2014/03/10 STROKE AND FIBEROPTIC ENDOSCOPIC EVALUATION OF - - PDF document

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2014/03/10 STROKE AND FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING (FEES) IN A CANADIAN ACUTE CARE SETTING AJAY MYSORE NARASIMHA Key Learn rning g Goals 1. Appreciating the benefits of FEES in an acute care setting 2. Usefulness of

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STROKE AND FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING (FEES) IN A CANADIAN ACUTE CARE SETTING

AJAY MYSORE NARASIMHA

2

Key Learn rning g Goals

  • 1. Appreciating the benefits of FEES in an

acute care setting

  • 2. Usefulness of FEES in acute stroke

3

London

  • n Health

th Sciences nces Centre: tre: Did You Know? w?

  • One of Canada’s largest acute care teaching

hospitals

  • Serves the needs of the London- Middlesex

community

  • Provides the broadest range of patient services of

any hospital in Ontario

  • More than one million patient visits each year
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4

LHSC: C: Speech ch-La Langu guage ge Path thol

  • logy
  • gy

(S (S-LP LP)

  • 12.5 FTE S-LPs at two sites
  • University Hospital
  • Victoria Hospital

5

Pre-FEE FEES: : Assess sessment ment of Adults ts with Dysphagi gia

  • Clinical Assessment
  • Instrumental Assessment:
  • Modified Barium Swallow (MBS)

6

MBS: : Challenges enges

  • Exposure to radiation
  • Environmental Factors:
  • Use of barium
  • ? Naturalistic
  • Patient factors:
  • Transportation
  • Medical fragility
  • Positioning
  • Education
  • Reports
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7

MBS: : Challen enges ges

  • Number of appointment times
  • 12 Victoria Hospital
  • 11 University Hospital
  • Wait times
  • Limited times
  • Physician consent

8

NPO: : A Tough gh Sell

  • For the patient:
  • Patient quality of

life

  • Tube feeding and

equipment

  • Nursing time
  • “Burden” of care
  • Discharge

destination and timing

  • For the team:
  • “This is holding up

discharge”

  • “How are we going to

give medications?”

  • “If he is aspirating, can

it be tolerated?”

9

How were e we going g to solve e this? s?

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10 11

Syste tems ms Thinking g

“Systems thinking organizes complexity into a coherent story that illuminates the causes of problems and how they can be remedied in enduring ways” ~ Peter Senge

12

Syste tems s Think nking ng 101

  • “Integrative thinkers build models rather than choose

between them

  • Consider customers, employees, competitors,

capabilities, cost structures, industry evolution, and regulatory environment

  • View the problem as a whole, rather than breaking it

down and farming out the parts

  • Creatively resolve tensions without making costly

trade-offs, turning challenges into opportunities" http://www.rotman.utoronto.ca/

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13

So How Does s this s FEES Initiati tive e Fit With “Systems Thinking”?

14

Syste tems ms Thinking g and FEES

Complex Situation Shared Reality – Shared Vision Surfaced Assumptions Leveraged Actions Significant Change

15

FEES: : The e Proposa

  • sal
  • Capital equipment proposal
  • Collaboration with Otolaryngology and

Respirology

  • Dr. Kevin Fung
  • Dr. David Leasa
  • Potential benefits of FEES
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16

Approval…What Next?

  • Finding equipment
  • Request for tender
  • Review of equipment
  • Procurement of a FEES system
  • Establishing a process
  • Nasendoscopy (Delegation vs. Directive)
  • Nasendoscopy training…where, when, how, with whom
  • FEES: procedures and documentation format
  • Executing the training
  • Use of and transition to independence
  • Selecting the paradigm
  • Autonomy and efficiency

17

Medica cal Directi ective

  • Education and skills to complete

nasendoscopy

  • Indications and contraindications
  • Risks, complications and solutions

18

Where re Are We Now?

  • All SLPs achieved competency between

September 2012 - January 2013

  • Continued use of FEES in the clinical

setting

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19

THE STROKE JOURNE NEY Y

ER SWALLOWING SCREEN WITHIN 24 HRS FAIL SLP CONSULT BEDSIDE SWALLOWING AX FEES MBS PASS ORAL DIET

72 72

HOURS 24 HOURS

20

ACUTE STROKE KE DYSPHAG AGIA A SCREENING TOOL

21

CANADI ADIAN AN BEST T PRACT ACTICE CE STRO ROKE E GUIDE DELIN LINES

  • Patien

ent has to be scre reen ened ed within firs rst 24 hours rs of admission

  • n (Evi

viden dence e Level vel C)

  • Instru

rumen ental asses essmen ent shou

  • uld

d be perfor rformed ed on all patien ents with high risk for aspi pirati ration

  • n or based

ed on beds dside de swallow

  • wing assessmen

ent , strok

  • ke

e location

  • n

(brai rainstem em stro roke e etc.) .) or other er clinical feature res (e.g .g., ., multipl ple e strok

  • kes

es etc.) .) (Evi viden dence e Level vel B)

  • The

e decision

  • n to proc
  • ceed

eed with tube be feedi eding shou

  • uld

d be made e within 72 hours rs/3 3 days of admission

  • n in

collabor boration

  • n with patien

ent, family or Subs bstitute e Decision

  • n maker

er and d inter er-pro profes fession

  • nal team.

