Speech-language pathologists in New Jersey have successfully overturned a state prohibition against the use of FEES (Flexible Endoscopic Evaluation of Swallowing) and gained recognition of the procedure in the state's scope of practice for SLPs.
As FEES has become more widely used, most states have not explicitly prevented SLPs from passing the endoscope, although many state laws consider any endoscopy procedure to be medical or surgical. In New Jersey, however, four years ago the state restricted SLPs' autonomy in performing the procedure. Clinicians' participation was restricted to feeding, observing and interpreting, but the physician had to pass the scope.
"Many states are silent on such issues as FEES, tracheo-esophageal puncture, suctioning, and cerumen management, and SLPs and audiologists can include these procedures in their clinical practice," noted Hilda Pressman, an SLP involved in the effort. "But when a state explicitly prohibits a procedure, the policy is difficult to reverse."
In their efforts, clinicians were motivated by patients' need for the procedure. "At the time, I had only thought about learning to do FEES. We pushed for recognition of this procedure because patients need it," said Pressman.
"In some cases, patients with swallowing problems may not be able to participate in videofluoroscopy, or it might not be available. It's important that patients have options so that their clinical needs can be met."
In 2001, the state's Audiology and Speech-Language Pathology Advisory Committee of the Division of Consumer Affairs responded negatively to queries by the New Jersey Speech-Language-Hearing Association (NJSHA) and ASHA about whether FEES was within the state's scope of practice.
"The answer was no," Pressman said. As a result, NJSLHA had no choice but to inform the state's clinicians to "cease and desist" from performing FEES.
But the state association's healthcare committee quickly sprang into action, formulating a plan to ask the advisory committee to "reinterpret" the decision.
Members of the state association did their research, gathering information from ASHA and from members around the country who had been involved in FEES (see resources). They prepared a detailed packet on FEES, which included background information and addressed a wide range of issues, including:
- description of the procedure
- historical perspectives
- patient consumer safety
- ASHA practice document on FEES
- clinical need for FEES in NJ
- patient impact
- economic impact
- information about videoendoscopy and videostroboscopy
- statement by the American Academy of Otolaryngology Head and Neck Surgery (which at that time supported SLPs performing FEES independently; in 2003 AAO-HNS developed its own position statement and requested that ASHA withdraw the joint statement)
- CPT codes for FEES and FEEST
- videotape of FEES procedure
With their research in hand, NJSHA representatives asked for a hearing. They made a verbal presentation to members of the advisory committee, including a member of the medical committee, in late 2002. NJSHA members Susan (Hiss) Butler, William Roche and Hilda Pressman, accompanied by the NJSHA lobbyist appeared before the committee. Besides providing a summary of the written information, the clinicians presented a videotape of the FEES procedure.
"We pointed out that the scope of practice included selecting, fitting, and establishing effective use of tracheoesophageal valves which had a comparable level of specialization," said Pressman, who appeared before the committee along with colleagues Butler and Roche. "We kept our presentation focused on meeting patient needs and the negative impact on the quality of care for patients if FEES was not included in the scope of practice. The committee asked a lot of questions, particularly about patient safety and the training required to perform FEES."
Subsequent to the presentation, the state's advisory committee decided to develop regulations governing SLPs' use of FEES. Once the committee reached consensus, the rules and regulations had to pass through multiple levels of oversight and review. Finally, proposed rules were published in May 2004 with a 60-day period for comment.
NJSHA prepared comments with assistance from ASHA and members of Division 13, Swallowing and Swallowing Disorders. Four years of advocacy paid off on Jan. 3, 2005, when the final regulations were published.
"We were excited, especially since they took effect earlier than we expected," Pressman said. She recalled a similar success on newborn hearing screening that she had led with the help of Anne Eckert.
"I hadn't thought about it in years, but the memory came flooding back," she said. "We had worked in a similar way with a small group writing the proposed regulations and, with ASHA's help, pushing the issue forward.
"Based on our experience, I would encourage other SLPs to check with their state association first rather than directly asking the licensing board," Pressman added.
"Also you should be credentialed to carry out these procedures."