Swallowing disorders may occur because of a wide variety of neurological and non-neurological conditions-including oropharyngeal or esophageal cancer; neurologic diseases such as stroke, traumatic brain injury, spinal cord injury; and degenerative neurological diseases. They are common in military veterans, in part because of the demographics of the population. As a result, dysphagia care has become the primary clinical activity for speech-language pathologists at the Veterans Health Administration (VHA), the nation's largest integrated health care system.
Consider the demographics: Veterans are older than the general population, with 49% older than 65. Veterans tend to be sicker than patients of the same age and are more socio-economically challenged than the general population. Only 7% of VHA patients are female, but the number of female veterans is expected to increase.
As part of the Department of Veterans Affairs (VA), VHA has a budget of $31.5 billion and 198,000 employees, and is one of the nation's largest employers of audiologists and speech-language pathologists. VHA operates 154 medical centers (at least one in each state, Puerto Rico, and the District of Columbia) and more than 1,400 sites of care, including 875 ambulatory care and community-based outpatient clinics, 136 nursing homes, and 44 residential rehabilitation treatment programs. More than 5.3 million people received care in VA health care facilities in 2005. Of these, 586,000 were veterans. VA's outpatient clinics registered nearly 57.5 million visits.
VHA employs 252 clinical SLPs, 16 research SLPs, 19 clinical fellows, and 42 master's trainees at 112 VA medical centers. As elsewhere, VHA SLPs are involved in the management of stroke, dysphagia, cognitive-linguistic deficits, geriatric and degenerative neurological diseases, and traumatic brain injury in a variety of clinical settings.
Significant Role for SLPs
Given the potential for mortality and morbidity and the impact on quality of life and medical status related to dysphagia, VHA is developing a system-wide approach to dysphagia care. This approach is characterized by streamlined referrals to SLPs for clinical or instrumental swallowing evaluations, enhanced risk communication, interdisciplinary collaboration, evidence-based treatment and management, coordination and collaboration across the continuum of care, monitoring of long-term diet consistency orders, and standardization of diets and diet terminology.
VHA established a multidisciplinary task force including dietitians, dentists, and dental hygienists, nurses, occupational therapists, pharmacists, physicians, and SLPs to develop comprehensive policies and guidelines addressing identification, evaluation, treatment, monitoring, and follow-up of patients with dysphagia disorders.
The VHA's National Audiology and Speech Pathology Program Office appointed a Dysphagia Task Force to develop guidelines and to advise VHA on national policy. The task force developed national guidelines related to:
- Using clinical and instrumental techniques in evaluation of patients with oral, pharyngeal, and upper esophageal dysphagia
- Implementing dysphagia management (compensatory), treatment (rehabilitative) and follow-up care
- Monitoring and re-evaluation of diet modifications
- Posting feeding and/or swallowing information in accordance with Joint Commission Association on Accreditation of Healthcare Organizations (JCAHO) standards and patient privacy rules
- Using assistive swallowing devices (for oral and pharyngeal dysphagia) and assistive feeding devices (for deficits manipulating the food from the plate to the mouth)
SLPs are also participating in multidisciplinary task forces to develop nursing assessments for swallowing disorders (with nursing), standardization of diets and diet terminology (with nutrition and food services), and guidance on pre-thickened liquids for inpatients and residents (with dietetics) and thickening agents for outpatients through the VHA national system of pharmacies (with dietetics and pharmacy).
Evidence-based research studies, published clinical reports, clinical experience, and varying clinical scenarios were utilized to develop dysphagia guidelines with primary support obtained from ASHA's position statements and technical reports on dysphagia and from ASHA's Special Interest Division 13.
VHA dysphagia care recognizes the importance of interdisciplinary communication among physicians and nurses, pharmacists, SLPs, dietitians, and other health care practitioners involved in the management of patients and residents with swallowing problems. Physicians refer any patient identified with swallowing problems during the initial nursing assessment, or at any time during hospitalization or stay, for clinical examination or instrumental swallowing evaluation by a speech-language pathologist within 72 hours. Until this examination is completed, physicians use clinical judgment to order nothing by mouth (NPO), with specific instructions for nutrition and medication by non-oral means (e.g. nasogastric tube); or, order that the patient be placed on a modified diet to enhance safety.
Physicians and SLPs enter appropriate clinical warnings in the electronic patient record to enhance risk communication. SLPs enter dysphagia diagnoses in an electronic problem list monitored by all health care practitioners. Nurses ensure that all patients admitted to the facility receive an initial nursing assessment of oral hygiene, swallowing, and feeding status within 24 hours after admission. Nurses immediately notify the physician responsible for the care of the patient that a swallowing or feeding problem has been identified during initial assessment or at any time during the hospital stay and immediately initiate the referral (consultation) process to an SLP for clinical examination and swallowing evaluation. Pharmacists assess the medication regimen in patients with swallowing disorders following guidelines developed by the Pharmacy Service. Prescription thickening agents have been added to the national formulary and will be available at all VHA outpatient pharmacies.
The dysphagia care approach is part of an ongoing focus on quality improvement. In the last three years, positive reviews of the VHA system have appeared in Fortune magazine, Business Week, the Journal of the American Medical Association. In 2003, the New England Journal of Medicine compared VA health care and fee-for-service Medicare on 11 specific measurements of quality and found VA patients fared "significantly better" than patients in the private sector. The independent National Committee for Quality Assurance, which ranks health care plans according to 17 performance criteria, found VA out-performing America's best private sector hospitals in all areas in 2004.
The American Customer Satisfaction Index (ACSI), which ranks customer satisfaction with various federal programs and private-sector industries, gave VA's inpatient care a rating of 83 on a 100-point scale, as compared to a 73 rating for inpatient care by the private-sector health care industry.
Disclaimer: The opinions expressed herein are solely those of the authors and do not reflect the views or official policies of the United States Government or the Department of Veterans Affairs.