Report of the Professional Issue Forum on

Dysphagia Montreal, QC, June 2006

Introduction

The CAOT Professional Issue Forum on Dysphagia was held at the Fairmont Queen Elizabeth Hotel, Montreal, QC on June 2, 2006 from 1:30-4:30 pm. There were 52 participants including panelists, invited representatives of CAOT constituent and stakeholder groups, and conference delegates.  The Professional Issue Forum was facilitated by Elisabeth Churcher.

Format

The Forum consisted of panel presentations, roundtable discussions, and an open session in which participants identified critical issues and shared comments for CAOT to take forward in a position statement on Occupational Therapy and Dysphagia.  

Presenters

Heather C. Lambert,  PhD, OT(C), erg., CHSRF - CADRE Postdoctoral Fellow, Centre for Health Services and Policy Research, Queen’s University, Kingston, ON

Isabelle Germain, P.Dt. M.Sc., Dietitian in Research, Ste-Anne's Hospital (Veterans Affairs Canada), Ste. Anne de Bellevue, PQ 

Catriona M. Steele,  Ph.D., M.H.Sc., SLP(C), CCC-SLP, Reg. CASLPA, Research Scientist and Corporate Practice Leader for Speech-Language Pathology and Audiology, Toronto Rehabilitation Institute, Toronto, ON

Nathalie Blouin, M. D., Physician-in-charge, Rehabilitation, Institut universitaire de gériatrie de Montréal, Faculty of Medicine, University of Montréal, Montréal, PQ
 
Jacques Gauthier, erg., Services professionnels, Ordre des ergothérapeutes du Québec
Montréal, PQ

Patricia Currie, Client of Dysphagia Services, Gooderham, ON

Facilitator

Elisabeth Churcher,  B.O.T. O.T. Reg.(Ont.), Professional Practice Leader, Occupational Therapy, Children’s Hospital of Eastern Ontario (CHEO), Associate of The Research Institute at CHEO.

Objectives

The specific objectives of the Forum were to:

1. Explore the contribution of occupational therapy within the interdisciplinary health team in dysphagia care.
2. Identify the required conditions to promote collaboration among health professionals in providing evidence-based dysphagia practice.
3. Explore the shared principles in dysphagia evaluation and management.
4. Formulate a position statement on “Occupational Therapy and Dysphagia” for publication in 2006. 

Presentations

Dr Heather Lambert PhD, OT(C), erg., CHSRF-CADRE
Occupational therapy practice in dysphagia varies across Canada. Practitioners most likely to be working in dysphagia are likely those who “got there first,” have had some training or interest in dysphagia, as well as the time and availability to develop a feeding and swallowing program. Dr. Lambert noted discord among occupational therapists, speech pathologists and dietitians concerning the required competencies to practice in dysphagia. No scientific studies on practice guidelines could be found in the occupational therapy literature. Dr. Lambert identified the following basic coursework relevant to dysphagia in Canadian occupational therapy university education programs: anatomy, physiology, neuroanatomy, neurophysiology, activity analysis, assessment techniques, treatment modalities and equipment adaptations.  An informal survey of 5 university education programs revealed that a range of 6 to 25+ hours are devoted to dysphagia-specific curricula.
 
Isabelle Germain P.Dt., MSc 
Ms. Germain reviewed the education, scope of practice, and role of registered dietitians in assessment and treatment of dysphagia. Position statements addressing these topics have been issued by the Dietitians of Canada, as well as from the College of Dietitians of Ontario and the Ordre professionnel des diététistes du Québec.  Ms. Germain described dietitians as having a unique understanding of nutrients, texture and consistency, food services, microbiology and food safety, food allergies/intolerance, and selection available within prescribed diets and/or by food services of the institution. Evidence regarding the treatment of dysphagia is inadequate, however Ms. Germain identified that there is sound evidence that dysphagia is associated with under nutrition.  Experts agree that the treatment of dysphagia must include feeding the patient foods of modified texture and/or modified consistency. Rheological parameters (e.g. viscosity, adhesion, cohesiveness, elasticity) of liquids and solids are complex and require further study so consistency in the use of food descriptors is maintained. As well, modified texture foods and beverages have to be rigorously standardized and controlled for their texture and consistency parameters. 

Ms Germain reviewed the varied, potential members of an interdisciplinary dysphagia team, and acknowledged that in reality a health care practitioner is often working alone as the only resource available.  Possible strategies to address professional issues and concerns include 1) establishing networks to provide support for a sole practice therapist working with dysphagia, 2) explaining the complexity of dysphagia management to hospital administration, 3) issuing guidelines by governing bodies to recommend an interdisciplinary approach, and 4) including continuing education objectives in dysphagia assessment and treatment.

