FRIED CHICKEN AND COFFEE

Transcription

1 FRIED CHICKEN AND COFFEE JEAN L FOSTER MA-CCC/SLP, BCS-S MBS ADVANTAGE, INC ST LOUIS, MISSOURI DEFINITION OF COMPLIANCE formal act of obeying a rule, order..cambridge English Dictionary NON-COMPLIANT DISOBEYING ORDERS, DISOBEYING A RULE 1

2 Non-compliant patients? If the patient would only listen, they would get better. Is Coffee and Fried Chicken LIFE THREATENING? 2

3 UNDERSTANDING THE RELATIONSHIP BETWEEN ASPIRATION AND ASPIRATION PNEUMONIA MANAGEMENT TOOLS CASE STUDY NOT A CLEAR THRESHOLD FOR ASPIRATION EVERYONE ASPIRATES.. Slovarp, et al. People aspirate small amounts and have dysphagia, mostly normal and healthy, are usually at low risk of pneumonia. 3

4 28% to 35.7% of asymptomatic healthy older adults with no hx of swallowing problems penetrate and demonstrate intermittent trace aspiration on liquids Repeat study still found they were aspirating, but did not have any medical consequences. Stability of Aspiration Status in Healthy Adults, (Todd, MD, et al. 2013) Aspiration in Healthy Elderly Daniels et al. (2004) Straw Drinking in Young and Older Adults Yoshikawa et al. (2005) Aspects of Swallowing in Healthy Elderly.over age 80 Butler et al. (2011) Effects of Bolus Type on Healthy Elderly. Patients taking thickened liquids aren t necessarily protected from pneumonia. Drink less/dehydration Increase in UTI s/confusion in older patients 4

5 Swallow Protocol 201, 2008; Logemann and Robbins 750 patients, age Dementia or Parkinsons, Parkinsons Dementia Aspirated of thin liquids Nectar, Honey, and Chin down DEMENTIA PATIENTS (211) CONCLUSION NOT FAVORABLE FOR THICKENED LIQUIDS PARKINSONS DISEASE WITH OR WITHOUT DEMENTIA APPROXIMATELY 500 PATIENTS NECTAR, HONEY AND CHIN TUCK PATIENTS WHO WERE ON HONEY THICKENED LIQUIDS NOT FAVORABLE Kuhn, M (2013, 2014)Poster ASHA, Abstract DRS Effects of Aspirated Thickened Water on Pulmonary Health and Survival in Lagomorph Model 5

6 THE THICKER THE LIQUID THE SAFER THE SWALLLOW We know that Aspiration Pneumonia IS multi-factorial. It s not just about the food/liquid 6

7 ASPIRATION PNEUMONIA ORAL/PHARYNGEAL BACTERIA PATIENT FACTORS IATROGENIC FACTORS PREDICTORS OF ASPIRATION PNEUMONIA IN NURSING HOME RESIDENTS LANGMORE, STATES OVER PATIENTS 7

8 James Coyle, PhD YOU GOT TO HAVE DYSPHAGIA TO HAVE DYSPHAGIA. DYSPHAGIA CAN BE AMBIGUOUS NO CLEAR THRESHOLD FOR ASPIRATION PNEUMONIA PATIENT CENTERED CARE/QUALITY OF LIFE MANAGEMENT TOOLS 1. Effective Communication 2. Instrumental Exams 3. Critical Pathways for Evaluation and Management Tanner,

9 -COMMUNICATION EFFECTIVE COMMUNICATION 2/3 terminally ill patients reported NO discussion about their goals for end of life care (including tube feeding) 1/3 terminally ill patients who did have discussions -COMMUNICATION COULD WE APPLY THIS TO COPING WITH our patients who do not follow recommendations? -COMMUNICATION PATIENTS WHO HAVE SIGNIFICANT DISCUSSIONS WITH THEIR CAREGIVERS AND PROFESSIONALS ABOUT THEIR PREFERENCES APPEAR TO HAVE BETTER OUTCOMES 9

10 -COMMUNICATION HOW DO WE FACILITATE COMMUNICATION IN OUR FACILITIES? -COMMUNICATION Effective communication = Education and Dialogue PROCESS SHOULD BEGIN PRIOR TO ANY EVALUATION, at ADMISSION -COMMUNICATION Develop a FACT SHEET/Q & A sheet for patients and families on Dysphagia, the facility s policy s/procedures, rights, and concerns Develop a Standing Committee whose sole purpose is to educate patient/poa and document their concerns and wants, and then communicate Provide literature in your facilities (ie: Dementia and tube feeding) depending on your population Provide free in-services to families bring in speakers, etc. 10

11 -COMMUNICATION Patients/Families are more likely to follow advice and may be less likely to file a lawsuit if they understand and are in control of their situation. Tanner, COMMUNICATION Swaminath et al., 2010 Pennsylvannia, GI Physician Group -COMMUNICATION Training modules for staff Speech Pathologist s role staff education 11

