Implications of Variability in Clinical Bedside Swallowing Assessment Practices by Speech Language Pathologists

Abstract

Speech language pathology (SLP) clinical bedside swallowing assessments (CBSA) are a cornerstone of quality care for patients in acute hospitals who have dysphagia. The CBSA informs clinical diagnosis and decisions regarding further instrumental assessment, and is used to develop a management plan and monitor progress. However, self-report and retrospective research shows that SLPs are highly variable in their use of assessment components considered by experts to be important for quality CBSA, casting doubt on the validity and reliability of CBSA. This prospective study describes the components included by SLPs when designing a standardised evidence-based dysphagia assessment protocol for acute care patients and observed patterns of component use. The findings confirm that SLPs use the CBSA for multiple purposes beyond diagnosis of aspiration risk and dysphagia presence/severity. They are highly variable in their use of certain components, but also demonstrate consistent use of a core set. It is apparent that SLPs prioritise the application of clinical reasoning to tailor their CBSA to the patient over following a highly structured itembased protocol. The variability in component use likely reflects a complex clinical reasoning process that draws on a wide variety of information combined with expert knowledge as is also observed in many other medical specialties. Rather than promoting the standardisation of CBSA protocols that constrain SLP practice to strict item-based assessment protocols, consideration should be given to promoting the value of, and facilitating the clinical reasoning process that supports the utility of, the CBSA for diagnosis, patient-centred management and treatment planning.

Impact of Dysphagia Assessment and Management on Risk of Stroke-Associated Pneumonia: A Systematic Review

“…Most speech and language pathologists (SLPs) apply their clinical reasoning to tailor their bedside assessment over using a standardised assessment [15] such as the Mann Assessment of swallowing ability [16]. To complicate matters further, the terminology describing DSPs and bedside clinical assessments is often used inconsistently and interchangeably [12].…”

Swallowing patterns after adenotonsillectomy in children

“…For the ability to achieve oral ejection, 10.59% of participants recorded alterations, and 14.12% had residue in the oral cavity. The poor performance of lip and tongue behavior observed at the clinical evaluation can explain the oral ejection alteration, demonstrating the close relationship between clinical and instrumental evaluation . This highlights the fact that one protocol does not exclude the other due to the possibility of silent aspiration which is verified by videofluoroscopy …”

Screening for Dysphagia: Perspectives and Practices of Speech and Language Therapists in the Republic of Ireland

“…McAllister et al [41] advocate this in CSE protocols. Nevertheless, it is argued here that SLTs need to consider the diagnostic accuracy data of a swallow screening test particularly when performed by staff not formally trained in dysphagia, as the consequences of missing dysphagia are too considerable for patients and healthcare services.…”

“…Surveys of SLTs’ approaches to dysphagia management in head and neck cancer [35] and other older persons and at risk populations [36] found limited consistency in practice between respondents as well as poor adherence to clinical guidelines. International surveys on practices with regard to dysphagia assessment [37-41] all have shown variability in practice within countries but some degree of consistency in practice, overall. These studies have not focused on swallow screening but rather on CSEs and instrumental assessments.…”