3 Dysphagia Evaluation and Management: Clinical Training, Clinical Competency and Speciality Recognition* Bonnie J.W. Martin** Programme Director: The Evelyn Trammel Voice and Swallowing Center Director : Rehabilitation Services Department, Saint Joseph's Hospital of Atlanta Atlanta, Georgia, United States of America KEY WORDS : dysphagia, swallowing disorders, speech-language pathologist, training, intervention An increasing number of speech-language pathologists have become involved in the evaluation and management of patients with swallowing disorders. Approximately sixty percent of practicing speech-language pathologists in health care settings throughout the United States are in- volved in dysphagia intervention according to the 1993 ASHA Omnibus survey (ASHA ,1995). It has been esti- mated that nearly 15 million Americans suffer from disor- ders of deglutition that potentially alter their quality of life, rehabilitation potential and survival (Simmons, 1986). In addition to increased patient demand impacting on the growing number of clinicians involved with dysphagic pa- tients, consumers (e.g., patients, families, physicians, etc.) have also begun to recognize dysphagia management as a clinical science and the value added patient care service. The majority of dysphagic patients seen in hospitals and skilled nursing facilities have concomitant communi- cation problems that may include disorders of voice, mo- tor speech, language or cognition (Martin & Corlew, 1990). From a continuity of care arid cost perspective it follows that the speech pathologists! traditionally trained in the function of the neurologic system and vocal tract, also treat the functionally impaired upper aerodigestive tract com- prised of structures common to the communication proc- ess (Martin & Corlew, 1990)1 However, speech-language pathologists have met with several challenges in their at- tempts toward dysphagia intervention with the often medi- cally complex, multisystem involved patient. These chal- lenges include the following: 1. Inadequate educational and clinical preparation at the undergraduate and graduate level; 2. Lack of methods for completing and measuring clinical competency in the areas of dysphagia management; 3 Special patient populations (i.e., pediatric, ventilator dependent, head and neck surgical, tracheotomized) warrant acquisition of specific skills obtained in facili- ties not available to many student clinicians; 4 Most employment opportunities in medical settings require dysphagia training and experience. Because only a handful of accredited university pro- grams in the United States offer courses in swallowing function and disorders, clinicians have sought other train- ing alternatives that include conferences and workshops presented by colleagues who have self-acquired clinical ex- periential expertise, journals and books, or through ob- servation of practicing dysphagia clinicians in medical settings. However, the body of clinicians maintain the sentiment that these methods fail to sufficiently meet the knowledge base and experience required to clinically or instrumentally manage dysphagic patients. These challenges have not only surfaced in the clinical area of dysphagia, but have also presented in other areas of clinical science with expanding knowledge bases. The end result has been the development of specialty recogni- tion programs in specific areas of clinical practice by the American Medical Association. In addition, health care professions such as dentistry, pharmacy, physical therapy, occupational therapy, and nursing have also implemented specialty recognition programs that encompass compe- tency training, measurement and methods for recognition. The primary incentive of these programs was not to em- bellish the concept of specialty practice in an age when general practitioners are becoming the preferred health care model, rather to "... ensure the welfare, safety, com- fort, and quality of care of the public consumer" (Report on the ASHA Ad Hoc Committee On Specialty Recogni- tion, 1994). Even though the health care reform activities in the United States (e.g., shift to highly managed medi- cal care) has limited the patient's options in their selec- tion of health care providers, specialty recognition provides a vehicle for all consumers, including the individual pa- tient, payers, and in some cases employers to identify clini- cal professionals with specialty skills that best meet their health care needs. The American-Speech-Language-Hearing Association is no exception to the professional organizations that have witnessed an expanding scope of practice among its mem- bers because of the evolving body of information that has resulted as an outgrowth of clinical research, experience ** Dr. Bonnie Martin was an invited guest of SASLHAand presented workshops on dysphagia at various