Michelle Cimoli - DIG July 2017 Feel free to refer to the information contained in this presentation, but please acknowledge the original author, which is noted at the beginning of the presentation.

1. @michellecimoli
Michelle Cimoli
Senior Speech Pathologist, Austin Health
PhD Candidate, La Trobe University
Co-lead project officer, SPA FEES Clinical Guideline
Shine the
Endoscopic Light
on
Oropharyngeal
Dysphagia
Dysphagia Interest Group Victoria
July 2017
http://starceiling.eu/home-cinema/
Michelle.cimoli@austin.org.au

2. Acknowledgements
PhD team
• Dr Jennifer Oates, Associate Professor,
School of Allied Health, La Trobe
University (LTU), Melbourne
• Dr Emma McLaughlin, Castlemaine
Health; Adjunct lecturer, School of
Allied Health, LTU
• Dr Susan Langmore, Professor,
Speech, Language & Hearing
Sciences, Boston University Medical
Centre, USA
Austin Health Speech Pathology
Department
Rhonda Holmes
Shauna Poole, Helana Kelly, Lidia Davies

3. Session
Outline
• Oropharyngeal dysphagia
• Role of imaging in the assessment and
management of oropharyngeal
dysphagia
• Provide a brief overview of FEES
– Case examples to illustrate some of the
unique findings from FEES
• Discuss use of imaging within an
evidence-based and ethical practice
framework for Ax & Mgt of oropharyngeal
dysphagia (OPD)
– Relate these principles to the
implementation of SP-led FEES services
• Explore strategies for applying
EBPmproving access to imaging
assessments
– Austin Health experience
• Discuss current and new perspectives in
FEES training

4. • Acute hospital: 0.35% - 55% (USA, Australia,
Spain) (Altman, Yu & Schaeffer, 2010; Cichero, Heaton &
Bassett, Cabre, Serra-Prat, Palomera, 2010)
• Stroke 14-94% (Langdon, Lee & Binns, 2007)
• Brain Injury 61% (Cook, Peppard, Magnuson, 2008)
• Dementia 84% (Horner, Alberts, Dawson, Cook,
1994)
• Motor Neurone Disease 81% at time of
death (Hardiman, 2000)
• Chronic Obstructive Pulmonary Disease
27-84% (McKinstry, Tranter & Sweeney, 2010; Good-
Fraturelli, Curlee, Hollee 2000)
• Parkinson’s Disease 32% (Walker, Dunn & Gray,
2011)
• Cancer of head and neck 50% (Brodsky,
McFarland, Dozier, Blair, Ayers, Michel et al., 2010)
• Age (> 65 yrs) 10-30% (Barczi, Sullivan & Robbins,
2000)
• 1 million Australians; similar
prevalence rates to diabetes.Oropharyngeal
Dysphagia
Prevalence

5. • Malnutrition, dehydration,
aspiration pneumonia (Odderson,
Keaton & McKenna, 1995)
• Increased length of stay (up to
40% increase)
• Mortality increased substantially
in patients with dysphagia (13
fold increase) risk of mortality
during hospitalisation if
dysphagia (Altman, Yu & Schaefer, 2010)
Oropharyngeal
Dysphagia
Consequences

9. Decision #1

11. • Underestimates
presence of dysphagia
• Underestimates
presence of important
clinical information
about dysphagia e.g.,
aspiration and
pharyngeal residue
Linden & Siebens (1983), Wu,Hsiao, Chen, Chang & Lee
(1997), Garon, Engle & Ormiston, (1996), McCullough,
Wertz & Rosenbeck (2001), Mann, Hankey & Cameron
(1999), Splaingard Hutchins, Sulton & Chaudhuri (1988),
Linden & Siebens (1983), Warms & Richards (2000),
Smithard et al., (1988)
Clinical Swallowing Examination

