Fibreoptic Endoscopic Evaluation of Swallowing (FEES) An Advanced Practice for Speech Pathologists

Level 2 / 11-19 Bank Place T 61 3 9642 4899 office@speechpathologyaustralia.org.au Melbourne Victoria 3000 F 61 3 9642 4922 www.speechpathologyaustralia.org.au Position Paper Fibreoptic Endoscopic Evaluation of Swallowing (FEES) An Advanced Practice for Speech Pathologists Copyright 2007 The Speech Pathology Association of Australia Limited Disclaimer: To the best of The Speech Pathology Association of Australia Limited s ("the Association") knowledge, this information is valid at the time of publication. The Association makes no warranty or representation in relation to the content or accuracy of the material in this publication. The Association expressly disclaims any and all liability (including liability for negligence) in respect of use of the information provided. The Association recommends you seek independent professional advice prior to making any decision involving matters outlined in this publication. The Speech Pathology Association of Australia Limited ABN 17 008 393 440

ACKNOWLEDGEMENTS WORKING PARTY Project Officer PERKINS, Kylie Core task group CIMOLI, Michelle, HOLMES, Rhonda, PERKINS, Kylie Members of task group ATHERTON, Marie BURNS, Clare HANCOCK, Kelli LAWRENCE, Felicity MANN, Sally MORRIS, Mary MORTON, Ann Louise WEIR, Kelly Private Practitioner, Brisbane, Qld Austin Health, Heidelberg, Vic Austin Health, Heidelberg, Vic Private Practitioner, Brisbane, Qld Monash Medical Centre, Vic Gold Coast Hospital, Southport, Qld Princess Alexandra Hospital, Brisbane, Qld Flinders Medical Centre, SA Fremantle Hospital, Fremantle, WA Prince of Wales Hospital, Sydney, NSW Royal Brisbane & Women s Hospital, Brisbane, Qld Royal Children s Hospital, Brisbane, Qld We would like to acknowledge the contribution of Lynell Bassett, Leisa Beyers, Kate Bolton, Julie Cichero, Nicola Clayton, Pamela Dodrill, Julia Maclean, Ingrid Scholten, Joanne Sweeney, Katie Walker-Smith, Elizabeth Ward and Jane White. Contributing Special Interest Groups FEES Special Interest Group VICTORIA Speech Pathology Australia Representatives BALDAC, Stacey Position Paper Coordinator DAVIS, Phillipa Professional Standards National Coordinator This paper has been reviewed by members of Speech Pathology Australia who work in the area of FEES. Feedback from speech pathologists was sought across Australia. The Working Party contributed to this project on the basis of his/her particular work context, and the Working Party as a whole was considered to be representative of the range of contexts in which speech pathologists work. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper

Contents ACKNOWLEDGEMENTS... 1 Speech Pathology Australia Position Statement... 1 1 ORIGINS AND AIMS OF THE PAPER... 3 2 DEFINITIONS... 3 3 HISTORY AND BACKGROUND INFLUENCES... 4 4 SCOPE OF PRACTICE... 5 5 DESCRIPTION OF THE PROCEDURE... 5 6 RATIONALE FOR THE PROCEDURE... 6 6.1 Clinical Indications... 6 6.2 Contraindications... 7 6.3 Potential Candidates for FEES... 7 6.4 Limitations... 8 6.5 Comparison of FEES to Modified Barium Swallow and Clinical Bedside Assessment... 8 7 SERVICE DELIVERY... 8 7.1 Setting... 8 7.2 Staffing... 8 7.3 Role of the Speech Pathologist... 9 7.4 Role of the Medical Practitioner/Otolaryngologist... 9 7.5 Role of the Team... 9 7.6 Equipment... 9 7.7 Consumables... 10 8 KNOWLEDGE AND SKILLS... 10 8.1 Education and Training... 11 9 RISK MANAGEMENT... 12 9.1 Risks Associated with FEES... 12 9.2 Infection Control... 13 10 DOCUMENTATION... 14 11 CONTINUING PROFESSIONAL DEVELOPMENT... 14 12 ISSUES... 14 12.1 Organisational Support... 15 12.2 Cost/Staffing/Resources... 15 12.3 Use of Blue Dye... 15 12.4 Use of Topical Anaesthesia/Vasoconstrictors... 15 12.5 Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST)16 13 USE OF FEES IN PAEDIATRIC POPULATIONS... 16 13.1 History and Background Influences... 16 13.2 Scope of Practice... 16 13.3 Procedural Considerations when using FEES with Paediatric Populations... 17 13.4 Rationale... 18 13.5 Limitations... 18 13.6 Service Delivery... 18 13.7 Knowledge and skills... 18 13.8 Risk Management... 19 13.9 Current Issues and Future Research in the Application of FEES with Paediatric Populations... 19 14 LEGAL ISSUES... 20 14.1 Code of Ethics... 20 14.2 Speech Pathologists Responsibilities... 20 14.3 Duty of Care... 20 14.4 Standard of Care... 20 Fibreoptic Endoscopic Evaluation of Swallowing Position Paper i

14.5 Proxy Intervention... 21 14.6 Consent for Speech Pathologist Involvement... 21 14.7 Indemnity Cover and Insurance... 21 14.8 Service Guidelines... 22 14.9 Summary... 22 15 REVIEW... 22 16 RELEVANT SPEECH PATHOLOGY AUSTRALIA DOCUMENTS... 22 17 RECOMMENDED RESOURCES... 23 REFERENCES... 24 Fibreoptic Endoscopic Evaluation of Swallowing Position Paper ii

Speech Pathology Australia Position Statement The assessment of dysphagia using instrumentation is within the scope of practice of speech pathologists (Speech Pathology Australia, 2003). Fibreoptic Endoscopic Evaluation of Swallowing (FEES) is an instrumental imaging technique used to evaluate and manage dysphagia. The use of FEES is considered to be an advanced area of practice for speech pathologists, requiring specialised knowledge, skills and training. Speech pathologists intending to perform FEES are alerted that other professionals and professional bodies may not support the independent use of FEES by speech pathologists. It is essential that speech pathologists consult with relevant professional colleagues and engage the support of their employing organisation before performing FEES. Speech pathologists must obtain explicit workplace credentialing in public and private healthcare settings, accompanied by relevant clinical privileges to determine their authorised scope of FEES practice. This paper aims to reflect current best practice in Fibreoptic Endoscopic Evaluation of Swallowing (FEES), and where available to promote evidence based practice (EBP) in FEES. The term FEES will be used within this paper to describe the use of flexible endoscopy to assess and manage dysphagia. Other terms are used in the literature to refer to the use of fibreoptic endoscopy to evaluate and manage dysphagia. However, with the exception of additional sensory testing, the basic procedure is considered to be the same. This paper will address the use of FEES with adults, infants and children with the exception of Section 13 relating specifically to the use of FEES in the paediatric population. Those working with paediatric clients should read this paper in its entirety and not assume that the paediatric section alone addresses all aspects of care for this population. This position paper does not provide detailed protocols relating to the performance and interpretation of FEES. The use of FEES requires advanced skill and knowledge currently not taught as part of entry-level (Undergraduate or Masters) speech pathology university training. Speech pathologists intending to use FEES must participate in a formalised training program underpinned by an educational framework so as to ensure acquisition of the knowledge and skills required to competently perform FEES and/or interpret videoendoscopic images of swallowing. Speech pathologists with expertise and specialised training in FEES may perform and interpret this procedure for the purpose of: Evaluating swallowing function Providing information on the movement and function of oropharyngeal, velopharyngeal, pharyngeal and laryngeal structures in relation to swallowing function Guiding treatment of dysphagia Evaluating the effectiveness of therapeutic manoeuvres Providing biofeedback during dysphagia intervention programs Providing education to clients and carers regarding dysphagia. FEES is not intended to replace the upper aerodigestive tract examination performed by a medical practitioner such as an Otolaryngologist. Speech pathologists will not use FEES to diagnose pathology. Medical practitioners are the only professionals qualified to render a medical diagnosis. Speech pathologists with appropriate training can be responsible for passing the nasendoscope (with the exception of the paediatric population see 13.2), performing the examination and interpreting the images obtained. FEES must be performed within a multidisciplinary healthcare setting. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 1

