Getting in Sync These tips can improve communication about videofluoroscopy testing among SLPs. Features
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Features  |   May 01, 2017
Getting in Sync
Author Notes
  • Ianessa Humbert, PhD, CCC-SLP, is an associate professor in the Department of Speech, Language, and Hearing Sciences and co-director of the Swallowing Systems Core at the University of Florida. She is an affiliate of ASHA Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia). ihumbert@phhp.ufl.edu
    Ianessa Humbert, PhD, CCC-SLP, is an associate professor in the Department of Speech, Language, and Hearing Sciences and co-director of the Swallowing Systems Core at the University of Florida. She is an affiliate of ASHA Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia). ihumbert@phhp.ufl.edu×
Article Information
Swallowing, Dysphagia & Feeding Disorders / Features
Features   |   May 01, 2017
Getting in Sync
The ASHA Leader, May 2017, Vol. 22, 48-52. doi:10.1044/leader.FTR2.22052017.48
The ASHA Leader, May 2017, Vol. 22, 48-52. doi:10.1044/leader.FTR2.22052017.48
It happens every time.
In an audience of speech-language pathologists who treat dysphagia, a participant poses a specific question, always with a hint of frustration: How do I deal with inadequate videofluoroscopy reports from other SLPs?
With this question, the interest level of the audience surges. Everyone in the room seems to have a stake in this issue. Discussing solutions to this known problem could directly affect patient care, but also involves enough fault-finding to make some attendees uncomfortable.
What developments lead to this question—and the frustration behind it? And, most important, how do we improve our communication about swallow studies to better coordinate treatment of patients?

Videofluoroscopy documentation should be descriptive and objective, without undertones of worry and discomfort when swallowing disorders are observed.

Two clinical groups
The problem of inconsistencies in dysphagia management spurs much discussion in a course I co-teach with my colleague, Emily Plowman, to clinicians throughout the United States. Clinicians taking the course, “Critical Thinking in Dysphagia Management,” marvel at the fact that SLPs’ interpretation of videofluoroscopic images can vary. Most concerning to many of them is that normal physiology is frequently misidentified as disordered function.
In considering a question about inadequate reports, the clinicians are aware that SLPs involved in videofluoroscopy fall into two groups: evaluating clinicians who conduct videofluoroscopy and write reports and the treating clinicians who rely on those reports to guide treatment plans for their patients. The evaluating clinician is often hospital-based, with access to videofluoroscopy and a full caseload of patients from within the hospital as well as referrals from outside. When they assess patients from another institution—a skilled nursing facility, for example—evaluating clinicians have fewer opportunities to provide clarification to outside clinicians (such as physicians, nurses and other SLPs) who treat the patients to supplement medical documentation.
Videofluoroscopy documentation, therefore, should be informative and dispassionate, meaning it is descriptive and objective, without undertones of worry and discomfort when swallowing disorders are observed.
So what’s the problem?
Swallowing is an area in SLPs’ scope of practice that involves potentially significant medical risks: dehydration, malnutrition, aspiration pneumonia and death. Therefore, many SLPs have been trained, both inadvertently and directly, to be conservative when managing dysphagia. This perspective can contribute to inconsistencies in dysphagia management because decision-making during videofluoroscopy is based on “risk” of aspiration rather than actual aspiration. Treating clinicians need to know if their patients are actually aspirating, but conservative evaluating clinicians may fall short of identifying conclusive, objective outcomes about the patient’s swallowing ability (or disability).

Treating clinicians need to know if their patients are actually aspirating, but conservative evaluating clinicians may fall short of identifying conclusive, objective outcomes.

