STROKE AND FIBEROPTIC ENDOSCOPIC EVALUATION

OF SWALLOWING (FEES) IN A CANADIAN ACUTE CARE

SETTING

AJAY MYSORE NARASIMHA

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Key Learning Goals

1. Appreciating the benefits of FEES in an acute care setting

2. Usefulness of FEES in acute stroke

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London Health Sciences Centre: Did You Know?

• 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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LHSC: Speech-Language Pathology

(S-LP)• 12.5 FTE S-LPs at two sites

University Hospital

Victoria Hospital

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Pre-FEES: Assessment of Adults with Dysphagia

• Clinical Assessment

• Instrumental Assessment: Modified Barium Swallow (MBS)

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MBS: Challenges

• Exposure to radiation• Environmental Factors:

Use of barium ? Naturalistic

• Patient factors: Transportation Medical fragility Positioning Education

• Reports

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MBS: Challenges

• Number of appointment times 12 Victoria Hospital 11 University Hospital

• Wait times

• Limited times

• Physician consent

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NPO: A Tough 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?”

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How were we going to solve this?

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Systems Thinking

“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

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Systems Thinking 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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So How Does this FEES Initiative Fit With “Systems Thinking”?

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Systems Thinking and FEESComplex Situation

Shared Reality – Shared Vision

Surfaced Assumptions

Leveraged Actions

Significant Change

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FEES: The Proposal

• Capital equipment proposal

• Collaboration with Otolaryngology and Respirology

Dr. Kevin Fung Dr. David Leasa

• Potential benefits of FEES

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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

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Medical Directive

• Education and skills to complete nasendoscopy

• Indications and contraindications

• Risks, complications and solutions

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Where Are We Now?

• All SLPs achieved competency between September 2012 - January 2013

• Continued use of FEES in the clinical setting

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THE STROKE JOURNEY

ERSWALLOWING SCREEN WITHIN 24 HRS

FAIL

SLP CONSULTBEDSIDE

SWALLOWING AX

FEES

MBS

PASS

ORAL DIET

72 HOURS

24 HOURS

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ACUTE STROKE DYSPHAGIA SCREENING TOOL

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CANADIAN BEST PRACTICE STROKE GUIDELINES

Patient has to be screened within first 24 hours of admission (Evidence Level C)

Instrumental assessment should be performed on all patients with high risk for aspiration or based on bedside swallowing assessment , stroke location (brainstem stroke etc.) or other clinical features (e.g., multiple strokes etc.) (Evidence Level B)

The decision to proceed with tube feeding should be made within 72 hours/3 days of admission in collaboration with patient, family or Substitute Decision maker and inter-professional team. (Evidence Level B)

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FEES IN ACUTE STROKE DYSDYSPHAGIA AND PNEUMONIA The reported incidence of dysphagia in acute

stroke with instrumental assessment is 64% to 78% . (Martino et.al 2005)

Incidence of pneumonia in acute stroke 16% to 19% (Martino et.al 2005)

The risk of pneumonia dysphagia > without dysphagia, dysphagia +confirmed aspiration > dysphagia without aspiration (Martino et.al 2005)

> 3 fold increase in pneumonia risk in stroke patients with dysphagia (Martino et.al 2005)

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FEES IN ACUTE STROKESENSITIVITY AND SPECIFICITY

Good inter- and intra-rater reliability between FEES and MBS on Rosenbek Penetration and Aspiration Scale (Kelly et al, 2007)

Incidence of pneumonia was significantly lower with FEES than MBS in stroke patients (Aviv, 2000)

FEES has better outcome (behavioral and dietary) in stroke as it readily identifies fatigue of the pharyngeal phase and effect of fatigue (Aviv, 2000)

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FEES IN ACUTE STROKE

SAFETY

FEES could be performed within 48 hours of onset of stroke symptoms

>80% of patients reported no or mild discomfort during FEES (Warnecke et.al, 2008)

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FEES IN ACUTE STROKE

AADVANTAGES OF FEES Immediate and repeated assessments Better visualization and information regarding

sensory/afferent component compared to MBS (Aviv 2000)

Can be used as a bio-feedback tool Able to assess secretion management Visualization of anatomic soft tissue ,

anomalies (e.g., vocal cord paralysis etc.) Portable to bedside Test patients who are difficult to position or

transport

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FEES TRUISMS

FEES Truisms

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Discharge FacilitatedCASE 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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Bio-Feedback Tool in Treatment

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

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The Story So Far….

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Questions

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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Why?

Fees fever picture

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How has FEES impacted inter-professional care ?

• 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

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Future Directions for our Department

Related to: 1. FEES 2. Clinical Excellence

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Future Directions

Related to FEES:1. Setting up our tool kit with on site staff training

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Future Directions

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

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Future Directions

Related to Clinical Excellence:

1. Carry over to other disorders• Continue case studies

2. Carry over to other projects • Model

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In Summary• 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

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Acknowledgments

• 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

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References• 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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References

• Langmore SE, Schatz K, Olsen N. endoscopic and videofluoroscopic evaluation of 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 organization. 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