Session #: R10 CASE STUDIES IN DYSPHAGIA DIAGNOSIS, TREATMENT AND REDUCTION OF REHOSPITALIZATIONS

Transcription

1 Session #: R10 CASE STUDIES IN DYSPHAGIA DIAGNOSIS, TREATMENT AND REDUCTION OF REHOSPITALIZATIONS PRESENTERS Dr. ERIC BLICKER, CCC-SLP.D., BCS-S COMMUNITY CARE PARTNERS, INC. PHONE: MS. JESSICA MAY, M.A. CCC-SLP LEAD ENDOSCOPIST OHIO, PENNSYLVANIA MOBILE ENDOSCOPIX, LLC PHONE: Objectives: Explain effect of dysphagia diagnosis and rehospitalization risk Understand how dysphagia correlates to frequent diagnoses associated with preventable readmissions Convey importance of early intervention and diagnosis 1

2 Objectives Continued Explain why FEES (Fiberoptic Endoscopic Evaluation of Swallowing) is a highly accurate diagnostic tool to detect swallow disorders and achieve optimal patient outcomes Discuss potential cost savings when the number of patients on modified diets is reduced Experience a live demonstration of FEES to help visualize how it can be used on site, even at bedside to help make immediate diet recommendations DEFINITION OF DYSPHAGIA Difficulty in swallowing. IMPACT OF DYSPHAGIA PER THE AMERICAN SPEECH HEARING ASSOCIATION 2018 WEBSITE: Malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking, and even death may be a consequence of dysphagia. 2

3 PREVALENCE AND IMPACT OF DYSPHAGIA Prevalence of Dysphagia Dysphagia affects 75% of nursing home residents. Dysphagia impacts as many as 15 million Americans, with about 1 million patients receiving a new diagnosis of the condition every year. [1] PREVALANCE OF DYSPHAGIA IN THE ELDERLY In the general Midwestern population, the prevalence of dysphagia is reported to be between 6% and 9% In community-dwelling persons over age 50, dysphagia is estimated to be between 15% and 22% In Assisted Living and Skilled Nursing Facilities, it is reported that between 40% - 60% of the residents are reported to have feeding difficulties. [2] IN-PATIENT COSTS RELATED TO A DYSPHAGIA DIAGNOSIS Mean hospital length of stay is 8.8 days for those with a dysphagia diagnosis versus 5.0 days for those without (a 76% increase.) Patients with dysphagia are 33% more likely to be discharged to a post-acute care facility. [3] 3

4 COST OF DYSPHAGIA Avoidable readmissions for just 3 of the top 10 conditions cost Medicare about $4.3 billion in [4] 78% of 30-day hospital readmissions from a SNF are preventable. [4] 5 of the top 10 conditions related to readmissions are associated with dysphagia. [4] 5 CONDITIONS RELATING TO DYSPHAGIA AND HOSPITAL READMISSIONS [4] CHF COPD Respiratory Infections/Pneumonia UTI Sepsis DYSPHAGIA AND HOSPITAL READMISSIONS CHF (ICD 10 code: I50.3) Weakness Meal Fatigue Respiratory Difficulty Impaired Swallow Coordination 4

5 DYSPHAGIA AND HOSPITAL READMISSIONS Case Study: Patient with CHF DYSPHAGIA AND HOSPITAL READMISSIONS Respiratory Infection/Pneumonia (ICD 10 codes J00-J99) Breath Support Swallow Coordination Aspiration Pneumonia after Stroke (J69.0) [7-9] Aspiration Pneumonia due to other conditions[10] DYSPHAGIA AND AVOIDABLE HOSPITAL READMISSIONS Case Study- Recurrent PNA 5

6 DYSPHAGIA HOSPITAL READMISSIONS COPD (ICD 10 code: J44.9) Impaired swallow coordination Shortness of breath Coughing DYSPHAGIA AND HOSPITAL READMISSIONS Case Study: Patient with COPD DYSPHAGIA AND HOSPITAL READMISSIONS Sepsis (ICD 10 code: A41.9) Weakened Immune System Cognitive Impairment [11] 6

7 DYSPHAGIA AND HOSPITAL READMISSIONS UTI (ICD 10 code: N39.0) Prevalence of thickened liquids Reduced intake and hydration Cognitive impairments [11] DYSPHAGIA COMPLICATIONS DEHYDRATION: One of the most common causes of hospitalization among elderly individuals living in the community or long term care facilities Dehydration can impact physical & cognitive abilities Contributes to greater fatigue Increased fall risk [12-13] COMPLICATIONS OF DYSPHAGIA MALNUTRITION 54% of all SNF admissions are malnourished 60% experience an initial weight loss following admission [14] Research has been conducted to determine the characteristics of patients that are at risk to aspirate. Malnutrition is a trait in patients at risk to aspirate. Among patients with aspiration pneumonia assessed, 80% of these patients were also malnourished as determined by a dietitian. [15] 7

8 Dysphagia Affects Social Enjoyment Lack of self confidence Tendency to isolate No longer view mealtimes as a social gathering [16] DIAGNOSING DYSPHAGIA Swallow Evaluation Options Clinical Bedside Swallow Exam (CBSE) Videofluoroscopic Swallow Study(VFSS)/Modified Barium Swallow Study (MBSS) Fiberoptic Endoscopic Evaluation of Swallowing (FEES) 8

9 Clinical Bedside Swallow Exam (CBSE) Comprehensive Swallow Evaluation Clinical Inferences Only 42% accurate in identifying aspiration. [17] Beyond the Bedside Exam.False Negative Rate How many times has a patient appeared to perform well at bedside and then have an instrumental exam with different results. False negative rate determines the failure of a test to ID a group at high risk. Dr Leder from Yale found that the CBSE had a 14% FNR for acute stroke patients. In these instances, family and staff had been told that the patient was performing well with swallowing, when in actuality, the instrumental exam showed what the bedside could not. Leder et al Aspiration risk after acute stroke: comparison of clinical exam and FEES: According to Dr.Leder: even if the clinical examination is negative, visualization of the pharyngeal swallow is necessary [18] Videofluoroscopic Swallow Studies (VFSS)/ Modified Barium Swallow Studies (MBSS) See all Phases of the Swallow Helpful in identifying oral, cervical, and esophageal concerns X-ray Sample sizes of foods and liquids Barium Limited recording time Family cannot be present during x-ray 9

10 FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING (FEES) Flexible endoscope attached to a camera Passed through the base of the nasal pathway Superior view of the pharynx Swallow process recorded in color Images projected onto a laptop in real-time Hi-definition, live color video FEES is portable No transportation to and from the hospital Evaluate patients in their natural eating posture No use of barium No radiation exposure No time limitation during exam Accurate results are immediately available for prompt intervention to plan of care Signs and symptoms of reflux are viewable BENEFITS OF FEES Food preferences can be accommodated Determine the risk of poor oral hygiene Familiar environment (especially important for patients with Dementia) Assessment of structural changes in the larynx and pharynx Assessment of movement and sensation Assessment of secretions and management Direct visualization of swallowing function for food and liquid Response to therapeutic interventions Interdisciplinary team approach CBSE compared to FEES Case Study Pt placed on Puree/HTL following CBSE FEES determined one of the primary impairments to be pharyngeal constriction which made Puree/HTL some of the most difficult consistencies to tolerate 10

11 MBS vs FEES: What does the research say? Kelly et al (2007): FEES and MBS done simultaneously, graded severity of swallow with Penetration-Aspiration Scale (PAS) and PAS levels showed more severity with FEES exams. (Assessing penetration and aspiration: How do Videofluoroscopy and Fiberoptic Endoscopic Evaluation of Swallowing compare) The Laryngoscope, 117(10), ). [18] Singh et al (2009): patients had both FEES and MBS exams and FEES identified aspiration after the swallow with greater accuracy when compared to MBS. (Investigation of aspiration: Milk nasendoscopy versus videofluoroscopy. European Archives of Oto- Rhino-Laryngology, 266(4), ). [19] FEES vs MBS FEES photo is from Dr. Aviv. MBS photo is from FEES vs VFSS/MBSS 11

12 MBS vs FEES Remember this guy: Difference between FEES and MBS for Dementia patients FEES no barium use, this is an important consideration with Dementia patients Many Dementia patients reject barium and may have more willingness to accept unaltered bolus with FEES. MBS has radiation exposure which is important to consider when assessing swallow fatigue, as the FEES exam can be extended if needed. Many Dementia patients present with increased dysphagia behaviors as the meal progresses and FEES can capture this swallowing fatigue. Since there is no radiation, it is important to consider that FEES can be easily repeated in serial assessments on a patient as their clinical condition changes. Reasons to Refer for Instrumental Evaluation Known diagnosis of dysphagia Unknown root cause of the dysphagia Suspect silent aspiration Repeated bouts of chest infections or pneumonia Globus sensation Wet or gurgly vocal quality Weight loss over time Modified diet/diet upgrade 12

13 FEES Accommodates Various Conditions Isolation precautions Obesity Medical complexities Pressure ulcers/bed bound Feeding tubes Supplemental oxygen Speaking valves Ventilator dependence Dementia Success Rate of FEES Participation 99% of patients would undergo a repeat FEES exam[21] 82% of patients rated their discomfort level during a FEES exam at none to mild [21] Cost Savings An Instrumental Exam May Decrease the Need For: Pre-thickened liquids Alternate means for nutrition (i.e., health shakes) Enteral feeding Facility labor for altering food textures Transportation and staff time for hospital appointments 13

14 Billing and Reimbursement Evaluate Swallowing Function: (Reimbursement: $84.83) Endoscopy Swallow (FEES): (Reimbursement: $182.15) Facility SLP: Dysphagia Therapy or Cognitive Therapy (Reimbursement: $83.90) Physician: Interpretation of FEES Report (optional) (Reimbursement: $41.71) LET S SEE A FEES THIS PRESENTATION BROUGHT TO YOU BY: A Multi-State provider of Mobile FEES For more information contact us at:

15 REFERENCES 1. Dysphagia Fact Sheet DJO Medical Encore Medical, L.P., Aslam, M. and Vaezi, M. (2013 December) Dysphasia in the Elderly. Gastroenterology and Hepatology. PMC : PMID: November 16, 2017, Economic and Survival Burden of Dysphagia among inpatients in the U.S. Based on the massive AHRQ Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample ( ) database of 88 million patient records. 4. Healthcare Cost and Utilization Project: April Conditions with the Largest Number of Adult Hospital Readmissions by Payer, Mor V, Intrator I, Feng V et al. The revolving door of hospitalization from skilled nursing facilities. Health Affairs 2010;29: Garcia, J. M., Chambers IV, E., & Molander, M. (2005). Thickened liquids: Practice patterns of speech-language pathologists. American Journal of Speech-Language Pathology, 14, doi: / (2005/003) 7. Foley, N., Teasell, R., Salter, K., Kruger, E., Martino, R. Age and Ageing Volume 37, Issue 3, 1 May 2008, Pages Holas MA, DePippo KL, Reding MJ. Aspiration and relative risk of medical complications following stroke. Arch Neurol 1994;51: Daniels SK, Brailey K, Priestly DH, Herrington LR, Weisberg LA, Foundas AL. Aspiration in patients with acute stroke. Arch Phys Med Re- habil 1998;79: Liantonio, J., Salzman, B., Snyderman, D. Preventing Aspiration Pneumonia by Addressing Three Key Risk Factors: Dysphagia, Poor Oral Hygiene, and Medication Use. Volume 22-Issue 10; October Annals of Long Term Care and Aging. 2014;22(10): REFERENCES 11. Garcia, J.M., Chambers IV, E., & Molander, M. (2005) Thickened Liquids: Practice patterns of speech language pathologists. American Journal of Speech-Language Pathology, 14, Doi: / 12. Sheffler, MC, CCC-SLP, BCS-S; Richardson, MA, RDN, LD CDE, FAND. Thickened Liquids: One Tool in Our Dysphagia Toolbox. Presentation Nutricia Learning Center. 13. Rowan, Mary Gorham, Department of Communication Sciences and Disorders, Valdosta State Univerisity, July 18, 2014 published in the Journal of Communication Disorders, Deaf Studies and Hearing Aids. 14. Curfman, S. Dysphagia and Nurtrition Management in Patients with Dementia: The Rose of the SLP Bouchard, J. (2009). Association between aspiration pneumonia and malnutrition in patients from active geriatric units. Canadian Journal of dietetic practice and research, 70(3), Fari, A., Accornero, A., Burdese, C. Social Importance of Dysphagia: Its Impact on Diagnosis and Therapy. ACTA 2007, April; 27(2): Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G. Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Archives of Physical Medicine & Rehabilitation, 01 August 1988, vol./is. 69/8( ) REFERENCES 18. Leder, S.B. (2002). Aspiration risk after acute stroke: Comparison of clinical examination and fiberoptic endoscopic evaluation of swalling. Dysphagia, 17(3), Kelly, A.M. et al. (2007). Assessing penetration and aspiration: How do Videofluoroscopy and Fiberoptic Endoscopic Evaluation of Swallowing compare. The Laryngoscope, 117(10), Singh, V et al. (2009). Investigation of aspiration: Milk nasendoscopy versus videofluoroscopy. European Archives of Oto-Rhino-Laryngology, 266(4), Aviv, J.E., Kaplan, S.T., Thompson, J.E., Spitzer, J., Diamond, B., Close, L.G. The safety of flexible endoscopic evaluation of swallowing with sensory testing: an analysis of 500 consecutive evaluations. Dysphagia. 2000;15:

16 Additional Resources Langmore, S. (2001). Endoscopic Evaluation and Treatment of Swallowing Disorders. New York: Thieme. Aviv, J.E., Murray, T., Zschommler, A., Cohen, M., Gartner, C. Flexible endoscopic evaluation of swallowing with sensory testing: patient characteristics and analysis of safety in 1340 consecutive examinations. Annals of Otology, Rhinology & Laryngology. 2005;114: Langmore, S.E., Skarupski, K.A., Park, P.S., Fries, B.E. Predictors of aspiration pneumonia in nursing home residents. Dysphagia. 2002; /s Founder of FEES - ASHA Medical Review Guidelines for Speech Language Pathology Service. - Knowledge and Skills for Speech-Language Pathologists Performing Endoscopic Assessment of Swallowing Functions - The Role of the Speech-Language Pathologist in the Performance and Interpretation of Endoscopic Evaluation of Swallowing: Guidelines - The Role of the Speech-Language Pathologist in the Performance and Interpretation of Endoscopic Evaluation of Swallowing: Position Statement - The Role of Speech-Language Pathologist in the Performance and Interpretation of Endoscopic Evaluation of Swallowing: Technical Report 16