Evaluating clinician role
If a clinician’s only goal is to avoid risk (see “Patient Wishes Before Risk”), then dysphagia management may equate to mitigating or minimizing aspiration. Even a clinician’s moderate risk-averse tendencies may influence clinical decision-making. But there are risks to avoiding aspiration at all costs: Modified diets to prevent aspiration may lead to dehydration or malnutrition, and surgeries to insert feeding tubes can lead to infection.
Risk-averse tendencies may manifest in videofluoroscopy and a subsequent report in the following ways:
  • The clinician observes aspiration but offers little additional information. A common complaint among treating clinicians is that the videofluoroscopy report identifies the presence of aspiration without commenting on why the patient is aspirating. Not all causes of aspiration are straightforward, but the SLP should attempt to clearly describe the observed pathophysiologies.

  • The clinician uses only “safe” bolus viscosities, volumes and quantities in trials. Testing only the boluses that the patient has historically swallowed safely (purees or honey thick, for example), but not the boluses that might induce penetration or aspiration (for example, thin liquids) provides insufficient information. It’s akin to an allergy test that includes substances that will not induce a reaction, but not the substances that pose risk of an allergic reaction. Discontinuing videofluoroscopy at the first sight of penetration or aspiration can be a disservice to the patient and may disproportionately focus the documentation on negative outcomes. Similarly, testing unsafe boluses (if identified) with strategies that mitigate aspiration is very important.

  • Clinicians may be more conservative when testing a patient they don’t know. The evaluating clinician is charged with being the eyes and ears for the treating clinician, and should provide the most thorough videofluoroscopy possible.

  • The clinician’s report focuses only on risks. Documentation that includes only risks, without mention of benefits, indicates that the goal of the evaluation was to identify all that is nonfunctional, but not what is functional.

It’s important to note that conservative clinical decision-making is warranted and, at times, vital—depending on the patient’s overall health status, the clinician’s level of preparedness, and the availability of essential tools and resources to make the best clinical decisions. There are several ways to document all aspects of the swallow study.
  • In addition to listing unsafe bolus types, a balanced videofluoroscopy also examines and reports the types of boluses that were safely swallowed.

  • If a patient does penetrate or aspirate, it is important to indicate whether the patient attempted to clear the bolus and whether those attempts were successful.

  • If a patient has post-swallow residue, documentation should include whether the patient eventually cleared the residue with additional swallow attempts or a liquid wash.

If a patient does penetrate or aspirate, it is important to indicate whether the patient attempted to clear the bolus and whether those attempts were successful.

Treating clinician role
The treating clinician often sees the patient in a facility or the patient’s home, and must refer the patient to a hospital for a swallow study. Under optimal conditions, the treating clinician accompanies the patient to the study, an arrangement that combines the expertise of two swallowing specialists—one with more experience in conducting videofluoroscopy, and the other with more knowledge about the patient’s health and clinical swallowing profile. However, most treating clinicians are unable to participate in their patients’ videofluoroscopy at outside institutions—or sometimes even within their own facility.
Regardless of the circumstances, the treating clinician also has a responsibility to ensure the quality and documentation of the videofluoroscopy by managing expectations, building relationships and cultivating collegial accountability.
Managing expectations. When treating clinicians criticize videofluoroscopy reports as inadequate, I typically ask them whether they tried to communicate the patient’s needs to the evaluating clinician prior to the evaluation. Some respond with a fervent and frustrated, “Yes, but …” The “but” is that the evaluating clinician follows a specific hospital videofluoroscopy protocol with every patient, so the study is rarely customized to their patients’ needs.
Other responses include variations of “I feel like I did.” Many others demonstrate that they didn’t try to communicate, justified with explanations of time constraints, futility and an unwillingness to tell evaluating clinicians how to do their jobs.
Managing expectations—and communicating them to the evaluating SLP before videofluoroscopy—is critical. If this study is going to be the only one the patient receives—a reality for many, especially patients in some facilities—treating SLPs need to communicate their high expectations for a thorough and patient-centered evaluation to the evaluating SLP.
Building relationships. Clear and continual communication is easier when two professionals have a collegial relationship, but the two are not necessarily mutually inclusive. A professional relationship between evaluating and treating clinicians should lead to an understanding of and appreciation for the other’s clinical approach, mutual respect for the constraints imposed on the other (time, resources, preparedness), trust (giving the other the benefit of the doubt) and, importantly, support and advocacy as fellow SLPs. Either clinician can initiate the development of a positive and productive relationship.
Cultivating collegial accountability. Are today’s clinicians adequately prepared to manage dysphagia? Many SLPs are unsure of their colleagues’ preparedness. Yes, that issue may require major changes in the academic curriculum and clinical training. However, each clinician can contribute to increasing competencies by holding themselves and others accountable for higher standards. Certainly, most clinicians recognize growth in report-writing skills and clinical decision-making over their careers, but positive, influential colleagues can help others acquire and refine skills as well.
What’s the solution?
Treating and evaluating clinicians can also take specific steps to better communicate with one another.
For instance, the treating SLP can:
  • Indicate the patient’s food allergies or preferences and review the clinical swallow examination as part of the medical history shared with the evaluating SLP.

