The Pulse

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.

Patient Information: Male, Age 65

Diagnosis: Stroke / Oropharyngeal Dysphagia

History: This gentleman was admitted to a skilled nursing facility for rehabilitation services following hospitalization due to a stroke. He was diagnosed with oropharyngeal dysphagia (difficulty swallowing). His swallow initiation was inconsistent and he had difficulty managing his own secretions. He could not take any food or liquid by mouth and a feeding tube was placed. Prior to his stroke, he ate a regular diet.

Patient Information: Female, Age 69

Diagnosis: Heart Failure / Dysphagia

History: This woman, a long-term rehab center resident, was admitted to the hospital due to heart failure which resulted in dysphagia (difficulty swallowing). A feeding tube was placed and she was not allowed to eat or drink by mouth. Following hospitalization, she was referred to speech therapy with a goal to return to eating a regular diet and drinking thin liquids independently in the dining room.

As speech-language pathologists (SLPs) we often make diet recommendations. The unfortunate reality is we have scant information to direct these decisions. There is some evidence concerning the impact of volume and viscosity on swallowing kinematics (Barikroo, 2015; Chi-Fishman, 2002; Miller, 1996; Nagy, 2015; Watts, 2015). However, a systematic review (Steele, 2015) revealed little evidence to guide practice with respect to different degrees of modifying solid foods for patients with dysphagia. This means SLPs must rely on the sound understanding of the mastication process to make these decisions. Unfortunately, the system is quite complex and difficult to evaluate. This article represents the first of a series related to mastication that will address how mastication works and some possible assessment methods. Armed with this knowledge, SLPs may formulate more informed recommendations as part of a comprehensive patient care plan.

In the previous two articles in this series we examined the evidence concerning the clinical indictors of coughing and a runny nose. The conclusion was, both indicators provide us with weak information concerning swallowing function. In this edition, the evidence for wet vocal quality as a meaningful clinical finding will be discussed.

Patient Information: Male, Age 77

Diagnosis: Oropharyngeal Dysphagia / Hypoxic Respiratory Failure / Childhood bulbar polio
with paralyzed vocal cord