Week 1 Readings Flashcards
why is disphagia a malpractice ligation?
Can cause aspiration pneumonia and lead to serious medical complications
Dysphagia ligations and expert witnesses
Who? professor or speech & hearing scientist
What? give opinions about commissions and omissions (failure to do something) by other slps, healthcare providers and other healthcare professionals
Defining dysphagia legally
15 million have swallowing disorder
Definition: “Impairment of the emotional, cognitive, sensory and motor acts involved with transferring a substance from the mouth to stomach, resulting in failure to maintain hydration and nutrition and posing a risk of choking and aspiration
assessing responsibility fro negative dysphagia management outcomes
team approach includes: primary care physician, registered nurse, nurse assistant, dietician/nutritionist, radiologist, OT, respiratory therapist, gastroenterologist, neurologist, social worker, SLP
Primary care: ultimately responsible for medical management of dysphagia BUT other can be sued
- attorneys research for proffesionals responsibilities of where it went wrong
Places where happens: nursing homes, hospital emergency wards, private physicians, medical and nursing consultants and home health agencies
Dysphagia Clinical Timeline
GOAL: determine who did what and when the probable clinical outcomes
attoruney, legal team must agree on timeline
the possible probable continuum: Dysphagia
Possible: suggest that a clinicians action possibly resulted in a clinical outcome is non-descriptive and essentially a useless expert opinion because virtually anything is possible
Probable: indicates that the expert believes the action likely caused the clinical effect
Clinical proficiency in the management of dysphagia
Witnesses deicide if lcinitian shows competency in:
- identify individual w/ dysphagia
- performed oral pharyngeal and respiratory examinations
- review medical history
- performed competent instrumental/structural physiologic examinations with feeedback from others
- appropiate patient/client management decisions with: oral intake, risk precausions, candidacy and treatment strategies
- appropiate treatment procedures
ASLO if goals objectives and procedures were logical
Videofluorographic swallow study
central to many medical malpractices
- provides the most objective info about the patients swallowing function
- usually provided too late (bc they usually stay with the bedside swallowing evaluation)
- should be routinely conducted
-
misleading 4 independent stages
oral preparation, transporation, pharyngeal, and laryngeal esophageal
BC of chewing and swallowing
dividing them is analogous to viewing running as many movements
Bedside: only determine possible strutural, neurological or muscular deficiencies that interfere with bolus or liquid movement
adequacy of professional communication
Formal communication: medical chart, consultation copies
Informal verbal communication: staff meetings, telephone conversations and personal contacts.
Lawyers usually look at recommendations made about:
nothing by mouth (NPO)
videofluorographic swallow studies
dietary recommendations
clinical documentation
inadequate clinical documentation: handwritting is illegible, diagnosis reports and notes are too brief and vague
Bedside: Answer within functional limits (WFL) within normal limits (WNL) not adequately assessed (NAA) *WNL but actually mean incompletely asses, patient was unresponsive and only partially assessed
diagnostic and treatment practices relative to current professional standars
Main question: parties involved fell below current accepted and general standards of professional conduct in their management of the patient
usually asked “if a clinician practicing within professional stands have made the same conclusion this clinician made?
dysphagia
a swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction.
consequences of dysphagia
malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking, and even death.
disinterest, reduced enjoyment, embarrassment, and/or isolation related to eating or drinking.
Dysphagia intervention may concentrate on
swallowing exercises, compensatory swallowing strategies (including posture considerations), bolus consistency modification, and caregiver/patient education.
Incidence
refers to the number of new cases of dysphagia identified in a specified time period.
Prevalence
refers to the number of people who are living with dysphagia in a given time period.
