Dysphagia Assessment and Treatment During the COVID-19 Pandemic: Lessons Learned from the Transition to Telepractice
By Gabrielle Carrier, Veronica Rodriguez and Dr. Rosemary Martino
In the context of the COVID-19 pandemic, many speech-language pathologists (S-LPs) are facing challenges in providing care to patients using traditional face-to-face intervention. On March 19, 2020, the Ontario Ministry of Health released requirements for healthcare professionals to significantly reduce and/or cease non-essential service (Chief Medical Officer of Health, 2020). In response, organizations began advocating for telepractice where possible to reduce unnecessary person-to-person contact.
In the Swallowing Lab at the University of Toronto, this Ministry of Health directive triggered a rapid adaption in how swallowing therapy was being delivered to participants enrolled in the PRO-ACTIVE research study, a pragmatic multi-site randomized controlled trial evaluating the impact of prophylactic swallowing therapy for head and neck cancer patients undergoing radiation. In this trial, participants are randomized to receive bi-weekly face-to-face swallowing intervention with an S-LP during their radiation treatment, which includes a clinical swallowing assessment, education on symptom management and depending on randomization, instruction on swallowing exercises. For more information on the PRO-ACTIVE study, consult this webpage. In the context of the ongoing pandemic, the shift to telepractice for these interventions occurred quickly in order to meet study protocol timelines. This article will briefly review relevant telepractice literature, and share the lessons learned from our clinical implementation of virtual dysphagia assessment and treatment.
What is telepractice?
Telepractice is the use of telecommunication technology to provide professional services at a distance (College of Audiologists and Speech-Language Pathologists of Ontario [CASLPO], 2014; Speech-Language & Audiology Canada [SAC], 2006). It encompasses telecommunication between clinicians and patients, as well as clinician-to-clinician consultation (Brennan et al., 2010). Telepractice can be carried out in two forms: synchronous (live and interactive) and asynchronous (pre-recorded for review outside of real time).
Evidence supporting dysphagia telepractice
Research evaluating dysphagia telepractice is based on the premise that this model of care should be at least equivalent to face-to-face intervention (American Speech-Language-Hearing Association [ASHA, n.d.; CASLPO, 2014; SAC 2006). In recent years, many have assessed the value of telepractice, with the work by Ward and colleagues in Australia being most prominent. These efforts have shown comparable results between speech-language pathology clinical swallowing assessments administered via a standardized telepractice protocol vs face-to-face (FTF) in patients with normal to mildly impaired cognition (Ward et al., 2012) regardless of dysphagia severity (Ward et al., 2014). Specifically, there was a high degree of agreement between both models of care for clinical ratings of dysphagia severity as well as recommendations for oral vs nonoral feeding and safe oral fluid/solid textures. In these studies, S-LPs conducted teletherapy in a hub and spoke setting using high quality video and audio equipment, including portable cameras and lapel microphones, as well as trained non-S-LP healthcare aids to help with setup and feeding. An ideal setup such as this one is not feasible in the improvisatory context of the COVID-19 pandemic, where patients are situated at home using any equipment they have readily available.
Currently, there is limited research evaluating dysphagia telepractice using an adaptable platform within a patient’s home environment. Collins et al. (2017) assessed the feasibility of conducting home-based synchronous telepractice dysphagia management. In this study, patients attended a short FTF instructional session on telepractice, received an assessment resource kit, and completed their dysphagia management session at home using a smart device. Based on questionnaires administered after the intervention, there was no significant difference in patient satisfaction with the speech-language pathology services provided via telepractice compared to the standard of care. Despite occasional technical issues with video and audio, clinicians rated their interactions as successful in that they felt able to achieve adequate rapport with patients and were confident in their assessments of dysphagia for the majority of cases. Although the study suggests that this adaptable home-based dysphagia telepractice yields adequate patient and clinician satisfaction, the intervention provided was not evaluated for accuracy.
In evaluating the impact of dysphagia teletherapy on clinical outcomes, early findings suggest no significant difference between patient adherence to swallowing exercises prescribed FTF or via a standardized telepractice platform (Wall et al., 2017). Furthermore, no significant difference was reported in oral intake status, swallow physiology or aspiration risk for head and neck cancer patients treated with prophylactic swallowing exercises by either FTF clinician-guided, asynchronous telepractice, or patient-directed exercise programs during radiation treatment (Wall et al., 2020).
