The interdisciplinary health care team is responsible for providing medical care based on a patient-centered model while maintaining professional and ethical standards. However, an emerging body of research suggests that ineffective and inappropriate care, or fatal errors, arise from the lack of productive communication between patients, families, and medical caregivers. This has prompted the evolution of a new health care discipline, patient safety, which became increasingly prominent in the 1990s. The purpose of this article is to bridge the gap between the discipline of patient safety and its relationship to the diagnosis of dysphagia.
“To err is human; to forgive, divine.” —Alexander Pope
The father of Western medicine, Hippocrates, introduced the concept of patient safety. The modernized version of this oath, for contemporary medicine, “primum non nocere,” (first do no harm), must be upheld, not only by physicians, but also by the entire interdisciplinary health care team. The interdisciplinary team is responsible for providing medical care based on a patient-centered model while maintaining professional and ethical standards. However, an emerging body of research suggests that ineffective, inappropriate care, or fatal error, arises from the lack of productive communication between patients, families, and medical caregivers. This has prompted the evolution of a new health care discipline, patient safety, which became increasingly prominent in the 1990s. The World Health Organization (WHO) reported that heath care errors collide with 1 in every 10 patients around the world. The Joint Commission’s Annual Report on Quality and Safety, 2007, identified the root causes of more than 50% medical errors are attributable to poor interdisciplinary communication and inadequate and incomplete education to patients and their families. The purpose of this article is to bridge the gap between the discipline of patient safety and its relationship to the diagnosis of dysphagia.
Dysphagia across health care settings
Dysphagia is a widespread term in any medical institution, yet it has various perceived definitions by members of the hospital and rehabilitation team. The definition, being complex and involving many physiologic components and neuromuscular interactions, may result in varying levels of understanding by the interdisciplinary team. Deglutition entails simultaneous and interactive movements involving the oral, pharyngeal ,and esophageal stages of swallowing. As discussed in an article from Becker and colleagues, dysphagia clinically manifests itself with complications arising during eating, drinking, and reduced secretion management. In addition to the physical consequences, dysphagia is also a disorder involving psychosocial and emotional complications for patients and families. Dysphagia may lead to several complications, such as dehydration, malnutrition and weight loss, pulmonary complications, and pneumonia.
The incidence and prevalence of dysphagia across health care settings varies. The American Speech-Language and Hearing Association reports that the epidemiologic studies indicate that the prevalence may be as high as 22% for individuals over age 50. Reports indicate that 61% of adults with dysphagia are admitted to acute trauma centers; 41% are admitted to rehabilitation settings Thirty percent to 75% of patients reside in skilled nursing facilities, and 25% to 30% are admitted to hospitals. The likelihood of dysphagia is more common in certain patient populations. In total, between 300,000 to 600,000 patients across the United States are afflicted with dysphagia yearly. The prevalence of dysphagia in patients who have been diagnosed with stroke is 25% to 70%, with 10% to 30% of this population identified as having dysphagia with aspiration. Other disorders with a high prevalence of dysphagia include traumatic brain injury, amyotrophic lateral sclerosis, Parkinson disease, and head and neck cancer.
Within the last 2 decades, the health care industry has undergone a pivotal change in medical and technological advances. This progression has increased the number of dysphagic patients with medically complex diagnoses, such as pulmonary, circulatory, gastrointestinal, and neurologic involvement, who are treated by the speech–language pathologist (SLP). The management of dysphagia in this population requires specialized training by the SLP, as well as a sophisticated understanding of diagnostic and treatment methods. As such, SLP treatment protocols and recommendations are a medically essential aspect of patient care.
Identification of dysphagia
Approximately 10 million Americans are referred to SLPs yearly for evaluations of swallowing. Evaluations to rule dysphagia can be conducted along the entire continuum of care: acute, rehabilitation unit, subacute rehabilitation, and the home setting. Early identification of dysphagia signs in the medical and rehabilitation settings is the responsibility of all members of the medical team. The speech pathologist within each clinical setting should educate the medical team on the early signs that would raise suspicion of a dysphagia diagnosis. The following clinical pearls can be incorporated into a patient’s history and physical examination, upon admission, to any clinical setting. An answer of “yes” to one or more of the following questions may indicate that a patient is at high risk for a swallowing impairment; therefore, a referral to the SLP is strongly recommended ( Box 1 ).
Identification of dysphagia
Approximately 10 million Americans are referred to SLPs yearly for evaluations of swallowing. Evaluations to rule dysphagia can be conducted along the entire continuum of care: acute, rehabilitation unit, subacute rehabilitation, and the home setting. Early identification of dysphagia signs in the medical and rehabilitation settings is the responsibility of all members of the medical team. The speech pathologist within each clinical setting should educate the medical team on the early signs that would raise suspicion of a dysphagia diagnosis. The following clinical pearls can be incorporated into a patient’s history and physical examination, upon admission, to any clinical setting. An answer of “yes” to one or more of the following questions may indicate that a patient is at high risk for a swallowing impairment; therefore, a referral to the SLP is strongly recommended ( Box 1 ).
Comperhensive and integrated speech pathology approach
As a member of the health care team, the SLP serves a myriad of roles during the diagnosis of dysphagia. Routine dysphagia screening by the SLP may not always be possible. Therefore, the SLP needs to rely on the medical team for referrals when dysphagia is suspected. However, failure or incomplete screening of the patient’s swallowing by the medical team may delay or prevent the initial referral to the SLP, placing the patient at risk for dysphagia related complications. To expedite this referral process, the SLP should also assume the role of educating the medical team on the clinical indicators as listed in Box 1 . Once the initial referral is received, the SLP may begin using the comprehensive and integrated speech pathology approach, (CISPA), focusing on the patient as the nucleus of this model. The SLP’s implementation of this approach will ensure effective dysphagia management, contributing to the safety of the patient. Fig. 1 outlines the components of the CISPA, summarizing the process of evaluation, treatment, and education for patients, families, and the medical team, implemented by the SLP.
Related posts:
Patient Safety and Quality Improvement in Rehabilitation Medicine
Medication Safety in Rehabilitation Medicine
Patient Safety Considerations in the Rehabilitation of the Individual with Cognitive Impairment
Patient Safety in Rehabilitation Medicine: Traumatic Brain Injury
Patient Safety in the Rehabilitation of the Adult with an Amputation
Safety Considerations During Cardiac and Pulmonary Rehabilitation Program
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