Scheduling Swallow Studies as easy as 1-2-3

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With staff shortages in hospitals and clinics, many of our patients with dysphagia are having to wait weeks and even months for an instrumental swallow evaluation. 

Meanwhile, patients may have compromised nutrition and hydration, may be suffering with unwanted symptoms of dysphagia (coughing with meals, pain with swallowing, or difficulty eating solids, to name a few), or may be at increased risk for aspiration related pulmonary complications. Delayed swallow studies, also delay care in many ways, as therapists are often awaiting swallow study results to plan treatment based on the physiological deficits identified.

More importantly, dysphagia may be a symptom of an underlying condition, which warrants timely intervention. For instance, think of patients who following a swallow test are referred to an ENT or neurologist, because results from the exam revealed bolus flow characteristics concerning for a possible malignancy or neurological disease. 

As a mobile clinic, dedicated primarily to providing dysphagia evaluations, we are able to provide a solution to this situation.  Speech and Swallowing Specialists of Florida, has the ability to complete swallow studies in the following locations:

  • Skilled Nursing Facilities
  • Physician Offices
  • ALF/ILF
  • Patient’s Homes  
  • Outpatient Clinics

In addition, we partner with outpatient clinics throughout Palm Beach County. Locations include:

  • East Boca Raton
  • Palm Beach Gardens
  • Boynton Beach

Swallow studies performed by our company are completed by out lead endoscopist, an experienced clinical swallow specialist, with over 16 years of experience in the medical field. 

Our endoscopic video swallow studies provide a comprehensive assessment of swallow function, utilizing real foods patients consume every day (no contrast utilized). Patients are given immediate results regarding the safest diet to consume and recommendations for referrals or treatment, as appropriate. Physicians receive a detailed report, with color images with a through description of the exam findings and suggested recommendations, so they can further discuss with their patients. 

If you, your loved one, or one of you patient is in need of a swallow study, contact us to inquire about our services and insurance coverage. Studies are completed within days of referrals.

Scheduling IS really as simple as 1-2-3:

  1. Obtain a physician order (and referral if needed).
  2. Fax Rx/referral to (888) 828-2757 . Call or text if exam needs to be completed ASAP (954) 261-3181.
  3. Our office will contact you to schedule your exam. 

If you have any questions, or would like to schedule a free consultation , please contact us at (954) 261-3181. 

What is FEES and Why is Everyone Talking About it?

While FEES is recognized as a Gold Standard for evaluation of dysphagia worldwide, it may be new to you or your facility. At times, lack of familiarity with FEES has led to underuse of a procedure that has proven to be a valuable tool in the evaluation of many patients with dysphagia, across the life span, and across many healthcare settings.

WHAT IS FEES?

FEES stands for Flexible Endoscopic Evaluation of Swallowing. It is an instrumental assessment of swallowing function, that allows us to directly visualize the patients throat while they are eating and drinking. We can determine the presence of aspiration, pharyngeal residues, and identify deficits to devise a personalized plan of care. FEES involves the passage of a small flexible scope through the nares. It is well tolerated by most patients. However extremely agitated patients are not good candidates. 

FEES is portable and can be completed at bedside. There is no exposure to radiation with FEES. 

WHY FEES IF YOU ALREADY HAVE ACCESS TO VIDEO SWALLOW TESTS?

Both tests are great tools to evaluate patients with suspected pharyngeal dysphagia. You can think of them as you would a CT scan and MRI of the head for the evaluation of a patient with a stroke. Each test has advantages and disadvantages, indications and contraindications. 

For some patients, a video swallow test may not reveal the reason why a patient is showing signs of aspiration at bedside, or may only show us half of what is causing the symptoms. For instance, only FEES can visualize the presence of an infection such as thrush, reflux related changes resulting in “globus” sensation (i.e. something stuck in the throat), reduced mobility of the vocal cords, or the presence of a space occupying lesion affecting the flow of the bolus. 

FEES is also a great option when patients refuse or cannot have barium (i.e. allergy, healing wounds in throat or mouth after surgery, fear of constipation) or don’t want to be exposed to radiation.

