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.