Overall, the early literature suggests that telepractice swallowing interventions can be feasible, yield high patient and clinician satisfaction, and provide reliable assessment results when using a standardized technological setup. This is encouraging given the necessary shift to dysphagia telepractice many S-LPs are facing in the context of COVID-19.
Practical advice for telepractice dysphagia intervention
In this next section, we share lessons learned from our experience in conducting dysphagia intervention sessions for the PRO-ACTIVE study. The suggestions outlined below are based our careful review of the literature, mainly focused on ideal telepractice setup recommended by Ward et al. (2012) as well as the home-based telepractice setup described in Collins et al. (2017). We made adaptations to their methodologies to suit the physical distancing requirements imposed by COVID-19 and adhered to synchronous telepractice delivery, which was most in keeping with our original research protocol.
Technical setup
Software: Choose a software which allows both video and audio connections through computers, smartphones and tablets. The ideal software should be easy to use for patients and offer end-to-end encryption to meet provincial/territorial privacy standards. Software with screensharing capacity would be beneficial as it allows the clinician to display resources during the session. Ensure the selected platform also meets your organization’s regulations and policies. Examples of available software can be found on the SAC website.
Internet speed: An internet speed of at least 384 kbit/s is ideal (Collins et al., 2017). If it is not possible to guarantee this speed on the patient end, as it was in our case, clinicians should test and optimize their own internet speed prior to each session.
Optimizing audio quality: Use of noise cancelling headphones and portable microphones for both the clinician and patient can increase the success and accuracy of assessment. In our experience, it can be difficult to reliably assess vocal quality after oral trials via videoconferencing, particularly for patients with dysphonia. As such, measures to improve audio quality can yield a more accurate assessment. Likewise, patients with hearing impairments would also benefit from this equipment to minimize the impact of their hearing deficits.
Text-based communication: Text-based options can help to clarify communication breakdowns for all patients, but particularly for those with hearing loss or speech impairments. Most videoconferencing software contain a chat function where clarifications can be typed. Applications such as Streamcast can also overlay captions into a live videoconference.
Prior to your first virtual session
Determine barriers: Contact your patient by telephone to determine willingness and ability to participate in the telepractice session. Discuss the patient’s options for audio/video setup and determine any potential barriers to a successful session such as vision or hearing loss, cognitive impairment or communication impairments. In circumstances when the patient has access to videoconferencing but does not feel comfortable using the technology, we have had success in guiding the patient through the setup on the telephone. Often, this only took a few minutes and increased patient comfort during our session considerably.
Identify appropriate assessment materials: During telepractice, patients are responsible for providing liquids and foods for the swallowing assessment. We suggest taking a brief inventory of the patient’s swallowing complaints, either via chart review or by telephone, in order to determine which textures are appropriate for the assessment. Make sure to provide the patient with specific examples of each texture that you would like to test.
Caregiver participation: Ask your patient if he/she wants a loved one present during the telepractice session. In cases where the patient has cognitive, communication or motor difficulties, caregiver attendance is recommended to aid in setup and feeding, and receive education.
Consent to e-mail communication: This allows you to send e-mail instructions for setting up the telepractice session, a checklist of items that patients should bring for the session, as well as useful dysphagia educational resources.
Assessment toolkit: If feasible to provide physical resources for patients while maintaining physical distancing, a toolkit can be prepared prior to your patient’s first session, including (but not limited to) an instruction booklet for telepractice setup, printed dysphagia resources, a flashlight, a jaw opening measure, a tongue depressor, thickened fluids (if necessary) and clear plastic utensils.
During your virtual session
Consent: Begin each session by obtaining consent for the telepractice session. This should include a discussion about the risks of gathering and disclosing health information via videoconferencing. Please refer to your provincial regulations for specific consent guidelines. Of note, in the context of the COVID-19 pandemic, the CASLPO has acknowledged that it may not be possible to meet all practice standards and guidelines while providing services. They require that clinicians continue to provide services only if they are in the best interest of patients. Clinicians must then “document [their] rationale for deviating from any standards, as well [their] consent discussion with the patient that outlines what aspects of the intervention may not follow the standard(s).” (CASLPO, 2020)
Safety precautions: Clinicians are responsible for having safety measures in place in case an emergency arises during the session. A common concern in the context of a dysphagia assessment is that a patient may aspirate or choke. Clinicians should verify the patient’s current location and address at the beginning of each session in case emergency services need to be contacted. When possible, the presence of another adult in the household may be beneficial in case of an emergency.
