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

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 FEES in acute stroke 2 London on 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 3 1

2014/03/10 LHSC: C: Speech ch-La Langu guage ge Path thol ology ogy (S (S-LP LP) • 12.5 FTE S-LPs at two sites  University Hospital  Victoria Hospital 4 Pre-FEE FEES: : Assess sessment ment of Adults ts with Dysphagi gia • Clinical Assessment • Instrumental Assessment:  Modified Barium Swallow (MBS) 5 MBS: : Challenges enges • Exposure to radiation • Environmental Factors:  Use of barium  ? Naturalistic • Patient factors:  Transportation  Medical fragility  Positioning  Education • Reports 6 2

2014/03/10 MBS: : Challen enges ges • Number of appointment times  12 Victoria Hospital  11 University Hospital • Wait times • Limited times • Physician consent 7 NPO: : A Tough gh Sell • • For the team: For the patient:  Patient quality of  “This is holding up discharge” life   “ How are we going to Tube feeding and equipment give medications?”   “ If he is aspirating, can Nursing time it be  “Burden” of care tolerated?”  Discharge destination and timing 8 How were e we going g to solve e this? s? 9 3

2014/03/10 10 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 11 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/ 12 4

2014/03/10 So How Does s this s FEES Initiati tive e Fit With “Systems Thinking”? 13 Syste tems ms Thinking g and FEES Complex Situation Shared Reality – Shared Vision Surfaced Assumptions Leveraged Actions Significant Change 14 osal FEES: : The e Proposa • Capital equipment proposal • Collaboration with Otolaryngology and Respirology  Dr. Kevin Fung  Dr. David Leasa • Potential benefits of FEES 15 5

2014/03/10 Approval…What Next ? • F inding equipment  Request for tender  Review of equipment  Procurement of a FEES system • E stablishing a process  Nasendoscopy (Delegation vs. Directive)  Nasendoscopy training…where, when, how, with whom  FEES: procedures and documentation format • E xecuting the training  Use of and transition to independence • Selecting the paradigm  Autonomy and efficiency 16 Medica cal Directi ective • Education and skills to complete nasendoscopy • Indications and contraindications • Risks, complications and solutions 17 Where re Are We Now? • All SLPs achieved competency between September 2012 - January 2013 • Continued use of FEES in the clinical setting 18 6

2014/03/10 THE STROKE JOURNE NEY Y 24 ER SWALLOWING SCREEN WITHIN 24 HOURS HRS FAIL PASS 72 72 SLP CONSULT HOURS ORAL DIET BEDSIDE SWALLOWING AX FEES MBS 19 ACUTE STROKE KE DYSPHAG AGIA A SCREENING TOOL 20 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 on (Evi viden dence e Level vel C)  Instru rumen ental asses essmen ent shou ould d be perfor rformed ed on all patien ents with high risk for aspi pirati ration on or based ed on beds dside de swallow owing assessmen ent , strok oke e location on (brai rainstem em stro roke e etc.) .) or other er clinical feature res (e.g .g., ., multipl ple e strok okes es etc.) .) (Evi viden dence e Level vel B)  The e decision on to proc oceed eed with tube be feedi eding shou ould d be made e within 72 hours rs/3 3 days of admission on in collabor boration on with patien ent, family or Subs bstitute e Decision on maker er and d inter er-pro profes fession onal team. . (Evi viden dence Level vel B) 21 7

2014/03/10 FEES IN ACUT UTE STROKE DYS DYSPHAG AGIA AND PNEUMON ONIA  The report orted incidence ce of dysphag agia a in acute strok oke with instru rumental al assessm ssment is 64% to 78% . (Martino o et.al al 2005 05)  Incidence ce of pneumon onia a in acute strok oke 16% to 19% % (Mart rtino o et.al al 2005 05)  The risk of pneumon onia a dysp sphag agia a > withou out dysphag agia, a, dysp sphag agia a +con onfi firm rmed aspirat ration on > dysp sphag agia a withou out aspirat ration on (Mart rtino o et.al al 2005 05)  > 3 fold increase ase in pneumon onia a risk in strok oke patients s with dysp sphag agia a (Mart rtino o et.al al 2005 05) 22 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 on and d Aspi pirati ration on Scale e (Kel elly et al, , 2007) 7)  Inciden dence e of pneu eumon onia was signifi ficantly lower er with FEES S than MBS in strok oke e patien ents (Aviv, , 2000 00)  FEES S has better er outcom ome e (beh ehavi vior oral and d diet etary ry) in strok oke 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) 23 FEES IN ACUTE UTE STROKE SAFETY FEES S could d be perform formed ed within 48 hou ours rs of onset et of strok oke e sympt ptom oms >80% % of patien ents repor orted ed no or mild d discom omfort fort duri ring FEES (Warn rnecke et.al, , 2008) 8) 24 8

2014/03/10 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 on and d inform formation on regardi rding sensor ory/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 on managem emen ent  Visualiza zation on of anatom omic soft ft tissue e , anom omalies es (e.g e.g., ., vocal cord rd paral ralysis etc.) .)  Portabl ble e to bedside de  Test patien ents who o are diff fficult to position on or transpor port 25 FEES Truisms FEES TRUI UISMS MS 26 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 27 9

2014/03/10 Bio-Feed eedback ck Tool ol 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 28 The Story So Far…. 29 Questi stion ons 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 ? 30 10

2014/03/10 Why?  Fees es fever er picture re 31 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 32 Future ure Direc ecti tions ons for our Departm rtment ent Related to: 1. FEES 2. Clinical Excellence 33 11