Dysphagia Q&A

Will you be working as the sole dietitian at your worksite? If you, as an RD(T), are in a sole and private practitioner role, as defined in the Temporary Registration Policy, you must have a mentorship agreement in place. The details of a mentorship agreement can be found in  Sole and Private Practitioner and its Interpretive Guide. Mentorship can take place in-person or remotely, as per section 6c) of RC-19: “Mentorship must include regular, communication (in-person, telephone and/or or internet) between the CDBC full registrant and the temporary registrant.”

Per section 4: “The mentor must be:

1. i) a current, full registrant, of the CDBC, in good standing; and
   ii) actively working in a dietetics field that supports the temporary registrant’s intended practice area, as a sole and private practitioner.
   iii) registered to practice the required restricted activities if the temporary registrant’s intended practice area includes enteral or parenteral nutrition support.
   iv) free from conflict of interest, including personal relationships and family.”

Dysphagia and swallowing assessments are within the dietetic scope of practice. Swallowing assessment and management competencies are part of the Integrated Competencies for Dietetic Education and Practice for the BC dietetics program, and indeed, for all accredited Dietetics programs in Canada. Dysphagia management is not a restricted activity and there are no special courses or certificates in BC that are required to perform bedside swallowing assessments (although instrumental assessments require a certification in some professions and jurisdiction). The Alliance of Canadian Dietetic Regulatory Bodies has developed a document called Competencies for Dysphagia Assessment and Management in Dietetic Practice. It may be helpful to use this document in considering competency to perform swallowing assessment and management and in identifying continuing education needs.

Here are some questions to reflect on:

1. Do you have the knowledge, skills and judgement to take on this aspect of practice safely, ethically and competently? Included in the Standards of Practice, “a Dietitian uses critical thinking to obtain assessment date, determine practice problems, plan, implement and evaluate professional services.”  It is important for you to have the skills necessary to be deemed capable in this area of practice. These skills can be gained with training opportunities provided by your employer such as on-the-job training, courses and workshops offered by Dietitians of Canada and/or workshops offered by other dietitians with an expertise in this area.
2. The College encourages you to reflect on your practice question using the CDBC’s newly developed resource, Decision Tool for New Aspects of Dietetic Practice. Using this framework, if you find you are outside of your personal scope (i.e. being able to identify and assess dysphagia), you may reflect on this Standard of Practice: ‘A Dietitian provides professional services concurrently with another provider from the same or a different profession only when the concurrent provision of services is beneficial to the client’, by choosing to refer to another health professional for independent or collaborative practice, as appropriate. Ultimately, it is your responsibility to ensure you are capable and competent to provide swallowing assessments, should you need or be requested to perform these in your job.

 Refer to Q10 for resources.

The dysphagia competencies set out the expectations for safe, ethical, and effective dietetic practice in the area of dysphagia assessment and management. The dysphagia competencies build on entry to practice competencies (Integrated Competencies for Dietetic Education and Practice – ICDEP) and identify additional performance indicators for this area of practice. The competencies apply to dietitians through the career continuum, from initial stages where one might be gaining experience to those with many years of experience and expertise.

The updated dysphagia competencies (see Q1 for link) may be helpful in this instance. Dysphagia and swallowing assessments are within dietetic scope of practice. However, you may want to consider the following points:

What is your work environment? Is the role of dysphagia management under the umbrella of your job description in your workplace?

For example, in some Health Authorities, as outlined in employer policy, some aspects of dysphagia management may fall under the responsibility of the Speech-language Pathologist (SLP) and/or Occupational Therapist (OT). In this instance, the dietitian’s role may not include conducting swallowing assessments; rather, it would be to use the assessment findings and recommendations to elaborate the most appropriate nutrition care plan considering the client’s context. The dietitian is also the liaison with the kitchen to ensure the diet provided is culturally appropriate and within the range of safe texture and fluid consistency while considering the preferences and other medical conditions of the patient, as well to monitor the intake, acceptance and adequacy of that diet.

If the role of the dietitian in your workplace is expanding to provide swallowing assessments, it is important to consider your own personal scope. You are encouraged to refer to the Decision Tool for New Aspects of Dietetic Practice. Do you have the knowledge, skills and judgement to take on this aspect of practice safely, ethically and competently? Included in the Standards of Practice, “a Dietitian uses critical thinking to obtain assessment date, determine practice problems, plan, implement and evaluate professional services.”  It is important for you to have the skills necessary to be deemed competent and safe in this area of practice. These skills can be gained with training opportunities provided by your employer such as on-the-job training, courses and workshops offered by Dietitians of Canada and/or workshops offered by other dietitians with an expertise in this area. See Q10 for more information.