HOW WILL I KNOW IF THE PATIENT/RESIDENT NEEDS FEES OR A VIDEO SWALLOW TEST?

The speech therapist in your building is likely to know when each one of these tests is indicated. 

You can also access our FEES vs VFSS guide below, or you can contact us to discuss. 

HOW DOES THE FACILITY BENEFIT FROM HAVING FEES?

  • Patients do not leave their room, reducing risk for infection and reducing staff required to transport patient.
  • Treating SLP present during exam (They may bill for their therapy session on the same date as well).
  • Staff and family may be present during exam for improved patient compliance and staff education on results and precautions. 
  • Ability to better suit the needs and preferences of patients and families. 
  • Cost savings range from $200 to >$1000 depending on type of service used for video swallow tests. 

Hope this helps you better understand the value of FEES and why we are thrilled to bring this service to facilities in South Florida. We pride ourselves in providing excellent customer service, and compassionate, patient centered care. If there is ever anything we can do to make your experience better, or your patients needs specific accommodations, please don’t hesitate to ask.

WHY NOT CHANGE THE WAY WE MANAGE DYSPHAGIA?

We all know how prevalent swallowing disorders are, especially in our elderly population. We know how dysphagia can cause pulmonary complications and even systemic disease that can increase patient mortality. 

So why not do things differently, to change outcomes, improve patients’ quality of life, and reduce costs associated with hospitalizations?

What can we do differently??

If patients are admitted from the hospital on modified diets –> do an instrumental assessment after a reasonable period to allow for recovery (5-10 days depending on a number of factors).  Patients do recover from their acute deficits and may no longer need thickened liquids. 

This saves the facility money $$$    and drives satisfaction scores up!

If patients are on thickened liquids and show signs of aspiration (cough, wet vocal quality, persistent throat clearing, etc.) –> do a follow up instrumental ASAP. Thickening liquids even more (such as downgrading from nectar to honey) is not a smart solution. There is a higher incidence of silent aspiration with thickened liquids. In fact, the thicker the liquids, the more likely the patient with dysphagia will aspirate silently.  Plus, there is mounting evidence that aspiration of thickened fluids is MORE detrimental to the lungs.

Bottom line, thickening liquids based on clinical exams, could increase your patients chances to get a lung infection. It could also result in dehydration and all the cascade of problems that come with it.

Another scenario where the right test saves you money$$

Prioritize oral care–>  Adequate oral hygiene doesn’t happen in many hospitals and long-term care facilities for many reasons. For our patients with dysphagia, this is a likely contributor to aspiration pneumonia. If they aspirate food/liquids, they are likely aspirating their secretions. Think about how many residents who are PEG dependent or consuming “the safest diet” end up with pneumonia. While the development of aspiration pneumonia is multifactorial, if oral hygiene is not properly maintained, the risk to develop aspiration pneumonia is much higher.

A small investment in oral care supplies and staff training, can reduce resident morbidity and mortality and save the facility money $$

Help the speech therapist help your residents –> Trust me, we, SLPs would love to take the credit. But the truth is, we cannot determine how to help our patients without an instrumental exam revealing what is wrong with the patient’s swallow. 

Accurate diagnosis via instrumental assessment (video swallow study or FEES) leads to effective treatment plans. Otherwise, we are treating blindly, and that is, well, unethical. Plus, it could potentially be detrimental to the patients: we just don’t know. Investing a few hundred dollars in FEES for instance, can make a huge difference in functional outcomes, increase patient satisfaction, and maybe reduce the number of patients on modified diets. Yes, that can also save the facility money $$

Use real food items during swallow studies –> I can’t tell you how many times I get consults for a patient who choked on corn or rice, or bread.  Or the patient will only eat certain items that are not included on the prescribed diet. While we can’t test every possible food item the patient eats, there is a way to use real food instead of a barium contrast during instrumental exams. Have you heard about FEES? FEES is a dynamic endoscopic exam, completed at the bedside or dining room, that allows evaluation with real food items, without the time constraints of an Xray exam. Is there a specific soup the family wants to bring, and you are not sure if it’s safe for the patient? Let’s try it too. As an added benefit, FEES is more cost effective than video swallow tests. Just a little extra saving$$ while keeping our patients safe. And FEES also provides all information your SLP need for her plan of care. 