venues during 1995 Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 42, 1995 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 4 Bonnie J.W. Martin and technological advancements. The Legislative Coun- cil (LC) of ASHA approved a position statement explain- ing that the scope of practice in the profession has ex- panded and involves a "... broad range of services offered within the profession" (LC 6-89). Position statements and clinical guidelines were developed for several areas of prac- tice that were also submitted to and adopted by the LC. The clinical areas encompassed in these documents in- cluded assessment and management of oral myofunctional disorders (ASHA, 1991a), learning disability (ASHA, 1991b), language learning disorders (ASHA, 1982a), mi- nority language populations (ASHA, 1983b; 1985), men- tal retardation (ASHA, 1982b), cognitive communication impairments (ASHA, 1988), balance system assessment (ASHA, 1992a), electrical stimulation for cochlear implant selection and rehabilitation (ASHA, 1992b), cerumen man- agement (ASHA, 1992d) and dysphagia (ASHA, 1992e; ASHA 1991a; ASHA 1991b; ASHA 1982a; ASHA 1982b; ASHA 1983b; ASHA 1988; ASHA 1992a; ASHA 1992b; ASHA 1992d; ASHA 1992e). Continued technical ad- vances obviated the need for additional guidelines in the areas of augmentative and alternative communication (ASHA, 1991c), neurophysiologic intraoperative monitor- ing (ASHA, 19920, tracheoesophageal iistulization proce- dures (ASHA, 1992c), and vocal tract visualization and imaging (ASHA, 1992g; ASHA 1991c; ASHA1992f; ASHA 1992c; ASHA 1992g). Most of the position statements and guidelines describe the range of proficiencies, knowl- edge bases and competencies required for provision of serv- ices by a clinician in the specific area of clinical practice (Report of the ASHA Ad Hoc Committee On Specialty Rec- ognition, 1994). Concurrent with the efforts to detail position statements and practice guidelines in specialty areas of the profes- sion, Special Interest Divisions were approved (LC 35-86) in 1987 and implemented in 1991 in an attempt to pro- vide a structure in which ASHA colleagues with similar clinical and research interests could interact and exchange information. The development of the Special Interest Di- visions were one part of a two part initiative established by the Ad Hoc Committee on Specialty Recognition Re- port in 1986 (LC 35-86). In 1992 the Dysphagia Special Interest Division 13 was formed, and grew to be the larg- est Division in the Association in 1995. The Division has a Steering Committee that meets periodically, and the entire Division is invited to assemble annually at the na- tional convention of ASHA. A quarterly newsletter is also published that informs the Division members of current clinical and research activities in the area of Dysphagia, and offers a forum for professional interchange. The second part of the Ad Hoc Committee on Specialty Recognition Report (LC35-86) included development of a plan to recognize individuals demonstrating a particular expertise in an area(s) of clinical practice. Several models were developed and considered by the Association. In 1992 at the Association's Convention in San Antonio, Texas, the Ad Hoc Committee on Specialty Certification consulted with the Special Interest Divisions' Board of Coordinators and with selected SIDs at their membership meetings. The issue of specialty certification was addressed and the study of specialty certification was endorsed. In the context of the Dysphagia Special Interest Division 13 membership meeting, participants expressed verbal support of the specialty certification initiatives, but there continued to be concern regarding the limited educational and clinical opportunities available at the graduate level in univer- sity speech pathology programs that would assist clini- cians in achieving specialty certification in the area of Dysphagia. In an attempt to address the issue of limited formal training opportunities raised by the SID 13 members, a Task Force of the Division was formed whose charge was to devise a suggested graduate core curriculum for accred- ited speech-language pathology programs in colleges and universities throughout the United States. The format of the curriculum includes a basic graduate level lecture course with practical lab and observations, as well as sug- gestions to instructors for reference materials and clini- cal practicum. In addition, an advanced level course struc- tured and recommended for individuals who desire fur- ther training in swallowing and research in Dysphagia was also included. Recommended clinical contact hours for the post-graduate clinical fellowship year were sug- gested. The recommended core curriculum will be re- viewed by the SID 13 membership and forwarded to the Educational Standards Board (ESB) of ASHA. This