  • Suggest strategies that would help the hospital SLP successfully interact with the patient.

  • Share insights on the patient’s goals and desires regarding swallowing and feeding.

  • Request specifically what you want the evaluating SLP to tell you about the patient to help guide your treatment.

Meanwhile, the evaluating SLP can:
  • When sending out an appointment confirmation to the treating SLP, provide a checklist of requested information on the patient that the treating SLP can complete.

  • Comment on the patient’s ability to participate in the study normally. For instance, note if the patient was irritable, so the treating SLP understands that testing was challenging.

  • Provide a rationale for your recommendations for diet consistencies and compensatory strategies. This should be based on physiological rationales. For example, if you recommend effortful swallows, a sound rationale might be: “Given significant post-swallow residue with pudding consistencies due to limited pharyngeal constriction noted in AP view, three effortful swallow trials were tested and consistently led to significantly less post-swallow residue on pudding boluses.”

  • Ask if in doubt. Talk to the treating SLP to get additional clarification before report-writing if you need more insight into the patient’s baseline.

To cultivate better collaboration between evaluating and treating clinicians, I suggest that both parties:
  • Get the patient and caregivers involved. Patients who can reliably voice their wishes should be fully integrated into this process. It is the patient, after all, who will be immediately affected by your decisions. Caregivers can be very helpful in ensuring that the transfer of care and communication between facilities and clinicians is streamlined and clarified.

  • Work together to determine if a copy of the videofluoroscopic exam can be shared with the treating clinician. This can lead to a collegial dialogue in which you put your clinical heads together to create the best possible treatment plan.

  • Consider having periodic in-services or journal clubs that focus on increasing learning, creating standardization, and moving beyond medical documentation and specific patient outcomes. For many of us, our preparedness to manage dysphagia might not adequately match the significant responsibilities we face—a common occurrence in many other clinical domains. In-person discussion can foster trust and honesty as we continue to refine messages we send and ask for clarification on messages we receive.

Clinicians who have served in both roles—evaluating and treating dysphagia—over the course of their careers provide the best insight: Experience is the best teacher, and we most appreciate the plight of other clinicians when we have also performed those tasks. In our courses, there is an appreciable shift in disposition among attendees after such a remark. The shift is apparent in comments that focus on compromise, understanding and a willingness to build solidarity among SLPs who manage dysphagia across institutions.
The discussion among the attendees, and in this article, cannot address every possible aspect of this complicated issue, but continued dialogue that leads to improved clinical decision-making will undoubtedly promote the best patient care for patients with dysphagia.
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1 Comment
September 20, 2017
Jan Pryor
Excellent Article!!
Thank you Ianessa for putting your finger right on a problem I face on a regular basis! I will be adding this article to reading assignments for my next graduate Dysphagia Course at UW, Seattle. Great ideas and practical suggestions from both evaluating and treating SLP's positions.
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May 2017
Volume 22, Issue 5