Advocacy, Clinical Focus

The Waiting Game

How long have you had to wait when scheduling a MBSS? Lately, the shortest I have heard is 2 weeks and the longest is 2 months. What do you do in the meantime?

Do you treat the patient based on what you think is happening? This could be beneficial, however, you also might be providing therapy that is ineffective or even unnecessary. But can you wait?

Do you just hang out with the best recommendations you can make until the MBSS can be completed? Make conservative recommendations for diet? We know thickened liquids should not be used without imaging as they are not harmless but what if you think that the patient is aspirating thin liquids?

As I write this, I have no good answers. We have to do the best we can with what we have. 

At Midwest Dysphagia Diagnostics, I know that time matters. I don’t think you or your patients should have to wait and I don’t think your treatment plan should be based on your best guess. 

If you don’t have access to imaging, let me know. I can help you out with mobile FEES in Iowa or direct you to someone in your state. 

1-2 days or 14-60 days. Which sounds better for your patients?

I know I wouldn’t want to wait for treatment and your patients shouldn’t either. 


Read More

Advocate for FEES

If you work in skilled nursing and haven’t read this article in the latest edition of The Leader, you’re missing out. ASHA recently published, “Speak the SNF Lingo to Show the Need for Instrumental Assessments” which provides a wealth of knowledge. I am going to share some highlights and add in my experiences. Go read it and come back here. 

“SLPs might be well-versed on the evidence and recommendations driving the use of instrumental assessments, yet they may not know how to express them to administrators whose primary—typically business-driven—concerns differ from their own.” 

This is very true. Most administrators are not going to know the in’s and out’s of dysphagia and why instrumental assessment is so important. You might be the first SLP to really push for use of instrumentals, so they might not understand why you need them but the last SLP did not. That’s where we delicately share how instrumentals are not optional and the last SLP probably should have been asking for them as well. It’s our job to show them the evidence and to explain why FEES and MBSS are non-negotiable for the best care for their residents. Need evidence? Reach out and I will give you what you need!

“However, in the short term, SNF administrators may question the value of sending a patient for a study they perceive as having little benefit in relation to cost. Why invest in a swallow study, some might think, when you can simply put the patient on thickened liquids and a modified diet if you suspect a swallowing problem—or limit an SLP’s tools to just a bedside assessment of swallowing (which cannot provide adequate information about swallowing physiology)?”

Here is where you share the cost of thickened liquids (up to $7000 a year per patient) and the cost of tube feedings (hundreds of dollars each day). You can also hit them with the average of $30,000 for a hospital admission related to pneumonia. That FEES exam will suddenly seem very affordable. This is not to say that all administrators only care about money. That is far from the truth. I have met with many administrators that just want the best care for their residents regardless of cost. 

The article lists some great conversation starters and advice for SNF SLP’s. My favorite piece of advice is to reach out to your local mobile FEES provider (Hey there!). As a mobile provider, I have spoken to many administrators and have the answers they want. I love getting the instrumental studies to the people that need them so do not ever hesitate to reach out for advice, resources, or to set up a meeting. I’ll even bring the snacks! 


Here’s the link to the article: 

Read More

June is Dysphagia Awareness Month

June is dysphagia awareness month. Dysphagia impacts almost 1 in every 25 people but most people don’t even know what it is until it affects them or someone they know. This month is all about raising awareness to help those with dysphagia or with a loved one with dysphagia feel less alone and to find resources to help. 

What can we do as SLP’s? Let’s all help get the word out. This month, I will be sharing different stories and case studies I have encountered that may be familiar to you or someone you know. Stayed tuned for success stories, interesting mysteries, and more. 

Are you someone that is struggling with dysphagia? You don’t have to be alone in this. Reach out here or to an SLP in your area. We would love to help. Dysphagia can be very treatable and there are options for everyone. 

Are you someone with dysphagia that would like to share your story? Please do! We would love to spotlight you here with Midwest Dysphagia Diagnostics. 

Stay tuned and #ScopeOn

Read More
Advocacy, Clinical Focus, Education

What Does ASHA Say?

ASHA, our governing body provides us guidance for clinical decision making. Below is the information they provide for adult dysphagia assessment. Note that the bolded text is from ASHA and the unbolded text is my own thoughts. 

Instrumental Swallowing Assessment

SLPs use instrumental techniques to evaluate oral, pharyngeal, laryngeal, upper esophageal, and respiratory function as they apply to normal and abnormal swallowing. In addition, instrumental procedures are used to determine the appropriateness and the effectiveness of a variety of treatment strategies.

Instrumental techniques are usually conducted either independently by the SLP or by the SLP in conjunction with other members of the interprofessional team (e.g., radiologist, radiologic technologist, physiatrist). Competence in videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) requires appropriate training and education. SLPs help guide medical decision making regarding the appropriateness of these procedures given the severity and nature of the patient’s swallowing deficits. SLPs interpret and apply the results of objective testing to the formulation of dysphagia treatment plans, and they also determine patient capacity and safety for oral feeding.

