Dysphagia Grand Rounds 8

Although the Modified Barium Swallow Study (MBSS) is an important diagnostic tool for the evaluation of swallowing function, it requires caution related to the use of ionizing radiation. One strategy that is popularly used to decrease radiation exposure is reducing the pulse rate of the radiation beam emitted during MBSS. Although temporal resolution appears to be critical for viewing the swallow in its entirety, it is not known if decreasing fluoroscopy pulse rates negatively affects the ability to make judgments regarding swallowing impairment.

Dysphagia Grand Rounds 8 reviews a research study aimed at improving our understanding of the clinical implications of pulse rate, on diagnostic yield and dysphagia treatment recommendations. Read the paper below first and then watch the DGR 8 webinar to learn why these findings are important for your clinical practice. 

Article: Preliminary Investigation of the Effect of Pulse Rate on Judgments of Swallowing Impairment and Treatment Recommendations
Authors: Heather Shaw Bonilha, Julie Blair, Brittni Carnes, Walter Huda, Kate Humphries, Katlyn McGrattan, Yvonne Michel and Bonnie Martin-Harris
Journal: Dysphagia. 2013;28(4):10.1007/s00455-013-9463-z

Read DGR 8 article here:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3762944/

Watch DGR 8 webinar here: http://dysphagiagrandrounds.yondo.com/playlist/dgr-8-august-2017/403

Abstract: 
Reducing fluoroscopic pulse rate, a method used to reduce radiation exposure from Modified Barium Swallow Studies (MBSSs), decreases the number of images available from which to judge swallowing impairment. It is necessary to understand the impact of pulse rate reduction on judgments of swallowing impairment and, consequentially, treatment recommendations. This preliminary study explored differences in standardized MBSS measurements (Modified Barium Swallow Impairment Profile (MBSImP™©) and Penetration Aspiration Scale (PAS) scores) between two pulse rates: 30 and simulated 15 pulses per second (pps). Two reliable speech-language pathologists (SLPs) scored all 5 MBSSs. Five SLPs reported treatment recommendations based on those scores. Differences in judgments of swallowing impairment were found between 30 and simulated 15pps in all 5 MBSSs. These differences were in six physiological swallowing components: initiation of pharyngeal swallow, anterior hyoid excursion, epiglottic movement, pharyngeal contraction, pharyngeal-esophageal segment opening and tongue base retraction. Differences in treatment recommendations were found between 30 and simulated 15pps in all 5 MBSSs. These findings suggest that there are differences in both judgment of swallowing impairment and treatment recommendations when pulse rates are reduced from 30pps to 15pps to minimize radiation exposure.

Dysphagia Grand Rounds 7

Despite the wide implementation of dysphagia therapies, it is unclear whether dysphagia-related SLP recommendations are being successfully communicated beyond the inpatient hospital setting. Poor discharge communication could lead to inappropriate post-hospital dysphagia care, with resultant aspiration pneumonia and need for costly rehospitalizations.

Dysphagia Grand Rounds 7 reviews a retrospective cohort study, investigating the rate of dysphagia recommendation omissions in hospital discharge summaries for high-risk subacute care patients. Read the paper below to see what the authors found and then watch the DGR  webinar to learn about the clinical implications of these findings. 

Article: Omission of Dysphagia Therapies in Hospital Discharge Communications
Authors: Amy Kind, Paul Anderson, Jacqueline Hind, Joanne Robbins, and Maureen Smith Journal: Dysphagia. 2011;26(1):49-61. 

Read DGR 7 article here:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888892/ 

Watch DGR 7 webinar here: http://dysphagiagrandrounds.yondo.com/playlist/dgr-7-july-2017/382

Abstract: 
Background
Despite the wide implementation of dysphagia therapies, it is unclear whether these therapies are successfully communicated beyond the inpatient setting.

Objective
To examine the rate of dysphagia recommendation omissions in hospital discharge summaries for high-risk sub-acute care (i.e., skilled nursing facility, rehabilitation, long-term care) populations.

Design
Retrospective cohort study

Subjects
All stroke and hip fracture patients billed for inpatient dysphagia evaluations by speech-language pathologists (SLPs) and discharged to sub-acute care in 2003-2005 from a single large academic medical center (N=187).

Measurements
Dysphagia recommendations from final SLP hospital notes and from hospital (physician) discharge summaries were abstracted, coded, and compared for each patient. Recommendation categories included: dietary (food and liquid), postural/compensatory techniques (e.g., chin-tuck), rehabilitation (e.g., exercise), meal pacing (e.g., small bites), medication delivery (e.g., crush pills), and provider/supervision (e.g., 1-to-1 assist).

Results
45% of discharge summaries omitted all SLP dysphagia recommendations. 47% (88/186) of patients with SLP dietary recommendations, 82% (93/114) with postural, 100% (16/16) with rehabilitation, 90% (69/77) with meal pacing, 95% (21/22) with medication, and 79% (96/122) with provider/supervision recommendations had these recommendations completely omitted from their discharge summaries.

Conclusions
Discharge summaries omitted all categories of SLP recommendations at notably high rates. Improved post-hospital communication strategies are needed for discharges to sub-acute care.