Do I need special certification from ASHA to treat dysphagia or to perform instrumental assessments such as fiberoptic endoscopy (i.e., FEES) and modified barium swallow studies?
No. ASHA's Code of Ethics states that "Individuals shall engage in the provision of the professions that are within the scope of their competence, considering their level of education, training, and experience." How one attains and maintains competency in a given area is up to that individual and her director and/or facility. ASHA's practice policy documents include knowledge and skills statements that can be used to guide members or institutions in developing competency assessment programs.
ASHA's clinical specialty certification program is a means by which individuals with advanced knowledge, skills, and abilities can be recognized. The Special Interest Group for Swallowing and Swallowing Disorders has established a specialty board which will receive applications from those interested in specialty certification for swallowing. Specialty certification is a voluntary program and is not required by ASHA to practice in any disorder area.
Some instructors of workshops or courses offer a certificate upon completion of their program, or stipulate more specific guidelines to becoming "certified" in a procedure or area of practice. ASHA does not recognize nor require these certifications.
Does a physician need to be present during endoscopic evaluations of swallowing (also known as FEES)?
According to the "Scope of Practice in Speech-Language Pathology" (2001), the practice of speech-language pathology involves, "using instrumentation (e.g., videofluoroscopy, EMG, nasendoscopy, stroboscopy, computer technology) to observe, collect data, and measure parameters of communication and swallowing, or other upper aerodigestive functions in accordance with the principles of evidence-based practice". Further, "speech-language pathologists with expertise in dysphagia and specialized training in fiberoptic endoscopy are professionals qualified to use this procedure for the purpose of assessing swallowing function and related functions of structures within the upper aerodigestive tract," according to the position statement "Roles of the Speech-Language Pathologist and Otolaryngologist in the Performance and Interpretation of Endoscopic Examinations of Swallowing" (1999). It is important, however, to check with your state licensing board, as some states may specifically prohibit SLPs from passing the endoscope or require that a physician be present. In addition, payers (e.g., Medicare, private health plans) may have specific requirments regarding physician involvement.
The radiologist in my facility no longer wants to participate in modified barium swallow procedures. Is this allowed by ASHA?
Currently, there is no national Medicare policy regarding the presence of the radiologist. However, local Medicare Administrative Contractors (MACs) and some state regulatory agencies for radiology procedures may require a radiologist's presence during VFSS. It is not required by ASHA that a radiologist or other physician be present during the study. However, the document states that, "relative to today's standard level of practice, most VFSSs are performed with both the SLP and radiologist present." If the radiologist or other physician is not present, the SLP must assess and comment on swallowing physiology and function only. No medical diagnoses can be rendered by the SLP (e.g, reflux, the presence of a tumor). While the radiologist or physician's presence is not required by ASHA policy, Medicare and state guidelines should also be considered. For more information, see "Must a radiologist be present during a videofluoroscopic swallowing study?" [PDF]
My administrator wants me to train the occupational therapist in my facility to perform dysphagia evaluations and treatment. Should I do this?
ASHA maintains that SLPs are primary providers of dysphagia services and that the foundation of their knowledge and skills in swallowing and feeding is not transferable to other professions. In addition, the document Multiskilled Personnel states that "cross-training of clinical skills is not appropriate at the professional level of practice." The Code of Ethics states that "individuals shall delegate the provision of clinical services only to persons who are certified or to persons in the education or certification process who are appropriately supervised." Each profession is different in its academic and clinical preparation; thus, a professional cannot make assumptions about the knowledge base or experience of someone from another discipline. SLPs could be held responsible for a professional in another discipline working under the auspices of SLP training. Furthermore, many such requests from administrators may be based on the expectation that competency in dysphagia management can be acquired quickly by attending a course or by observing another professional for a short period of time. Working with your administrator to investigate alternative strategies for staffing and service provision by competent professionals is highly recommended.
I currently provide dysphagia services to adults and have been asked to see children with swallowing problems as well. Is there any additional knowledge or training I need to serve the pediatric population?