The process of role delineation and description should be approached in a collaborative manner that ensures consultation with key stakeholders from a multidisciplinary team, including medical practitioners, nursing staff and other relevant stakeholders. Collaboration must also include employers/employing organisations. Speech pathologists should ensure that protocols and policies within their healthcare setting include the role of the speech pathologist in FEES. Contracts for services should where appropriate, specifically include reference to the FEES procedure. Speech pathologists must obtain explicit authorisation from their employer/employing organisation and adhere to their appropriate policies and procedures relating to the use of FEES. Speech pathologists wishing to perform FEES must ensure the FEES procedure forms part of their position description. Skill training and education in the use of FEES should be conducted by a speech pathologist and/or a medical practitioner with expertise in the use of FEES. Practical components of training must be conducted in a multidisciplinary healthcare setting and with a variety of clients with different aetiologies, under appropriate supervision. Speech pathologists performing FEES must update their knowledge and skills on a regular basis sufficient to maintain competency. FEES is considered a safe procedure when performed by competent speech pathologists in a multidisciplinary healthcare setting and when all contraindications and risk factors have been considered. Complications are rare, but speech pathologists need to be aware of the risks to clients. Speech pathologists performing FEES must ensure that an appropriate risk management strategy is in place to ensure client and staff safety. Speech pathologists must ensure that when performing FEES suitably qualified medical and nursing personnel are available in the facility where the procedure is being performed so as to manage potential adverse events. Speech pathologists intending to perform FEES must ensure their employer s and their own professional liability insurance specifically covers their performance of the procedure. Speech pathologists performing FEES should identify, develop and complete projects related to FEES within departmental continuous quality improvement programs to ensure that clinical practice is safe, effective and ensures maximum benefit to clients. This Position Paper should be read in conjunction with the Dysphagia-General Position Paper (Speech Pathology Australia, 2004). Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 2

1 ORIGINS AND AIMS OF THE PAPER This position paper has been developed to guide and support speech pathologists in the implementation of FEES in Australian healthcare contexts. This is the first Speech Pathology Australia FEES Position Paper. This position paper describes: Available evidence on the use of FEES Current clinical practice in Australia and internationally Knowledge and skill required to perform and interpret FEES Recommended minimum standards of practice Suggested models for training and education Relevant clinical governance issues to be addressed when implementing FEES into clinical practice, including risk management and credentialing. The position paper has been informed by current available evidence, international position statements, policies and guidelines published by the American Speech-Hearing Association (ASHA, 2004) and the Royal College of Speech-Language Therapists (Kelly, Hydes, McLaughlin & Wallace, 2005) and consensus opinion. 2 DEFINITIONS Standard precautions Basic level of infection control. Standard precautions include but are not exclusive to hand hygiene practices, use of protective barriers such as gloves, gowns, eye wear, appropriate handling and disposal of sharps and other waste, and the use of aseptic techniques. Standard precautions apply to minimise contact with all bodily fluids, secretions and excretions (excluding sweat), whether they contain visible blood or saliva, non-intact skin or mucous membranes. Additional precautions Additional precautions are used in addition to standard precautions to prevent transmission of infection by highly transmissible pathogens. These include high level disinfection and sterilisation procedures. Universal precautions This term was previously used to describe standards for infection control where all blood and body substances were considered as potential sources of infection. Standard and Additional Precautions replaces this term. Sterilisation A treatment aimed at completely destroying all micro-organisms and bacterial spores. High level disinfection Minimum level of treatment suggested for reprocessing semi-critical equipment such as endoscopes, for use in a non-sterile site. This involves inactivation of non-sporing microorganisms by chemical or thermal processing. Clinical governance A system of governance used to facilitate safe, accountable and quality services in health care organisations. Credentials Qualifications, formal training and clinical experience used to establish a health professional s suitability to perform an activity. Credentialing Formal processes used by a health care organisation to evaluate and verify qualifications, formal training and clinical and management experience of health care professionals. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 3

Clinical privileging This process follows credentialing and defines the scope of practice for an individual health professional to perform activities within a specific healthcare organisation. Competence The combined knowledge, skills and behaviours required to perform a specific task. Endoscope This term is used throughout this position paper to refer to flexible fibreoptic nasendoscope. Fibreoptic Endoscopic Evaluation of Swallowing (FEES) The procedure involves inserting a fibreoptic nasendoscope transnasally and evaluating swallowing function with the nasendoscope insitu. The term FEES originally carried a service mark. The service mark no longer applies and the term FEES is an accepted generic term used to describe the procedure. Healthcare organisations Inclusive of but not exclusive to public and private hospitals, medical centres and day surgery clinics. Otolaryngologist A medical specialist trained to conduct surgical and/or medical treatment of the head and neck, including the ears, nose and throat; commonly referred to as Ear, Nose and Throat (ENT) surgeons. Risk management A framework to ensure that procedures and interventions are as safe as possible and that there are mechanisms in place to monitor these risks and to implement change should the risk of an intervention become too high. 3 HISTORY AND BACKGROUND INFLUENCES Endoscopy has been used by otolaryngologists to assess nasal, velo-pharyngeal and laryngeal pathology since the 1970 s (Langmore, 2001). Endoscopy was first described as a tool for evaluating swallowing function in the United States in 1988 by two speech pathologists and an otolaryngologist (Langmore, Schatz & Olsen, 1988). Langmore et al (1988) are generally attributed with the first published description of the use of endoscopy to evaluate swallowing. This procedure was termed Fibreoptic Endoscopic Evaluation of Swallowing Safety (FEESS). Initially described as a screening procedure, the procedure now widely known as Fibreoptic Endoscopic Evaluation of Swallowing (FEES) has evolved to become a comprehensive tool for evaluating oro-pharyngeal dysphagia (Wilson, Hoare & Johnson, 1992; Langmore, 2001). The American Speech and Hearing Association (ASHA) and the Royal College of Speech- Language Therapists (RCSLT) first issued position statements on the use of endoscopy for the assessment of dysphagia in 1992 (ASHA, 1992) and 1999 respectively (RCSLT,1999). Since then FEES has been widely adopted into clinical practice in the United States and the United Kingdom. Despite widespread use in the United States and the United Kingdom, FEES has only recently been introduced in Australian healthcare settings. Other authors have published variations of this procedure using different nomenclature: Videoendoscopic Evaluation of Dysphagia -VEED (Bastian, 1991); Flexible Endoscopic Evaluation of Swallowing with Sensory Testing FEESST (Aviv, Martin, Keen, Debell & Blitzer, 1993). However, with the exception of additional sensory testing, the basic procedure is considered to be the same. FEES is the term used in this position paper to describe the use of endoscopy to evaluate swallowing. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 4