12. Clinical Swallowing Examination
Retrieved from:
http://www.google.com.au/search?client=safari&rls=en&q=icebergs&oe=UTF-
8&gws_rd=cr&um=1&ie=UTF-
8&hl=en&tbm=isch&source=og&sa=N&tab=wi&ei=URg5UrvEE42TiAeKpoDYAw#hl=en
Retrieved from: http://www.google.com.au/search?client=safari&rls=en&q=icebergs&oe=UTF-8&gws_rd=cr&um=1&ie=UTF-
8&hl=en&tbm=isch&source=og&sa=N&tab=wi&ei=URg5UrvEE42TiAeKpoDYAw#hl=en&q=icebergs%20underwater%20view&revid=1182982174&rls=
en&tbm=isch&um=1&imgdii=_

13. CSE may not always
provide sufficient
information to develop
an effective
intervention or
treatment plan
– Use of interventions without
firstly determining
pathophysiology, may do
more harm than good
(Baylow, Goldfarb, Taveira & Steinberg,
2009; Steele, 2006)
– Need to be able to
evaluate the
effects/outcomes of
interventions (Daniels &
Huckabee, 2009)
Oropharyngeal Dysphagia
Aim to be active in our intervention

14. The graphicsfairy.com
Role of Imaging in
Management of
Oropharyngeal
Dysphagia
• Elucidate the internal
process of
swallowing
• Contribute to greater
confidence in clinical
decision-making

15. The graphicsfairy.com

16. Audio
FEES

17. Considerations for Evidence-Based &
Ethically-Informed Models of Practice
QWhich patients get an
instrumental assessment?
– Are these decisions
based on
• Evidence?
• Practical
considerations?
• Patient-centered
models of care?
Patient values?
• Culture? Custom and
practice / Tradition?
Research
Evidence
Patient
Values
Clinical
Judgment
Prior ExperienceKnowledge
Complexity and Uncertainty
Meta-analyses Environment
Patient
characteristics
Observational
Studies
RCTs Patient
goals
Clinical
Decision
Making

18. Considerations for Evidence-Based &
Ethically-Informed Models of Practice
Portney, 2004, pp. 47
Research
Evidence
Patient
Values
Clinical
Judgment
Prior ExperienceKnowledge
Complexity and Uncertainty
Meta-analyses Environment
Patient
characteristics
Observational
Studies
RCTs Patient
goals
Clinical
Decision
Making

19. How do decide
which patients
need imaging of
their swallowing?
• Use of standardised
assessments
– Screening tools
• TOR-BSST (Martino et al., 2012)
• Logemann, Veis & Colangelo,
1999
– MASA
• Developing protocols (Altman,
2011)
• Use of a consistent framework
to guide assessment
(McCullough & Martino)
• Developing a consensus
definition/criteria for
‘dysphagia’ - Daniels

20. How can we improve rates of
access to imaging assessments
for our patients?
Barriers Solutions
Accessibility for sites that do not have imaging
Geographical barriers
Increased accessibility – all sites to have VFSS
More staff trained in VFSS and FEES
Time
- time needed to set up – nursing, equipment, time to bring pt down
- Time to clean the scope
- Time to write the reports
- Especially VFSS – takes >2hrs to do a report
Increase funding to have additional SP staff
More time for instrumental slots
Looking at time mgt
Increase efficiency
Modifying the VFSS rating proforma
Medical approval needed for VFSS
Can’t always access
Staff skill and confidence
VFSS too early in the morning Allocate SPs to cover VFSS and FEES
Steer away from treating SP doing the procedure

21. 93.2 91.2
78
9.65 8.8
25.42
0%
20%
40%
60%
80%
100%
Austin HRH RTRC
Percentage of dysphagia
referrals receiving
instrumental Ax
percent
received
instrumental
percent
received CSE
only
Acknowledgements: Shauna Poole, Helana Kelly, Lidia Davies
93.2 91.2
78
6.8 8.8
22
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Austin HRH RTRC
Percentage of dysphagia
referrals receiving VFSS
percent received
VFSS
100 % dysphagia
referrals
93.2 91.2
78
6.8 8.8
22
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Austin HRH RTRC
Percentage of
dysphagia referrals
receiving VFSS
percent
received VFSS
100 %
dysphagia
referrals
0
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
800
850
900
Austin HRH RTRC
No. Dysphagia referrals,
VFSS, FEES
CSE only
VFSS
FEES
0
200
400
600
800
1000
Austin HRH RTRC
819
181
59
56
16
13
23
0
2
Dysphagia referrals
Feb-July 2015
FEES
VFSS
CSE only
0
5
10
15
20
GenMed
Neurology
Resp
Spinal
CardiacSx
MaxFac
ShortStay
unknown
No. VFSS / FEES by
unit, Feb - July 2015
No. VFSS
No. FEES