. (Evi viden dence Level vel B)

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22

FEES IN ACUT UTE STROKE

DYSDYSPHAG

AGIA AND PNEUMON ONIA

  • The report
  • rted incidence

ce of dysphag agia a in acute strok

  • ke with

instru rumental al assessm ssment is 64% to 78% . (Martino

  • et.al

al 2005 05)

  • Incidence

ce of pneumon

  • nia

a in acute strok

  • ke 16% to 19%

% (Mart rtino

  • et.al

al 2005 05)

  • The risk of pneumon
  • nia

a dysp sphag agia a > withou

  • ut dysphag

agia, a, dysp sphag agia a +con

  • nfi

firm rmed aspirat ration

  • n > dysp

sphag agia a withou

  • ut

aspirat ration

  • n (Mart

rtino

  • et.al

al 2005 05)

  • > 3 fold increase

ase in pneumon

  • nia

a risk in strok

  • ke patients

s with dysp sphag agia a (Mart rtino

  • et.al

al 2005 05)

23

FEES IN ACUT UTE STROKE

SENSI SITI TIVITY TY AND SPECIFI FICITY TY

  • Good

d inter er- and d intra ra-rate rater r reliability between een FEES S and d MBS S on Rosen enbek ek Penet etrati ration

  • n and

d Aspi pirati ration

  • n

Scale e (Kel elly et al, , 2007) 7)

  • Inciden

dence e of pneu eumon

  • nia was signifi

ficantly lower er with FEES S than MBS in strok

  • ke

e patien ents (Aviv, , 2000 00)

  • FEES

S has better er outcom

  • me

e (beh ehavi vior

  • ral and

d diet etary ry) in strok

  • ke

e as it readi dily iden entifi fies es fatigue e of the e phary ryngea eal phase and d effec fect of fatigue e (Avi viv, v, 2000) 0)

24

FEES IN ACUTE UTE STROKE

SAFETY

FEES S could d be perform formed ed within 48 hou

  • urs

rs of onset et of strok

  • ke

e sympt ptom

  • ms

>80% % of patien ents repor

  • rted

ed no or mild d discom

  • mfort

fort duri ring FEES (Warn rnecke et.al, , 2008) 8)

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25

FEES IN ACUT UTE STROKE

  • AADVANTA

NTAGE GES S OF FEES S

  • Immedi

ediate e and d repeated eated asses essmen ents

  • Better

er visualiza zation

  • n and

d inform formation

  • n regardi

rding sensor

  • ry/aff

ffer eren ent compon ponen ent compa pare red d to MBS S (Avi viv 2000) 0)

  • Can be used

ed as a bio-feed feedba back tool

  • Able

e to asses ess secre retion

  • n managem

emen ent

  • Visualiza

zation

  • n of anatom
  • mic soft

ft tissue e , anom

  • malies

es (e.g e.g., ., vocal cord rd paral ralysis etc.) .)

  • Portabl

ble e to bedside de

  • Test patien

ents who

  • are diff

fficult to position

  • n or transpor

port

26

FEES TRUI UISMS MS FEES Truisms

27

Disch charge rge Facilita tate ted

CASE STUDY 1

  • 71 year old female with history of kyphosis from NH
  • Right Middle Cerebral Artery (MCA) stroke, dense left hemiplegia,

unilateral Upper Motor Neuron (UMN) dysarthria on Thursday night

  • Not a TPA candidate
  • Failed dysphagia screening due to left facial droop
  • Seen by SLP Friday a.m. for a clinical swallowing assessment -

inconsistent clinical signs of penetration/aspiration therefore NPO recommended

  • Kyphosis preclude positioning for an MBS
  • Also, no MBS slot until Tuesday
  • FEES completed Friday afternoon – patient initiated on a pureed solids

with regular thin liquids

  • NG tube was avoided
  • Discharged to stroke rehab – day 5
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28

Bio-Feed eedback ck Tool

  • l in Treatment

tment

CASE STUDY 2

  • 55-year-old man post brainstem stroke with subsequent

tracheostomy due to aspiration of secretions

  • Admitted to the ICU
  • Dysphagia managed by nasogastric tube
  • Able to follow directions and participate in therapy to rehabilitate the

swallow

  • Repeated FEES studies completed with the goal of providing

biofeedback/visualization

  • First step, learning to swallow secretions and utilizing a volitional

cough to laryngeal vestibule

  • Decannulation in one week with improvement in secretion

management

  • Second step, within two week, patient learned chin tuck maneuver

and initiated a full fluid diet

  • Nasogastric tube removed

29

The Story So Far….

30

Questi stion

  • ns
  • 1. How has FEES influenced the number of

patients receiving MBSs?

  • 2. How has FEES influenced the number of

swallowing referrals?