4 SCOPE OF PRACTICE The use of FEES is considered within a speech pathologist s scope of practice (Speech Pathology Australia, 2003) as an advanced area of practice, requiring specialised skills and training. Speech pathologists with appropriate training can be responsible for independently passing the nasendoscope, performing the examination and interpreting the images obtained. A speech pathologist's involvement in conducting FEES is dependent upon: The preferred model of service delivery of the employing organisation The support and explicit authorisation of the employing organisation for the speech pathologist to perform FEES Access to training and demonstration of competence Consideration of clinical governance issues, including the development of a risk management strategy and establishment of formalised processes for recognising competence and obtaining approval to perform FEES independently. According to Speech Pathology Australia s Code of Ethics (Speech Pathology Australia, 2000), individual speech pathologists are responsible for practising professionally and acting within their scope of practice, given their level of education, training and experience. Training and education requirements will be discussed further in Section 8. Speech pathologists will not use FEES to provide a medical diagnosis. FEES must never be performed in lieu of assessment of the upper aerodigestive tract conducted by a medical specialist such as an Otolaryngologist. 5 DESCRIPTION OF THE PROCEDURE FEES is an instrumental procedure used to evaluate swallowing function and guide the treatment of swallowing disorders. It involves passing an endoscope transnasally to provide direct visualisation of the surface anatomy of the critical structures of swallowing in order to evaluate the movement of these structures in response to swallowing regular food and drink. The endoscope is manoeuvred insitu to maximise visualisation of these critical structures, secretions, the presence of any pharyngeal residue, and/or aspiration. A camera is attached to the endoscope to enable the image to be viewed on a monitor and the procedure to be recorded. These recordings are essential to making judgements of swallowing movements and other features of the swallow which may be missed during the on-line examination. The recordings can also serve as documentation of change, enhance education of clients and carers and can be used as visual feedback for therapy. Various protocols are described in the literature (Langmore, 2001; Murray, 1999) however, the basic components of FEES are generally considered to include: Anatomic-physiologic assessment: velar, pharyngeal and laryngeal anatomy, movement and sensation in relation to swallowing Direct assessment of swallowing of food and liquid Application of therapeutic manoeuvres, dietary modification and behavioural strategies and evaluation of their effectiveness (Langmore, 2001). Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 5

6 RATIONALE FOR THE PROCEDURE The clinical dysphagia assessment provides inadequate information regarding the pharyngeal stage of swallowing and underestimates the risk of aspiration by up to 40% when compared with Modified Barium Swallow (Splaingard, Hutchins, Sulton, Chaudhuri, 1988). Please refer to the Dysphagia Position Paper (Speech Pathology Australia, 2004) and the Modified Barium Swallow (MBS) Position Paper (Speech Pathology Australia, 2004) for a description of clinical bedside assessment and MBS respectively. The use of instrumental procedures such as FEES offers the potential to enhance a speech pathologist s understanding of the physiologic and anatomic basis for dysphagia. FEES can be used to evaluate oropharyngeal swallowing function and formulate recommendations for treatment and management of dysphagia, including provision of advice regarding a client s suitability for oral intake. A speech pathologist s decision to perform FEES is based on: Clinical indications identified through the clinical dysphagia assessment Practical considerations (access, time, convenience and availability) Efficacy of various instrumental examinations based on available evidence and current best practice FEES may be considered the instrumental examination of choice where the aim is to: Evaluate the functional impact of normal and abnormal anatomy and physiology on swallowing Visualise the surface anatomy Obtain views of mucosa (oedema, erythema) Identify management of secretions Grossly assess sensation Identify aspiration of food and drink during swallowing Directly view the bolus and residue within the hypopharynx Evaluate the integrity of laryngeal function and airway protection as it relates to swallowing function Identify and evaluate the effectiveness of interventions Devise recommendations for optimum delivery and maintenance of nutrition and hydration Use biofeedback in the treatment of dysphagia Make observations of swallowing function over an extended period of time, or repeated examinations Minimise radiation exposure Conduct a conservative examination and minimise the risk of aspiration Assess swallowing function in patients for whom positioning and access to other instrumental dysphagia assessment techniques is problematic (e.g. MBS) Provide more timely assessment where access to MBS is restricted Use real foods and drink to evaluate swallowing function (Langmore, 2001). 6.1 Clinical Indications The following signs and symptoms of dysphagia may indicate a client s suitability to undergo FEES: History of pharyngeal dysphagia Difficulty managing oral secretions Difficulty co-ordinating swallowing with respiration Abnormal vocal quality and suspected dysphagia Odynophagia Fatigue during swallowing Globus pharyngeus. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 6

6.2 Contraindications Speech pathologists must consult the treating medical practitioner prior to performing FEES on clients who present with any of the following signs, symptoms and medical issues: Severe agitation and reduced ability to cooperate Severe movement disorders History of vasovagal or fainting episodes History of severe epistaxis Nasal trauma Recent treatment for head and neck cancer (surgery/chemotherapy/radiotherapy) where mucosal condition may be compromised/traumatised by insertion of the nasendoscope Obstruction of both nasal passages Where mucosal condition is suspected to be poor and insertion may cause further trauma Unstable cardiac conditions Currently taking anticoagulation medication Nasopharyngeal stenosis Base of skull/facial fracture Sino-nasal anterior skull base surgery/tumours The presence of an insitu nasogastric tube in infants and young children. This is not an exhaustive list. 6.3 Potential Candidates for FEES The application of FEES in dysphagia management in specific client groups with dysphagia is acknowledged in the literature (Langmore, 2001). FEES may be suited to many different client populations including: 1. Neurological stroke acquired/traumatic brain injury progressive neurological disease encephalitis/ meningitis tumour congenital neuromuscular disorder 2. Post-surgical head and neck neurosurgery spinal craniofacial impaired supraglottic function laryngeal dysfunction 3. General medical local trauma connective tissue disorders medically complex 4. Respiratory acute/chronic obstruction pulmonary disease ( COPD) cardiothoracic/thoracic post extubation This is not an exhaustive list. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 7

6.4 Limitations FEES provides visualisation of many of the critical structures of swallowing and swallowing events. However, there are some events and structures which cannot be visualised: The oral cavity is not visualised Laryngeal and hyoid movement is implied rather being directly observed The view of the hypopharynx is lost during the height of the swallow due to white out. White out is caused by the approximation of tongue and pharynx reflecting the light from the tip of the endoscope back up to the camera. White out prevents visualisation of events which may occur in close temporal proximity to the swallow. Penetration/aspiration during the swallow is therefore not able to be visualised. However, as 90% or more of aspiration events occur before or after the swallow (Smith, Logemann, Colangelo, Rademaker, Roa Pauloski, 1999), the majority of aspiration events are directly witnessed The moment of white out limits the ability to quantify the extent of aspiration The cricopharyngeus and upper oesophageus are not able to be visualised Structural anomalies such as anterior cervical osteophytes and Zenker s diverticulum are unable to be viewed. 6.5 Comparison of FEES to Modified Barium Swallow and Clinical Bedside Assessment FEES has been compared with both the clinical bedside dysphagia examination and the MBS to determine its sensitivity for detecting clinical features of dysphagia. Clinical bedside dysphagia examination has been shown to underestimate aspiration risk by 14% when compared to FEES (Leder & Espinosa, 2002). Several studies have compared MBS with FEES (Langmore, Schatz & Olsen, 1991; Wu, Hsiao, Chen, Chang & Lee, 1997; Perie et al. 1998; Leder, Sasaki & Burrell, 1998; Aviv 2000). These studies have shown agreement between MBS and FEES for identifying important indicators of dysphagia such aspiration and detection of pharyngeal residue (Leder and Espinosa, 2002). It is important to acknowledge that both MBS and FEES provide different information, and therefore neither can be considered the ideal examination for all contexts. 7 SERVICE DELIVERY 7.1 Setting FEES is considered a safe procedure when performed by skilled operators in healthcare settings. Speech pathologists performing FEES must ensure that suitably qualified medical and nursing staff are immediately available to manage adverse events should they occur. 7.2 Staffing Staffing requirements include: An endoscopist a speech pathologist with specialised skills and training or medical practitioner competent to perform FEES or medical practitioner competent to perform endoscopy A suitably trained assistant to feed the client, operate recording equipment and assist the endoscopist as required Medical and nursing staff to manage adverse events. It is imperative that the process of role delineation and description be approached in a collaborative manner in consultation with the appropriate medical practitioner and employing organisation, and other relevant key stakeholders. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 8

