Turning to Telepractice in trying times

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If you’re sitting at a desk. If you’re sitting at home. If you’re sitting with your patience/client or with your family. Please know we are all still united as healthcare providers. We all still carry the same goal: to care for our patients. Unfortunately, right now, we carry that burden, more closely watched than ever, while also keeping our loved ones immediately at the forefronts of our minds.

Many of us may be thinking, What do we do? Others may be thinking, How do we stay healthy? Some may also be looking outward, How else can we still give effective, efficient, best practice intervention to our patients?

While there are still many unknowns, with too many questions without answers, the article provided can help those working with this population by looking back, to think about possibilities moving forward.

Title: Conducting Real-Time Videofluoroscopic Swallow Study via Telepractice: A Preliminary Feasibility and Reliability Study
Authors: Burns, Ward, Hill, Phillips, & Porter
Journal: Dysphagia
Year of Publication: 2016
Design Type: Feasability study
Purpose: “The aim of this study was to test the feasibility and reliability of using a telepractice system to enable live VFSS assessment.”
Population: Twenty patients (inpatient/outpatient caseloads), consecutively recruited from the Speech Pathology Department at the Royal Brisbane and Women’s Hospital, Brisbane, Australia
Inclusion criteria: referred from healthcare team for VFSS to assess swallow function
Exclusion criteria: cognitive impairments per medical records; high medical dependency; significant auditory/visual impairments

  • Only got a sec?
    • With further research to study its effectiveness and reliability, a VFSS telepractice clinical model may be an applicable prospect on the horizon
  • Only got a minute?
    • For any telepractice model, it is critical to determine that service delivery via telepractice is not inferior, equal, or superior to current care
    • The high levels of agreement reported in the results of the current study support the feasibility of conducting remote live administration of a VFSS assessment using the system described
    • This study confirms the potential to develop a VFSS telepractice clinic model that supports remote online dysphagia assessment by speech pathologists and radiologists that is comparable to standard care
    • Building on these positive results, further studies are now required to evaluate this VFSS telepractice model across facilities spanning larger geographical distances to comprehensively evaluate its capability to deliver an effective and reliable remote clinical VFSS service
    • Got more time? Keep Reading!!

No, we may not be there yet with this title. And maybe this is not what some may be thinking about right now. But, being the strong-willed SLP I’ve somehow become over the years, I couldn’t help but think, ‘Why not?’ (in my head there was likely an additional expletive 😉 ).

Some things to keep in mind:

  • Some other studies had already looked at this, finding problems with a) reduced frames per second (between 10 and 30), b) delayed transmissions and poor image quality, c) difficulty relying solely on recorded images for post-interpretation and analysis
  • Because the study was a feasibility study, only a limited sample of participants with ‘less complex’ disorders and issues was utilized (meaning no cognitive or medically complex patients)

Now’s a perfect time to review what exacly that last point means:

“Feasibility studies are studies that are done largely to ask questions..We’re taking a hypothesis that may have been developed at the preclinical level, and now we’re actually trying the technique, but we’re not yet doing the experiment.” https://academy.pubs.asha.org/2014/01/a-five-phase-model-of-intervention-research/


Here’s a link on how to conduct your own! https://www.asha.org/practice/feasibility/

So what did they do?

They took 20 participants, each with their own treating SLP (feeder), an SLP present in the fluoro room, a different SLP in a typical office room located somewhere else in the department away from the fluoro room to give a “simulated” remote trial but still able to visualize and hear the evaluation, and a radiologist (whose experience apparently ranged from new grad to 14 years😳).

They could all communicate to each other as needed, but did NOT communicate any interpretations/recommendations etc. (only questions about medical history, technical adjustments etc.). Apparently, at the facility having a feeder is usual practice! This time, the ‘feeder’ was able to give thorough patient handoff information to both the present and telepracticing SLP, otherwise following the directions of the face-to-face SLP in the fluoro suite (**this SLP was also behind glass watching/analyzing/instructing, NOT in the actual room**). BTW–the authors give an adorable picture of this whole setup to visualize easier👍👏🙌.

