Video Swallow Study Protocol

	STANDARD OF CARE/PRACTICE VIDEOFLUOROGRAPHIC STUDY OF ORAL AND PHARYNGEAL SWALLOWING(Inpatient & Outpatient)	ISSUE DATE:   10/93	No.:  PFF1-TX 70
		REVISION DATE(S):	Page  1  of  8
JCAHO STANDARDS/DHS REGULATION:RI, PE, TX, PF, IM, Title 17 – Radiology Safety, Title 22 – Speech Language Pathologist		REVIEW DATE(S):
		CROSS REFERENCES:Oral Care, Airway Clearance

DESCRIPTION

The videofluorographic study of oral and pharyngeal swallowing incorporates a set of modifications in bolus size, texture, patient positioning, and radiographic focus to facilitate optimum visualization of the oral, pharyngeal, laryngeal structures and their function during swallowing.  The effects of compensatory maneuvers on bolus transport during swallowing are able to be studied radiographically.  This procedure is often referred to as the “modified barium swallow,” video swallow study, or videofluoroscopic swallowing function study or examination.

Purpose of the Evaluation:

1.    Measure speed of swallow (oral & pharyngeal transit times)

2.    Measure efficiency of swallow

3.    Define movement patterns of structures in oral cavity, pharynx and larynx

4.    Determine if aspiration occurs and when, why and how much

5.    Examine effectiveness of rehabilitation strategies

STANDARD OF CARE

1.    Patient can expect to receive appropriate pre-swallowing treatment to improve his/her swallowing skills.

2.    Patient can expect to know what kinds of foods he/she can swallow safely.

PATIENT POPULATION

1.    Patients in whom bedside or clinical evaluation results are inconclusive or suggest dysphagia and/or aspiration.  The modified study is recommended if the patient is alert and possesses sufficient cognitive awareness to complete the study.

2.    Patients who can sit in the chair up to 45 minutes without difficulties.

3.    Patients who are inpatients or outpatients.

STANDARD OF PRACTICE

1.    The SLP will identify appropriate pre-swallowing interventions to improve patient’s swallowing skills.

2.    The videofluoroscopy team will identify what type of food patient can swallow safely.

LEVEL OF PRACTITIONER

The videofluoroscopy team will consist of the following:

1.    Radiologist or another physician certified to perform videofluoroscopy studies.

2.    A radiology technologist

3.    Technical supervisor/Lead tech/RT.

4.    A speech-language pathologist.

EQUIPMENT

Video cassette recorder (VCR)                              A video counter timer

Fluoroscopy table                                                              Fluoroscope

Lead apron                                                                        Monitoring badge for radiation

Vess chair                                                             Suctioning equipment

Oximeter

Implements Used:

Tongue blade                                                        Straw

Cups                                                                      Theraspoons/metal spoons

Masks                                                                    Towels

I & P lubrication                                                                Gloves

Goggles/glasses

 

Food:

Video Swallowing Evaluation Tray:                                                          At Satellite Units

2oz scrambled egg                                     2oz ham-chopped                    1 nectar-thick liquid

1 pkg graham crackers/Lorna Doone         4oz apple juice                                    1 pudding

4oz nectar-thick juice                                Pudding/applesauce                 Bread

1 fruit cup

1 juice

Other food consistencies with which the patient appears to have difficulty.

Supplies:

Liquid barium    Powdered barium            Barium paste (Esophatrast)

PROCEDURE

(For videofluorographic studies performed at Satellite Units please refer to ASatellite@ section in the table below)

The speech-language pathologist will administer and modify the bolus material (e.g., consistency, size, texture), positioning of the patient, examining compensatory swallow maneuvers and interpretation of the physiology of the swallow.  The Technical Supervisor/Lead tech arranges swallowing procedure, transports the patient, and suctions the patient.  The radiology technologist prepares the fluoroscopic equipment and controls the video.  Dietary provides video swallowing evaluation tray.