7.3 Role of the Speech Pathologist FEES is considered an advanced procedure requiring specialised knowledge and skills. A speech pathologist s role may include: Passing and operating the endoscope Directing the evaluation including decision making regarding appropriate food and drink to trial Instructing the client in the performance of therapeutic manoeuvres and compensatory strategies Interpreting the images obtained via FEES Reporting and documenting the results Formulating a management plan including therapy programs where appropriate Referral to other professionals where indicated Educating clients and carers about the severity and implications of oropharyngeal dysphagia. In some models of service delivery, a medical practitioner may pass the endoscope and the speech pathologist is responsible for directing the procedure and interpreting the images. In such a case, the speech pathologist would need to demonstrate competence to interpret the images. Knowledge and skill requirements will be discussed in further detail in Section 8. A multidisciplinary approach similar to that described above is the most common model of service delivery described in the literature regarding the use of FEES in the paediatric population (Miller & Willging, 2003; Hartnick et al 2000). They describe models where a paediatric otolaryngologist is responsible for the insertion and manipulation of the endoscope whilst the speech pathologist focuses on the oromotor development of the child and functional aspects of swallowing. 7.4 Role of the Medical Practitioner/Otolaryngologist Medical practitioners are the only professionals qualified to provide a medical diagnosis. Medical specialists/ Otolaryngologists are responsible for making any medical diagnoses or decisions regarding structural or mucosal abnormalities in the upper aerodigestive tract (Langmore, 2001). For this reason, when used for medical diagnostic purposes FEES must be viewed and interpreted by an Otolaryngologist or other medical practitioner with training in this procedure. An Otolaryngologist or other medical practitioner may act as a supervisor to direct a speech pathologist s development of knowledge and skills to perform endoscopy in order to conduct FEES. Models for training will be discussed further in Section 8. 7.5 Role of the Team The potential consequences and complexities associated with dysphagia require speech pathologists to work as a team with other health professionals, clients, families and carers. The composition of these teams depends on clinical indicators, aetiology of the dysphagia and the preferred models of service delivery within the employing organisation. It is strongly recommended that the treating medical practitioner be informed of the use of FEES in the management of the client s dysphagia. 7.6 Equipment All equipment utilised in FEES must be used and maintained in accordance with the manufacturer s specifications. Standard FEES equipment includes: endoscope camera head camera processor Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 9

light source leak tester & air pump high level disinfection equipment monitor recording equipment VCR/DVD/CD-ROM microphone 7.7 Consumables Equipment for performing endoscopy includes: alcohol wipes gauze lubricant topical anaesthetic swab sticks Equipment for a swallowing assessment may include: spoons straws cups barium blue/green food colouring optional (refer to Section 12.3) food for trials (may vary for each client) ice chips 8 KNOWLEDGE AND SKILLS Speech pathologists intending to undertake training in the use of FEES are expected to demonstrate advanced knowledge and skills in the assessment and management of dysphagia as outlined in Section 8.1 of the Speech Pathology Australia Dysphagia Position Paper (Speech Pathology Australia, 2004). FEES is not a competency required of or appropriate for Entry-Level speech pathologists (refer to Competency Based Occupational Standards (CBOS, Speech Pathology Australia, 2001). Specific skills and knowledge required to perform FEES encompass three general areas: Technical skill and knowledge required to operate the equipment safely and effectively Procedural skill and knowledge to provide a comprehensive and complete examination Interpretive skill and knowledge to document and summarise findings, and formulate a treatment and management plan based on the findings. Specific advanced competencies relevant to the performance and interpretation of FEES include: Knowledge of normal and abnormal aerodigestive physiology for respiration, airway protection and swallowing. Recognition of anatomical landmarks as viewed with an endoscope Recognition of altered anatomy as it relates to swallowing function Recognition of age related changes in swallowing Identification of the indications and contraindications for FEES Identification of potential candidates for FEES, including knowledge of client groups that may benefit from FEES Recognition of the limitations of FEES Knowledge of the risks and potential complications associated with FEES Knowledge of appropriate strategies to minimise risk Knowledge of specific requirements relating to consent for FEES Demonstrated ability to inform the client about the procedure and obtain consent Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 10

Demonstrated knowledge of specific equipment and materials required to complete FEES. Demonstrated knowledge of equipment set up and client preparation for FEES Operation and maintenance of the equipment required to perform FEES Awareness of the accepted protocol for disinfection of equipment needed to perform FEES Recognition of the issues relating to the application of anaesthesia for FEES Insertion and manipulation of the endoscope in a manner that causes minimal discomfort to clients and reduces the potential for adverse events Insertion and manipulation of the endoscope to obtain optimal visualisation of swallowing Performance and demonstrated specific knowledge of the elements of a comprehensive FEES protocol Identification of salient findings during a FEES Interpretation of the results from a FEES to develop an appropriate management plan Application of appropriate treatment strategies to optimise oral intake /to progress to oral intake Application of FEES as a biofeedback tool Application of FEES to facilitate education of the client, family and professionals Preparation and dissemination of documentation that is relevant to the procedure and meets the minimum standards/requirements of the employing organisation. Refer to Section 13.7 for additional specific advanced competencies relevant to the performance and interpretation of FEES in infants and children. 8.1 Education and Training Currently, skills and knowledge required to use FEES are not addressed within the Bachelors or Masters Degree Entry-Level university training. Speech pathologists therefore must undertake appropriate workplace training to meet the level of competency required to perform and interpret FEES. Acquisition and demonstration of the advanced level of knowledge and skill required to perform FEES in a healthcare setting must be achieved by a combination of all of the following: Tutorials and self directed learning activities such as reviewing commercially-available teaching tapes and related websites Theoretical preparation including review of current literature and evidence-based practice related to FEES, population studies and review of anatomy and physiology of swallowing Observation Practice under direct supervision, with maintenance of a log book of time spent under supervision and in training, including a record of any adverse events Indirect practice with indirect supervision with recording as above. In addition, speech pathologists must undertake any mandatory training required of employees of the employing body or service purchaser, i.e. workplace, health and safety training, Cardio-Pulmonary Resuscitation (CPR)/Basic Life Support training (BLS). Undertaking supervised, hands-on training is integral to any training program for FEES. A supervisor may include a suitably qualified speech pathologist or Otolaryngologist or other medical practitioner with expertise in the performance and interpretation of FEES. Performance may be measured using the following methods: Formal written examination Procedural testing with a trained examiner Interactive multimedia activities Peer evaluation including inter rater activities with trained peers Case presentation to trained peers. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 11