Without getting into too much detail about all the high-tech equipment (mainly because my brain doesn’t compute that stuff right🤨😓🤯), a specific telepractice-fluoroscopic system was used and calibrated:

  • Siemens Artis Zee MP digital fluoroscopy system (fluoro system)
  • Video Graphics Array (VGA) output to provide an image source display at 30 frames per second (fps)
  • Cisco TelePresence C60 System (C60) (local system) was connected via a Digital Video Interface (DVI) output from the fluoroscopy machine (for the “tele” part)
  • Sony television monitor + echo canceling microphones + wireless lapel microphone + pan/tilt/zoom
  • inspector gadget videoconferencing camera (to hear, see, and interact everything going on)

Now, since I never worked at Radioshack and get intimidated going into Best Buy, I can’t quite compare and contrast differences (the names are for all those system-seekers😉🤓), so I can’t help but be biased and pretty easily impressed.

Aside from all those gadgets, it really was pretty similar to what most of us are (hopefully) still able to do:

  • No standardized protocols for food consistencies/amounts and order (poor MBSImP 😢) but typical 2-3 bolus amounts per consistency, individualizing per patient
  • Thinner to thicker consistencies to solid foods
  • Lateral and A-P view (plus esophageal screen, yes I know this is sometimes our fantasy at night🦄)
  • Something I did find different and interesting:
    • per institutional protocol at the testing site, fluoroscopic images of fast flowing liquids (i.e., thin fluids) were captured at a rate of 30 fps, while trials of all other thickened fluids and food consistencies were captured at 15 fps.

Guess it’s back to the library to find me some of that research!🙂🤓🧐

The big question…..🥁🥁🥁🥁🥁🥁🥁🥁🥁🥁

Was telepractice for VFSS equivalent to real-time/in-person?


While the in-person/real-time SLP and the telepractice SLP had many strongly agreeing measures, including their perceptions of the VFSS session (both agreeing that “the telepracticing SLP was able to develop rapport with the patient and clinicians across all the telepractice sessions, and was able to effectively direct the clinicians in 95% of the VFSS sessions” along with agreeing on adequate audio/visual quality)..

Like many of us, they essentially rated and looked at the safety of a swallow (aspiration/penetration), and the efficiency of a swallow (residue, responsiveness) in real-time during each bolus with VFSS. What does that mean? Well, instead of simultaneously answering these questions in our head, they recorded the presence/absence of each of the following with a simple yes/no:

  • laryngeal penetration
  • presence of aspiration
  • response to clearing airway invasion
  • presence of residue with airway risk

They also had to judge and record their recommendations (yes/no) for:

  1. oral vs non-oral intake safeness
  2. diet consistencies for solids/liquids according to National Dysphagia Diet (I hear IDDSI knockin on this study’s door 😉 😉 )
  3. Dysphagia Outcome Severity Scale (DOSS) rating (1-7)
  4. any compensatory strategies
  5. need and/or type of feeding assistance recommended
  6. further recommendations for FEES
  7. other healthcare referral recommendations (and who)

No, nothing in life is that simple. And no, dysphagia is definitely NOT that black and white.

“The face-to-face clinicians’ ratings confirmed that post VFSS the cohort consisted of 5 patients with no dysphagia, 5 with mild dysphagia, 9 with moderate dysphagia, and 1 patient with severe dysphagia.” p.479

Where a percentage for exact agreement between the raters was >80% (used for the yes/no parameters), percentage clinical agreement was ±1 point on a 5-point scale (for all measures with more than 1 possibility), and a statistical level of agreement was set for >0.6, “Overall, the level of agreement between the raters met criterion [for both] across the majority of clinical decisions for the fluid and food trials.”

While some other measures failed to live up to those agreeable standards for ‘presence of penetration on moderately thick fluids‘ and ‘presence of residue with airway risk on extremely thick fluids,‘ their percentages and stat levels were actually pretty close to the goal (75% and 0.529; 77% and 0.57, respectively).


When it came down to mild thick liquids and different solid textures (puree and soft diced fruit), the results were more mixed for the percentages being there, but after all was said and done the stats just didn’t match.

So why was there disagreement on issues relating to aspiration/penetration (29 to be exact) and differing consistencies? I have a big hunch, but after they looked more closely they found:

“For 16 (55%) of these instances, the face-to-face-SLP identified penetration/ aspiration which was not detected by the telepractice-SLP, while the telepractice-SLP detected airway invasion on 13 (45%) of consistencies which were not identified by the face-to-face-SLP.” p.479

There really was no rhyme of reason to the rating differences. It wasn’t the patient. The consistency didn’t matter. And it wasn’t the clinician’s fault for missing it either.🤷🏻‍♀️

Do you think they agreed on what to do and recommendations with the telepractice VFSS?