23. • Comprehensive view of all
structures and their inter-
relationship.
• Some events and structures
are best visualised using
VFSS.
• Not appropriate for all
patients
– Radiation exposure,
positioning requirements
etc.,
• Issues if there is limited
access to radiology suite.
Videofluoroscopy
(VFSS)

24. Endoscopy and
Oropharyngeal Dysphagia
Murray, 1999; pp.160

25. • First described by Langmore, Schatz &
Olson (1988).
• Initially used as a screening tool; Evolved
to become a tool to comprehensively
evaluate of swallowing function.
• Use real foods and drink.
• No radiation exposure.
• Can be repeated, and conducted over
an extended period of time.
• Has applications as a conservative
examination.
• Often a more practical solution for
patients who are difficult to position.
• Offers an alternative examination if access
to VFSS is restricted.
Murray, 1999; pp.160
Fibreoptic Endoscopic Evaluation of
Swallowing (FEES© )

26. FEES also provides the opportunity
to assess some unique aspects of
swallowing function (c.f. VFSS):
• Secretion management (Murray,
Langmore, Ginsberg & Dostie, 1996; Donzelli, Brady, Wesling &
Craney, 2003)
• Condition/appearance of
mucosa (Postma et al., 2007)
– erythema
– oedema
• Compromised
laryngopharyngeal sensation (Aviv
et al., 2002; Postma et al., 2007;)
• Relationship between respiration
and swallowing events (Martin, Logemann,
Shaker & Dodds, 1994)
• Biofeedback (Denk & Kaider, 2007; Manor, Mootanah,
Freud, Giladi & Cohen, 2013)
FEES
Fibreoptic Endoscopic Evaluation
of Swallowing (FEES© )

30. Decision #2
VFSS vs FEES?

32. Factors influencing VFSS > FEES
Research
Evidence
Patient
Values
Clinical
Judgment
Prior ExperienceKnowledge
Complexity and Uncertainty
Meta-analyses Environment
Patient
characteristics
Observational
Studies
RCTs Patient
goals
Clinical
Decision
Making
Access to equipment?
Access to training?
Local approval and
governance
processes?
Clinician preference?

33. Reasons for Establishing an SP-led
FEES Service
• Examples (not an exhaustive list):
– Need to provide greater access to
instrumental assessment as part of an
evidence-based approach to managing
dysphagia
– Need to obtain information about swallowing
that is uniquely available using FEES
– Need for repeatable examinations, or
examinations over longer period (e.g., meal-
time)
– VFSS not available

34. FEES Staffing Models
• Positive impact on productivity and waiting times (Bax,
McFarlane, Green & Miles, 2014)
• Cost benefits (Bax, McFarlane, Green & Miles, 2014; Cimoli & Sweeney, 2012)
SP-led
Speech pathologist (SP)
independently operates
the endoscope, directs the
procedure & interprets the
findings
Medically-led / joint
Medical Officer (MO)
operates the endoscope;
SP directs the procedure &
interprets the findings

35. • Established SP-led FEES
service in 2004
• Trained and
implemented service in
outpatient setting.
• Expanded service to
inpatients 18mths later.
• Available to patients
from all clinical units.
• Well accepted by
stakeholders
Speech pathology-led FEES staffing
model
Austin Health