At this time, there is no formally defined set of competencies for speech pathologists conducting FEES in Australia. Speech Pathology Australia supports the establishment of formal training programs that are overseen by an accredited training institution. Speech Pathology Australia believes such programs will ensure that educational frameworks are addressed and optimised. However, currently there is no accredited training program in Australia. As such, training in the use of FEES currently takes place within individual workplaces. Speech Pathology Australia supports workplace training as an interim measure to the establishment of formal training programs, provided there is a solid educational framework, skill base and competency program underpinning all workplace training. Speech pathologists must ensure that their employing organisation is informed and satisfied with their credentials and training before performing FEES. Some organisations may be guided and supported by local processes developed and monitored by formalised credentialing and clinical privileging procedures. Credentialing processes are critical to ensure that speech pathologists practice in accordance with Speech Pathology Australia s Code of Ethics (Speech Pathology Australia, 2000). The opportunity for student observation of FEES in a clinical setting is currently limited. However, as the use of the procedure becomes part of routine clinical practice, these opportunities may become available. 9 RISK MANAGEMENT FEES has been demonstrated to be a safe procedure when performed by trained speech pathologists (Hiss & Postma, 2003). Speech pathologists must be aware of the risks to clients in undertaking this procedure. Speech pathologists must ensure there is a local risk management strategy in place to maximise safety of clients and staff when performing FEES. This risk management plan may include: Identification of risks associated with FEES Informing the employing organisation of risks associated with FEES Proficiency in Basic Life Support Completion of risk management training/education (e.g. certified by Clinical Nursing Education Units or other organisational education groups familiar with management of adverse events which may occur when performing FEES) Familiarisation with local requirements for cleaning/disinfecting/sterilising equipment Implementation of standard precautions with additional precautions where indicated Developing processes for reviewing the local incidence of adverse events and implementing appropriate risk reduction plans should the incidence of these events exceed that described in the literature Establishing local credentialing procedures to ensure that speech pathologists satisfy their employing organisation s requirements for training and have obtained the approval of the employing organisation to perform FEES independently Conducting FEES in a healthcare setting with immediate access available to appropriately qualified nursing and medical staff should an adverse event occur. If atypical structure and function of the nasal cavity, pharynx or larynx is observed or suspected, the speech pathologist must inform the client s medical practitioner who may refer the client for upper aerodigestive tract examination to assess for the presence of pathology or disease. 9.1 Risks Associated with FEES Laryngospasm (closure of vocal folds which then prevents breathing) Laryngospasm is a rare complication associated with FEES. In a study with a cohort of 349 procedures laryngospasm was not observed (Cohen, Setzen, Perlman, Ditkoff, Mantucci & Guss, 2003). Fibreoptic intubation carries a higher risk of laryngospasm because of Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 12

decreased conscious state and potential to manipulate the vocal folds. FEES however is conducted with the endoscope placed well above the vocal folds to capture a view of the laryngopharynx including the base of tongue. This positioning therefore, poses a lower risk of laryngospasm. Resolution of laryngospasm is generally spontaneous. Syncope collapse (including fainting, vasovagal syncope) Vasovagal syncope is the most likely type of syncope to occur during FEES (Langmore, 2001). In a study where 500 FEESST procedures were performed, there were no reported episodes of vasovagal reactions and insignificant changes in heart rate (Aviv, Kaplan, Thomson, Spitzer, Diamond & Close, 2000). The small risk of a vasovagal response increases during the initial insertion of the nasendoscope. This may be attributable to direct stimulation of sensory fibres in the nasopharynx, fatigue, client anxiety, or hunger. Epistaxis (nose bleeding) There have been less than 1.1% cases of epistaxis reported during FEES performed by trained speech pathologists (Cohen et al, 2003). Speech pathologists conducting FEES are advised to be aware of clients on anticoagulation therapy, those who have blood clotting disorders, or who have undergone recent nasal surgery. Person-to-person and environmental contamination In addition to the risks of contamination associated with performing a clinical bedside swallowing examination, FEES also presents additional opportunities for transmission of infection. During FEES, endoscopes come into contact with mucous membranes and non intact skin. An endoscope can be contaminated by the microrganisms present in clients secretions (Spach, Silverstein & Stamm, 1993). 9.2 Infection Control Speech pathologists intending to perform FEES must be aware of appropriate procedures for infection control. The Spaulding classification system published in 1968, guides current international practice in Infection Control (Spaulding, 1968). Australian healthcare standards for infection control are guided by the Australian Government s Department of Health and Ageing Infection Control Guidelines (2004). Specific infection control procedures may include, but are not limited to: Protective eye-wear Masks Gowns Gloves Hand-washing Aseptic technique Appropriate waste and sharps disposal. In addition, speech pathologists must: Adhere to guidelines, policies and procedures for infection control imposed by their employing organisation Ensure that the setting, clinical equipment and materials are maintained in a sanitary condition in accordance with the Principles of Practice (Speech Pathology Australia, 2001). In most organisations, ancillary staff or nurses are responsible for cleaning, decontaminating and disinfecting endoscopes. However, speech pathologists should be aware of their local organisational standards for cleaning endoscopes. The choice between cleaning and processing endoscopes using sterilisation or high-level disinfection will be guided by the employing organisation s infection control policies. Cleaning endoscopes may include: Inspection to detect structural defects/damage, dysfunction and gross soiling Testing before use e.g. pressure leak testing Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 13

Cleaning and decontaminating immediately after each use, according to manufacturers written instructions Sterilisation or high-level disinfection. Rinsing Drying Storage (Association of Perioperative Registered Nurses, 2003; Alvorado & Reichelderfer, 2000). Single-use endosheaths are available to cover the flexible portion of an endoscope. There is limited literature to support the use of these sheaths in place of disinfection (Baker, Chaput, Clavet, Clark, Varney, To & Lytle, 1999). These sheaths do not cover the handle or controls of the endoscope. These portions of the endoscope, unless disinfected/sterilised, have the potential to provide a vehicle for environment-to-person contamination. Speech pathologists considering the use of endosheaths are encouraged to consult local infection control policies and procedures. 10 DOCUMENTATION Speech Pathology Australia specifies minimum standards of reporting within the Dysphagia Position Paper General (2004). In addition to these minimum standards, a FEES report may include: Record of informed consent Administration of anaesthesia or vasoconstrictors by a medical practitioner Description of adverse events, immediate management and follow-up required. Documentation is likely to vary with the policies and procedures of the employing organisation. Both the written FEES report and the recorded image are considered part of the client s record and are medico-legal entities. 11 CONTINUING PROFESSIONAL DEVELOPMENT Speech pathologists who have obtained approval from their employing organisation to independently perform FEES are obliged to ensure that competency is maintained. Speech pathologists must consult with key stakeholders (e.g. Otolaryngologist, Speech Pathology Manager) to establish a process for maintaining and demonstrating competency. Failure to comply with local guidelines governing this process may result in withdrawal of approval for an individual to perform FEES independently, as well as expose an individual to professional liability risks. Examples of continuing professional development activities which may facilitate maintenance of skill and knowledge required to perform FEES may include: Performing a minimum number of procedures annually Peer review activities, inter-rater activities, joint rating of FEES recordings Attendance at special interest groups Attendance at formal workshops and seminars specific to FEES Mentoring sessions. 12 ISSUES This section identifies some of the current controversies or areas where a lack of clarity exists in the literature. Speech pathologists are encouraged to access the evidence based literature and their organisation s policies and procedures when addressing any issue or controversy relating to FEES. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 14

