If you missed the first two parts, make sure to go back and read them. They explain all about the costs (or more like no costs) and the clinical reasons for why we need instrumental evaluations. In this third and final post in the series, I will explain how to show the value of these evaluations for your facility and your patients. 

So when I look back and think about the positive outcomes for some of my patients who I have either sent out for an instrumental examination or performed the FEES myself, I would say that generally there were good outcomes. I can’t really think of a time where there was a negative from an instrumental evaluation. I can think of specific patients, usually those who can lose their feeding tubes as a result but that’s about it. Off the top of my head, I am not able to give a good objective look at the benefits. That’s why I keep track of ratings, scales, and numbers to show a clear picture of the changes and benefits. I would encourage you to do the same! I find that when you can present an organized report of the impact of instrumental swallow studies, it really gets the whole team to start to advocate for them. At one facility I used to work at, whenever a patient came to us on a modified diet or thickened liquids, nursing would automatically ask when I wanted to schedule the MBSS or FEES! (It was amazing!)

So what do I use? First, I think the Functional Oral Intake Scale (FOIS) is a great tool. Developed by Dr. Crary and Dr. Carnaby-Mann (2005), this scale is very quick to complete (literally seconds) and shows a clear idea of change. This scale assigns a number from 1-7 based on the type of oral intake. A 7 would be no restrictions, 1 would be only non-oral nutrition, and the rest fall in-between. So for example, let’s take a patient that has a feeding tube for nutrition and hydration. This patient will sometimes have water or ice chips and would be at a FOIS level 2. A FEES is completed and thin liquids and regular solids are recommended. This patient would now be at a FOIS level 7. It is easy to understand that moving from a 2 to a 7 is a great improvement, even if you have no idea what the numbers mean. Check out the scale here. 

The next scale to implement is the MASA or Mann Assessment of Swallow Ability. Developed in 2002, this scale looks at 24 items related to swallowing ability and assigns a numerical score for each item. The cumulative score gives an idea of the severity and level of risk for each patient. This is great to use in your initial evaluation and then in subsequent sessions to show progress. This scale can seem somewhat intimidating at first, but once you learn what the items are, it can be completed very quickly. There is even an app for it! This is another great way to show numbers to nursing and administration. 

I think it is important to get an idea from the patient’s point of view as well. I like to use the EAT-10. This is a 10 question scale where a patient rates different aspects of swallowing and eating on a  scale from “No Problem” to “Severe Problem.” Each rating has a number associated with it and the cumulative score gives an idea of how severe the patient feels that their swallowing problem is and how it is impacting their quality of life. Check out a pdf version  here or an online version here. 

The last rating scale that I use on a regular basis is the Dysphagia Outcome and Severity Scale or DOSS. This is a rating system that provides a scale from 1-7 that rates the severity of a patient’s swallow. There is specific criteria for each level and also provides a qualitative rating from “Within Normal Limits” to “Mild” to “Severe.” I use this scale in all of my FEES reports because then I know when I say that someone has “moderate dysphagia” it is a consistent rating not based on my own opinion. This allows for quick and easy comparison from one evaluation to the next. Check out an open access pdf of the article and scale here.

I recommend keeping a running spreadsheet to organize all of the data. You do not have to use patient’s names or identifying information. I assign a number to each patient so there is no PHI used at all. This data can then be quickly printed out or turned into graphs or other visual representations to show how great you are at treating dysphagia when you use instrumental evaluations. You could even use the cost information from the first part of this series to show how much money you are saving your facility (Believe me, if you use instrumental swallow studies this will add up fast). 

If you put all three parts together into advocating for FEES in your facility, you will develop an instrumental evaluation loving team and happy patients with an improved quality of life. 

If you need help with advocating in your facility, let me know! I am always happy to speak to your team to show the value and necessity of FEES. Let me do the work for you!

#ScopeOn 

References:

Antonios, N., Carnaby-Mann, G., Crary, M., Miller, L., Hubbard, H., & Hood, K. et al. (2010). Analysis of a Physician Tool for Evaluating Dysphagia on an Inpatient Stroke Unit: The Modified Mann Assessment of Swallowing Ability. Journal Of Stroke And Cerebrovascular Diseases, 19(1), 49-57. doi: 10.1016/j.jstrokecerebrovasdis.2009.03.007

Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, and Leonard RJ. Validity and reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol 117: 919-924, 2008.

Crary MA, Carnaby-Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil 2005;86:1516-1520.

O’Neil, Karen & Purdy, Mary & Falk, Janice & Gallo, Lanelle. (1999). The Dysphagia Outcome and Severity Scale. Dysphagia. 14. 139-45. 10.1007/PL00009595. 

This is the second part in a three part series about how to advocate for FEES. If you missed the first part, check it out. It’s all about the money side of things. This post will focus more on the clinical side of things. 

I think we SLP’s have done ourselves a disservice by accepting that instrumental swallow studies are difficult to get approved in the SNF setting and so many give up and just rely on the clinical swallow examination. Administrators may be used to the previous SLP never asking for a swallow study and then you come in armed with your EBP and they wonder why you are so much worse at your job because the last SLP could do these things at the bedside. (Insert deep sigh here). 

I think we need to remember that WE are the experts in dysphagia, not the administrator, so we have the responsibility to effectively advocate for our patients. No one really likes to admit they were wrong but sometimes that is exactly what we need to do. We need to say we used to think that way, that the bedside or clinical swallow examination was sufficient, but now we know better and we know we were wrong. 