How can WE help?

  • We can help you establish an oral hygiene program and provide staff training on adequate oral care protocols. 
  • We can provide Flexible Endoscopic Swallow Evaluations (FEES) at your facility in a timely manner.
  • We can collaborate with your Speech Therapist during swallow studies, to ensure all concerns are addressed and we correlate clinical presentation with exam findings. Visual feedback can be provided for staff and caregiver education, as well as patient training on strategies identified as helpful during FEES.
  • We serve as expert consultants regarding dysphagia management.
  • We welcome patients to try their preferred foods. After all safe and efficient swallowing are just as important as good nutrition.
  • We can address any family questions and concerns based on results from our FEES exams.

Can you think of something else?? 

Just  email us at: swallowspecialistsfl@gmail.com

Lighting the path to recovery.

The value of FEES

Flexible Endoscopic Evaluation of Swallowing (FEES) may be new to you. However, FEES has been used by Speech Language Pathologists since the early 90s. FEES was actually initially created by Dr Susan Langmore back in 1988, when she decided to explore the use of endoscopy, as used by ENTs, to visualize swallowing function.

Since then, the technology has evolved tremendously and its efficacy tested numerous times, and FEES has become a Gold Standard test to evaluate pharyngeal dysphagia. While in some places, FEES is the most widely used exam to evaluate patients with dysphagia, in other areas, FEES is only performed by a limited number of clinicians and physicians, and offered in a limited number of facilities.

This is the case with South Florida, where many healthcare practitioners have limited information about FEES. I have encountered this situation as I have visited facilities and requested scripts from doctors. Considering FEES provides a convenient and accurate way to evaluate patients with dysphagia in numerous settings and across the life continuum, it is a cost effective alternative, allows for direct visualization of laryngeal and pharyngeal anatomy and physiology, and may the the only option for certain patient populations, it is well worth the effort to increase awareness and educate practitioners in our community about FEES.

So why is FEES so valuable?

The best way to explain the difference between video swallow studies (the most used alternative in this area) and FEES to many healthcare practitioners, is to use the CT scan vs MRI analogy. Like the latter tests, FEES and video swallow studies, have many things in common, but are also very distinct, at times warranting use of both of these tests to evaluate one single patient.

What does FEES offer that a video swallow does not:

-Direct view of the pharynx and larynx, allowing for assessment of symmetry, movement, cranial nerve integrity, reflux related changes, anatomical changes related to intubation (i.e. granuloma), etc.

-No need to transport the patient to the radiology suite. The patient is typically seen in their natural environment (i.e. dining room). Patients are also seen at the bedside, if in an acute or post acute care setting. Examination at physicians offices is also common.

-Allows evaluation of patients who are bed bound, wheelchair bound, or have positional constraints due to body habitus or conditions that prevent optimal position to obtain lateral or AP views for video fluoroscopic swallow studies.

-Patients are assessed while consuming real food items. This makes the evaluation more naturalistic and more likely to resemble a meal. In addition, specific food items that have been reported as “problematic” may be tested to assess effect on swallowing safety and efficiency.

-Patients are assessed for a longer period of time (average 10 min vs 3 min of videofluoroscopy), during which the scope is always on. This is beneficial to assess change over time (common in some populations), assess patients with a larger number of trials to establish a pattern of deficits, determine efficacy of compensations and diet modification with larger volumes (compared to a video swallow test, which is limited due to exposure to X-ray).

-Visual feedback is provided to assist with patient and caregiver understanding of swallowing deficits, and provide opportunities for training in strategies/maneuvers.

-FEES findings may also incidentally uncover findings that warrant further referrals, and provide insight into patients deficits and symptoms (i.e. reduced vocal fold mobility, presence of lesions, glottic stenosis, etc).

