Newsletter :: June 2006

ASHA’s position

It is the position of the American Speech-Language-Hearing Association that speech-language pathologists (SLP’s) should not train, via professional education courses or on-the-job training, or provide direct clinical supervision to individuals or groups of individuals from other professions in the delivery of evaluation and treatment for infants, children, and adults with swallowing and feeding disorders. In operationalizing this statement, ASHA’s Continuing Education Board developed a process that required CE providers to sign a form affirming their adherence to the Position Statement. Many providers contacted Division 13 and the National Office to inform them that the statement was causing significant problems. When CE providers were offering courses to multi-disciplinary audiences (e.g. physicians, nurses, occupational therapists), they thought they had to restrict attendance to speech-language pathologists. At the Division 13 business meeting in November 2005, there was unanimous support to draft a resolution to rescind the Position Statement solely based on the difficulties encountered by CE providers. The Legislative Council (Speech-Language Pathology/Speech-Language Science Assembly) approved the resolution and rescinded the Position Statement in March, 2006. This decision does NOT mean that ASHA endorses SLP’s training others to deliver services in dysphagia. Indeed, there are many current ASHA policy documents that clearly delineate ASHA’s views. The 1997 Position Statement on Multi-skilled Personnel provides guidance on the topic of cross-training. It states that “cross-training of clinical skills is not appropriate at the professional level of practice”. The Glossary of Terms defines cross-training of clinical skills as involving “training practitioners in one discipline to perform services traditionally regarded as within the purview or scope of practice of another discipline in an attempt to more efficiently deploy the clinical workforce to meet the needs of the patient caseload as in fluctuates at any particular point in time”. In 1999 the Executive Board approved a document called “Educating Other Professionals About What Audiologists and Speech-Language Pathologists Do” This document encouraged CE providers to teach about what we do, but not to teach what we do. The 2001 Position Statement, “Roles of SLP’s in Swallowing and Feeding Disorders”, states that the SLP plays a “primary role in the evaluation and treatment of infants, children, and adults with swallowing and feeding disorders” and lists twelve appropriate roles for SLP’s. The pertinent ones regarding training are:

• Teaching and counseling individuals and their families about swallowing and feeding disorders;
• Educating other professionals regarding the needs of individuals with dysphagia, and the speech-language pathologists’ role in the evaluation and management of swallowing and feeding disorders;
• Advancing the knowledge base on swallowing and swallowing disorders through research activities.

The document clearly does NOT indicate that SLP’s should train others to provide dysphagia services.
So….if you or a colleague is asked to train another discipline to “do” dysphagia, specific documents support ASHA’s position to not cross train. The documents referenced above are easily accessed on ASHA’s web site. Please note that the technical report, “Speech-Language Pathologists Training and Supervising Other Professionals in the Delivery of Services to Individuals With Swallowing and Feeding Disorders ,” is still in effect and provides thorough background information.

Glasgow Outcome Scale (GOS) – was developed to rank outcomes after head injury, but has been used in stroke studies. It is a single item scale. Stroke Scale update – 5 points = good recovery, 4 points = moderate disability, 3 points = severe disability,

2 points = vegetative state, 1 point = Death

Dysphagia Tidbit – Cuff deflation

Groher(1999) noted 3 reasons for not feeding patients orally while their trach cuff is inflated.

If a patient’s medical condition is so precarious that a cuffed trach is warranted, perhaps oral feeding is too premature. It has been demonstrated radiographically that liquid bolus may and can get past the cuff and enter the lower trachea. Presence of an inflated cuff prevents pulmonary air from clearing the larynx. If a patient is aspirating a bolus it is vital to know when it occurs so that suctioning can be done immediately. With an inflated cuff this knowledge is delayed. It is so important to note that an inflated cuff does not prevent aspiration (Bone, Davis, Coameron, 1974; Dettelbach et. al, 1995). The tracheostomy tube is below the larynx and below the vocal cords. If there is food or liquid sitting on the inflated cuff, that material has already been aspirated. Swallowing trials and evaluations are typically ordered after deflation of the cuff is tolerated and often the use of a Passy-Muir Valve is initiated. Symptoms associated with trach-induced dysphagia include: decreased laryngeal elevation, obstruction by the cuff, decreased subglottic pressure and reduction of the adductor vocal fold reflex. A MBSS can be done with all trachs but DiagnosTEX prefers the pt be able to tolerate cuff deflation before the MBSS evaluation.