STEPS	RATIONALE	SPECIAL CONSIDERATIONS
PRE-PROCEDURE:1.   SLP will check with the physical therapist regarding patient’s sitting endurance.	Patient needs to be able to tolerate the procedure for 45 minutes.
2.   SLP will request physician’s order for videofluoroscopic study.	To comply with regulations.
3.   Physician will then explain procedure to the patient and document such in the Progress Notes.	To respect patient’s rights.
4.   Informed consent will be obtained according to hospital policy.	To comply with regulations.
5.   SLP coordinates date and time of procedure and notifies the following staff of the scheduled time:$  Physician$  House Supervisor$  Radiology Technologist$  Technical Supervisor/Lead tech/RT $  Dietary Supervisor, clerk	To coordinate services.
6.   On the day of the study, the radiology technologist will set up room with equipment, making sure all the equipment is functioning properly before patient is brought to study.	To prevent delays.
7.   The RT/Technical Supervisor/Lead tech will prepare patient and arrange  transportation for the study.  Patient is to be placed on vss-chair for transportation to the study, if indicated.	To conserve patient’s energy.	Patient can be transported in a wheelchair if he can transfer independently or with minimal assistance and is not on the ventilator.
8.   Patient’s chart will also accompany patient to the procedure.	For documentation and reference.
9.   Upon receipt of notification, Dietary will provide a video swallowing evaluation tray 15 minutes prior to scheduled time.  Tray consists of items listed on equipment food.	To prevent delays.
10. The SLP explains the study to the patient and prepares food/supplies for presentation to the patient during the study.	To respect patient’s rights.
11. The following professionals need to be present at the scheduled time for the procedure:$  Physician$  Radiology Technologist$ RT/Technical Supervisor or Lead Tech$  Speech-Language Pathologist	Technical expertise is needed to perform the study.
12. SLP will wash hands, put on gloves, (goggles), and wear lead apron along with safety badge and thyroid shield.	Infection ControlEmployee Safety	Lead apron to be used on patients who are still of reproductive age.
13. Radiology technologist turns on the TV/VCR and places microphone close to the patient.	Documentation
14. The radiology technologist spells out the patient’s name in lead letters on adhesive tape and places the tape on the fluoroscopy table behind the patient’s head.	Patient’s identification for documentation purposes.
15. The SLP identifies patient on the videotape.	Documentation
16. The RT/Technical Supervisor/Lead Tech suctions the patient.	Airway clearance
17. The physician will check the fluoroscopy image to be sure that the physiological structures are in view.	Accurate imaging
MODIFIED BARIUM SWALLOWING PROCEDURE:I.    Lateral view planeThe patient is viewed in the lateral plane.  His/her side rests against the table of the fluoroscopy machine and the vocal tract is viewed laterally.	Permits a number of measures and observations critical to the identification of the swallowing disorder.	NG tube may be pulled out during the study if the NG tube interferes with the patient’s swallowing.
1.  Puree followed by other solid consistencies as indicated.	Examine the way the patient is able to handle the varying materials.  Define the reason for aspiration and the amount of aspiration.	Extra presentation of food may be given to the patient with cuff deflated, if applicable.
2.  Nectar-thick liquid by spoon, then by cup if indicated, followed by other liquid consistencies as indicated.	To examine movement pattern of the structures in the oral cavity and pharynx.
a. SLP moves away his/her hands and body from the fluoroscopy tube when the fluoroscopy is turned on and instructs patient to swallow.	To time the duration of the oral and pharyngeal stages of the swallow.
b. The oral cavity and pharynx should remain in view through out each swallow and for several seconds after the swallow.	To evaluate patient’s response to residues or aspiration.
c. During each swallow, the SLP should examine and discuss with the physician the physiology of the oral-pharyngeal stages of swallow and the way in which the bolus flows.  SLP uses the data collection sheet for fluoroscopy studies if indicated.	Patient’s safety
3.  Presentation of other consistencies	Patient’s safety
II.   Anterior/Posterior Plane:$   Reposition the patient facing the radiographic tube.	Assess symmetry of the swallows, symmetry of pharyngeal functions (valleculae-pyriform sinuses).
1.  The SLP presents food and liquid consistencies as indicated and swallow is observed.	To reduce radiation exposure.
