Three Pillars of Preparedness: How do you prepare for BIG dysphagia risks?

What is risk? It's funny because it's a simple word but difficult to define. It's a possibility that can only be measured as a probability. It's elusive. It's not real. It's not tangible. In his book Same as Ever, Morgan Housel defines risk as something you can't see. If you could see it and knew it would happen, it wouldn't be a risk. So, what is the risk in terms of dysphagia? What can't we see? A lot, unfortunately. 

Scratching the Surface

We've only scratched the surface regarding the whole dysphagia mystery. If dysphagia knowledge were an iceberg, what we know would only be the tip sticking out of the water. The rest, sitting under the depths of the deep, dark ocean, is not only largely unknown but unknowable, at least at the moment. There is a dearth of research in our field, and much of it is limited or flawed in some way. Our research colleagues are doing a tremendous job in bridging this gap, but it still exists, unfortunately. Plus, no literature in ANY field is perfect. No research perfectly reflects the patient that's sitting in front of us.

So, predicting risk is a challenging game to play. It's still worth playing, though. In this article, I discuss my process for anticipating and managing risk in deciding between PO vs. NPO in a patient status post-extubation. It's not impossible to identify risk and predict how and when an adverse event might occur, but it's an imperfect science by its very nature, and we need to fully grip its limitations before we start poking around within it.

Risk prediction is difficult because there are so many different variables to consider in dysphagia management. These variables are not independent of one another. They're not satellites with a predictable trajectory we can study and define. They're more like a storm of asteroids constantly bumping into each other, changing each other's directions and velocities, subject to the terrifying randomness of life. 

So, while prediction is possible and often helpful, the real benefit is less in pinpointing a quantity and more in preparing for that risk. How do we prepare for risk as it relates to dysphagia? There are three main ways. 

Three Pillars of Preparedness 

1. Research: Even though it's limited, it's still valid. A map with a few tears and holes is better than no map at all. While the information can be confusing and contradictory, some big takeaways arise from the chaos—for example, the notion that oral care reduces the risk of aspiration pneumonia. Few things are simpler, cheaper, and more effective than brushing your patient's teeth (and tongue). How often it's neglected is mind-boggling, but that means there's a huge opportunity for improvement that we don’t want to miss.

2. Testing: Adequate testing provides more than a pass/fail verdict or snapshot of function. Testing via an instrumental swallowing evaluation or standardized clinical assessment provides us with the patient's function, strengths, and weaknesses, giving us the information and insight we need to make an informed decision.

3. Education: This one is twofold: #1. We should educate ourselves through courses and training to stay current on the most effective approaches, as proven by the research and instructors with many years of clinical experience—#2. We should educate the patient on the possibilities, what to look out for, the recommended options, and the pros and cons of each option. 

So the goal is to dedicate ourselves to understanding the research, improve the quality of our testing, and educate ourselves and our patients on what works best. This, of course, will not eliminate harmful incidents from occurring, but it can minimize their frequency and impact; especially for those big risks like aspiration pneumonia and choking. Big risks such as these don't typically pop out of nowhere. They start with multiple small risks that compound over time. Let's use an example to demonstrate this.

Linda

Take Linda. Linda was a smoker (risk factor #1) who had been healthy her whole life until she got older (#2), and seemed fine until she started getting weaker (#3), and warded off any problems until she had a stroke (#4), and could get by until she started coughing during meals (#5), and still made it through until she fell and broke her hip, giving her altered mentation (#6), and increased signs of aspiration (#7). Eventually, Linda got aspiration pneumonia. Were we surprised? In retrospect, no. This isn’t a Houdini, rabbit out of a hat trick. The risk of aspiration pneumonia didn't just rise out of thin air. It was never guaranteed to occur, of course. Her family assumed she was as strong and healthy as a horse despite her years of smoking until she started to show signs of decline. And those signs didn't just pop up one day. It was a slow and subtle deterioration, and the combination and compounding of risk factors were easy to ignore. Until they weren't. 

If you were the SLP screening Linda after her stroke, what could you have done or said to improve her chances down the road? Let's look at our three pillars of preparedness: 

1. Research- 1 out of 5 patients may experience dysphagia after a CVA, and smoking is one of the top predictors of stroke and aspiration pneumonia. 

2. Testing—A screen may have given us some crude information, but if we dug a little deeper and did a comprehensive swallow evaluation and an MBSS or FEES, we could identify some deficits worth addressing or, at the very least, receive a baseline to measure against once she declined later on. 

3. Education—Discussing our findings and recommendations with the patient to provide some precautions, exercises, and compensatory strategies to address her deficits and improve the prognosis immediately. Outside of dysphagia, PT/OT could have given some basic information on the risk of falling and some precautions to take. 

Big Takeaway for Big Risk

Risk is ubiquitous and inevitable, but if we look hard enough, we can see it coming from a mile away. While there is value in trying to predict it, most of the value we can provide comes with preparation, which we can do through research, testing, and education. It's the BIG risks we want to focus on because they come with the highest stakes, and are often the easiest to predict. Lowering that risk, even a little bit, can mean the difference between a devastating adverse event and a person continuing to live a happy, healthy life.

*New course offered for ethics credit: Let Us Eat: The ethics of swallowing in older adults at high risk