12 -COMMUNICATION HOW DO WE COMMUNICATE WITH OUR PATIENTS AND FAMILIES? Paternalistic Relationship Informative Relationship Interpretative Relationship -COMMUNICATION INTERPRETIVE HELP PATIENTS DETERMINE WHAT THEY WANT While giving them information What is most important to you with your diet? What are your concerns? Then we talk to them. -COMMUNICATION Effective Communication Diet, NPO, enteral feeding status Why are you on this diet? What is your prognosis? What are your risks? What are your choices? 12

13 COMMUNICATION Brett and Rosenberg, 2001 Looked at how records related to g-tube placements in community teaching hospital Had documented a decision making discussion with the patient/family COMMUNICATION Effective Communication means The patient/family fully understands the risks associated with their dysphagia and what their choices are for treatment and diet Careful explanations that are documented COMMUNICATION COMPASSIONATE CARE FEEDING or COMFORT CARE FEEDING Supporting and respecting the patient s right to eat what he/she wants for quality of life as tolerated 13

14 COMMUNICATION WAIVERS 7 different methods utilized to address patient non-compliance Education and involving others in treatment plan were most utilized However signing waivers was also reported as a method to deal with non-compliance King and Ligman, COMMUNICATION Having a patient sign a waiver could be seen by the courts as an attempt to coerce the patient into making a decision Patient Self-Determination Act of 1990 Healthcare institutions have responsibility to respect decisions of their patients and they have the right to refuse treatment 14

15 COMMUNICATION Waivers don t recognize that aspiration pneumonia multifactorial. Not a clear relationship between food/liquid and aspiration pneumonia -COMMUNICATION Most malpractice cases plaintiffs alleged that dysphagia diagnostic and treatment orders, referrals and recommendations were not communicated in a clear and timely manner. Tanner,

16 -COMMUNICATION 2 cases Soft mechanical diet ordered Patients requested PB Dietary and Nursing assumed that peanut butter was acceptable Garcia and Chambers, COMMUNICATION SPEECH DIETARY/KITCHEN NURSING/PHYSICIAN ADMINISTRATION -COMMUNICATION Effective Communication Pathways Acknowledge that dysphagia is ambiguous and simple solutions will not work MULTIDISCIPLINARY 16

17 MANAGEMENT TOOLS 1. Effective Communication 2. Instrumental Exams 3. Critical Pathways for Evaluation and Management -INSTRUMENTALS During trials and depositions, lawyers, judges, and juries rely on VISUAL evidence of swallowing disorders as opposed to bedside swallow evaluation clinical assumptions. Tanner, INSTRUMENTALS majority of legal cases involving aspiration pneumonia.deemed it was too expensive or for other unstated reasons.all the cases expert testimony revealed that the patient s autopsy revealed they had aspirated food particles and/or liquids prior to their deaths 17

18 -INSTRUMENTALS Neglecting to conduct an instrumental evaluation of the swallow in cases of suspected dysphagia is analogous to refusing to X-ray a leg for suspected fractures. Tanner, INSTRUMENTALS Instrumental exams clear and concise objective information that confirms clinical judgement -INSTRUMENTALS We need to keep healthcare costs down with unnecessary tests, administrators should understand that settlements involving dysphagia cases involve millions of dollars. 18

19 Management Tools 1. Effective Communication 2. Instrumental Exams 3. CRITICAL PATHWAYS PATHWAYS Critical Pathways for Evaluation and Management Screenings-everyone is involved!!!! Pathway for referral Clear, definition on nuts and bolts of aspiration precautions Pathway for Evaluation of patients and Management PATHWAYS So what about the patient on pureed diet, honey thickened liquids chicken eating coffee drinker? COMPLIANCE..LET S THINK DIFFERENTLY 19

20 PATHWAYS So compliance is. Part of it is following the rules UNDERSTANDING THE RULES PATHWAYS We should not be limiting people s choices in the name of safety, but INCREASING THEM FOR THEIR QUALITY OF LIFE. CASE STUDY CASE FOR DISCUSSION 82 year old female 2L of oxygen/nasal cannula Significant COPD past hx of smoking (40 years) Mild Dementia Hypertensive Postal worker for 30 years Limited medications-htn medication, inhalerhx of dysphagia; MBS July 2015 after a fall. At the time she was NPO, g-tube because hospital found she was aspirating. Had 2 other MBS s and eventually. Regular diet was recommended. Patient returned home with her sister 20

21 She had the tube removed shortly after. Patient was tolerating diet up until November and she started c/o about difficulty swallowing In December 2016, she felt that her swallowing was becoming worse and was referred for an outpatient modified barium swallow by her internist. Radiology report-aspiration of liquids Outpatient speech therapist NPO and recommended g-tube. She was admitted that night for placement of the tube and re-admitted to the NH for skilled therapy. Sister reports patient is significantly depressed and dreams of food. The nurses report patient is non-compliant at times and steals coffee. She reported that the therapist told her that she would acquire aspiration pneumonia unless the tube was placed. No other education documented. What would you recommend? How do you protect your facility against a lawsuit while complying with regulations? 21

22 IS LIFE THREATENING? -CONCLUSION MANAGEMENT OF THE RESIDENTS/PATIENTS EFFECTIVE COMMUNICATION CLEAR PATHWAYS FOR E & M INSTRUMENTALS AS NEEDED 22