They did agree on everything BUT [🤫diet recommendations🤫] (*whisper voice due to hotness of topic*😬😳). However, they came close, and were also statistically significantly exceeding the set goal!

“All ratings met the set criteria for PEA except for diet recommendations. Although decisions regarding diet recommendations had a percentage exact agreement of 70%, percentage clinician agreement was 100% with each recommendation being within one diet consistency grade (i.e., mince moist diet & soft diet or soft diet & general diet) and all decisions were considered safe by the telepracticing-SLP and face-to-face-SLP.”

“Decisions regarding oral versus non-oral intake, fluid consistency, and feeding assistance required were in 100% agreement, followed by DOSS rating, compensatory strategies recommended, FEES recommendation, and referral to other professionals all having 95% agreement.” p.479

After I took a small step back from letting those numbers and results sink in, I realized something about them. Because it seems we are pretty much 100% agreeable on DIET RECS, strategies, and PO vs NPO. Plain and simple….

BUT, we still do not have the best reliability between clinicians (present or not) on the actual safety/effectiveness of the issues like aspiration/penetration, residue, etc. And we can’t even begin to think and piece apart the differences of actual swallow pathophysiology that cause these issues, even without telepractice! (see the MUST READ reference below for more on this! 😉 😉 ). I really tried not to let any strong biases or soapboxes get in here, but after reading I also couldn’t help but let it slip that having a bottom-up approach to learning and training for dysphagia and everything related is so much more needed versus the top-down approach we may have all gotten so comfortable with. End of personal internal built up frustration.😩😩🤐

dark room

Before we start setting up laptops in our radiology rooms and act like the radiologists examining films…in the dark…for hours…(obviously some of us actually crave that level of excitement and separation😄)

Yes agreement was high in most measures and most areas. Yes this would be spectacular news to be able to not only perform these studies out of location to rural areas, lesser trained clinicians, and staff shortages. This would be pretty great to be able to do now.

But, we’d first need to make dang sure that the methods used in this study are adequate enough, cross multiple setting, multiple locations, multiple internet speeds/systems, multiple patients, multiple clinicians, multiple protocols, etc. etc. etc. (Not to mention the face-to-face and telepractice clinicians were trained in the interrater reliability beforehand as well).

While the benefit could be HUGE, the risks could be equally huge, and those risks are what would need to be found out longer before rolling this out.

Luckily, I feel like replicating this study could potentially answer some of those issues.

Another really interesting thing to help not get too bogged down about is the inconsistencies in agreements across multiple measures, patients, consistencies, and clinicians.

“It is well documented that inter-rater reliability in VFSS is variable. For example, in other studies using binary ratings to detect the swallowing features, McCullough et al. reported unacceptable levels of inter-rater reliability and Stoeckli et al. reported poor agreement on all parameters except for penetration/aspiration. Hence, some disagreement is both normal and expected in VFSS research.” p.481

(also definitely checkout “A Survey of Clinician Decision Making When Identifying Swallowing Impairments and Determining treatment” for an eye-opening look at this!!!)

How can YOU use this article?

Do you think this is too ‘out there?’

Do you think your facility or department could use this?

Is this what you’ve already been thinking about right now??

What are your worries? What are your concerns?

What are some ways we can continue this journey on utilizing all of our modes of service delivery including telepractice? How about replication with:

  • Aspiration-Penetration Scale Ratings?
  • Modified Barium Swallow Impairment Profile?
  • similar years of experience? (see reference above on that one also 😉 )
  • researchers and clinicians for rater groups?

I know I may be thinking big here, and I know right now many of us are just trying to keep our heads above thin or thick water depending on your location and facility. But we as professionals have accomplished a s**t ton in the recent decades. With the same gumption that’s brought us this far, just think where we can keep going!🤩👩‍🔬👩‍⚕️🙆‍♀️

Together we can get through this, and together we can go push our profession even further. ❤️❤️❤️❤️


Referenced Article:

Burns, C. L., Ward, E. C., Hill, A. J., Phillips, N., & Porter, L. (2016). Conducting Real-Time Videofluoroscopic Swallow Study via Telepractice: A Preliminary Feasibility and Reliability Study. Dysphagia31(3), 473–483. doi: 10.1007/s00455-016-9701-2

Quick Exciting Update!!

For more current information about Dysphagia & Telepractice, click here for Dr. Malandraki’s expertise at this Facebook Event!!!

APRIL 24 2020  @7pm EST !!!

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