Indications for an instrumental exam include the following:

  • Concerns regarding the safety and efficiency of swallow function
    • Contribution of dysphagia to nutritional compromise
    • Contribution of dysphagia to pulmonary compromise
    • Contribution of dysphagia to concerns for airway safety (e.g., choking)


At times we may fall into the trap of focusing in too closely on the patient’s dysphagia only. We have to remember to look at the entire picture, look at the patient as a whole. When we collaborate with the medical team, the outcomes can only improve for the patient. 


  • The need to identify disordered swallowing physiology to guide management and treatment

We can’t treat what we can’t see. Let me say that again. We can’t treat what we can’t see. 

  • Inconsistent signs and symptoms in the findings of a non-instrumental examination

Remember that there is not always a cough response to aspiration. And sometimes, there will be a cough with aspiration of thin liquids but no cough with thickened. We can’t depend on the bedside swallow evaluation to determine when aspiration happens. 

  • The need to assist in the determination of a differential medical diagnosis related to the presence of pathological swallowing

SLP’s can sometimes be the first medical professional to identify signs/symptoms of a neurological condition. 

  • Presence of a medical condition or diagnosis associated with a high risk of dysphagia

Think CVA, TBI, COPD, HANC, Parkinson’s Disease, Progressive neurological conditions, MS, dementia, etc. 

  • Previously identified dysphagia with a suspected change in swallow function that may change recommendations

If there is a change in status for a patient with known dysphagia, an instrumental swallow study is warranted and needed whether it is a change for the better or for the worse. 

  • Presence of a chronic degenerative condition with a known progression or the recovery from a condition that may require further information for the management of oropharyngeal function

We are an important part of the care team for these patients. 

Contraindications for an instrumental exam include the following:

  • The patient is not medically stable enough to tolerate the procedure.
  • The patient is not able to participate in an instrumental examination (e.g., cognitive difficulties, inability to maintain an appropriate level of alertness).
  • The SLP’s clinical judgment indicates that the instrumental assessment would not change the clinical management of the patient.

Similar to non-instrumental assessment, instrumental assessment also includes a thorough case history; an oral mechanism exam; and assessment of overall physical, social, behavioral, and cognitive/communicative status (see previous section on Non-Instrumental Swallowing Assessment for details on these components of an evaluation). 

The purpose of the instrumental examination is to enable the SLP to

  • visualize the structures of the upper aerodigestive tract;
  • assess the physiology of the structures involved in swallowing and to make observations, measures, and inferences of symmetry, sensation, strength, pressures, tone, range of motion, and coordination or timing of movement to determine the diagnosis of dysphagia;
  • determine presence, cause, and severity of dysphagia by visualizing bolus control, flow and timing of the bolus, and the individual’s response to bolus misdirection and residue;
  • visualize the presence, location, and amount of secretions in the hypopharynx and larynx, the patient’s sensitivity to the secretions; and the ability of spontaneous or facilitated efforts to clear the secretions;
  • determine the cause(s) for laryngeal penetration and/or aspiration; and
  • determine with specificity the relative safety and efficiency of various bolus consistencies and volumes.

You can see above that at no time does ASHA recommend that a clinician only rely on a bedside swallow examination when there is suspected dysphagia. We can’t treat what we can’t see. Mobile FEES with Midwest Dysphagia Diagnostics provides easily accessible, high quality instrumental examinations for your patients and residents. Reach out today!

American Speech-Language-Hearing Association. (n.d.). Adult Dysphagia. (Practice Portal). Retrieved month, day, year, from

Read More
Advocacy, Clinical Focus, Education

With a Little Help From My Friends

In past blogs and social media posts, I have offered help in whatever way I can. I believe strongly that we should help each other instead of being competition. In that spirit, I want to share more specific ways I can offer help and assistance. Check out the list below and if you feel like you could benefit, please reach out! 


Have you been asked by your facility to provide an inservice? Feel like the staff at your building could benefit from a refresher on dysphagia? Not sure where to start? Midwest Dysphagia Diagnostics provides free inservice to facilities. We are prepared to speak on dysphagia in general, diet consistencies, how to fill out section K, or how FEES could benefit the facility and residents. We are ready to provide the entire inservice or collaborate with you. We’ll even bring the snacks! 


Have a difficult dysphagia case that you aren’t quite sure what to do with? Need some resources? Reach out! We have a large library of EBP articles ready for you to implement in your practice*. Ran into a diagnosis you have never seen before? Let us know! We can talk about dysphagia all day. 