Catriona M. Steele, Ph.D. M.H.Sc., SLP(C), CCC-SLP, Reg. CASLPA
Dysphagia defined as difficulty swallowing, is seen in both adults and children with a broad spectrum of disorders such as cancer, neurological injury, degenerative conditions, and congenital anomalies. Dr. Steele identified that dysphagia results in enormous physical, emotional, and quality of life implications including nutrition and hydration, aspiration and respiratory sequelae, ability to enjoy food and beverages, imposed dietary restrictions, loss of choice, opportunity to eat socially with family and friends, difficulties adjusting to/tolerating enteral feeding and complications arising from tube feeding. An interdisciplinary dysphagia team involves speech language pathology, medicine, nursing, respiratory therapy, pharmacy, clinical nutrition, and occupational therapy.  Dysphagia intervention is patient-centred and considers the following questions:  What is the nature of the patient’s swallowing problem? Has the patient’s swallowing changed? How? Are compensatory interventions appropriate? If so, which ones? Are rehabilitation interventions appropriate? If so, which ones?  Based on these questions, it can be determined which health professional can optimally address the identified aspects of the patient’s dysphagia. Safe and effective dysphagia requires careful clinical judgment. Dr. Steele stressed the significant risk of harm associated with inappropriate assessment, misinterpreted results, and unsuitable recommendations.  

Dr. Steele stated that the skills to manage dysphagia cannot be taught or acquired in isolation (such as weekend courses). Dr. Steele identified that speech-language pathologists have the foundational training to comprehensively, efficiently and safely assess and treat swallowing disorder as key members of the dysphagia team.    
 
Nathalie Blouin M.D.
Dr. Blouin provided the physician’s perspective in the diagnosis and treatment of dysphagia. In the acute setting, the physician establishes a probable diagnosis, etiology and prognosis. Complications of dysphagia such as gastro esophageal reflux disease and COPD are also screened for, and treated. The physician participates in the interdisciplinary team rehabilitation plan that is respectful of the patient’s values.  The physician assesses the patient’s general competency and assures the patient’s understanding of the dysphagia treatment plan and consequences including the risk for aspiration. 

Dr. Blouin stated that she values an interdisciplinary approach to the treatment of dysphagia believing this approach assures a better understanding of dysphagia and its complications. Dr Blouin described the components of a good interdisciplinary team:  competency of each professional, clear definition of the roles of different team members, respect for member’s roles, expertise and personalities; collaboration, stability, positivity, continuous education, periodic reevaluation of the team’s objectives and functioning, and good leadership and humility. 

Jacques Gauthier, erg.,
Mr. Gauthier presented an occupational therapy regulator’s perspective on dysphagia. In Québec, occupational therapists, dieticians and speech therapists are professions with reserved titles. Their field of practice is not exclusive, with the exception of reserved activities to each profession. Reserved activities are defined by the Professional Code, most of them are shared by two or more professions. In the province of Quebec the assessment of dysphagia is not reserved to any profession however, the diagnosis is an exclusive act reserved for physicians. Occupational therapists have been involved in dysphagia care for more than 50 years, initially for children with cerebral palsy and poliomyelitis, and currently for a wide variety of clients covering all age and diagnostic groups, in both public and private sectors. 

The Ordre des Ergothérapeutes de Québec and the American Association of Occupational Therapists have both defined the role of occupational therapy in the area of dysphagia assessment and intervention. Occupational therapists assess the patient’s functional abilities affecting feeding, eating or swallowing. Occupational therapists also evaluate the relationship between the activity of eating or being fed to the person’s other occupations, the role of the environment, the influence of mealtime on their daily occupational schedule and the social meaning of eating. In the intervention phase, the occupational therapist’s goals are to improve, restore, develop or maintain skills required for safe and independent eating and swallowing; and compensate difficulties with swallowing techniques, posture modification, environmental modifications and/or the use of adaptive equipment. Family and caregiver education are also included in the process. 

Mr. Gauthier reminded the participants that an occupational therapist must refuse any request for service which lies beyond their competency and that the therapist must respect the right of the patient to consult a colleague or member of another professional organization. He further reinforced the importance of co-operation between colleagues and members of others regulatory associations for the good of the patient.   