You are correct in that dietitians may not administer an instrumental exam for dysphagia assessment and management. The act of administering a device beyond the pharynx (such as in a FEES), and the application of X-rays for diagnostic or imagine purposes (such as in MBS) are considered restricted activities in BC. Section 3.12 of the dysphagia competencies outlines the scope for a dietitian during an instrumental swallowing study. You’ll note that “review and interpret findings, including limitations [of the test]” is included. Depending on the settings, dietitians can attend and observe the exams or use the results to develop and revise their nutrition care plan.

The College encourages you to reflect on your practice question using the CDBC’s resource, Decision Tool for New Aspects of Dietetic Practice. Using this framework, if you find you are outside of your personal scope (i.e. being able to identify and assess dysphagia), you may reflect on this Standard of Practice: “A Dietitian provides professional services concurrently with another provider from the same or a different profession only when the concurrent provision of services is beneficial to the client”, by choosing to refer to another health professional for independent or collaborative practice, as appropriate. Ultimately, as for any other area of practice, it is your responsibility to ensure you are capable and competent to assess and manage dysphagia, should you be requested to perform these in your job.

Currently under revision.

Consider the following questions:

• Does your job description include (1) virtual care, and (2) dysphagia assessment and management?
• Are in-person assessments possible? What are the consequences of delaying the assessment if in-person is impossible?
• Do you have liability insurance to undertake this task?
• Are you the best person to be completing this task? For example, is this task usually done by SLP or OT in your work area?
• Is the level of care you are able to provide virtually equivalent to the provision of in-person care?
• What type of assessment is involved? A meal observation, a bedside assessment, a potential for requirement of an instrumental assessment?
• What is the purpose of the assessment? Downgrading or upgrading the diet? Who is conducting the physical component of the assessment on the client side? A nurse, a caregiver, family?
• What is the practice setting? LTC? Home?
• What type of client may receive such a virtual dysphagia assessment? Do you have guidelines that outline which type of client can safely receive virtual swallowing assessments versus when a client needs in-person care? Or perhaps which type of client requires immediate assessment by the first the health professional available versus one that may benefit from being assessed collaboratively or another health professional (for example, where a VFSS is required)?
• What are the risks associated the swallowing issues of this specific client and how does that fit with a virtual assessment (for example, is the client at high risk for choking or is there a high risk of silent aspiration?)?
• How responsive is the client? Are they cognitively able to answer questions during the assessment? If needed, is the client supported by another person who is able to answer questions or complement the observations you are able to make virtually?
• Do you have an adequate emergency response plan in place?

In the context of these questions, you should review workplace/Health Authority policies and guidelines regarding dysphagia assessment to determine if and where you may have a role.

From the College perspective, per the Dysphagia Assessment and Management document, here are highlighted the following competencies that may be difficult to achieve virtually:

• 011b.  Assess anatomy and function of the swallow. [Practice Illustration:  Assesses strength of lips and tongue]
• 011j . Manage adverse events. [Practice Illustration:  Ensures nursing staff are accessible during the assessment in case of a choking episode]
• 011l. Perform Cardiopulmonary Resuscitation and manage airway obstruction (RD is certified in CPR if assessing without another health professional certified in CPR). [Practice Illustration:  Ensures health care professionals certified in CPR are available during the swallowing assessment]

Any dysphagia assessment has some level of risk and an assessment that is considered to be of higher risk may not be appropriate to complete virtually so there is some required clinical judgement. As with in-person clinical dysphagia assessment, clinicians are limited in what can be ascertained at the bedside.

Risks associated with virtual dysphagia management can be mitigated, at least partially, by adequate preparation/education. Ensuring support is in place means that potentially all of the Dysphagia Competencies listed in 3.011 can be met. Having a capable person (caregiver, family member) involved and educated is key. It is unlikely ever appropriate to complete a virtual swallowing assessment where the client is in isolation, unless to downgrade a diet for safer eating until further assessment can be done.

The resources you may find interesting include, but are not limited to:

• Communiqué | SAC-OAC Blog
• Virtual Dysphagia Evaluation: Practical Guidelines for Dysphagia Management in the Context of the COVID-19 Pandemic (sagepub.com)
• Telehealth Dysphagia assessment: a decision making tool | RCSLT
  • Risk Assessment Tool – this one is a decision tool and has a lot of useful links within.
  • Flow Chart – this one touches on “is it clinically appropriate”? (this could be extrapolated to also ask a dietitian, if it is clinically appropriate, are you the best person to complete the assessment?). Of note, “obtain and record informed consent” should be added in your steps.

