Speech and Language Therapy Guidelines for Practitioner Led Videofluoroscopy Service. Contents

Transcription

1 Speech and Language Therapy Guidelines for Practitioner Led Classification: Clinical Guidelines Lead Author: Laura O Shea AHP Lead for Adult SLT Additional author(s): Lisa Lyon Senior Radiographer Authors Division: Clinical Support Services and tertiary medicine Unique ID: Sal2(05) Issue number: 6 Expiry Date: June 2019 Contents Section Page Who should read this document 2 Key messages 2 Scope of service 2 What is new in this version 2 1 Guidelines 3 Protocol1 Reserch Thin fluids 6 Protocol 2 Clinical Thin fluids 7 Protocol 3 Clinical Thickened fluids 8 Protocol 2 Clinical Puree / Diet textures 9 2 Standards 13 3 Explanation of terms/ Definitions 13 4 References and Supporting Documents 13 Appendix 1 Videofluoroscopy report form 2 Penetration / Aspiration Scale Document control information (Published as separate document) Document Control Policy Implementation Plan Monitoring and Review Endorsement Equality analysis Page 1 of 13

2 Who should read this document? This protocol should be read by Speech and Language Therapists (SLTs) and Specialist Radiographers who carry out videofluoroscopy (VFS) examinations for oropharyngeal dysphagia. Scope of Service: The service provides VFS assessment and review for patients with neurogenic dysphagia (for example following stroke) and patients with n-complex oropharyngeal dysphagia. The service provides follow-up assessments for patients previously assessed in the consultant-led service who only require further monitoring of oropharyngeal function or treatment strategies. For the provision of clinical VF the service is coordinated and run by a Senior GI Radiographer and Specialist SLTs. The clinic also incorporates some research slots that are staffed by the Senior GI Radiographer and existing research staff. The whole service operates under the indirect supervision of Dr H Burnett and Dr N Townsend as part of GI radiological investigations. The clinic runs over one session a week and comprises two research slots and three clinical slots. Key Messages Speech and Language Therapists (SLTs) and Specialist Radiographers will carry out videofluoroscopy (VFS) examinations for oropharyngeal dysphagia in the Practitioner Led Clinic in accordance with this protocol. Background & Scope The Royal College of Speech and language Therapists (RCSLT) recommends that any person with feeding or swallowing difficulties have equal access to a timely, responsive and quality instrumental evaluation of swallowing as part of a dysphagia care pathway. VFS should be performed in a multidisciplinary context. Typically, the professionals involved include SLTs specialised in the procedure, radiologists and radiographers. Reports indicate that access to VFS for patients in the UK is under threat (Begg and Paton 2004) due to workforce difficulties and pressure on radiologist time (Royal College of Radiologists : Clinical Radiology workforce in crisis 2002). Against this background, RCSLT considers that it is within the scope of SLT practice to establish joint VFS clinics with specialist radiographers. A steady increase in referrals for VFS locally led to the development of the Practitioner Led VFS Service at Salford Royal NHS Foundation Trust. This document provides a guideline for staff involved in VFS without the presence of a radiologist, primarily SLTs, radiographers and research staff. Page 2 of 13

3 What is new in this version? No ammendments made. Guidelines 1.1 Referral: Patients must undergo an appropriate clinical assessment of swallowing by an SLT prior to VFS being undertaken. For clinical VF a report form should be filled in and saved on the shared drive (Appendix 1). For research VFS a member of the research team completes a standard Salford Royal NHS Foundation Trust barium investigation referral form and sends it to the superintendent radiographer. The referring SLT will contact x-ray by phone to book the patient in and then fill in the patient s hospital number against the relevant slot in the electronic VFS calendar. The imaging request is also completed and sent to the x-ray department It is the responsibility of the referring clinician to ensure that the request is completed fully and in particular to inform of any infection control risks eg MRSA. Referrals will only be accepted by radiology from an SLT with the appropriate training. Requests must be forwarded to radiology at least one working day before the clinic. For clinical VF, the referring SLT will indicate on the referral his/her opinion as to whether the patient requires a practitioner-led or Consultant-led slot. This enables the Senior Radiographer to discuss the referral with the GI radiologist to confirm justification for the examination under the IRMER regulations. If appropriate the patient is allocated to either the practitioner-led service or a consultant-led service. 1.2 Exclusion Criteria: Any patients with the following conditions should be referred directly to the consultant-led clinic for their initial assessment. Head and Neck Cancer Tracheostomy and/or Respiratory Support Complex Physical Disability Learning Disability Spinal Injury/Surgery Any condition where pharyngo-oesophageal problems are suspected Any patients with complex or unkwn aetiology Page 3 of 13