2.  Patient is positioned to afford view of vocal cords.	To remove the mandible from overlying the vocal cords.
3.  The SLP asks the patient to inhale.  The SLP asks the patient to phonate rapidly (ah, ah, ah, ah).	To cause vocal cord adduction.  Rapid adduction/abduction permits speech-language pathologist to locate the vocal cords in the neck.
4.  The SLP asks the patient to inhale deeply, then phonate prolonged “ah” (3 seconds), inhale again, phonate prolonged “ah” (three seconds).	Allows observation of the symmetry of vocal cord movement.
III.  Provide documentation on monitoring patient before, during, and after procedure.
VARIATIONS OF THE MODIFIED BARIUM SWALLOW PROCEDUREWhen patient aspirates, the SLP should determine:1.   the physiology or anatomic etiology of the aspiration.2.   the compensatory strategies, the postural variations, and varying food consistencies required by the patient.3.   the therapy techniques for the patient to improve neuro-muscular control.	To determine the safe ways for the patient to swallow.
END OF THE MODIFIED BARIUM SWALLOWING PROCEDURE:1.   SLP will clean the patient’s mouth according to oral-care protocol.	Patient’s safety and comfort.
SLP will review the video results with the patient and family, if available.	Respect for patient’s rights.Patient/family education.
3.   The RT/Technical Supervisor/Lead Tech will transport the patient back to his/her room.	Patient’s safety and continuity of care.	Discharge criteria for outpatient.
4.   SLP will report results to patient care coordinator and Lead Tech will report results to patient=s respiratory therapist.
5.   The SLP will discuss swallowing study results with physician and provide recommendations regarding treatment plan.	To promote collaboration and continuity of care.	In the event of aspiration, the appropriate management will be ordered by the attending physician.Within 24 hours of the procedure, the health care team will monitor for signs of aspiration, hypoxemia, changes in vital signs, changes in sensorium.
6.   The SLP will notify the patient/family and health care team.	To promote collaboration and continuity of care.
Videofluorographic Studies Performed at Satellite Units:1.   When an order for a videofluoroscopy study is written by the MD, the PIH/Barlow staff receiving the order, will notify the SLP to inform him/her of the order for the videofluoroscopy.	To ensure for complete communication of such orders.
2.   SLP will schedule date and time for the video with X-ray, and will let PIH/Barlow floor staff know.
3.   Floor staff will enter the date that SLP gives them into the computer.  this will be sent (via computer order) to the following department/individuals:$  Respiratory Therapy$  Physical Therapy$  Radiology$  Nutrition Services	To ensure all departments are aware of the videofluoroscopy.
4.   2 hour before the video is scheduled, floor staff will order the following  tray from nutrition services:$  1 Thick liquid – nectar$  1 Pudding$  Slice bread$  1 Juice $  1 Crackers	To ensure tray is ready prior to the video study.	Other food consistencies with which the patient appears to have difficulties with may also be included.
5.   SLP will pick-up this tray from the kitchen.
6.   PIH RT will transport the patient to Radiology.	To ensure respiratory care needs of patient are continuously met.
7.   The following individuals will be with the patient in Radiology during the Videofluoroscopy:*BRH – SLP*PIH Radiologist*PIH RT
8.   Videofluoroscopy occurs in Radiology.
9.   Patient is transported back to his/her room by the RT

EVALUATION

Expected Outcomes:

1.    The patient will receive a comprehensive videofluorographic study in timely and safe manner.

2.    The patient can expect to know the etiology for aspiration and the strategies he/she can learn to improve his/her swallowing skills.

3.    The patient can expect to know what kinds of food he/she can swallow safely.

 

Unexpected Outcomes:

1.    Unable to perform the test due to equipment failure.

2.    Unable to complete the procedure due to patient=s shortness of breath, fatigue and/or severe aspiration.

DOCUMENTATION

1.    The SLP will complete the Swallowing Videofluoroscopy Evaluation form within 24 hours of the study, and place in chart.

2.    The physician writes his/her report on the Progress Note.

3.    The respiratory therapist writes his/her report on the flow sheet.

4.    Nursing staff write their report on the flow sheet.

PATIENT/FAMILY EDUCATION

The patient shall be instructed regarding the process of Videofluorographic Study, and outcomes.

 

 

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