12.1 Organisational Support Speech pathologists intending to perform FEES are alerted that other professionals and professional bodies may not support the independent use of FEES by speech pathologists. It is essential that speech pathologists consult with relevant professional colleagues and engage the support of their employing organisation before performing FEES. It is essential that an employer recognises and agrees that FEES falls within the scope of practice of the speech pathologist with advanced skills and training. This may occur through formalised credentialing processes verifying competency to perform FEES. In particular, the role of a speech pathologist in the independent performance of FEES should be defined within individual position descriptions. For speech pathologists who are private practitioners (e.g. private speech pathologists referred a client in a private hospital), the referring medical practitioner must consent to the FEES procedure being performed by a speech pathologist. Access to medical and nursing assistance must be readily available in the case of an adverse event. 12.2 Cost/Staffing/Resources Implementation of FEES is often limited by access to the equipment required, availability of suitably trained clinicians and time required to participate in training to perform FEES. Some speech pathology departments may be able to negotiate the sharing equipment with other specialties. However, this will be determined by demand for equipment and cleaning/sterilisation requirements. 12.3 Use of Blue Dye Speech pathologists performing FEES have sometimes added green or blue food colouring to food and drink given as oral trials in order to distinguish it from the mucosa of the hypopharynx. (Langmore & Aviv, 2001). This practice seems to be based on tradition and assumption rather than objective evidence. A recent study demonstrated the reliability of FEES to detect critical features of pharyngeal dysphagia including aspiration as consistently high using either blue dyed or non-blue dyed foods (Leder, Acton, Lisistano & Murray, 2005). Increased awareness of the health and safety concerns associated with the use of blue food dye during swallowing evaluation arose following issue of the Food and Drug Administration (FDA) (Public Health Advisory, 2003) which reported serious complications including death after the use of large quantities of blue dye in enteral feeds. To date, there have been no studies in the literature regarding the safety of using coloured food dye during FEES In light of the lack of standardisation, the recent health and safety concerns associated with the use of blue food colouring and the lack of evidence to support its use, it is advisable for speech pathology departments to establish policies to clarify their position on the use of food colouring during FEES. 12.4 Use of Topical Anaesthesia/Vasoconstrictors Topical anaesthesia or vasoconstrictors (nasal decongestants) have been administered by medical practitioners to clients undergoing transnasal fibreoptic laryngoscopy in order to decongest and anaesthetise the nasal mucosa, and minimise client discomfort during the procedure (Johnson, Belafsky & Postma, 2003). There are conflicting views on the effects of topical anaesthesia on swallowing function. One report documented a reduction in the sensitivity of the oropharyngeal region, with the potential to disrupt swallowing competency (Ertiken, Kitlioglu, Tarlaci, Keskin & Aydogu 2000). Other studies have found no compromise in swallowing function (Bastian & Riggs 1999). Administration of topical anaesthesia or vasoconstrictors by a speech pathologist for the purpose of FEES is a scope of practice issue not yet addressed. At this time the legal implications of a speech pathologist administering topical anaesthesia or vasoconstrictors to conduct FEES is unclear. As such, the administration of topical anaesthesia or vasoconstrictors for the purpose of FEES remains outside the speech pathologist s scope of practice. Speech pathologists are advised to collaborate with relevant medical professionals Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 15

and refer to their organisation s policies and procedures with regard to their requirements for the prescription and administration of topical anaesthesia or vasoconstrictors for insertion of a nasendoscope. 12.5 Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) FEESST is a procedure used to evaluate the motor and sensory components of swallowing. The procedure combines FEES with a technique used to determine laryngopharyngeal sensory thresholds. This technique involves delivering pulses of air through an internal port to the laryngopharyngeal mucosa innervated by the superior laryngeal nerve (Aviv et al. 1998). Various studies have investigated the correlation between sensory deficits and aspiration (Aviv et al. 1997; Kidd, Lawson, Nesbitt & MacMahon, 1993; Kidd, Lawson, Nesbitt, MacMahon, 1995). Further research is required to establish how sensory input relates to airway protection and swallowing, and the types of treatment that can be offered (Langmore, 1998). 13 USE OF FEES IN PAEDIATRIC POPULATIONS 13.1 History and Background Influences The use of FEES to diagnose and treat dysphagia in paediatric populations has been developed in the United States of America (Hartnick, Miller, Hartley & Willging, 2000; Link, Willging, Miller, Cotton & Rudolph, 2000; Miller, Willging, Strife & Rudolph, 1994; Willging, 1995; Willging, Miller, Hogan & Rudolph, 1996) and reported in the care of infants and children ranging from 10 days of age to 24 years with multiple diagnoses. Currently in Australia, FEES is emerging as an instrumental assessment for the evaluation of paediatric feeding and swallowing difficulties. Although, nasendoscopy forms part of the evaluation process for voice disorders and velopharyngeal inadequacy in children ranging from approximately 4 18 years, FEES has been used as an exploratory tool with older children only. However, FEES is identified as a credible diagnostic tool for use with children of all ages and its use is expected to be increasingly incorporated into evaluation and management of swallowing disorders in infants and children (birth to 18 years) in Australian healthcare settings. Potential candidates for FEES in a paediatric population are similar to the client groups described in Section 6.3. Additional client groups include those with bronchopulmonary dysplasia (BPD), genetic syndromes such as Di George Sequence, patent ductus arteriosis, gastro-oesophageal reflux disease and necrotizing enterocolitis (Leder & Karas, 2000). Many children present with multiple complex conditions involving neurological, structural, gastroenterological, cardiopulmonary, metabolic and behavioural disorders. 13.2 Scope of Practice In Australia, FEES remains within the scope of practice for speech pathologists with advanced skills in managing a paediatric dysphagia population within a multidisciplinary team context in a medical setting. Due to the medical fragility and developing anatomical structures of infants and young children, the speech pathologist should always work in conjunction with an otolaryngologist or respiratory physician. The physician is responsible for passing the nasendoscope, maintaining the appropriate view during the procedure and diagnosing anatomical anomalies. The speech pathologist is responsible for: Directing the swallowing examination Observation of secretions Direct assessment of swallowing function for food and liquid Direct assessment of therapeutic manoeuvres if age appropriate Interpreting the images of oropharyngeal swallowing physiology. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 16

13.3 Procedural Considerations when using FEES with Paediatric Populations 13.3.1 Positioning An infant may be held by its mother or primary care-giver throughout the assessment, which may more closely approximate the child s regular feeding position, provide emotional support, decrease procedural anxiety and improve tolerance of the procedure. Older children are typically positioned upright. Children with physical disabilities are able to be scoped while in their adaptive seating and positioning systems, approximating their regular mealtime positioning (Migliore, Scoopo & Robey, 1999). Children should be positioned appropriately to avoid spontaneous or reflexive movements that may compromise the safety of the examination (Manrique et al, 2002). 13.3.2 Presentation of food and fluid textures Textures: Food and fluid textures should be age appropriate and include textures/consistencies regularly given in the home. This may include puree, semisolid (lumpy), solid textures and thin fluid and thickened fluid consistencies. Taste preferences should be given to assist compliance. Food allergies should be noted and possible implications regarding use of foods or dyes/colourants investigated. Feeding Utensils: The child s caregiver should be asked to bring the child s usual bottles, teats, cups, spoons, other utensils and food packaging (e.g. tetra pak of preferred juice). 13.3.3 Compensatory strategies Compensatory strategies and therapeutic manoeuvres may be introduced during the evaluation as developmentally appropriate. Common strategies include introducing positional alterations, altering flow rate or viscosity of liquids, varying texture, and modifying utensils (i.e. teats, bottles). 13.3.4 Instrumentation Small diameter flexible nasendoscopes ranging from 1.4 3.2 mm are used with a paediatric population. All other standard equipment for FEES is outlined in Section 7.6. 13.3.5 Patient and caregiver preparation Familiarisation: Education programs for children and parents, including visiting the endoscopy suite if possible and use of age appropriate reading material, assists in familiarising the child and family with the environment and procedure and may enhance children s compliance. Timing of Feeds: Pre-procedural fasting will assist in maximizing feeding readiness and procedural compliance. Removal of Nasogastric tubes: Ideally, nasogastric tubes should be removed prior to the evaluation particularly in young infants who are breast or bottle fed and who are obligatory nasal breathers. The nasendoscope will partially occlude one nostril and as suckle feeding relies on the competency of nasal airflow, a patent second nostril is necessary. Procedural anxiety: The use of topical anaesthesia, vasoconstrictors and insertion of the flexible nasendoscope may be poorly tolerated by young children, those with sensory or cognitive impairments and children who have undergone multiple invasive procedures such as nasogastric tube insertion, facial taping, and ventilation. Procedural anxiety may lead to reduced compliance and challenging behaviour Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 17