4 1.3 Assessment Protocols: Screening Assessment (thin liquid 60% w/v) All research patients are assessed in the first instance using protocol 1 (appendix 2). The protocol is based on the assumption that all patients are able to:- a. Understand the assessment process b. Give their written consent c. Comply with the physical demands of the assessment For clinical VFS, there is evidence to support modifying the protocol depending on the videofluorographic findings (Periman et al 1997). The protocol should be used as a guide initially but may be tailored to address specific questions raised during the procedure. In addition to texture modifications, clinical VF assesses the potential benefits of postural s (eg chin tuck, head rotation) and airway protection techniques (eg effortful swallow, supraglottic swallow, Mendelsohn Maeuvre). The examination is only commenced and continued when positioning and images are of sufficiently high quality to achieve accurate assessment and determine the exact course of any aspirated material. The image quality and positioning is continually monitored by the radiographer to ensure the acquisition of useable date. If there is concern the procedure is discontinued. The protocol has been designed to allow for the swallow mechanism to be tested with increasing bolus volumes and consistencies. However, this is dependent on patient tolerance and amount of aspiration or risk identified. All clinicians should be aware that they have a clinical duty to minimise aspiration and risk and the protocol should be discontinued if risk is identified. Both research and clinical protocols include an examination of the anterior posterior view of their oropharynx. The boluses are screened as they pass through the oropharynx and into the cervical and thoracic oesophagus, or as far as the screening equipment permits. In addition to this they may help to inform clinical use of swallow s/postures. The swallow is evaluated for the degree of airway compromise using the Penetration-Aspiration scale (Rosenbek 1996) (see appendix 3). 1.4 Safety Criteria: Research Procedures The procedure should be terminated if: a. The patient has aspirated more than 50% of the bolus on 3 occasions. b. The patient is estimated to have aspirated more than 15mls barium. 1.5 Clinical Procedures: The clinical protocols documented offer structured management of risk throughout the assessment with clear guidance on when a procedure should be terminated (see appendix 4-6). Page 4 of 13

5 1.6 Other Criteria: In addition to the above, all procedures carried out should be discontinued if: the patient refuses; ii. the patient fatigues; iii. the patient becomes unwell; iv. there is a medical emergency; v. there is a hospital emergency; vi. adequate data is acquired; vii. there are technical difficulties. Where there is concern about aspiration affecting the respiratory system an appropriate opinion will be sought on the need for chest x-ray and physiotherapy follow up. 1.7 Reporting and Follow up: For research procedures the baseline assessment form (protocol 1 see appendix 2) is completed during the examination. A summary is entered into the medical records as an account of the protocol followed with general comments about the patient s swallow performance. For clinical VF the DVD is reviewed and a report compiled using the SLT Videofluoroscopy Report Form (see appendix 1). After verification the report will be available on EPR. 1.8 Assessment Materials: Thin Barium liquid is made up using E-Z Paque (Barium sulphate Ph Eur 96% w/w) manufactured by EZ-EM. The ratio of barium sulphate powder to water should be 60%. This is made by adding 350mls water to 177grams of E-Z-Paque. All other liquids and purees are made by adding Nestle Resource Thicken Up Clear to the above suspension in accordance with the recipes available in the Speech and Language Therapy Department. 1.9 Equipment: Videofluoroscopy is carried out using either a Siemens Artis Zee MP with images captured using Syngo software (Siemens Aktiengesellschaft medical Engineering, Henkestrasse 127, D Erlangen, Germany). X-ray images are acquired in real time using Fluorospot T.O.P software and recorded by digital video (Sony DHR 1000, Sony UK Ltd., Weybridge, Surrey, United Kingdom). Instructions for equipment use are available in fluoroscopy rooms. All staff should be appropriately trained in the use of equipment. A suitable chair is available for patients who are unable to stand Data Storage: Data is stored on DVD (Verbatim DVD +RW). The digitised images are acquired using pulsed fluoroscopy and have a configuration of 1024 x 1024 with 10 bits per pixel, allowing for 1023 increments on a grey scale From the Artis Zee equipment, images can be sent to PACS if requested by the Speech and Language therapist. These images are downscaled to 512 x 512 prior to transfer to PACS. All DVDs are stored in a locked cupboard in Fluoroscopy and must be signed out before removal. Data will be stored for 7 years in accordance with Trust policy for medical records. Page 5 of 13

6 50 mls 5 mls Research - Protocol 1: Videofluoroscopic Baseline Assessment for Thin Liquids Documentation Questions (answer all) Recommendation PA Score % Aspirated Trace / Frank Do 100% of swallows score > 5 on P/A scale PROCEED Bolus 1 Continue No Do 100% show aspiration > 50% of volume given? PROCEED Bolus 2 Continue No Bolus 3 Go to Questions Is the patient distressed or refusing? No PROCEED Are the team concerned about risk to the patient? PROCEED Bolus 4 Continue No Have you answered answer to one or more questions? Bolus 5 Continue Review tape frame by frame & repeat Q s Repeat Does the patient have a answer to one or more questions? PROCEED Bolus 6 Q s Yes No STOP & PROCEED TO PROTOCOL 2 Bolus 9 No of Swallows Laryngeal pattern continuous / mixed / repeat Page 6 of 13 Worst Overall Time to complete

7 Protocol 2 - Clinical Videofluoroscopy Thin Fluids symmetrical Assess using 5ml thin fluid x 2 in lateral P/A => 5 Assess using 5ml x 1 thin AP Assess symmetry Turn patient back o lateral to assess amount of residue and consider appropriacy of trialing posture/maeuver. trial appropriate Assess posture/ P/A =>5 asymmetrical Head turn t effective trial t appropriate Start Assess using 10ml thin x 2 lateral Assess using head turn Stop assessment and go to protocol 3 - thickened fluids Posture/ t effective Head turn effective Posture/ effective Assess cup drinking 50ml in lateral Commence rmal fluids P/A => 5 Posture/ effective Consider appropriacy of trialing posture/ maeuver. trial appropriate Assess posture/ KEY Action required trial t appropriate Stop assessment Speech & Language Therapy Guidelines for Posture/ and go to protocol Practitioner Led t effective 3 - thickened fluids Page 7 of 13 Action &/or decision leading to two possible outcomes

8 Appendix 5: clinical Protocol 3 - Clinical Videofluoroscopy Thickened Fluids Posture/mauevre effective Did trial with thin (or syrup) fluids result in excess residue which the patient could t clear? Start Assess posture/ Posture/ t effective trial appropriate Discontinue Assess using 2 x 5ml in lateral P/A >= 5 Consider appropriacy of trialing posture/ maeuver. trial t appropriate Stop assessment and go to protocol 4 - diet textures Is there excessive residue? Commence thickened fluids P/A >= 5 Assess using 2 x 10ml in lateral P/A >= 5 KEY Is there excessive residue? Assess using 50ml cup drinking Is there excessive residue? Action required Discontinue Page 8 of 13 Action &/or decision leading to two possible outcomes

9 Appendix 6: Clinical Protocol 4 - Clinical Videofluoroscopy Puree/Diet Textures Start Did trial with thin or thickened fluids result in excessive residue? Discontinue Not appropriate Trial 1 bolus of diet texture P/A >= 5 Consider appropriacy of trialing posture/ Posture/ t effective appropriate Discontinue Is there excessive residue that the patient cant clear? Trial posture/ Not appropriate Posture/ t effective Consider appropriacy of trialing posture/ P/A >= 5 Trial further boluses as indicated by clinical need Posture/ effective appropriate KEY Trial posture/ Posture/ effective Is there excessive residue that the patient cant clear? Discontinue Action required Introduce diet Current Version texture is held on the Intranet Page 9 of 13 Action &/or decision leading to two possible outcomes

10 2. Standards A description of the responsibilities of all professionals undertaking VFS must be clearly stated in the individual s job description. Theoretical kwledge and clinical practice in VFS must be evidenced within an individualised competency framework and annual review. All staff must read and work within the Directorate of Clinical Radiology Local Rules. All staff involved in VFS procedures should be appropriately trained in accordance with their professional guidelines and local standards. All staff must be appropriately trained to hoist patients in accordance with the Trust s Moving and Handling Policy. A written record of consent to VFS for research patients should be documented (eg documentation of discussion in patient s tes). If there are agreed standards that must be followed (as will be the case for a policy or protocol) then these should be listed in this section Explanation of terms & Definitions Terms explained in document. 4.0 References and Supporting Documents Videofluoroscopic Evaluation of Oropharyngeal Swallowing Disorders (VFS) in Adults. The role of Speech and language Therapists. Begg T, Paton, G Issues of access. Bulletin of the Royal College of Speech and Language Therapists 2004; 627 (July) Royal College of Radiologists Clinical Radiology. A Workforce in Crisis London, August Perlman A L, Luc, Jones B Radiographic contract examination of the mouth, pharynx and oesophagus. In: Perlman A, Schulze-Delrieu Ks editors. Deglutition and its disorders. Anatomy, physiology, clinical diagsis, and management.1st ed San Diego: Singular; 1997 Rosenbek J C, Robbins J A, Roecker E B, Coyle J L, Wood J L, A Penetration aspiration scale. Dysphagia, Spring; 11 (2) : Page 10 of 13

11 APPENDIX 1: SLT VIDEOFLUROSCOPY REPORT FORM Patient s Name: DOB: Hospital No: Radiographer/Radiologist: Date of Study: Speech & Language Therapist: Date of Report: Medical Diagsis and Reason for Referral: Summary of Findings: Conclusions and Recommendations: Signed.Date:. Page 11 of 13

12 APPENDIX 2 Penetration / Aspiration Scale Rosenbeck et. Al (1996) Score Criteria 1 Material does t enter the airway 2 Material enters the airway, remains above the vocal folds, and is ejected from the airway 3 Material enters the airway, remains above the vocal folds, and is t ejected from the airway 4 Material enters the airway, contacts the vocal folds, and is ejected from the airway 5 Material enters the airway, contacts the vocal folds, and is t ejected from the airway 6 Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway 7 Material enters the airway, passes below the vocal folds, and t ejected from the trachea despite effort 8 Material enters the airway, passes below the vocal folds, and effort is made to eject Page 12 of 13

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