The research shows that most of the measures we use during a clinical swallow examination are not reliable or based on actual research. For instance, palpating for hyolaryngeal elevation and excursion is very unreliable. It is impossible to reliably diagnose “reduced hyolaryngeal elevation and excursion” at bedside. Cervical auscultation is another technique that has been debunked as unreliable. Mathers-Schmidt and Kurlinski (2003) found a high level of inconsistency when they surveyed medical SLP’s. I completed a brief search on this topic and found similar articles from all over the world. So while I do think that the clinical swallow examination is important and useful, we should not base our recommendations and treatment plans on it. We can’t treat what we can’t see and we need to stop doing exactly that. 

So back to advocacy! I am always willing to say what I don’t know. When the nurse asks me what diet someone should be on, I am ready to answer with, “I don’t have all the information I need to make that recommendation.” (I think a more professional way of basically saying I don’t know). Next, explain that we need a FEES. I might say, “I am guessing that this individual has pharyngeal dysphagia but I can’t know for sure until I see it.” If I am almost sure that there is an issue (say the person coughs and coughs after every time they take a drink) I still don’t know the why. I don’t know what the physiological deficit is. If I don’t know what I am treating, there is no way that I would do a good job at treating it. 

Some other common facts from the literature I share are:

• Patients with dysphagia may cough when they aspirate thin liquids but have no cough response when aspirating thickened liquids. So at bedside if we give our patient a trial of thin liquids and they cough, then a trial of nectar-thick and they don’t, it does not necessarily mean that the nectar-thick is safe. We need the instrumental to know. 
• We over-diagnose dysphagia 70% of the time (Leder, 2002). This can be costly which you can learn all about in the previous post. 
• We miss silent aspiration. How could we know this at bedside?

So let’s take a look at a specific situation to illustrate what we don’t know from a clinical swallow examination. Let’s say you have a patient and they cough after they drink thin liquids during your examination. First, we can’t even be sure that they were aspirating. And if they were, did it happen before, during, or after the swallow? Is it a timing issue? Is it from incomplete airway closure? Is it because of residue? If they are aspirating what strategy will help? Chin down? Head turn? Effortful swallow? Supraglottic swallow? I know I am sounding like a broken record but we don’t know. How do we find out? FEES of course!

Once we demonstrate why we need the instrumental, the administrator who might not know much or anything about dysphagia will understand why you are actually better at your job and not worse. 

Next time I will focus on how we show the benefits of including FEES. 

If you want to get your hands on my concise guide for advocacy, comment below or reach out to katie@MWDysphagiaDiagnostics.com

#ScopeOn

Leder, S., Espinosa, J. Aspiration Risk After Acute Stroke: Comparison of Clinical Examination and Fiberoptic Endoscopic Evaluation of Swallowing . Dysphagia 17, 214–218 (2002). https://doi.org/10.1007/s00455-002-0054-7

Mathers–Schmidt, B.A., Kurlinski, M. Dysphagia Evaluation Practices: Inconsistencies in Clinical Assessment and Instrumental Examination Decision-Making . Dysphagia 18, 114–125 (2003). https://doi.org/10.1007/s00455-002-0094-z

This is the first in a three part series of how to advocate for FEES in your facility. If you would like a concise version you can present to your administrator, DOR, DON, or whoever else, drop your info in the comments below and I will send one your way. 

As you read the post below, please keep in mind that patient safety and quality of life of course is more important than money. I don’t want to make it sound like money spent or saved is more important than good quality care because it’s not. I also don’t want to make it sound like administrators care more about money than their residents. They don’t. The unfortunate truth is we do have to think about money with healthcare because there won’t be any care for the residents if the facility closes down. 

The number one question I am asked when I am talking to administrators is “How much does it cost?” Makes sense since they are responsible for keeping the doors open and employees paid. I like to respond by telling them that the real question is how much money can it SAVE your facility. So let’s get down to numbers.

Dysphagia is expensive. Studies show that if a patient has dysphagia, their average time spent in the hospital is longer and the overall cost is higher. Dysphagia is also the cause or a contributing cause of many re-hospitalizations which cost an average of around $30,000 (yikes). 

Thickened liquids or the thickener to make thickened liquids costs between $174 and $289 per month per patient. That’s $2,088 to $3468 each year just for liquids. The yearly cost for keeping a patient on a feeding tube is around $35,000. That doesn’t include the cost for the care provided by nursing. The cost of TPN (IV nutrition) is around $80 per day. 

Looking at these costs, it is clear that effective treatment of dysphagia is a lot more cost effective than any of the alternatives. If you are able to get rid of a feeding tube for one patient, this would more than pay for all of the FEES examinations for the year by a lot. 

It does cost money to pay SLP’s to treat dysphagia of course. However, early identification of dysphagia results in higher reimbursement for this care. If a FEES is completed in the first three days of an admission and dysphagia is diagnosed, the facility is able to receive an additional $122 per day in order to provide the care that the patient needs. So in a way, if you follow best practice and recommend a FEES for all patients with dysphagia, suspected dysphagia, or risk factors for dysphagia, the facility really isn’t out any additional money and in the end will most likely save a ton. 

Even if you are advocating for this service for your patients to someone that has no idea what dysphagia is, the numbers speak for themselves. 

Remember to drop your email below or send it to katie@MWDysphagiaDiagnostics.com and I will send a guide your way! 

Next week will be part 2 of this series. Stay tuned and #ScopeOn