Keep it Simple Silly: The simplest things can have the biggest impact on dysphagia
It’s true. Sometimes the simplest things can make the most difference for our patients. With a flurry of incoming research, advanced technologies, and innovative techniques, the med SLP may find him or herself wondering what has the greatest impact on our patients. While keeping up with our studies and training is crucial to staying up to date and remaining effective for our patients, let’s not lose site over what has worked consistently and has stood the test of time.
Keeping our eye on the ball
Advances in healthcare have been a beautiful thing. In just the past 100 years our life expectancy has risen more than 20 years and continues to rise. About 1500 new medications have been introduced by the FDA, advanced and complex surgeries costing hundreds of thousands of dollars are now commonplace, and new technologies are being introduced every year to help track, manage, and improve care. But what actually makes the most difference? The simplest things, actually. Like hand washing, keeping a procedural checklist, and basic primary and preventative care. So in light of this, what can the medical speech pathologist do to improve care and outcomes in the simplest AND most effective way?
The basics
Our field is always changing. But knowing and understanding what doesn’t change is often just as, if not more, important. Knowing the varying levels of normal anatomy and physiology, understanding neuroanatomy, and being able to recognize abnormalities is the foundation of an effective SLP. But of course these basics are not so basic. Some consider swallowing as the most complex reflexive mechanism controlled by the central nervous system. You CANNOT study this mechanism enough. Being able to recognize varying levels of normal and disordered swallows and to identify how these may impact function and health requires a lifetime of study, training, and practice. Where do we start? Take (and re-take) courses, train ourselves and each other, and make sure we are familiar with the types of patients we normally see so we can learn how to best treat them. It’s as easy and as difficult as that.
Understand the context
Once you get to the point that you can accurately and consistently identify disorders and make diagnoses, you’re still not done yet. What’s most important is to understand what the diagnosis means for the patient and to use that information to make practical recommendations based on the patient’s unique situation.
Aspirating? Well then what’s the risk for aspiration pneumonia?
Inefficient swallow? What’s the risk for weight loss?
A chin tuck works? Will they remember to do it?
Benefits from thickened liquids? How likely are they to actually drink them?
Needs to be fed? Does the person feeding know all the information they need to in order to feed this patient safely?
What is actually going to make a difference in this patient’s life? Not just for today or tomorrow, but after they leave your facility and you never see them again. Having a comprehensive view of the medical status, risks, and preferences will help you make the best recommendations that fit the individual needs of that specific patient. Following up with education and resources to support those recommendations is a sure way to make sure the patient, staff, and family successfully follow them.
Consistency is key
One of the major problems in speech pathology (and healthcare more broadly) is the inconsistency of practice patterns. For example, a 2018 study by Vose and colleagues looked at how well we were able to spot disorders on MBSS and how much we agreed with our colleagues on how to manage those disorders. The conclusion? Neither was very promising. Not only do we need better training and education on the things we are already doing, but we need our colleagues to be on the same page. The best way to do this is to create procedures and checklists to make sure everybody on your team is following the same steps, looking at the same things, and training in the same ways. The use of standardized tests is an added bonus. Staying consistent is A LOT easier to talk about than to actually do. We are imperfect human beings who experience fatigue, hunger, and stress (all of which makes our behavior inconsistent). Atul Gawande tells us in his superbly written Checklist Manifesto that something as simple as a checklist keeps our memories sharp and our behaviors honest. Oh, and of course improves outcomes for the patients.
Would you kiss your mother with that mouth?
Oral care is similar to hand washing in that it’s quick, cheap, easy, and effective in reducing the risk of infection. Why? Poor oral health is associated with pneumonia and aspiration pneumonia typically only occurs with the presence of oral bacteria in the lungs. Ideally, we would want to be cleaning the mouth three to four times a day, but this almost never happens in practice (especially for those patients who are dependent on somebody to clean their mouths for them).
Picture an elderly patient who comes into the hospital for altered mental status. In the first couple of days after her admission, the hospital team works diligently to find out what’s wrong. Complex, high-tech, and expensive tests are completed on loop such as CT scans, MRIs, chest x-rays, and lab work. During these crucial days everyone seems to be doing everything to keep her stable and safe. Except cleaning her mouth. No tooth brushes, no tooth paste, no mouth wash. Nada. A dry desert and a microbiotic playground for bacteria to sneak down the unprotected hatch during a time when she has poor awareness and decreased sensation. After two clear chest x-rays after admission, on the third day the radiologist documents concern for aspiration pneumonia. Who knew a tooth brush could wield so much power?
You can’t treat what you can’t see
It’s no surprise that I am an advocate for instrumental studies. But I don’t believe so strongly in them because I own a mobile FEES company, I own a mobile FEES company because I believe so strongly in them. You can’t treat what you can’t see so why try? Instead of wasting your time guessing at the bedside or blindly providing rehab, spend that time advocating for the tools you need to treat your patients. I know it’s not easy. Trust me, I do. Changing minds is a tough business. But it can and needs to be done in order to meet a very basic level of care, which all of our patients deserve.
Conclusion
There is only so much time in the day. Only so much we can get done in a lifetime of studying. Getting lost in the latest trends and waiting for new research is only going to make ourselves (and our patients) more frustrated. There is so much we can do right now to make our practice better. Knowing the basics, the context, and keeping things consistent in our practice are simple, yet effective ways to make a big difference. Advocating for basic, yet crucial elements of effective care such as instrumental studies and oral care can mean the difference between recovery and decline for our patients. All of the exciting things that are coming out tomorrow certainly deserve our attention. A dedication to research, technology, and new techniques are a worthy way to spend our time. But what we can do right now will ultimately make the most difference when it matters most. And if not now, when?