  • 3. How has FEES impacted the use of

instrumental assessments?

  • 4. How has FEES impacted inter-professional

care ?

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31

Why?

  • Fees

es fever er picture re

32

How has s FEES impacted cted inter- professiona essional care e ?

  • Results perceived as more “credible”
  • Greater agreement with recommendations
  • Better understanding of the swallowing

impairment

  • Recognition for contributing towards access

and flow

  • “You can do that today?!”
  • Enhanced professional profile staff

empowerment

33

Future ure Direc ecti tions

  • ns for our Departm

rtment ent

Related to:

  • 1. FEES
  • 2. Clinical Excellence
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34

Future re Direc ecti tion

  • ns

s

Related to FEES:

  • 1. Setting up our tool kit with on site staff

training

35

Future re Direc ecti tion

  • ns

s

Related to FEES:

  • 1. Incorporation into the student placement

experience

  • 2. New staff: A different training model
  • 3. Data collection: Trends through statistics
  • 4. Research opportunities

36

Future ure Direc ecti tions

  • ns

Related to Clinical Excellence:

  • 1. Carry over to other disorders
  • Continue case studies
  • 2. Carry over to other projects
  • Model
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37

In Summary mary

  • Fees proven to be a useful method of performing instrumental

assessments in in and outpatients across multiple patient populations especially in Acute Stroke.

  • FEES has been found to be an alternative to MBS and can be

utilized effectively in the acute care setting

  • FEES may allow for early optimal assessment for stroke patients

with medical fragility, dependence on the ventilator, difficulty with positioning, or fatigability

  • Quicker instrumental assessment for stroke patients resulting in

earlier swallowing/nutrition plans and facilitating discharge to most appropriate medical setting (e.g., rehab)

  • The initiation of FEES has influenced MBS usage at LHSC
  • The reduction of MBS usage has the potential to reduce costs for

the organization

38

Acknowl

  • wledgment

gments

  • Drs. Fung and Leasa who provided tremendous

support, expertise, and time in assisting us with the introduction of “FEES” at LHSC

  • Dr. Vanessa Burkoski for recognizing the impact of

FEES on patient care and supporting this significant financial investment

  • Donna Bandur for seeing the potential in FEES and

championing this initiative

39

Refere erenc nces es

  • Acceptance of Delegation of a Acceptance of Delegation of a. (2008). Retrieved

September 1, 2013, from CASLPO OAOO: http://www.caslpo.com/Portals/0/positionstatements/mpsdeleg.pdf

  • A Guide to Medical Directives and Delegation. (n.d.). Retrieved September 1,

2013, from Federation of Health Regulatory Colleges of Ontario: http://www.regulatedhealthprofessions.on.ca/WHOWEARE/default.asp

  • Aviv JE. Prospective, randomized outcome study of endoscopy versus modified

barium swallow in patients with dysphagia. Laryngoscope. 2000;110:563-574

  • Kelly AM, Drinnan MJ, Leslie P. Assessing penetration and aspiration: How do

videofluroscopy and fiberoptic endoscopic evaluation of swallowing compare?

  • Laryngoscope. 2007; 117:1723-1727.
  • Leder SB, Sasaki CT, Burrell MI. Fiberoptic endoscopic evaluation of dysphagia

to identify silent aspiration. Dysphagia. 1998;13:19-21

  • Lindsay, M. P., Gubitz, G., Bayley, M., & Philips, S. (2013). Canadian Best

Practices and Recommendations for Stroke Care. Canadian Stroke Best Practices and Standard Group. Retrived from http://www.strokebestpractices.ca/wp- content/uploads/2010/10/Ch4_SBP2013_Acute-Inpatient- Care_22MAY13_EN_FINAL4.pdf.

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40

Referen erences es

  • Langmore SE, Schatz K, Olsen N. endoscopic and videofluoroscopic evaluation
  • f swallowing and aspiration. Ann Otol Rhinol Laryngol. 1991;100:678-681
  • Langmore, S. E. (2001). Endoscopic Evaluation and Treatment of Swallowing
  • Disorders. New York: Thieme NewYork.
  • Leder, S. A. (2005). Fiberoptic Endoscopic Evaluation of Swallowing (FEES) with

and without Blue-Dyed Food. Dysphagia, 157-162.

  • Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia

after stroke: Incidence, Diagnosis, and Pulmonary Complications. Stroke. 2005;36:2756-2763.

  • Senge, P. (1990). The fifth discipline: the art and practice of the learning
  • rganization. New York: Doubleday.
  • Steele, C. M. (2008). Practice Standards and Guidelines for Dysphagia

Intervention by Speech-Language Pathologists. Retrieved September 1, 2013, from CASLPO OAOO: http://www.caslpo.com/Portals/0/ppg/Dysphagia_PSG.pdf

  • Wu CH, Hsaio TY, C CJ, Chang YC, Lee SY. Evaluation of swallowing safety with

fiberoptic endoscope: Comparison with videofluoroscopic technique.

  • Laryngoscope. 1997;107:396-401