Definitely. ASHA's Code of Ethics states that "Individuals shall engage in the provision of the professions that are within the scope of their competence, considering their level of education, training, and experience." There are significant differences between adults and children when swallowing problems occur. Not only is the anatomy different, but treatment techniques vary depending on the age and abilities of the population. Before beginning pediatric dysphagia services, seek out additional training. You can do a literature search and read books and journal articles about pediatric dysphagia, attend workshops or take self-study programs, and seek a mentoring relationship with clinicians already serving this population. Current ASHA policy documents regarding swallowing and feeding, as well as videofluoroscopic swallowing studies, outline information specific to pediatrics.
My hospital administrator wants to reduce costs and thinks that reducing dysphagia services will save money. What data is there to show that dysphagia services are cost-effective?
The Agency for Health Care Policy and Research (AHCPR) developed a report about dysphagia in 1999. They found that bedside exams can detect aspiration risk with an 80% accuracy rate. Using this figure, and the fact that approximately 75% of all stroke patients exhibit some form of dysphagia, it was concluded that 150 of every 1000 stroke patients who aspirate would be missed. The AHCPR report noted that 37% of patients with aspiration develop aspiration pneumonia. Therefore, approximately 56 of the 150 patients missed would develop pneumonia at a cost of $11, 000-$15, 000 per hospital course of treatment for pneumonia (total cost = $616,000-$840,000).
More recent data indicates that the average cost of hospitalization for people who have pneumonia post-stroke is $21,043, compared to $6,206 for people who have had a stroke without pneumonia. This is a $14,836 increase per patient and the researchers found that in their sample of Medicare patients, pneumonia occurred in 5.6% of those who had had a stroke (Katzan, I.L, Dawson, N.V., Thomas, C.L., Votruba, M.E., & Cebul, R.D. (2007). The cost of pneumonia after acute stroke. Neurology, 68, 1938-1943).
A typical instrumental assessment to identify aspiration risk costs approximately $250. If all patients identified with dysphagia at bedside were followed up with an instrumental assessment, the cost would be $200,000 (800 patients x $250/exam). As you can see, this figure is well below the cost of treating pneumonia. Proper dysphagia treatment can save a facility thousands of dollars per patient, which makes it very cost effective.
I have heard that the use of blue dye in swallowing assessments is being questioned by many facilities. What is ASHA's position about using blue dye?
The FDA recently published an advisory on " Reports of Blue Discoloration and Death in Patients Receiving Enteral Feedings Tinted With the Dye, FD&C Blue No. 1". The purpose of this advisory was to alert practitioners about reported cases of patients experiencing blue discoloration of the skin or other organs, as well as more serious complications, after receiving blue-tinted tube feedings. Although a definitive link between the blue dye and these complications has not been established, many facilities have reduced or even banned the use of blue dye. ASHA does not endorse any procedure or therapeutic technique and therefore does not have a position about the use of blue dye for swallowing assessments. Certainly, SLPs who use blue dye need to be aware of this FDA advisory and consider the use of blue dye in patients who may be at risk for complications. In a 2003 ASHA Leader article, Nancy Swigert summarized the issues surrounding the use of blue dye in swallowing assessments. It should be noted that there no longer appear to be any distributors selling single-use vials of sterile blue dye.
I work in a skilled nursing facility and have recommended that one of my patients with advanced dementia not eat orally because she is not eating enough and is at high risk for aspiration. The family has refused a feeding tube. Should I remove myself from this case?
This is a common scenario faced by SLPs who work with medically complex patients, particularly those nearing end of life. An SLP asked to evaluate a patient is being asked to give a professional, clinical opinion about the best course for that particular patient and make appropriate recommendations. A patient with decision-making capacity, or the family or other established decision-maker, has the right to accept or refuse such recommendations. If the SLP believes that there is something to offer in the way of suggestions for how to safely eat orally, it is in the best interest of the patient to offer such suggestions. If, however, the SLP can suggest nothing that may help the patient eat more safely, the SLP may have to discontinue services, but should be available in the event that there is a change in status or the patient or family would like to discuss the situation further. In any case, careful documentation of evaluation results, observations, recommendations, discussions with the patient, family, and staff, etc. is very important and will be the clinician's best reference in the event that the SLP is questioned about recommendations and participation in the case.
ASHA has a number of articles and resources that discuss approaches to these complex clinical and ethical issues: