The Pulse

Patient Information: Female, Age 78

Diagnosis: Oral Cancer / Dysarthria / Oropharyngeal Dysphagia

History: This woman, a long-term care resident of a skilled nursing facility, has a history of oral cancer four years ago. At that time, she underwent removal of 50% of her tongue, tissue grafting for her palate, and has resultant decreased jaw movement, oropharyngeal dysphagia (difficulty swallowing), and dysarthria (difficulty with speech production). Additionally, she underwent a tracheostomy (tube inserted into the trachea to assist with breathing) and a feeding tube was placed to provide nutrition due to her inability to eat and drink by mouth. She has received intermittent speech-language pathology services over the four years. Prior to her cancer, this woman had no limitations in eating, drinking, and speaking.

Patient Information: Female, Age 66

Diagnosis: Hemorrhagic Stroke / Oropharyngeal Dysphagia

History: This woman was admitted to a skilled nursing facility for rehabilitation services following hospitalization due to suffering a hemorrhagic stroke. As a result, she was diagnosed with altered mental status and oropharyngeal dysphagia (difficulty swallowing) and a feeding tube was placed to provide nutrition and hydration. Prior to her stroke, this woman ate a regular diet and drank thin liquids.

Patient Information: Female, Age 62

Diagnosis: Stroke / Oral Dysphagia (difficulty swallowing)

History: This woman was referred to outpatient speech therapy services due to continued deficits in her ability to speak, eat, and drink following a stroke seven months prior.

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.

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).

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.

Speech-language pathologists (SLPs) are commonly involved in the rehabilitation of patients with cardiopulmonary disorders. Patients hospitalized with respiratory diseases such as COPD and heart failure (HF) are identified as at risk for development of oropharyngeal dysphagia. Additionally, patients who experience prolonged endotracheal intubation have an increased risk of developing dysphagia. (Malandraki et al., 2016) This is often seen in patients hospitalized for COVID-19.