ini- tiative represents a critical step forward toward the en- hancement of the theoretical and working knowledge of entry level dysphagia clinicians. In addition to graduate core curriculum and CFY con- tact hours, the Specialty Task Force also recognized the need for speech pathologists to be able to demonstrate basic clinical competencies in the work setting prior to treating the often medically and behaviourally complex dysphagic patient. Dysphagia management often involves relatively invasive methods that have not been traditionally utilized by clinicians in the field of speech-language pathology. Also, treatment recommendations and methods can im- pact directly on the medical status, nutrition, and safety of the patient. Further, the health care industry, includ- ing third party payers, will demand improved functional outcomes that can only be provided by highly competent dysphagia clinicians. Therefore, the Task Force endorses that the specific work setting establish basic clinical com- petencies for dysphagia clinicians that may be very spe- cific to the environment and needs of a particular patient population. At the Evelyn Trammell Voice and Swallow- ing Center of Saint Joseph's Hospital of Atlanta, a model clinical competency training program has been devised and implemented that encompasses training modules, direct observations, supervised and independent contact hours and continuing education vehicles in the areas of swal- lowing assessment and treatment. In addition, if clini- cians will practice in highly specialized areas of the hospi- tal, such as critical care units, the clinician must meet clinical competencies that relate to the medically complex and unstable patient (Martin, Martin & Cobb, 1993). Dysphagic patients, particularly those in the critical care setting often present with multisystem dysfunction that impact upon their communication and swallowing status. The physiologic implications of 'whole body sick' on communication and swallowing functions, however, are often poorly understood and neglected when evaluating and planning dysphagia treatment. Speech pathologists are traditionally trained in the neurologic and respiratory systems as they relate to speech, voice and language. However, knowledge of body multisystem influences on speech and swallowing abilities is often incomplete. Swal- lowing and swallowing therapy methods have been shown to produce changes in the respiratory system, and these The South African Journal of Communication Disorders, Vol. 42, 1995 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 3. 4. Provides the highest probability that future changes in the clinical services in a particular area can be ac- commodated in changes in the competency verification mechanisms applied to the discipline; The model places the burden of responsibility for de- velopment and maintenance of the recognition program in the hands of the practicing clinicians (Report of the ASHA Ad Hoc Committee On Specialty Recognition, 1994). Dysphagia Evaluation and Management: Clinical Training, Clinical Competency and Speciality Recognition changes must be recognized and considered in planning safe and appropriate dysphagia treatments (Martin, 1991; Martin, Corlew, Wood, Olson, et al., 1993; Martin, Haynes, McConnel, O'Connor, Haring & Bouis, 1994; Martin, Logemann, Shaker & Dodds, 1993a; Martin, Logemann, Shaker & Dodds, 1993b; Nishino, Yonezawa & Honda, 1985; Selly, Flack, Ellis & Brooks, 1986; Smith, Wolkove, Colacone & Kreisman 1987). Further, dysphagia clinicians often evaluate and treat patients in the critical care units who undergo continuous cardiopulmonary monitoring. One purpose of these visual monitoring devices is to allow attending clinicians to modify their treatment plans based on the physiologic responses of the patient during the treat- ment sessions. This is troubling because the dysphagia clinician typically has not been trained in the basic inter- pretation of these physiologic visual signals, and leads to intimidation and incompetency in treating the critical care patient. Also, the functional status of critical care patients and their ability to tolerate swallowing therapy will vary linearly with their medical status. Therefore, the dysphagia clinician should become familiar with the clini- cal significance of relevant laboratory values, vital signs, pharmacological agents, pulmonary and radiographic tests that are typically reported in the patient's medical record. Competency training by dysphagia clinicians in these specialty skill areas has been incorporated into Saint Joseph's model because of the highly specialized tertiary nature of the facility. The competency training has re- sulted in elevation of the dysphagia clinicians' clinical in- sight, skill and confidence when providing care to the medically unstable dysphagic patient. This expertise