Patricia Currie 
Mrs. Currie shared her son Jeff’s story, in his words, of his motor vehicle accident in November 2002 and his subsequent hospitalization and rehabilitation. Jeff is a university graduate who was driving to visit friends when a patch of ice sent his car into the oncoming lane of a pick-up truck. Jeff broke the top two vertebrae in his neck and sustained a brainstem stroke. Jeff described with a detailed poignancy the loss of his independence and his ongoing progress in his rehabilitation. A newspaper article in the Haliburton County Echo December 13, 2005, describes Jeff’s progress as significant: “Before he could not breathe without a machine. Now he breathes on his own although he is only able to use one third of his lungs.  Before he couldn’t talk and used a spelling board to communicate.  Now he can talk but in a barely audible voice that forces the listener to come in close.  Before he had to be lifted by a crane to get in and out of bed.  Now he does without.”  Jeff resides at home with his parents and requires 24 hour care. His mother is the primary caregiver.

Jeff described the intervention he received while in hospital from speech language pathologists for his feeding difficulties. Occupational therapists were not involved in his dysphagia care. Jeff revealed the significant impact of dysphagia on his quality of life.

He was discharged home on a gastrostomy tube and received no further intervention. Mrs. Currie stated that Jeff’s story reveals the need for home and community dysphagia practice.  She also called for collaboration among health professionals in the assessment and treatment of dysphagia and the need to always keep the client foremost in our care.

Roundtable Discussion

Participants addressed the following questions in roundtable discussion:

1. a) What are the core principles in dysphagia assessment and treatment?
   b) What is needed to achieve consensus among disciplines regarding principles of 
   dysphagia practice
2. a) What are the required conditions to promote collaboration among health professionals to achieve the best client outcomes in dysphagia?
   b) What are the next steps to advance collaboration?

Summary Discussion

The core principles of dysphagia assessment and treatment are:

• Determination of level of risk; involve family and caregivers so that an informed decision can be made regarding risk vs. nutrition options
• Early detection of risk indicators to improve outcomes, reduce mortality, length of hospital stay, health care needs
• Comprehensive management of aspiration risk, malnutrition and dehydration
• Provision of client centered care; the client must be an active partner in dysphagia management
• Inclusion and education of caregivers in the management of the client with dysphagia
• Effective communication and documentation between health care practitioners

To achieve consensus among disciplines regarding principles of dysphagia the following are important:

• Intradisciplinary approach to assessment and treatment with fluid and overlapping competencies
• Knowledge of the other professionals’ responsibilities and skills
• Good relationships
• Good reputation
• Experience
• Skill demonstration

The conditions needed to promote collaboration among health professionals to achieve the best client outcomes may be achieved by:

• Confidence, respect and interest for each others interventions
• Sharing information and expertise
• Addressing competitiveness issues
• Appreciating that different settings require different service delivery models and that  team membership will vary in both professional representation and  number of members
• Supporting interdisciplinary learning and  mentoring
• Humility, respect, and trust
• Interdisciplinary research work and publication
• Ensuring evidence-based intervention
• Increasing the overall competency of each profession, individually and as a team
• Recognize that assessment and treatment of dysphagia is not attributable to any one profession
• Maturity of the interdisciplinary team

The next steps in advancing collaboration among different professions are:

• Define models of interdisciplinary interaction
• Establish a network of mentors or preceptors to facilitate the interdisciplinary process of a dysphagia team review -  similar to the peer review processes currently enacted through regulatory bodies. This would provide a vehicle to identify both excellence and difficulties in dysphagia teams
• Interdisciplinary collaboration centered around dysphagia during academic training through an interprofessional curriculum module
• Establish formal mentorship or apprenticeship of new clinicians
• Educate physicians as key stakeholders and facilitators of team dynamics via   education modules about interdisciplinary teams. This would facilitate appropriate engagement and appropriate  use of different professionals’ expertise

Plenary Comments and Critical Messages for CAOT:

• Occupational therapists, speech pathologists and dietitians recognize the assessment and management of dysphagia or feeding/swallowing disorders    within their individual scope of practice.
• In Canada there is a lack of consistency in education, the membership composition of dysphagia teams and the specific role of each professional working in this area.  Further work is needed in these areas.
• Can the occupational therapy, speech pathology and dietetic professions identify essential or core competencies which are shared across professions?
• It is recommended that CAOT support and facilitate best practice in the area of feeding/swallowing for occupational therapists in response to the challenge received by other professions regarding the competency of occupational therapy in this area. 
• A clear statement of the scope of practice of occupational therapy in the area of dysphagia is required. A pan-Canadian survey of existing occupational therapy practice and education in the area of feeding/swallowing would contribute to the development of this statement.
• Consultation with occupational therapy regulatory associations and university occupational therapy education programs is required for the development of a position statement on occupational therapy and dysphagia.
• It is recommended that CAOT support interdisciplinary education through developing courses, resources or tools which are targeted and accessible to different health professionals practicing in dysphagia.  

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