What are some of the contraindications of FEES:

Bilateral nasal passage obstruction.

Unstable facial fractures.

Severe agitation.

Refractory epistaxis.

Inability to cooperate with exam for any other reason.

How to order FEES?

FEES exams require a prescription from the patients physician, specifically stating the name of the procedure (see sample Rx below). FEES is covered by insurance (CPT code 92612).

To perform the procedure, an informed consent is also obtained. This may be signed by the patient, POA, or medical surrogate.

If you have any additional questions, please feel free to reach out to us, a speech language pathologist trained in FEES, or your local Mobile FEES endoscopist.

Sincerely,

Isabel Ramati, M.S., CCC-SLP

Speech Language Pathologist

A closer look at the 3 Pillars of Pneumonia

A closer look at the “3 Pillars of Pneumonia”

At this point , all of us are probably familiar with the 3 pillars of pneumonia: 3 factors that need to be considered together when assessing risk for developing aspiration pneumonia in our patients with dysphagia. 

According to this theory, which is now widely accepted within and outside of our field, and heavily supported by the literature,  aspiration pneumonia occurs only within the context of a serious illness.  That is, aspiration alone, does not cause aspiration pneumonia, except in cases in which “the resident immune defenses are insufficient to meet the challenge of bacterial or viral pathogens entering and colonizing the lower respiratory system” (Ashford, 2005).

Furthermore “Whether pneumonia develops from one or more episodes of aspiration depends on the volume of aspirated material, the characteristics of the aspirate (e.g., bacterial load, liquid versus particulate matter, pH level), the frequency of aspiration events, and the integrity of the immune system” 

Namely the 3 factors that comprise the 3 pillars of pneumonia are: 

  1. Oral health status: This can be assessed via clinical exam. The use of an oral health screen such as the OHAT is recommended. 
  2. Presence of aspiration: Assessed via VFSS or FEES, as clinical methods are known to be inaccurate and unable to reliably identify aspiration. 
  3. Health Status: Now things get complicated. Determining a patient’s health status requires understanding  and knowledge of the patients comorbidities, current, state of health, presence of acute or chronic illness, functional status, medications, etc. As SLPs in the acute care setting, consultation with members of the medical team and/or through review of the patient’s chart  (imaging, lab values, etc) are necessary to fully understand the patient’s level of illness and how this can impact their susceptibility to infections.

Effect of Illness on overall health:  In the article Pneumonia: Factors Beyond Aspiration, Dr. J. Ashford explains how acute or chronic illness can decrease the host’s ability to fight infection. For instance, in response to  severe acute illness, such as CVA, surgery, or trauma (cited in other articles)  there is a systemic stress response that leads to changes in HR, O2 intake, glandular secretion, and peripheral blood vessels. Blood flow is directed towards vital organs (i.e. fight or flight response). This also drives changes in the oral and pharyngeal cavities and lower airway that increase colonization of bacteria and impair normal pulmonary clearance. Pulmonary clearance is especially compromised in patients who smoke, leading to decreased ability to clear pathogens from the lower airway. 

As a way to re-establish homeostasis the body secretes stress hormones, such as cortisol, which lessen the stress response but also dampen the immune system.

Severe Illness also results in the release of increased numbers of WBC, especially neutrophils, which act as phagocytes in the bloodstream, identifying and destroying bacteria. An increased number of neutrophils would therefore be consistent with infection. If the pt also shows evidence of aspiration, this particular patient is at high risk for developing aspiration pneumonia. 

Why? The patient shows evidence of aspiration + has compromised immune system + has poor oral health status due to acute/severe illness.

Effect on muscle function: Acute illness results in weakness of slow and fast twitch muscle fibers. In prolonged illness there is also reduction of muscle mass, protein deficiency, and systemic debility. These patients tend to have poor wound healing, and may present with lethargy and generalized weakness. 

Complicated? Yes. But the more we are aware of changes brought on by illness, the better we can help out patients make educated decisions related to feeding and nutrition.

#themoreweknow