al- lows the clinician to begin treatment at an early stage in the patient's recovery, and expedites their return to safe oral intake. Demonstration of competency should not only be expected by health care department directors and su- pervisors, but will be demanded and respected by physi- cians, patients, family members and other consumers (Martin, Martin & Cobb, 1993). The Consumer Affairs Division of ASHA also discov- ered through consumer advocacy group conferences in 1990 and 1992 that consumer groups "strongly supported specialty designations in the j professions as guidance for consumers in selecting providers of services", and appeared to uphold ASHA's ongoing exploration of the need for a specialty recognition program that goes beyond demon- stration of basic clinical competencies as described above (Report of the ASHA Ad Hoc Committee On Specialty Rec- ognition, 1994). The 1994 Report of the Ad Hoc Commit- tee On Specialty Recognition contains a practitioner-driven model that has been selected as the proposed method for implementing specialty recognition within the ASHA (Re- port of the ASHA Ad Hoc Committee On Specialty Recog- nition, 1994). The model includes four salient features that highlight maximum participation by practitioners in the field for the development and maintenance of the specialty recognition program, and minimal participation by the central structure of ASHA: 1. Consumer need for recognition of a specialty area can be well defined and justified; 2. Practitioners involved in the delivery of services can be responsible for defining the knowledge, skills, and experience requisite to the delivery of services in the specialty area; l The proposed plan as described by the Ad Hoc Commit- tee on Specialty Recognition maintains a firm commitment to a broad-based practice by the majority of membership, and the concept of nonexclusionary specialty recognition is emphasized throughout the proposal. The plan provides a mechanism by which an individual can be recognized for specialty education experience and expertise, yet as- sumes that most practitioners will continue to provide broad-based clinical services. The specialty recognition plan is degree independent (Report of the ASHA Ad Hoc Committee On Specialty Recognition, 1994). Because the responsibility for developing the compo- nents of the plan has been left to the members of the or- ganization, an additional Specialty Recognition Task Force was formed by the Dysphagia Special Interest Division 13 in 1995, and a proposed specialty recognition program plan was devised. A draft of the Dysphagia proposal will be presented to interested members of ASHA at the national convention in Orlando, Florida in December, 1995. The proposed program is highly competency based, and incor- porates objective methods for competency measurement. In the plan proposed by the Ad Hoc Committee on Specialty Recognition, a formal petitioning group submits the final dysphagia specialty certification plan to a Clinical Specialty Board (CSB), and a Commission on Dysphagia would be formed if the group's application has met the Specialty Recognition Standards. The Specialty Commis- sion on Dysphagia would be responsible for maintaining the professional process for accepting, reviewing, main- taining, and renewing applications for recognition by dysphagia clinicians (Report of the ASHA Ad Hoc Com- mittee On Specialty Recognition, 1994). While the dysphagia specialty certification program is in its infancy proposal stage, it represents a hallmark ini- tiative toward the insurance of exemplary quality dysphagia care by recognized professionals who could po- tentially serve as clinical competency instructors to nov- ice clinicians in the field. Improved quality of care, pa- tient outcomes and cost containment result from reduc- tions in variability of practice and increases in standardi- zation of specialty patient care. A comprehensive gradu- ate core curriculum, clinical competency training and specialty recognition are modalities that will ultimately lead to improvement in the standard of care for dysphagic individuals provided by speech-language pathologists. The expanding scope of practice in the field of speech-language pathology is not unique to the United States. Professional associations of clinicians from other countries will likely meet similar challenges with the issues of ensuring ap- propriate education, clinical competency, quality outcomes and specialty recognition. They will need to face these challenges with opportunity by tailoring methods and ve- hicles to meet the needs of their swallowing practitioners and health care consumers. Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 42, 1995 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 6 REFERENCES American Speech-Language-Hearing Association (1982a, November). Language learning disorders. ASHA, pp. 937- 944. American Speech-Language-Hearing Association (1982b, August). Serving the communicatively handicapped mentally retarded individual. ASHA, pp. 547-553. American Speech-Language-Hearing Association (1983b, September). Social Dialects (and implications). ASHA, pp. 23-27. American Speech-Language-Hearing Association (1988, March). The role of speech-language pathologists in the identification, diagnosis, and treatment of individuals with cognitive- communicative impairments. ASHA, p. 79. American Speech-Language-Hearing Association (1991a, March). The role of the speech-language pathologist in assessment and management of oral myofunctional disorders, ASHA (Suppl. 5), p. 7. American Speech-Language-Hearing Association (1991b, March). Learning disabilities: Issues on definition. ASHA (Suppl. 5), pp. 18-20. American Speech-Language-Hearing Association (1991c, March). Augmentative and alternative communication. ASHA (Suppl. 5), pp. 9-12. American Speech-Language-Hearing Association Ad Hoc Committee on Advances in Clinical Practice (1992a, March). Balance system assessment. ASHA (Suppl. 7), pp. 9-12. American Speech-Language-Hearing Association Ad Hoc Committee on Advances in Clinical Practice (1992b, March). Electrical stimulation for cochlear implant selection and rehabilitation. ASHA (Suppl. 7), pp. 13-16. American Speech-Language-Hearing Association Ad Hoc Committee on Advances in Clinical Practice (1992c, March). Evaluation and treatment for tracheoesophageal fistulization/ puncture. ASHA (Suppl. 7), pp. 17-21. American Speech-Language-Hearing Association Ad Hoc Committee on Advances in Clinical Practice (1992d, March). External auditory canal examination and cerumen management. ASHA (Suppl. 7), pp. 22-24. American Speech-Language-Hearing Association Ad Hoc Committee on Advances in Clinical Practice (1992e, March). Instrumental diagnostic procedures for swallowing. ASHA (Suppl. 7), pp. 25-33. American Speech-Language-Hearing Association Ad Hoc Committee on Advances in Clinical Practice (1992f, March). Neurophysiology intraoperative monitoring. ASHA (Suppl. 7), pp. 34-36. Bonnie J.W. Martin American Speech-Language-Hearing Association Ad Hoc Committee on Advances in Clinical Practice (1992g, March). Vocal tract visualization and imaging. ASHA (Suppl. 7), pp. 37-40. ASHA Omnibus Survey, Personal Communication from Herb Bauma, ASHA, February 27, 1995. Martin, B.J. W. (1991). The influence of deglutition on respiration. Doctoral Dissertation, Northwestern University. Martin, B.J.W., & Corlew, M.M. (1990). The incidence of communication disorders in dysphagic patients. Journal of Speech and Hearing Disorders, 55, 28-32. Martin, B.J.W., Corlew, M.M., Wood, H., Olson, D., et al. (1993). The association of swallowing dysfunction and aspiration pneumonia. Dysphagia, 9 (1). Martin, B.J.W., Logemann, J.A., Shaker, R., & Dodds, W.J. (1993a). Normal laryngeal valving maneuvres during three breath hold maneuvres: a pilot investigation. Dysphagia, 8, pp. 11-20. Martin, B.J.W., Haynes, R., McConnel, F.M.S., O'Connor, Α., Haring, K., Bouis, H. (1994). Breathing and Swallowing Interrelationships. Dysphagia Research Society Meeting, McLean, Virginia, October 14, 1994. Martin, B.J.W., Logemann, J.A., Shaker, R., & Dodds, W.J. (1993b). The coordination between respiration and swallow: respiratory phase relationships and temporal integration. Journal of Applied Physiology, 76 (2), pp. 714-123. Martin, B.J.W., Martin, E., Cobb, R. (1993). Critical Care Competencies for Dysphagia Clinicians. Short Course presented at the annual meeting of the American Speech- Language-Hearing Association, Anaheim, California. Nishino, R., Yonezawa, R., & Honda, Y. (1985). Effects of swallowing on the pattern of continuous respiration in human adults. American Review of Respiratory Disease, 132, pp. 1219- 1222. Report of the ASHA Ad Hoc Committee On Specialty Recognition, August, 1994. Selly, W., Flack, F„ Ellis, R. & Brooks, W. (1986). Respiratory patterns associated with swallowing: Parti. The normal adult pattern and changes with age. Age and Ageing, 18, pp. 168- 172. Simmons, K. (1986). Dysphagia management means diagnosis, exercise, re-education. Journal of the American Medical Association, 255, 3209-3210, 3212. Smith, J., Wolkove, N., Colacone, Α., & Kreisman (1987). Coordination of Eating, Drinking and Breathing in Adults, Chest, 96, pp. 578-582. Ο X m PLAY A N D S C H O O L R O O M I I Ο X m SHOP 6L THE ROSEBANK MEWS 173 OXFORD ROAD ROSEBANK JHB. I PHONE 788-1304 FAX: 880-1341 TESTS, PROGRAMMES, BOOKS, TEACHING AIDS, JOURNALS AND RESOURCES FOR CHILD DEVELOPMENT SPEECH & LANGUAGE LEARNING DISABILITIES SPECIAL NEEDS ADULT REHABILITATION SOCIAL ACTIVITIES PO BOX 52137 SAXONWOLD 2132 The South African Journal of Communication Disorders, Vol. 42, 1995 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2)