which may impact on the applicability of findings. Distraction techniques, models and toys can be utilized to facilitate compliance. 13.4 Rationale The rationale for the use of FEES, clinical indications and potential candidates for FEES are similar in children as those documented for an adult population. However, in addition to the contraindications mentioned for adults, FEES is not recommended for a premature (pre-term) population due to the size of the head and neck, fragility of structures, medical fragility and issues of respiratory compromise. For more extensive information, refer to Section 6. 13.5 Limitations Limitations of FEES in the paediatric population are consistent with those described in Section 6.4 13.6 Service Delivery Service delivery of FEES in paediatric populations is similar to that described in Section 7, with the exception of the role and responsibilities of the speech pathologist and medical practitioner. Specific differences concerning the role of the speech pathologist and medical practitioner involved in the performance and interpretation of FEES in a paediatric population are highlighted below: Role of the speech pathologist: A speech pathologist s role in the performance and interpretation of FEES in infants and children is the same as documented in Section 7.3 with the exception of the responsibility of passing and operating the endoscope. Due to constant changes in paediatric anatomy and physiology associated with growth and the medical fragility of young infants, the speech pathologist should not pass the endoscope in this population. Role of the Medical Practitioner/Otolaryngologist: It is recommended that a paediatric sub-specialist such as paediatric Otolaryngologist, Respiratory Physician or Gastroenterologist, pass the nasendoscope for FEES evaluations in children. These professionals are suitably qualified in the developmental changes of the head/neck, respiratory and gastrointestinal tracts in children, effects of anaesthesia in this population and regularly scope infants and children as part of other investigative procedures. 13.7 Knowledge and skills Speech pathologists performing FEES on children require detailed knowledge of normal and abnormal velopharyngeal and laryngopharyngeal paediatric anatomy. A thorough understanding of the developmental changes that occur in the swallowing process as the child matures is essential. Specific advanced competencies relevant to the performance of FEES in infants and children include: Knowledge of aetiologies that result in or contribute to swallowing and feeding disorders (e.g. failure to thrive, genetic syndromes, brain injury, metabolic disorders, gastrointestinal tract disorders that affect premature and term infants) Knowledge of embryology, anatomy, swallowing physiology, neurophysiology, neurodevelopment and gastrointestinal health in infants and young children; and the changing proportions of infant oral, velopharyngeal, laryngopharyngeal and respiratory anatomy with growth Knowledge of feeding development from birth, through transitional feeding and changes during later childhood Recognition of the sensory processing underlying swallowing and feeding development Knowledge of postural development in relation to feeding and swallowing and implications for different positioning for infants and children of different developmental ages (e.g. side lying, semireclined, upright positioning and postural supports) Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 18

Recognition of cognitive and behavioural development in infants and young children Speech pathologists undertaking FEES in a paediatric population should have extensive experience with paediatric dysphagia to allow appropriate interpretation and application of the findings of FEES. Due to the multifactorial nature of paediatric feeding difficulties and the often physiologic instability of infants and young children, it is imperative that speech pathologists always work within a multidisciplinary team environment (Lefton-Grief & Arvedson, 1997), with a suitably qualified physician (e.g. Otolaryngologist, Respiratory Physician, etc). 13.8 Risk Management Management of the risks associated with FEES identified in Section 9 are also applicable to the use of FEES in a paediatric population 13.9 Current Issues and Future Research in the Application of FEES with Paediatric Populations Lack of normative data on swallowing parameters across developmental stages: Studies on the application of FEES in paediatrics report on FEES ability to detect pharyngeal pooling/residue, premature spillage, laryngeal penetration and aspiration in children with good agreement between FEES and MBS on these parameters (Leder & Karas, 2000; Link, Willging, Miller, Cotton & Rudolph, 2000; Willging, Strife & Rudolph, 1994). However, there is no data available regarding these swallowing parameters in a normally developing population, making it difficult to conclude what is abnormal or pathological versus a normal developmental process. This is particularly pertinent for children during the transitional feeding period (6-36 months) whereby children s feeding and swallowing skills develop from suckle feeding at the breast or bottle in a semireclined position, to chewing solid foods and drinking from a cup when in an upright position (Bosma, 1997). Normative data is required for the paediatric population over different age groups regarding the degree of hypopharyngeal secretions present, initiation of the swallow reflex related to different textures, premature spillage and the degree of pharyngeal pooling. Effect of the endoscope on upper airway resistance and exercise intolerance during suckle feeding: While very small diameter flexible nasendoscopes (ranging from 1.4 3.2 mm) are used with a paediatric population, little is known about the effect of partial nasal occlusion resulting from the presence of the scope, on the coordination of respiration and swallowing in infants and young children. This is particularly pertinent for children who are suckle feeding and thus dependent on nasal breathing to maintain respiratory support during continuous sucking from a bottle or breast. Infants are obligatory nasal breathers. Previous research has shown that young infants who have nasogastric tubes in situ experience considerable nasal obstruction exacerbated by increased nasal secretions and leading to an increase in nasal and total air-ways resistance, and oxygen desaturation (Daga, Lunkad, Daga & Ahuja, 1999; Stocks, 1980). Increased incidence of central apnoea and periodic breathing has also been associated with the use of nasogastric tubes (Van Someren, Linnett, Stothers & Sullivan, 1984). Therefore it appears possible that the presence of the nasendoscope may increase airway resistance in children who are suckle feeding, possibly leading to exercise intolerance, feeding hypoxemia, disruption of suck-swallow-breath coordination and predisposing young children to laryngeal penetration and aspiration over the course of a feed. Thus in some cases, findings of abnormality may be due to the procedure itself rather than underlying pathophysiology. Further research is required on the effects of the presence of the nasendoscope on upper airway resistance and oxygen desaturation in children of varying ages and on the ingestion of a range of food textures and fluid consistencies. Effect of nasendoscope placement on velopharyngeal closure: Little is known about the impact of nasendoscope placement on velopharyngeal closure in the Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 19

