Are Your “Best Practices” Unintentionally Harming Your Patients?

As a mobile FEES provider, I all too frequently receive reports from the treating SLP along the lines of “there was no instrumental completed at the acute level, I’ve been doing trials of x and y for the past few weeks and seems ok, but we wanted to do a study just in case there is silent aspiration.” Sure there is some variation to the report, but the main points remain the same – no initial instrumentation prior to initiating therapy, arbitrary trials/therapy at bedside, and post therapy instrumentals (if completed) feel more like a second thought or are reserved only for patients deemed “complex” with poor response to therapy.

Now there are a lot of points in the previous paragraph to take concern with, but today I want to focus on arbitrary PO trials. On this particular day, my referred patient, Mr. Smith (name changed) had a CVA approximately 8 week prior. His medical history included multiple chronic comorbidities and no history of dysphagia. Per this treating SLP, a PEG was recommended based on the hospital bedside swallowing evaluation. After being discharged from the hospital, Mr. Smith began receiving intensive rehab services under the treating SLP who referred for a FEES. The treating SLP reported Mr. Smith coughed “like crazy” when given trials of thin, but did NOT cough when given honey thick liquids and puree textures.

Based on this bedside exam, the treating SLP, began a “strengthening” treatment program and frequently utilized PO trials during therapy. After a few weeks, a FEES was requested to see if Mr. Smith could begin a full PO diet as “he looks well at bedside and is doing great with trials.”

During the exam, thin liquids were provided a multitude of ways – varying bolus size, delivery method, with and without compensatory strategies. Mr. Smith aspirated every thin bolus, but spontaneously coughed with each instance. While the cough may have been ineffective, the cough was present.

Moving onto nectar liquids and puree texture trials, Mr. Smith aspirated those trials as well, but this time there was no cough. Despite how the bolus was presented/manipulated, Mr. Smith continued to silently aspirate. On the outside, Mr. Smith appeared to be enjoying the food, requesting additional trials, commenting on how good it tasted. On the inside, frank silent aspiration and video evidence of severe pharyngeal dysphagia.

It’s well known that aspirating solids and thickened liquids into the lungs carries an increased risk for pneumonia and is generally advised against. (Side note: Aspiration alone does NOT cause pneumonia, but rather aspiration pneumonia is multi-factorial in causation. Check out John Ashford’s 3 Pillars of Pneumonia for more information). Mr. Smith had been consuming puree and honey thick liquids with frank aspiration for weeks with undue increased risk for pneumonia.

Needless to say, the treating SLP was shocked at the results of the FEES, not only regarding the aspiration, but with the severity of pharyngeal deficits. The SLP had no ill will toward Mr. Smith and truly wanted him to return to eating. Yet lack of knowledge, comfort with complacency, or overconfidence in clinical skills – however you want to label it – potentially exposed Mr. Smith to harm and delayed recovery, with what the SLP felt was “best practice.”

An instrumental prior to initiating therapy would have confirmed the need for alternative nutrition, answered the original referral question regarding presence of silent aspiration, visualized deficits (particularly pharyngeal in this case), and documented effectiveness of compensatory strategies. Not to mention having quantitative baseline data to compare with additional testing when indicated. The instrumental would have guided the development of an effective treatment plan to include falsetto and effortful pitch glides, chin tuck against resistance (CTAR), and 3 second bolus prep set to focus on the primary deficits including laryngeal vestibule closure, residue in pyriforms, and oral bolus transit timing coordination rather than the Masako tongue hold, k/g words for tongue base weakness (presumed to be the only deficit), and PO trials to guess at Mr. Smith’s tolerance/endurance (strategies research has shown to have no patient benefit to quasi-beneficial with the possibility to encourage maladaptive behaviors).

The time spent on dysphagia therapy from the acute care and through inpatient rehab cannot be taken back and one can only wonder how far Mr. Smith could have progressed in that same time frame given an appropriate treatment plan. Following his FEES, Mr. Smith was presented with a new treatment plan, along with its rationale given the video evidence, for his approval.

ASHA code of ethics clearly states a SLP should only engage in activities in which they are competent considering education, specialized training, and experience (II A) and shall not misrepresent competency, education, or training (III A). ASHA further recognizes the need to “enhance and refine their professional competence and expertise through engagement in lifelong learning” (II D). Regarding requesting instrumentals ASHA states, “Individuals shall exercise independent professional judgment in recommending and providing professional services when an administrative mandate, referral source, or prescription prevents keeping the welfare of persons served paramount” (IV B).

Moral of the story: It’s each SLP’s responsibility to not only practice within their own competencies (and recognize their own professional limitations), but to continue to develop and refine those competencies. If you make little to no attempt to continually familiarize yourself with the research or implement evidenced based best practices, can you truly call yourself competent to assess and treat? Can you say you are truly providing the highest level of care your patients deserve?

Sarah Vacha, M.A. CCC-SLP

For additional information regarding cough response and pneumonia associated with thicken liquids check out these articles:

  • Cichero, J. (2013). Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutrition Journal, 12(54), 1–8.
  • Holas,M.,Depippo, K. and Reding, M. (1994). Aspiration and relative risk of medical complication following stroke. Archives of Neurology, 51(October), 1051–1053.
  • Miles, A., McFarlane, M., Scott, S., & Hunting, A. (2018). Cough response to aspiration in thin and thick fluids during FEES in hospitalized inpatients. International Journal of Language and Communication Disorders, 53(5), 1–10. https://doi.org/10.1111/1460-6984.12401
  • Robbins, J., Gensler, G., Hind, J., Logemann, J., Lindblad, A., Brandt, D., Baum, H., Lilienfeld, D., Kosek, S., Lundy, D., Dikeman, K., Kazandjian, M., Gramigna, G., McGarvey-Toler, S. and Miller-Gardener, P. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence. Annals of Internal Medicine, 148, 509–518.
  • Schmidt, J., Holas, M., Halvorson, K. and Reding, M. (1994). Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia, 9, 7–11.

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