As with all nutrition care documentation, the CDBC Standards of Record Keeping must be followed, and in this circumstance, clearly outlining the dysphagia assessment process, informed consent, instruction, limitations of your virtual assessment, risk to client, and follow-up plans, are required.

In the Competencies for Dysphagia Assessment and Management in Dietetic Practice, Section 3.011 “Conduct a Clinical Swallowing Assessment”, page 18 includes:

1. Manage adverse events. [Practice Illustration: Ensures nursing staff are accessible during the assessment in case of a choking episode.]
2. Recognize when to terminate assessment related to adverse reactions. [Practice Illustration: Terminates assessment if there are signs of aspiration.]
3. Perform Cardiopulmonary Resuscitation and manage airway obstruction (RD is certified in CPR if assessing without another health professional certified in CPR). [Practice Illustration: Ensures health care professionals certified in CPR are available during the swallowing assessment.]

If the nursing staff are certified in CPR and First Aid and are on site and available to assist you should an adverse event occur during your swallowing assessment, it is not necessary for you to be trained. An exception to this would be any workplace or Health Authority policies that exist, that might require you to be trained. If you are performing swallowing assessment in a solo capacity (for example at the home of client), you must be certified and capable of providing First Aid and/or have an emergency response plan that identifies immediate access to First Aid.

The Competencies for Dysphagia Assessment and Management in Dietetic Practice don’t speak to this.

“Eat at risk” in long-term care, means to include any food texture or fluid consistency that is not aligned with the recommendations for safe intake (usually to decrease risk of choking or aspiration).

In this situation, you should collaborate with the physician and other health professionals’ part of the team (nursing, OT or SLP), to discuss what an eat at risk plan would look like as well as provide education to the client/substitute decision maker on the associated risks and ways to mitigate risk (if possible). An order in the chart would indicate that the client is eating at risk and which diet texture they have chosen.

Some sites use an “eat at risk” contract that is signed by the client or substitute decision maker. All of the above areas of risk and mitigation of risk must be discussed at this time. The CDBC doesn’t have templates for this, as it would never encompass all of the workplace considerations that need to be taken into account. What is key for dietitians to ensure, is that informed consent has been discussed and obtained and that client-centered care is maintained as a result of this decision. Risk definition and tolerance may also vary amongst different cultures and dietitians can play an important role in ensuring clients’ decisions are respected and not negatively impacting the rest of their diet and care.

Policies and directives in your workplace scope will determine how an order for “eat at risk” must be written, and by whom. It is important to understand and clarify your role as well as potential limitations for ordering this type of diet.

Finally, it is important that you document thoroughly and regularly, per the CDBC Standards for Record Keeping.

Dietitians of Canada.

• Best Practices for Nutrition, Food Service and Dining in Long Term Care Homes A Working Paper of the Ontario LTC Action     Group 2019, retrieved May 10, 2023 from https://www.dietitians.ca/DietitiansOfCanada/media/Documents/Resources/2019-Dietitians-of-Canada-Best-Practices-for-Nutrition,-Food-Service-and-Dining-in-LTC-Homes.pdf?ext=.pdf
•  Defining the Role of the Dietitian in Dysphagia Assessment and Management: A Statement of Dietitians of Canada (2015),          retrieved May 8, 2023 from https://www.dietitians.ca/DietitiansOfCanada/media/Documents/Resources/Dysphagia-Role-Paper-2015.pdf?ext=.pdf
• Dietitians of Canada – Dysphagia

Courses:

• Professional Practice in Dysphagia Management, from https://members.dietitians.ca/DCMember/LearnProduct?                      id=01tf4000003j6wGAAQ
• Swallow Screening and Assessment for Dysphagia, from https://members.dietitians.ca/DCMember/LearnProduct?id=01tf4000003ko1XAAQ
• Nutrition Care Process in Dysphagia, from https://members.dietitians.ca/DCMember/LearnProduct?id=01tf4000003j6wIAAQ

Networks:

• Join the Dysphagia Assessment and Treatment Network
• Join the Canadian section of the International Dysphagia Diet Standardization Initiative (IDDSI), to learn more about       implementation in workplaces.
• Nestle Health Sciences. Dysphagia 101, with Peter Lam, RD. Retrieved May 8, 2023 from  https://www.nestlehealthscience.ca/en/dysphagia/dysphagia101

SwallowStudy.com by Karen Sheffler. Retrieved May 8, 2023 from https://swallowstudy.com/