The Pulse

Patient Information: Female, Age 73

Diagnosis: Closed Head Injury / Intellectual Disability / Oropharyngeal Dysphagia

History: This woman, born with intellectual disability, was referred to a skilled nursing facility for rehabilitation services following hospitalization due to a fall at her group home, which resulted in a head injury and femur fracture. Prior to her fall, she lived in a group home with caregivers, was non-verbal, and consumed a regular diet with thin liquids. However, caregivers modified her diet to soft solids due to noted occasional difficulty in chewing and swallowing.

Respiratory diseases are among the leading causes of death and disability in the United States. In 2019, chronic lower respiratory disease including asthma, but predominately chronic obstructive pulmonary disease (COPD), was the 4th leading cause of death and influenza and pneumonia the 9th leading cause of death (Kochanek et al., 2020). The ranking for 2020 will likely change due to COVID-19-related deaths at greater than 500,000.

Patient Information: Female, Age 85

Diagnosis: Chronic Heart Failure (CHF) / Chronic Obstructive Pulmonary Disease (COPD) / Muscle Weakness

Patient Information: Male, Age 71

Diagnosis: Guillain-Barré Syndrome / Oropharyngeal Dysphagia

History: This gentleman was referred to a skilled nursing facility for rehabilitation services after a 3-month hospital stay. He was visiting his son in the United States from Venezuela when he began experiencing numbness in his legs. He was hospitalized and diagnosed with Guillain-Barré Syndrome (rare autoimmune disorder that causes rapid and unexpected muscle weakness). While hospitalized he experienced multiple complications including infection, being placed on a ventilator, and placement of a feeding tube. Prior to his hospitalization he lived independently and ate a regular diet.

Part 3: What about My Clinical Judgement?

We bring our EBP series discussion to a close with consideration of clinical expertise/expert opinion. This component of the triangle may be defined as “The knowledge, judgment, and critical reasoning acquired through [your] training and professional experiences” (ASHA, 2020).

Heart disease is the leading cause of death for both men and women in the United States with greater than 600,000 deaths attributed each year. Along with other conditions such as diabetes and obesity, heart disease may lead to heart failure which affects 6.2 million Americans per year (CDC, 2020).

Patient Information: Male, Age 91

Diagnosis: Parkinson’s Disease / Oropharyngeal Dysphagia /
COVID-19

History: This gentleman, a long-term resident of a skilled nursing facility, was diagnosed one and a half years ago with oropharyngeal dysphagia (difficulty swallowing), a complication of his Parkinson’s disease. Since that time he has had known aspiration (liquids entering the airway), altered diet, hospitalization for aspiration pneumonia, and COVID-19. Due to his complaint of his liquids being too thick, he requested to participate in swallowing therapy for possible return to thin liquids. As a result, swallowing evaluation and resultant therapy was initiated.

Part 2: Implementing Internal and External Evidence

We began our discussion on employing evidence-based practice (EBP) in swallowing rehabilitation during the spring newsletter, with careful consideration for upholding ethics in treatment and focusing on patient perspective. Let’s continue by delving deeper into incorporation of evidence in dysphagia therapy. ASHA defines the implementation of evidence as “The best available information gathered from the scientific literature (external evidence) and from data and observations collected on your individual client (internal evidence).” ASHA’s recommended EBP process includes the following steps: Frame the clinical question, gather evidence, assess the evidence, and make the clinical decision (ASHA 2020).

Not unique to the field of Speech-Language Pathology, integration of Evidence Based Practice (EBP) is a hot topic and is essential in ensuring we are practicing at the top of our profession. Let’s begin by reviewing the three characteristics comprising the EBP triangle as outlined by the National Joint Committee for the Needs of Persons with Disabilities (NJC): (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) the perspectives of individuals with severe disabilities and their families and friends to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve (NJC, n.d.). Over the next few months, we will discuss each of these areas in more detail. Although patient value and perspective is listed last, we will address this first, as this is an area worth consistent reflection and application.