Oral peripheral examination (OPE): Ensure that the patient is positioned in the center of the screen, directly facing the camera, in order to adequately assess lip and tongue symmetricity. When possible, ask the patient to bring the camera closer to his/her face to assess the oral cavity. In our experience, visualization of velar movement has been especially difficult through video-conferencing. Clinicians can assess nasality using speech tasks to gain insight into soft palate function. While range of motion and symmetry of most articulators can be assessed in this capacity, assessments of strength of movement are limited.
Oral trials: Clear cups and spoons allow for easier visualization of bolus size during oral trials. In order to assess hyolaryngeal excursion, Ward et al. (2012) suggest applying a piece of surgical tape over the thyroid notch and observing the swallow in lateral position. We have found that even without tape, it is often possible to adequately visualize the hyolaryngeal excursion in lateral view. Note that this may not be possible in cases where the patient has a beard (Morrell et al., 2017) or neck anatomy that obscures visualization of the thyroid notch. When visualization is impaired, clinicians can ask the patient or caregiver to count the number of swallows per bolus to verify observations. After the swallow, a flashlight is often necessary for an accurate assessment of oral residue. In our experience, telephone flashlights are adequate for this task. We have identified some obstacles in accurately assessing post-swallow vocal quality, especially in patients with dysphonia. Difficulties with assessing wet vocal quality have been reported even in studies using optimal technological setups (Ward et al, 2014). With this in mind, we have used our assessment of vocal quality conservatively when making clinical judgments.
Swallowing exercise training: When teaching exercises, we suggest to demonstrate them to patients from both the front and lateral view, before asking them to practice the exercise. Some exercises, such as the Mendelsohn maneuver, are especially difficult to teach and monitor without direct hyolaryngeal palpation. We advise to use your clinical discretion in determining the appropriateness of teaching an exercise using telepractice.
Adaptations for sessions via telephone
It may be necessary for S-LPs to conduct remote sessions via telephone when patients have no access to videoconferencing equipment. This requires further adaption as most components of a clinical swallowing assessment are not possible via telephone and patient report may not be reliable or accurate. In the context of the PRO-ACTIVE study, we only provided telephone sessions for patients who had received FTF intervention prior to the COVID-19 directive, and focused on obtaining a case history and providing therapy updates.
Consent: Consent should include a discussion about the increased limitations of this mode of intervention and associated risks.
Assessment: Efforts should be made to increase the accuracy and completeness of patient-reported symptoms. With consent, clinicians can obtain collateral information from family members. In cases where patients have difficulty describing their swallowing difficulty and the clinician knows enough about the patient’s swallow to consider it safe, we have found that asking patients to swallow liquids and/or foods during the telephone conversation can increase their ability to answer symptom-related questions.
Intervention: In the absence of direct swallowing assessment results, the clinician can provide general safe swallowing strategies, and when appropriate, make recommendations for diet texture downgrade in order to reduce the immediate risk of aspiration. Education should be focused on signs, symptoms and risks of aspiration to improve patient self-monitoring. Patients at risk for aspiration should also be educated about signs of pneumonia and when to seek medical attention.
Overall, telephone sessions are unlikely to adequately replace FTF or synchronous videoconferencing, especially for moderate or severe dysphagia. However, this mode of telepractice can be used to triage patients, identify the need for urgent or FTF follow up, and provide education to aid in reducing risks of aspiration in the interim.
Conclusion
The physical distancing requirements imposed by COVID-19 prompted us to change to a telepractice platform for carrying out dysphagia intervention for our currently open PRO-ACTIVE study. Through our shift to using this model of care, we have learned that successful dysphagia telepractice requires appropriate videoconferencing setup and considerable adaptations both before and during each session in order to optimize care. While we hope that the suggestions outlined above will benefit S-LPs working with dysphagia of various etiologies, it is important to note that the head and neck cancer patients enrolled in the PRO-ACTIVE study have, for the most part, intact cognition and good literacy skills, which made the shift to telepractice possible. Ultimately, it is the clinician’s responsibility to determine the appropriateness of telepractice for each patient, assess their own competency in providing services using this model, and make further adaptations to their dysphagia assessment and interventions if needed to ensure patient safety (CASLPO, 2014). As S-LPs across Canada are obtaining widespread access to telepractice software and gaining valuable experience and expertise in conducting sessions using this model of care, telepractice is likely going to remain a prominent model of care in coming years. The increase in utilization of telepractice will undoubtedly offer opportunity to further evaluate the safety, accuracy and outcomes of this mode of dysphagia assessment and treatment using practical home-based setups. This has the potential to expand the reach of S-LPs and improve accessibility to dysphagia services for all patients regardless of geographic limitations.
