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1 Development and Implementation of a FEES Program in a Hospital Setting Click to edit Master title style Angela S. Dubis-Bohn MA, CCC-SLP, BRS-S Click to edit Master subtitle style Marla D. Knight MA, CCC-SLP Kim Bernert MA, CCC-SLP

2 Goals of Presentation Identify potential resources/references for developing a FEES program Describe general process for implementing a FEES program Identify components for a suggested training program

3 Why Did We Pursue FEES? Complement to current dysphagia services Increasing complexity of caseload Use of endoscopy during treatment

4 Limitations of Previous OSUMC Dysphagia Services Unreliable findings of blue-dye swallow study Medical factors: trach/vent, fatigue, cardiac issues Physical factors: obese, SCI, contracture Swallow factors: secretion levels, need to visualize larynx Unavailability of radiology suite

5 What was out there? Limited resources for establishing a program ASHA position statement and technical papers Surveyed regional facilities Informal survey of state regulations

6 State Regulation Survey 70% of states responded 78% of respondents had a broad statement 4 of respondents had specific statement about FEES A number of states were unclear or had no statement Ohio allows FEES, but no specific statement

7 Champions of the Process Staff advocated for FEES for several years New PM&R attending familiar with FEES joined OSUMC in 2005 PM&R attending persuaded rehab administration

8 Proposal to Administration Indications and benefits of FEES provided Equipment demonstrated by sales rep Statistical data provided to justify procedure Proposed cost outlined

9 FEES FUNDING APPROVED!

10 Equipment Purchased Evaluated multiple scopes for ease of use and quality of image Purchased FEES mini-vision Additional components added: monitor and printer Additional scope added Cart purchased

11 FEES Planning Committee 3 SLP s with advanced dysphagia training and experience Team leader (manager) with speech background Physiatrist Adjunct committee members (i.e. epidemiology, campus safety)

12 Planning Process Brainstorming Session Identified programmatic and educational components to develop project completion dates Program development grid Committee member assignments Target completion date: January 2007 Actual completion date: May 2007

13 FEES Program Development Grid Medical Director Policy development Competency development Staff training Marketing Reimbursement Forms development Hospital credentialing Logistics

14 Project Planning Grid

15 Physician Support Medicare requirement to have physician on site for medical emergencies Rehab identified physiatrist as medical liaison. Acute care approached otolaryngology and pulmonology

16 Protocol Development Program utilization Referral process Evaluation process Emergency procedures Infection control Billing and reimbursement Competency development

17 Program Utilization Indication for FEES Contraindications for FEES Patient population criteria Qualifications of personnel

18 Referral Process Defined criteria for inpatient/outpatient referrals External Resources Professional Course Langmore (2001) text ASHA Technical Papers 2001

19 Evaluation Process Case history Bedside clinical exam Preparation for exam Examination procedures for FEES Post examination procedures Documentation

20 Emergency Procedures Required component for the service Internal resource: mandated by OSUMC hospital policy External resource: defined by a number of safety literature resources (Langmore, 2001 and Aviv, 2000)

21 Infection Control Compliance with JCAHO, hospital policies, & university policies Identification of exam process that promoted infection control Location of space for disinfection process Review of external resources Endoscopy equipment sales representative Product websites Consultation with other programs currently performing FEES Internal resources Endoscopy and pulomonary labs Epidemiology Hospital Safety and University Safety Commitees Central supply

22 Infection Control Procedure Environmental precautions-well ventilated area User precautionsuniversal precautions Manual reprocessing set up defined Manual reprocessing guidelines Chemical disposal Chemical storage Accidental spill policy

23 FEES and Reimbursement Charge code identified CPT Productivity figure defined Coordinated with financial department

24 Competency Development Technical knowledge Demonstration of skills

25 Technical Knowledge ASHA knowledge and skills for SLP s performing endoscopic assessment of swallowing function (2001) Langmore suggest 10 hours of formal class training Hiss (2003) suggests hours of formal class training, observation FEES, passing times under direct supervision of professional privileged in use of flexible endoscopy

26 Technical Knowledge cont. 2 lead clinicians attended 2 day course 2006 OSU hired independent consultants to provide CEU education course for therapy staff SLP staff viewed 2 hour video on FEES Content reinforced by website: Quarterly technical competencies

27 Demonstration of Skills OSUMC standards: 5 observations, 25 normal passes, 10 abnormal passes prior to independent practice Independent consultant hired to train 3 lead SLP staff Remaining staff trained in tiers Staff awarded letter acknowledging privileges Ongoing support provided by clinical trainer

28 Demonstration of Skills cont. Therapist required to observe & assist procedures on patients they referred Training Focus Equipment and materials setup Scope passing Anatomy identification Physiology assessment Bolus observation Compensatory strategy training Positioning challenges (bed vs. chair) Disinfection Process Documentation

29 Training Schedule Session 1 Introduction to equipment 5 Normal passes addressing mechanics of passing Session 2 Review of equipment assembly 5 Normal Passes addressing components of pharyngeal/laryngeal function Introduction to disinfection process Session 3 Supervised equipment assembly 5 normal passes with bolus observation Hands-on disinfection of scopes Session 4 Independent equipment assembly 5 normal passes with complete protocol Hands-on disinfection of the scope Session 5 Independent equipment assembly 5 normal passes with protocol modifications- compensatory strategy practice, bed positioning Hands-on disinfection Sessions 6-16 Patient passes throughout the continuum with emphasis on protocol completion, interpretation, documentation, and disinfection Anticipated training completion: 3 months

30 Credentialing/Hospital Compliance Determined hospital practice and legal policies Developed training program to meet our institution s standards

31 Marketing Inserviced PM&R physicians and targeted nurse practioners Educated RN/PCA through exam participation Networked with ALS Clinic Featured FEES program in College of Medicine alumni magazine Highlighted FEES program in rehab brochure

32 MBS vs. FEES July 2007-July 2008 ACUTE Procedures Rehab Procedures Billed Procedures MBS $141,570 FEES $35,695

33 Inpatient Rehab Impact Able to monitor patient for entire meals Assess difficult to position patients (i.e. SCI, power wheel chair) Instrumental assessment available on weekend Direct bolus observation with NMES to determine impact on swallow

34 Acute Rehab Impact Instrumental evaluation of patients previously unable to assess Increased information for treatment and discharge planning Timely input for tube feeding vs. p.o. decisions MD and RN satisfaction SLP confidence that highest level of service provided

35 What Have We Learned Longer process than originally anticipated Internal and external networking is key Less expensive over time to purchase larger FEES system Competency development guidelines need to be well defined and operational Need for flexibility in revision of process

36 Recommendations of FEES Program Review state and institutional legal practices Develop policies and procedures Investigate and purchase equipment Develop and initiate process for competency achievement Develop marketing plan Monitor utilization of program

37 QUESTIONS?