You’ve just finished that clinical swallow evaluation, VFSS or FEES exam. You are feeling pretty good about your recommendations. You’ve utilized the exam to start the patient on a safe and modified PO diet. You documented your findings clearly and concisely then speak to the nurse. You, even decided to call the MD and let him know the final results. You waved to the patient and family as you were walking out of the room. At the same time you high-step and give the PT a high-five for helping you slide the patient up in bed. Finally, you tear off some silk medical tape and whip out the bright orange sheet labeled: SWALLOW GUIDELINES and you check off a few things:
- Puree and Nectar Thick Liquids
- Via tsp volumes ONLY
- Sitting up 90 degrees during meals and for 45 minutes after
- 100% supervision during meals at ALL TIMES
- Double Swallow
- Alternate Liquids and Solids
- Cue patient to cough every 2-3 sips and THEN re-swallow
- Crush medications
- Thorough oral care 3-4x a day
10. Okay to have ice chips for oral gratification.
Now, I do like to over-exaggerate, but this can be a reality for many patients, families, caregivers and Nursing staff. All of these precautions serve a purpose and are often vital for patients to initiate or continue on a PO recommendation, but they can also be quite overwhelming at the same time. I have recently created a challenge for myself. I have decided to choose 2-3 guidelines that I think would serve the most benefit for the patient and garner the most compliance. Ah, compliance! Now different medical settings definitely warrant different measures of precaution as well as different expectations of compliance (we may have higher compliance expectations for our stable outpatients vs our acutely ill ICU patients). In the long term, it may benefit all, if we continue to challenge ourselves and ask the question “Which guidelines would give me the most bang for my buck?”
I took an informal survey recently. I asked, “If you had to choose one precaution or guideline, what would it be?” Every answer was 100% correct. I personally chose, Out of bed to a chair/cardiac chair with all meals. I choose this for several reasons:
- It is very basic
- It transcends most clinical settings
- Most support staff understand the concept of being upright in a chair with meals (as compared to head maneuvers or certain strategies, “What’s a double swallow?”)
- It may support goals and objectives for Physical, Occupational and Respiratory Therapy
- and finally…
- I suspect it may garner the most compliance of any guideline/precaution
So, does this all mean to abandon chin tucks and triple swallows with a cued cough with a 3.25 degree of difficulty? No, not at all! However, consider minimizing the check boxes on that beautiful orange sheet in the name of improving compliance. Who knows, once you get everyone on board you may be able to sneak in a little supraglottic swallow, if you’re lucky!
If you had to choose only one, what would it be and why?