36. Key
MO = medical
officer
SP = speech
pathologist
RN = registered
nurse
Cimoli & Sweeney, 2012, JCPSLP

37. FEES VFSS
Location of
procedure
At bedside or outpatient
clinic
Radiology Department
Procedure
Time/ Report
writing
30 mins
20 mins
30 mins
20 mins
Consumables Food
Blue dye
Gloves
Recordable media
High level disinfection
Food
Barium
Gloves
Recordable media
Equipment Existing (in part ) in ENT
Dept
Existing Radiology Department
Staffing 1 SP
1 nurse
50 mins
50 mins
Total time = 100
mins
1 SP
1 nurse
1
radiographer
1 radiologist
1 porter
50 mins
30 mins
30 mins
30 mins
20 mins
Total time = 160 mins
Cimoli & Sweeney, 2012, JCPSLP

38. Austin Health Episodes of Care
Swallowing Disorder ENT, Head and Neck
Surgical Unit (2008)
FEES Service Design
Aim to meet demand for service & needs of
patients
Austin Health Episodes of Care Primary Clinical
Disorder
Swallowing vs Non-Swallowing (2008)
Cimoli & Sweeney, 2012, JCPSLP

40. http://www.jjbooks.com/illustration-series/anita-sethi

41. FEES
Opportunity to assess impact of changes to
anatomy & morphology
Example: Radiation-Associated Dysphagia

43. • Split screen I
• Split screen II

44. A conceptual model of learning (Voorhees, 2001)
FEES Training

45. • FEES competency is not an entry-level competency.
• Content relating to FEES in entry-level academic training is
likely to be limited.
• LTU HCS 5ASP – FEES topic
• UoM?
• ACU?
• Other states?
• Training programs vary in regards to content,
structure, expectations
•ASHA, 2002; SPA, 2007; RCSLT, 2015; Dziewas et al., 2016
•La Trobe University & Austin Health FEES Competency Short
Course (2006, 2007)
•SA
•Qld
•Existing programs have not been validated.
FEES Training

46. • Observation➔direct supervision➔indirect
supervision / distant supervision
• With or without formal assessment
̶ Variation in who is responsible for assessment
(otolaryngologist vs SP?)
• Observation of trained colleagues
• Attendance of workshops involving practical
activities
• Presentations
• Self-directed study
̶ Training DVDs and online resources
FEES Training

47. • No specified standards
̶ Variation from site to site
̶ Minimum number of procedures to be performed
annually
̶ Peer review
̶ Group rating activities
• Professional development interest groups
can be helpful in providing opportunities
for corroborative rating activities.
FEES Training

48. Traditional paradigm
FEES competency often conceptualised as comprising
three elements:
▪ Technical skill & knowledge required to operate the
equipment safely & effectively
̶ Endoscopy
▪ Procedural skill & knowledge to conduct a
comprehensive & complete examination
▪ Interpretive skill & knowledge to analyse the images,
document & summarise findings, & formulate a
treatment & management plan based on the findings
FEES Training
Changing perspectives…

49. Traditional paradigm
• Competency often conceptualised as a linear
construct
• Task-focussed
• Atomistic approach to defining competencies
•Huge list of competencies
FEES Training
Changing perspectives…

50. FEES Training
Changing perspectives…
Alternative paradigm
Foundation competencies
Competencies are integrated and
overlap
• Competency is not a linear
construct
• FEES competency framework
needs to capture the
Competency framework needs to
support and foster life-long learning

51. • Who does the training? SPs, otolaryngologists, other
medical specialists (e.g., gastroenterologists, radiation
oncologists)
̶ Depends on local context
̶ Relationships with stakeholders
̶ Perceived role of SP
• Practising on colleagues/normals. Is this needed? Are
there any issues with this?
FEES Training
Changing perspectives…

52. • Use of simulation (Bendorm, 2012)
• low fidelity & high fidelity options
• Simulation can be very effective method of
teaching and learning
• Need to define the target skill clearly; feedback
needs to be specific.
• Support trainees to “think out loud”
FEES Training
Changing perspectives…

53. Key
Messages
Oropharyngeal dysphagia is an
important health concern to be
identified and managed.
Imaging assessments are often
needed to accurately diagnosis
and treatment oropharyngeal
dysphagia.
Know our populations.
Consider the limitations and
value of each technique - VFSS
vs FEES
SP-led FEES services can
contribute to improving patient
access to imaging.

54. Questions?