FEES Advocacy Help

Are you ready to implement FEES in your facility but not everyone is on board yet? Are they still in the dark as to the benefits of FEES? The information they need is right here. We have compiled the latest research and cost/benefit analysis material to show the staff in your facility. Getting the needed instrumental assessments to all patients is our passion and mission. Let us help you show the value and necessity of FEES. And again, we will bring the snacks!


Just feel like you need to vent? Looking for that one article that you can’t find*? Questions about MDTP? Want to do a job shadow? Reach out! We would love to hear from you. 

Remember it is community over competition and we are all stronger together. 




*We only provide full text versions of open access articles. 

Read More
Advocacy, Clinical Focus

What to do when the answer is no

I’m sure many of us have run into the problem where we ask for an instrumental swallow evaluation and we are told no whether it is nursing, the administrator, or the NP writing the orders. What then?

Let’s go through an example. Let’s say that a new admit to your facility arrived following a stroke. This patient did not have an instrumental swallow evaluation at the hospital because by the time it was appropriate, the patient was discharged to your facility. You complete the clinical swallow examination and administer the Yale 3oz Water Protocol. The patient is not able to pass. So you do what is supported by the evidence and ask for an instrumental examination. Then you are told no. 

What next? You provide evidence and education on why an instrumental swallow study is necessary for treatment. You explain why just putting the patient on thickened liquids is a terrible solution. You explain how getting a FEES would actually make the facility money because it would offer the proof needed for continued treatment. And still, the answer is no. 

So what are the options? 

1. You could just treat without the instrumental. You could guess which exercises may help and guess what would be the safest and most appropriate for the patient. You could just hope that what you are doing is keeping the patient safe. Not a great option…

Or 2. You could say that you can not ethically and effectively provide dysphagia therapy without imaging and so you are forced to discharge the patient. 

Does #2 cause anxiety? You might say, “well we can’t just not treat the patient.” I would ask, how do you know your “treatment” is doing more good than harm? How do you know it is making things better instead of worse? How do you know that the patient even needs treatment? 

What if the doctor never took your blood pressure but put you on a blood pressure medication “just in case?” How would you feel if your orthopedic surgeon decided to do knee surgery without imaging because “You probably need it?” Not great. 

So why do we allow this to happen with our dysphagia patients? Until we stop providing treatment without imaging, we will continue to hear “no.” Let’s change this for our patients. 


Read More

How to Advocate for FEES Part III: Show Your Worth!

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!



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. 

Read More

How to Advocate for FEES Part II: You Can’t Treat What You Can’t See

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


Leder, S., Espinosa, J. Aspiration Risk After Acute Stroke: Comparison of Clinical Examination and Fiberoptic Endoscopic Evaluation of Swallowing . Dysphagia 17, 214–218 (2002).

Mathers–Schmidt, B.A., Kurlinski, M. Dysphagia Evaluation Practices: Inconsistencies in Clinical Assessment and Instrumental Examination Decision-Making . Dysphagia 18, 114–125 (2003).

Read More

How to Advocate for FEES in Your Facility Part 1: FEES Pays for Itself

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 and I will send a guide your way! 

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

Read More

2020 ISHA Virtual Convention Recap

Last week was the annual convention for the Iowa Speech Language Hearing Association. In case you missed it, I thought I would highlight some of the things I learned!

First with head and neck cancer, the motto is “use it or lose it” in terms of swallowing. The team from UI Hospitals shared their expertise built over years working with cancer patients. Keeping a patient swallowing is the most important part of treatment. A head and neck cancer survivor shared that this was the most important part for him. He told himself that he had to keep swallowing even though it was painful and exhausting.

Dr. Ianessa Humbert shared that SLP’s aren’t always that great at interpreting results from fluoroscopy (the stats are bad…). Accuracy with interpretation did not improve with years of experience, experience with VFSS, or with board certification in swallowing (this was VERY surprising to me). The only thing that increased the accuracy was using Frame by Frame review. This part was great to hear because I have always and will always continue to use frame by frame review with every FEES examination I complete. This is why I can only do 2-3 FEES max per day. Frame by frame review takes time, but it’s what needs to be done.

Did you know that SLP’s have a role in lymphodema management? Joy Hesse showed us the swelling that can occur internally for head and neck cancer patients. We watched some FEES videos (my favorite part of course!) which showed what a difference treatment she has provided makes for these patients. I’m thinking future CEU goals….?

Veena and Maggie from The Ohio State University shared their research on biofeedback using FEES for dysphagia therapy. We again got to watch some pretty amazing FEES videos and were able to see patients learning in real time how to “fix” their swallows by watching themselves swallow (way cool!). Biofeedback with FEES is the way forward in dysphagia management. Have you noticed any of the biofeedback techniques I use when evaluating your patients? I try to include it as much as possible to improve outcomes.

Did you attend the convention? What were your favorite parts? Let me know in the comments below or reach out through the website or facebook!


Read More