent aspiration occurs 50% of the time. (Horner, 1988) Still not seeing the need for instrumentals?

Those VFSS’s at the hospital for $1,500 or better yet a mobile study for just a few hundred bucks to visualize a resident’s swallowing physiology and make appropriate recommendations doesn’t sound too bad after all, now does it?

Ok, so now I know you want to throw your phone or computer against the wall and scream from the top of your lungs that I just don’t understand, and you don’t have access to instrumentation. Believe me, I hear it daily. But you also know by now that I don’t just rant without giving you actionable solutions. This first post is really to just get you thinking critically about how serious the results of your recommendations can be. If the patient has written directives and doesn’t want to go on a dysphagia wild goose chase, no problem, but if you have a patient that is expecting a fully rehabbed swallow, you MUST use best practice.

As I stated above this is JUST Part 1 of a 4 part series. In Part 2, we’ll dive in to the financials involved in swallow studies. If you haven’t noticed, we are building up quite a case for you to be able to present to your administration. In the handout (green box) at the top, all of the key points of the entire series are written out for you. (Spoiler Alert!) My goal for this series is to have you so well versed in WHY access to instrumentation is so important, understand HOW all of the payments work, WHO can help you advocate for the studies, and WHAT to say once you finally get the meeting with your administrator. Go get ’em tiger!

References:

American Speech-Language Hearing Association. Code of ethics [Ethics]. 2015.

American Speech-Language Hearing Association. Preferred practice patterns for the profession of speech-language pathology [Preferred Practice Patterns]. 2004.

American Speech-Language-Hearing Association. (2000). Clinical indicators for instrumental assessment of dysphagia [Guidelines]. Available from www.asha.org/policy.

Daniels, S. K., & Huckabee, M. L. (2008). Dysphagia following stroke. San Diego: Plural Pub. Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J.

Dettelbach, Mark A., et al. “Effect of the Passy‐Muir valve on aspiration in patients with tracheostomy.” Head & neck 17.4 (1995): 297-302.

Horner, J., & Massey, E. W. (1988). Silent aspiration following stroke. Neurology, 38(2), 317-319.

Hwang, D. et al “Feeding Tubes and Health Costs Post Insertion in Nursing Home Residents with Advanced Dementia. J Pain Symptom Manage. 2014 Jun; 47(6): 1116–1120.

Leder, S.B., Espinosa, M.S. Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia. 2002; 17:214-218.

McCullough, G. H., Castell, D., Leopold, N., McCulloch, T., Mann, G., Martino, R., & Massey, B. W. (2003, October). Clinical assessment of swallowing function. Paper presented at Dysphagia Research Society Annual Meeting, San Francisco, CA.

Mor, V., et al. “The Revolving Door of Rehospitalization from Skilled Nursing Facilities.” Health Aff (Millwood). 2010 ; 29(1): 57–64. doi:10.1377/hlthaff.2009.0629.

Oh E, Weintraub N, Dhanani S., Can we prevent aspiration pneumonia in the nursing home? J Am Med Dir Assoc. 2004 May-Jun;5(3):174-9.

Policy, Enteral Nutrition ASPEN Public. “Disease-related malnutrition and enteral nutrition therapy: A significant problem with a cost-effective solution.”Nutrition in Clinical Practice 25.5 (2010): 548-554.

Raphael G(1), Raphael MH, Kaliner M. (1989) Jan;83(1):110-5. Gustatory rhinitis: a syndrome of food-induced rhinnorea. J Allergy Clin Immunol.

Wang TG, Chang YC, Chen SY, Hsiao TY. Pulse oximetry does not reliably detect aspiration on videofluoroscopic swallowing study. Arch Phys Med Rehabil. 2005;86:730–4.

If this entire post is completely greek to you, or if you would just like some additional support while trying to stay afloat on dysphagia island, please consider joining us for the Medical SLP Collective. We provide brand new weekly resources in the form of handouts and videos, a panel of experts to answer ALL of your Medical SLP questions (anonymously, and not limited to dysphagia) and monthly webinars for ASHA CEUs.