paediatric population. Small amounts of nasopharyngeal reflux are considered normal in premature and term infants, however nasopharyngeal reflux is problematic if it occurs repeatedly or in amounts large enough to compromise nasal breathing (Kramer 1985). The degree of velopharyngeal closure achieved under normal circumstances may not be possible with the nasendoscope in situ and may potentially lead to an increased finding of nasopharyngeal regurgitation. There is no available data concerning the potential implication of nasendoscope placement on velopharyngeal closure during swallowing for the paediatric population and further research is indicated. 14 LEGAL ISSUES The following matters should be considered by speech pathologists performing and interpreting FEES. 14.1 Code of Ethics Speech pathologists should adhere to the Speech Pathology Australia Code of Ethics (2000) and to any codes, directions or principles applicable to the organisation employing the speech pathologist, (e.g. Code of Conduct for the Victorian Public Sector). 14.2 Speech Pathologists Responsibilities Individual speech pathologists responsibilities will usually be identified in their position description, employment contract, contract for services, policies and procedures of the employing body, or service purchaser. Specifically, the FEES procedure should form part of the position description of all suitably qualified speech pathologists. Amendments should be sought to protocols and policies within an employing institution to include the speech pathologist s role in FEES. Regardless of the specified responsibilities however, the law imposes a duty on all speech pathologists to exercise reasonable care and skill in the provision of advice and treatment (i.e. an obligation to exercise the standard of care ) where the speech pathologist owes a duty of care. 14.3 Duty of Care A speech pathologist owes a duty of care to another person where the speech pathologist ought reasonably to foresee that their conduct may be likely to cause loss or damage to a class of persons to which the other person belongs. On this basis, it is clear that speech pathologists owe a duty of care to their clients. Speech pathologists may also owe a duty of care to their employing body and/or service purchaser. Where a speech pathologist owes another person a duty of care and the speech pathologist breaches the standard of care required, (either by a specified act, a failure to act, or providing misleading information or advice), the speech pathologist may be liable for damages in a civil action brought by or on behalf of the person to whom the speech pathologist owed the duty of care. 14.4 Standard of Care The standard of care which must be exercised by a speech pathologist is the reasonable care and skill of the ordinary skilled speech pathologist exercising or professing to have this special skill. It is important to note that an inexperienced speech pathologist must meet the standard of a reasonably competent and experienced practitioner providing speech pathology services. Accordingly, a speech pathologist who is aware that they lack the required level of skill in a particular area must seek further advice and guidance immediately. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 20

Such further advice and guidance may involve requesting support from a more experienced speech pathologist, supervisor, the employing organisation or the service purchaser. The courts will determine the standard of care required of a speech pathologist in each particular case. In the past courts have found medical practitioners to be negligent, i.e. to have breached the standard of care required, notwithstanding that the medical practitioner s treatment was in accordance with a practice accepted as proper by a reasonable body of medical opinion skilled in the relevant field. However, a court must have strong reasons for substituting its judgement for the clinical opinion of the medical practitioner where it has been properly arrived at and is supported by a responsible body of medical opinion. Accordingly, speech pathologists advice and treatment should always be in accordance with practices accepted as proper by a reasonable body of opinion skilled in speech pathology, but speech pathologists should be aware that acting in such a manner will not automatically preclude a court from finding them negligent. Further, it is important that speech pathologists be aware of recent literature in their field, current best practices carried out by others in their field, and the Speech Pathology Australia Code of Ethics (2000). 14.5 Proxy Intervention FEES is an advanced area of practice requiring specialised knowledge and skills, formalised training and demonstration of competency. As such, speech pathologists may only delegate performance of the FEES procedure, in whole or in part, to another clinician (the proxy or agent ) if that other clinician has the requisite advanced skills, training and competency. Generally, should a speech pathologist request a second clinician/proxy to perform the FEES procedure in their absence, the second clinician will assume full legal responsibility for the procedure. The second clinician must ensure client consent and understanding of the procedure, even if the first speech pathologist had previously obtained consent from the client. This responsibility extends to the FEES procedure itself and to all documentation, i.e. Individual Development Plans, progress notes, negotiated contracts, etc. It should be noted that depending on the particular circumstances, the speech pathologist may still be held liable in whole or in part for any liability from the intervention carried out by a second clinician. 14.6 Consent for Speech Pathologist Involvement The speech pathologist must obtain the client s consent prior to providing speech pathology services, including assessment, to the client. The client must be informed in broad terms of the nature of the treatment to be provided prior to giving consent. When discussing the risks associated with FEES, speech pathologists are advised to determine whether the client has a history of laryngospasm, syncope collapse or epistaxis. Consent should be in writing and is invalid unless it is voluntary. A client under the age of 18 years can consent to the provision of speech pathology services, provided the client has sufficient intelligence and maturity to understand the nature and consequences of the particular treatment. Where the client lacks the capacity to consent or their capacity to consent is in doubt, the consent of the client s parent or guardian must be obtained. All processes employed by speech pathologists should adhere to privacy legislation and freedom of information legislation. 14.7 Indemnity Cover and Insurance It is the responsibility of speech pathologists to ensure they have appropriate professional indemnity insurance cover. Professionals should be aware that there may be instances where the employing body will not necessarily indemnify them for their actions. It is recommended that all practising Speech Pathology Australia members who undertake FEES have professional indemnity insurance that specifically covers them for performing FEES. Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 21

Speech pathologists should clarify the insurance situation with their insurer for accidental loss, theft or damage to resources during transport. 14.8 Service Guidelines It is recommended that the speech pathologist adhere to all approved guidelines of the employing body in terms of clinical and service management. 14.9 Summary In summary, a speech pathologist performing and interpreting FEES should: Adhere to the Speech Pathology Australia Code of Ethics (2000) Adhere to the code of conduct and all relevant policies/service guidelines of the employing body Ensure their employer/employing organisation is informed and satisfied with their credentials and standard of training before performing FEES Ensure the FEES procedure forms part of their position description Ensure employing institutions include within their protocols and policies the role of the speech pathologist in FEES Not undertake intervention that is outside their experience or expertise as a professional Not overstate their expertise Seek advice from senior speech pathologists and/or fellow professionals as appropriate Obtain the client and/or parent/guardian s consent to treatment prior to commencing instrumental evaluation, Assure the client and parent/guardian remain well informed of the assessment process and intervention program Remain up-to-date with professional developments Undertake all mandatory training Maintain accurate records Ensure that all advice given to the client, parent/guardian, professionals or staff is documented Maintain up-to-date documentation and report writing Ensure the client environment is safe Ensure there is adequate professional indemnity insurance cover. 15 REVIEW This Position Paper should be reviewed every three years. 16 RELEVANT SPEECH PATHOLOGY AUSTRALIA DOCUMENTS Speech Pathology Australia (2000). Code of Ethics. Speech Pathology Australia (2001). Competency-Based Occupational Standards (C-BOS) for Speech Pathologists Entry Level. Speech Pathology Australia (2001). Principles of Practice. Speech Pathology Australia (2002). Scope of Practice in Speech Pathology Speech Pathology Australia. (2004). Dysphagia Position Paper General Speech Pathology Australia. (2005). Dysphagia: Modified Barium Swallow Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 22

Speech Pathology Australia (2005). Tracheostomy Tube Management 17 RECOMMENDED RESOURCES American Speech-Language Hearing Association. (2004). Role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing: guidelines. Available at http://www.asha.org/members/deskref-journals/deskref/default American Speech-Language Hearing Association. (2004). Role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing: technical report. Available at http://www.asha.org/members/deskref-journals/deskref/default American Speech-Language Hearing Association. (2004). Role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing: position statement. Available at http://www.asha.org/members/deskrefjournals/deskref/default Australian Council for Safety and Quality in Healthcare (2004). Standard for credentialing and defining the scope of clinical practice 14/10/05 Kelly A M, Hydes K, McLaughlin C, Wallace S. (2005). Fibreoptic endoscopic evaluation of swallowing (FEES): The role of speech and language therapy. RCSLT Policy Statement Fibreoptic Endoscopic Evaluation of Swallowing Position Paper 23

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