Clinical reasoning and hypothesis generation in expert clinical swallowing examinations

Abstract

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Dysphagia management: Does structured training improve the validity and reliability of cervical auscultation?

“…Accurate severity rating requires access to a range of patient information that cannot be captured by either a single swallow-respiratory assessment nor an isolated instrumental assessment. Holistic dysphagia management requires multifaceted patient/clinical information and high-level clinical reasoning (Doeltgen, McAllister, Murray, Ward, & Pretz, 2018;McAllister et al, 2020).…”

“…The CSE has been criticised for its lack of diagnostic ability, particularly in identifying aspiration. Yet, it has also been argued that the CSE is an essential part of holistic dysphagia management for acute-care with rapidly changing patient status, short lengths of stay; and non-acute care where patient behaviour, co-morbidities, fatigue, and fluctuations in physical, respiratory and cognitive abilities, are important considerations for safe eating (American Speech-Language-Hearing Association (ASHA), 2020; McAllister et al, 2020) This is particularly relevant when considering oral intake over an entire meal and mealtime behaviours for people with dementia, COPD exacerbations, cerebral palsy, traumatic brain injury, and others (ASHA, 2020;Howle, Baguley, & Brown, 2014;Lewis, Walterfang, Velakoulis, & Vogel, 2018). The CSE þ CA allows for functional assessment, ongoing follow-up and regular patient contact, facilitating person-centred care.…”

“…The current study, with sensitivities of 93-99% indicate that the addition of CA to the CSE/review, could assist in more appropriate referrals to instrumental assessment and use of resources. Rather than replacing instrumental assessments, CA as part of the CSE/review should be used to complement holistic dysphagia management, including improved referral to instrumental assessments, improved prompt followup after instrumental assessment, review and investigation of patient preferences during meal-times, and furthermore, has the likelihood to positively impact cost-effective, high-quality, patient-centred care (Gutenbrunner & Nugraha, 2020;McAllister et al, 2020).…”

“…The benefits of CSE þ CA include ongoing review of the patient's ability to manage compensatory strategies throughout mealtimes, ability (adherence) and accuracy in completing dysphagia manoeuvres/exercises. The opportunity for ongoing CSE/review þ CA, not only supports evidence-based intervention, but also allows for training and education of the patient and carers to ensure individualised goal-setting, rehabilitation and discharge planning (Bergstr€ om et al, 2014;Doeltgen et al, 2018;McAllister et al, 2020).…”

Contextualising clinical reasoning within the clinical swallow evaluation: A scoping review and expert consultation

“…The value of clinical reasoning is well established within dysphagia practice. Doeltgen et al ( 2019 ), and many others (Jones, Cartwright, Whitworth, & Cocks, 2018 ; Mathers-Schmidt & Kurlinski, 2003 ; McAllister et al, 2020 ; Pettigrew & O’Toole, 2007 ; Rumbach, Coombes, & Doeltgen, 2018 ), have shown that sound clinical reasoning is vital within dysphagia assessment and management to prevent poor patient outcomes. However, almost all this research has emerged from higher income contexts which cannot always be generalised to LMICs.…”