Each year, approximately ____ adults will experience a swallowing problem in the United States
one in 25
prevalence of dysphagia is more common among
older individuals and that sarcopenia (n age related, involuntary loss of skeletal muscle mass and strength) is positively associated with dysphagia
Dysphagia rates
3% adults ages 45 and up 15% - 22% in 55 yrs 60% in skilled nursing facilities 30% in old people receive inpatient medical treatment 68% are in long term care settings 13-38% living independently
pneumonia
- advance age is a risk factor for it
- 1/3 of patients with dysphagia develop it
- 60k individuals die from such complications
dysphagia in stroke population
low as 37% when found in screening procedures
high as 78% when using instrumental assessments
- occurs in 1/3 of patients who admitted into stroke rehabilitation units
- occurs in 6]29-64% of stroke patients
Dysphagia prevalence in Amyotrophic lateral sclerosis (ALS)/ PArkingsons disease
90%
Dysphagia prevalence in critical illness and covid
3-62% in illness
20.6% COVID patients
Dysphagia prevalence in dementia
13 - 57%
Dysphagia prevalence in GERD
14%
Dysphagia prevalence in head and neck cancer
50%
Dysphagia prevalence in parkingsons disease
82%
Dysphagia signs and symptoms
- drooling
- innefective chewing
- food or liquid remaining in oral cavity
- cant keep lips closed; leaking of food
- extra time needed to chew or swallow
- leaking form nasal cavity
- food “stiking” or “fullneck” on neck
- pain when swallowing
- change in vocal quality
- difficulty coordinating breathing and swallowing
Dysphagia causes
may develop secondary to damage to the central nervous system (CNS) and/or cranial nerves, and to unilateral or bilateral cortical and subcortical lesions
EX: stroke, TBI, dementia, parkingsons disease, spinal cord injury,
Head and nack like: cancer, radiation or chemoradiation, trauma or surgury, decayed or missing teeth
RARELY but: side effects of medication, metabolic disturbance, infection diseases, pulmonary disease
IPP
interprofessional practice s critical to successfully achieving the desired improvements and outcomes due to complexities of assessment and treatment of swallowing disorders.
SLP role in swallowing disorders
indeitify signs and symptoms,
assessing swallowing
providing treatment documenting process and adjusting treatment plans
providing educational consulting to individuals and caregivers
Screening
identifies the need for further assessment and may be completed prior to a comprehensive evaluation
- Swallowing Screening: is a procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services
PURPOSE: determine the likelihood that dysphagia exists and the need for further swallowing assessment
Maybe:
- interview or questionnaire
- monitoring the present of swallowing dysfunction
- patient/caregiver report or observation of difficulty with intake
- standardized screening protocols
- modified Evans blue dye test
Comprehensive assessment
includes non-instrumental and instrumental procedures.
Could be:
- review of medical records
- evaluation of impact of cognitive deficits on swallowing
- previous screening and assessment of swallowing results
- inspection of oral mechanism, cranial nerve assesment voice assesment, motor speech patterns cognition and communication
purpose of assessment is to identify and describe
- typical and atypical parameters of structures and functions affecting swallowing;
- effects of swallowing impairments on the individual’s capacity for, performance in, and participation in activities; and
- contextual factors that serve as barriers to or facilitators of successful swallowing and participation for individuals with swallowing impairments.
non-instrumental swallowing assessment
purpose: to determine the presence (or absence) of signs and symptoms of dysphagia, with consideration for factors such as fatigue during a meal, posture, positioning, and environmental conditions.
Consideration of: physical, social, behavioral and cognitive status vocal quality at baseline management skill's cranial nerve function posture and oral care
Instrumental Swallowing Assessment
used to evaluate oral, pharyngeal, laryngeal, upper esophageal, and respiratory function as they apply to normal and abnormal swallowing. Instrumental procedures are also used to determine appropriateness and effectiveness of treatment strategies
Main 2:
- Videofluroscopic swallowing study (VFSS)
- Flexible Endoscopic Evaluation of Swallowing
- do not require certification
Primary dysphagia intervention goal:
- support adequate nutrition and hydration (return to oral intake)
- determine best posture or assistance needed to reduce patient and caregiver burden and maximizing patients quality of life
- develop treatment plan to improve safety and efficiency of the swallow
Treatment of dysphagia includes:
restoration of normal swallow function (rehabilitative) and/or modifications to diet consistency and patient behavior (compensatory).
- exercises to create lasting functional improvement.
Biofeedback
incorporates the patient’s ability to sense changes and aids in the treatment of feeding or swallowing disorders
Types of treatments
- diet modifications
- electrical stimulation
equipment/environmental modifications - maneuvers (efforful swallow, mendelsohn maneuver, supraglottic swallow)
- swallowing exercises
- postural techniques
- tube feeding