Author Biographies
Gabrielle Carrier, MHSC; Speech-Language Pathologist (C) Reg. CASLPO
Gabrielle has been practicing as a Speech-Language Pathologist since graduating from the University of Toronto in 2014. She has a special interest in dysphagia assessment and intervention, and has experience working with swallowing disorders of various aetiologies in the acute care setting more recently in head and neck oncology. She is currently working as an SLP Clinical Research Coordinator for the PRO-ACTIVE trial.
Veronica Rodriguez, MHSC; Speech-Language Pathologist (C ) Reg. CASLPO
Veronica has been a practicing Speech-Language Pathologist since graduating from the University of Toronto in 2014. Her specialization is in dysphagia management in the adult acute care population with more recent focus in head and neck oncology. Currently, she is practicing as a SLP Clinical Research Coordinator in the PRO-ACTIVE trial.
Rosemary Martino, MA, MSc PhD; Speech Language Pathologist CCC-SLP, (C) Reg. CASLPO; Canada Research Chair (Tier II) in Swallowing Disorders
Rosemary is a Professor in the department of Speech-Language Pathology at the University of Toronto. She practiced clinically for over 15 years and has served as president of the Dysphagia Research Society (DRS). She has recently received a PCORI award to lead the PRO-ACTIVE study, which is an international trial targeting dysphagia treatment for patients with head and neck cancer.
References
American Speech-Language-Hearing Association. (n.d.) Telepractice. Retrieved from: https://www.asha.org/Practice-Portal/Professional-Issues/Telepractice
Brennan, D., Tindall, L., Theodoros, D., Brown,J., Campbell, M., Christiana, D., Smith,D., Cason,J., Lee, A. (2010). A Blueprint for Telerehabilitation Guidelines. International Journal of Telerehabilitation, 2(2), 4. doi:10.5195/ijt.2010.6063
Chief Minister of Health of Ontario. 2020. Directive #2 for Health Care Providers (Regulated Health Professionals or Persons who operate a Group Practice of Regulated Health Professionals). Ontario Ministry of Health. Retrieved from: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/directives/RHPA _professionals.pdf
College of Audiologists and Speech-Language Pathologists of Ontario. (2014). Position Statement: Use of Telepractice Approaches in Providing Services to Patients/Clients. Retrieved from: http://caslpo.com/sites/default/uploads/files/PS_EN_Use_of_Telepractice_Approaches_in_Providing_Services_to_Patients_or_Clients.pdf
College of Audiologists and Speech-Language Pathologists of Ontario. (2020, March 20). Coronavirus Update: Further Practice Advice. Retrieved from: https://caslpo.com/sites/default/uploads/files/INFO_EN_COVID19_Update_Further_Practice_Advice_March_20_2020.pdf
Morrell, K., Hyers, M., Stuchiner, T., Lucas, L., Schwartz, K., Mako, J., Spinelli. K. J., & Yanase, L. (2017). Telehealth stroke dysphagia evaluation is safe and effective. Cerebrovasc Dis, 44, 225-231. doi: 10.1159/000478107
Speech-Language & Audiology Canada (2006). Position Paper: The Use of Telepractice for SAC S-LPs and Audiologists. Retrieved from: https://sac-oac.ca/sites/default/files/resources/sac_telepractice_position_paper_english.pdf?_ga=2.211054493.986751111.1588596579-2121390970.1581464211
Wall, L.R., Ward, E.C., Cartmill, B., Hill, A.J., & Porceddu, S.V. (2017). Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors. Dysphagia, 32, 279–292. doi:10.1007/s00455-016-9757-z
Wall, L. R., Ward, E. C., Cartmill, B., Hill, A. J., Isenring, E., Byrnes, J., & Porceddu, S. V. (2020). Prophylactic swallowing therapy for patients with head and neck cancer: A three-arm randomized parallel-group trial. Head & Neck, 42(5), 873-885. doi:10.1002/hed.26060
Ward, E. C., Sharma, S., Burns, C., Theodoros, D., & Russell, T. (2012). Validity of conducting clinical dysphagia assessments for patients with normal to mild cognitive impairment via telerehabilitation. Dysphagia, 27(4), 460-472. doi:10.1007/s00455-011-9390-9
Ward, E. C., Burns, C. L., Theodoros, D. G., & Russell, T. G. (2014). Impact of dysphagia severity on clinical decision making via telerehabilitation. Telemed J E Health, 20(4), 296-303. doi:10.1089/tmj.2013.0198
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